PAP Smear examination
Vikram Prabhakar (DCP,DNB Pathology)

Patient details
• Pt is a 39 yr female, a housewife
• HIV positive since 2001
• Is on Regular ART

H/O present illness
• Pt visited gynecology OPD in December 2014
for a routine examination.
• No h/o dysmenrrhoea, white discharge p/v.
• No h/o irregular menstruation.
• No h/o chronic disease
• No h/o blood transfusion or surgery

Obstetric history:
P1L1, FT ND, male child, 19 yrs back
Menstrual history:
Regular cycle of menstruation
Menarche at 13 years

On Examination
P/A– Soft, non tender, no organomegaly
P/S– Cervix, Vagina healthy
P/V– uterus normal size, AV, FF, NFT
RS/CVS/CNS– NAD
PAP smear was done

Low power
• Adequate
• Inflammatory smear

Low power view
• Inflammatory smear

High power
• High N:C ratio
• Irregular nuclei
• Coarse chromatin

• High N:C ratio
• Irregular nucleus
• Hyperchromatic nucleus

Differential diagnosis
• ASC-h/HSIL
• ASCUS
• LSIL
• ASC-H mimic

ASC
Squamous
differentiation
High
N:C
ratio
Nuclear
changes

ASCUS
>90%
ASC-H
<10%
ASC

Criteria for ASC-H
• Cells are the size of a metaplastic cells with
nuclei 1.5 to 2 times the size of normal.
• Variable N:C ratio; may be very high
• Prominent nuclear irregularity
• Generally hyperchromatic nuclei but may be
normo- or hypochromatic.
• Lack of nucleoli

ASCUS
• Nuclei are 2.5 to 3
times the nucleus of a
normal intermediate Sq
cell or twice the size
• of a squamous
metaplastic cell nucleus
• Slightly increased N:C
ratio
• Minimal nuclear
hyperchromasia

LSIL
Mature squamous cells
with enlarged nuclei
Koilocytosis or perinuclear
cavitation
Binucleation/multinucleati
on is common
Variable size nuclei

Final Impression
• ASC--H

• Revisited the OPD on 30th May 2015.
• No specific gynecological complaints.
On examination:
P/A : soft, non-tender
P/S : Cx, vagina healthy
P/V : uterus normal size, FF, NFT.

• USG: Normal study, No obvious mass/focal
lesion in Cervix.
• PAP smear

Low power
• Adequate smear
• Moderate to dense
inflammation

• BB shots

Low power
• A syncytial cluster or
hyperchromatic
crowded group

• High N:C ratio
• Nuclear irregularity
• Hyperchromatic
• No nucleolus

• Variable nuclear
enlargement
• High N:C ratio
• Irregular nuclear margin
• delicate cytoplasm

• Isolated single
abnormal cell

• Abnormal, large
stripped nuclei are seen
that are considerably
bigger than the
intermediate cell nuclei.

Differential Diagnosis
• HSIL
• Non- keratinized Sq cell Ca
• Endocervical adenocarcinoma in situ (AIS)
• Mimics of HSIL

Criteria for HSIL
• Variable N:C ratio; may be very high
• Nuclear membrane notching and marked
irregularity
• Generally hyperchromatic nuclei but may be
normo- or hypochromatic
• Occasional mitosis
• Inconspicuous nucleoli
• In clusters-- Horizontal arrangement of cells at
periphery

Non keratinizing
Sq cell Ca
Pleomorphic
cell shapes
Tumor
diathesis
Prominent
nucleoli
Irregular
chromatin
distribution
HSIL
Coarse evenly
dispersed
chromatin
No tumor
diathesis
No nucleoli

Sq cell Ca v/s HSIL

Endocervical Adeno Ca in situ
Hyperchromatic crowded
cells with:
• Glandular
differentiation
• Columnar cells
• Strips and rosettes
• Psuedo stratification
• Snake eating an egg
appearance
• Feathering

• Rosettes are highly
characterestic of AIS
and are never seen with
HSIL

• Resemble HSIL but
feathering at borders
gives away the
glandular nature

Impression
• HSIL
• Biopsy was advised

• A cervical biopsy was sent for HPE (5325/15)
on 20/6/15.
• Imp: Carcinoma in situ of Cervix

Low power
• The abnormal
immature cells show
minimal maturation
• from the base of the
epithelium to the
surface with nuclear
size and shape variation

Low power

High power

Low power

• Dysplasia
• Koilocytic changes

High power
• Koilocytic change
• Dysplastic cells

Impression
• Carcinoma in situ cervix

Mimics of HSIL/ASC-H

Immature squamous metaplasia :-- Nuclear uniformity, smooth nuclear
borders, and fine and evenly distributed chromatin

Single benign
endocervical cells are
prone to cytoplasmic
lysis

Tubal metaplasia with
Cilia

HSIL in Atrophic smear
HSIL in atrophy may be difficult to distinguish from clusters of benign
atrophic squamous cells. Focusing in different planes allows one to
better distinguish them from the parabasal cells in the background

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