Pap smear

Cervical cytology reporting

system
Bethesda system
A. Specimen adequacy
Satisfactory for evaluation
Unsatisfactory for evaluation
(specify reason)

B. Interpretation/result:
- Negative for intraepithelial
lesion or malignancy (NILM)
- epithelial cells abnormalities
(Squamous/glandular)
- 0ther malignant neoplasm
Cervical histology
Cervical cytology
 Squamous epithelium
 ‘Metaplastic’ squamous epithelium
 Columnar epithelium (endocervical
glandular cells)
Squamous epithelial

 Superficial cell
 Intermediate cell
 Parabasal cell
 Squamous Epithelium
 Superficial cells :
 Most mature squamous
epithelium (estrogen stimulation)
 45-50 um
 Flat,
polygonal, with small,
dense, pycnotic nuclei
 Cytoplasm : Stained pink –
orange with papanicolau,
sometimes : light blue green.
 Seen in abundance during the
late proliferative and ovulatory
phases of the menstrual cycle.
At these points estrogen is at it's
peak.
Intermediate cells
 35-50 um
 Large polygonal cells
 Navicular cells : Angulated to
ellipsoid shape resembling
‘boat ‘
 Similar with superficial cells in size
and shape
 Nucleus : Slightly larger and
have more open vesicular
chromatin pattern than
superficial cells
 Intermediate squamous are
seen in abundance when the
progesterone hormone is at high
levels. This occurs during the
luteal and the early follicular
phases of the menstrual cycle
and the second and third
trimester of pregnancy.
 Parabasal cells :
 12-30 um
 Smaller than superficial or
intermediate cells
 Round rather than polygonal in
shape
 Round nuclei similar in size to or
slightly larger than intermediate
 The amount of cytoplasm in
considerably less
 Predominant in lack of
estrogrenic stimulation
 Along with basal cells, these
cells are seen in atrophic pap
smears from patients that are
pre-menstrual, postpartum,
taking estrogen restricting
hormones (ie. depo-provera)
and women who are post-
menopausal.
 Basal cells
 10-12 um
 Derived from the lowest layer of
the epithelium
 Notrecognizable in normal smear
based on morphologic alone
Metaplastic squamous epithelium
 Squamous metaplastic cells
have many features of
squamous cells, but they are
immature and occasionaly
contain ‘ mucin vacuoles’
 Round and similar in size to
parabasal cells
 Cytoplasm : Very dense, blue
or bluish-green stained with
Papanicolau
 Derived from transisional zone
Columnar Epithelium
(endocervical glandular
cells)
 Upper and middle endocervical canal
 Single layer of columnar cells or arranged in
sheets or strips with ‘honey coomb’ arrangement
 Mucin producing (not true glands)
 Nucleus : 54 um, Round to oval nuclei, located on
the basal side of the cells, have smooth contour
and display fine evenly dispersed chromatin with
one or two small nucleoli
 Cytoplasm : Diffuse finely vacuolated or granular.
Glandular (Endocervical) cells
Endometrial cells
 Endometrial cells in cervical smear is normal if the
smear is taken during the first 10 days of the
menstrual cycle
 Abnormal if :
 Pap smear is taken during the second half of menstrual
cycle
 Menopausal woman
(May be associated with : Endometrial polyp, endometrial
hyperplasia, endometrial carcinoma)
May be found as :
Single cells :
Smaller than endocervical cells and have little
cytoplasm
Balls of glandular and stromal component
Endometrial cells
Endometrial
cells
Transformation Zone
 The area adjacent to the border of the
endocervix and ectocervix is known as the
transformation zone.
 The Transformation zone undergoes
metaplasia, numerous times during normal life.
 When the endocervix is exposed to the harsh
acidic environment of the vagina it undergoes
metaplasia to squamous epithelium which is
better suited to the vaginal environment.
 Similarly when the ectocervix enters the less
harsh uterine area it undergoes metaplasia to
become columnar epithelium.
Transformation Zone
 Times in life when this metaplasia of the
transformation zone occurs:
 Puberty; when the endocervix everts
(moves out) of the uterus
 With the changes of the cervix associated
with the normal menstrual cycle
 Post-menopause; the uterus shrinks moving
the transformation zone upwards
 All these changes are normal and the
occurrence is said to be physiology
Cervical cytology reporting
system
Bethesda system
A. Specimen adequacy
Satisfactory for evaluation
Unsatisfactory for evaluation
(specify reason)

