Benign Non- Inflammatory

Conditions of the Cervix

ML 301 Cytology
Dr Pritinesh Singh
Department of Pathology
School of Health Sciences
Fiji School of Medicine
Objectives

„ Know the cytology of benign non -

inflammatory conditions affecting the
pap smear
„ Appreciate and classify the different
benign non- inflammatory conditions
causing cellular changes in the
cervical pap smear
Review

„ Basal cells
„ Parabasal cells
„ Intermediate cells
„ Superficial cells
 Atrophy

„ Pap smear is dominated by basal/

parabasal cells
„ Common in late postmenopausal period,
the postpartum period & during
childhood
„ Syncytial sheets of basal and parabasal
cells are characteristic of atrophy
Atrophy
„ Spindle parabasal cells are also common
(transitional metaplasia)
„ Can also be associated with nuclear
enlargement into the range seen in
dysplasia accompanied by mild
hyperchromasia
„ Air-drying is common in atrophic smears &
contributes to nuclear enlargement however
nuclear membranes are uniform and
chromatin is bland (smudgy)
Atrophy
 Atrophy
„ Also commonly
associated with
evidence of
inflammation
„ Such as evidence of
{ cellular degeneration,
including numerous
naked nuclei
{ nuclear pyknosis
{ pseudokeratinization
{ abundant
inflammation
 Atrophy

zA granular basophilic
background in which
blue blobs (mummified
parabasal cells) may
be identified.
 Benign Proliferative Reactions
Includes:

„ Squamous metaplasia
{ Immature - mature
„ Keratosis
{ Hyperkeratosis &
parakeratosis
 Squamous Metaplasia

„ Begins with reserve cell having the unique

ability to differentiate into either a glandular
or a squamous cell
„ Earliest change is known as RCH (reserve
cell hyperplasia)
{ Proliferation of undifferentiated reserve cells
underneath the endocervical glandular
epithelium
{ Rarely recognized in pap smear
 Squamous Metaplasia
„ Following RCH the cells start
acquiring squamous features
(beginning of true squamous
metaplasia.
„ This immature form is commonly
recognized in pap smears
{ It’s para-basal sized with rounded
cell borders, that are sharply
defined.
{ Form loosely aggregated flat sheets
in a characteristic cobblestone
pattern
{ Cytoplasm is thick and dense
Metaplasia

„ Immature metaplasia differentiates to

mature squamous metaplasia
characterized by immature sized cells
that are eventually indistinguishable
from native squamous cells
 Squamous Metaplasia

A and B: mature squamous metaplasia. C: immature

squamous metaplasia. D: immature squamous
metaplasia with pattern of transitional metaplasia.
 Keratosis
„ Occurs in response to severe stress or irritation
such as a pessary or uterine prolapse

„ Normal nonkeratinizing epithelium

hyper-differentiates into two additional cell layers
at the surface
{ a granular layer – characterized by superficial cells with
dark keratohyaline granules in the cytoplasm
{ A stratum cornuem – characterized by anucleate
squames (diagnostic of hyperkeratosis)
Hyperkeratosis
 Keratosis

„ Parakeratosis- another surface keratotic

reaction characterized by presence of
miniature superficial cells in the pap smear
which can be seen as single cells, layered
strips or pearls
„ Although these keratotic conditions are
benign they could mask an underlying
squamous abnormality, possibly including
cancer
Parakeratosis

Pearl appearance of parakeratosis

 Parakeratosis
„ Single cell
Benign Cellular Changes

„ Distinguishing inflammatory changes

from dysplasia is a common everyday
problem in cytology
„ Essential difference between
inflammatory atypia and dysplasia is
the nucleus
{ If its dark and big, it’s dyplasia!
Radiation Effect

„ Characterized by presence of
{ macrocytes ie cytomegalic cells with
enlarged or multiple nuclei & voluminous
cytoplasm but relatively normal NC ratio
{ Nuclei range from pale – hyperchromatic
(but smudgy) and may be vacuolated.
{ Cytoplasm often stains pink & blue
(polychromasia) and also may be
vacuolated
Radiation Effect

„ Cytoplasmic vacuoles may contain

leukocytes
„ Frequently accompanied by
repair/regeneration
„ May regress after therapy or persist for life
„ Macrocytes can also occur in condyloma &
Vit. Deficiency (folate, B12)
Enlarged nuclei with abundant polychromatic cytoplasm with vacuolization. Mild
nuclear hyperchromasia without coarse chromatin, prominent nucleoli (coexisting
repair). Note multinucleation (upper right corner insert).
Nuclear and cytoplasmic enlargement, smooth nuclear outlines
with mild hyperchromasia but chromatin is finely granular.
Cytoplasmic polychromasia and vacuolization
Multinucleated cell. Abundant polychromatic cytoplasm;
cytoplasmic vacuoles.
 Post-radiation Dysplasia

„ Serious lesion that sometimes develop after

radiation therapy, usually for squamous cell
carcinoma
„ It is probably more closely related to
ionizing radiation then to HPV
„ Patients who develop this lesion are at high
risk of recurrence particularly if it occurs
within 3 yrs of therapy.
Post-radiation Dysplasia

„ Changes include:
{ cytomegaly,
{ increased NC ratio,
{ oval/irregular hyperchromatic nucleus
{ Fine/ coarse granular chromatin
{ Eosinophilic / amphophilic cytoplasm
Self Assessment Questions

„ When should atrophic cells be seen?

„ What are some errors in preparing &
processing a papsmear that may give
rise to an atrophic smear?
„ What are some characteristic features
of atrophic pap smears?
Self Assessment Questions

„ What is squamous metaplasia?

„ How is squamous metaplasia identified on
pap smears?
„ What is keratosis?
„ What are the subtypes of keratosis and how
are they identified on papsmears?
„ How can radiation changes be distinguised
in a pap smear?