B. Interpretation/result:
- Negative for intraepithelial
lesion or malignancy (NILM)
- epithelial cells abnormalities
(Squamous/glandular)
- 0ther malignant neoplasm
Specimen adequacy

 Conventional smears :
- Min. 8000 – 12000 cells
- 1000 cells in 8 LPF (4x)
 Liquid Base Preparations
- Min. 5000 cells
- 500 cells in 10 HPF (40x)
 Specimen adequacy :
 Satisfactory for evaluation
 Appropriate labelling and identifying information
 Relevant clinical information
 Adequate numbers of well preserved and well
visualized squamous epithelial cells (cover more
than 10% of the slide surface)
 An adequate endocervical or transitional zone
component(metaplastic cells) : Minimum two
cluster of cells with each cluster composed of al
least five cells.
 Except in atrophic smear (metaplastic and
parabasal cells can`t be distinguished)
 Unsatisfactory for evaluation (specify
reason) :
 Lack of patient identification
A slide that is broken and can`t be repaired
 Scant squamous epithelial component (less than
10% of slide surface)
 Obscuring : Blood, inflamation, thick area, Poor
fixation, air drying artifact, contaminant, etc. that
precludes interpretation of approximately 75% or
more of the epithelial cells

Unsatisfactory means : The spesimen in

‘unreliable’ for the detection of cervical
epithelial abnormality
Non-neoplastic Findings
NILM :Negative for Intraepithelial
Lesion or Malignancy
1. Infection :
 Trichomonas vaginalis
 Fungi (Candida Spp.)
 Coccobacilli (shift in vaginal flora)
 Bacteria : Actinomyces Spp.
 Herpes simplex virus
 Nuclei : Ground glass appearance,
with enhancement of nuclear
envelope
 Dense eosinophilic intranuclear
inclusion surrounded by hallo or
clear zone
Herpes virus
 Large multinucleated epithelial cells
with molded nuclei
 2. Other Non-neoplastic findings

 Reactive cellular change associated

with :
 Inflamation
 Radiation
 IUD
 Post hysterectomy
 Atrophy
NILM – Reactive cellular
change associated with
inflamation
 Criteria :
 Nuclear enlargement (usually minimal), 1,5-2x the
area of normal intermediate cell nucleus.
 Binucleation or multinucleation may be observed
 Mild hyperchromasia may be present, but the
chromatin structure and distribution remain uniformly
finely granular
 Nuclear outlines are smooth, rounded, and uniform
 Prominent single or multiple nucleoli may be present
 Pseudokoilocyte (+), cytoplasmic polychromasia,
vacuolization.
Reactive cellular change-
Inflammation (NILM)
 NILM
Reactive cellular change
associated with atrophy
 Criteria :
 Generalized nuclear enlargement in
atrophic squamous or parabasal like
cells without significance
hyperchromasia
 Autolysis may result in ‘naked’ nuclei
 An abundant inflammatory exudate
and basophilic granular background
or basophilic amorphous material
(blue bobs) may be seen.
Reactive
cellular
change
ATROPHY
Reactive cellular change
associated with IUD
 Criteria :
 Glandular cells occur in small clusters, 5-15
cells in clean background
 Occasional single epithelial cells with
increased nuclear size and high
nuclear/cytoplasmic rasio
 Nucleoli may be prominent
 The amount of cytoplasm varies, and
frequently large vacuoles may displace
the nucleus, creating a ‘ signet-ring cell
appearance’
Reactive
cellular
change
associated
with IUD
Epithelial cell abnormalities :
Squamous Cells:
 Atypical squamous cells (ASC)
Of undetermined significance (ASC-US)
Cannot exclude HSIL (ASC-H)
 Low-grade squamous intraepithelial lesion (LSIL)
Encompassing: HPV/mild dysplasia/CIN1
 High-grade squamous intraepithelial lesion (HSIL)
Encompassing: moderate and severe dysplasia, CIS/CIN2,
and CIN3
** With features suspicious for invasion (if invasion is
suspected)
 Squamous cell carcinoma
Glandular Cell:
Atypical
Endocervical cells (NOS or specify in comments)
Endometrial cells (NOS or specify in comments)
Glandular cells (NOS or specify in comments)

Atypical
Endocervical cells, favor neoplastic
Glandular cells, favor neoplastic

Endocervical adenocarcinoma in situ

Adenocarcinoma
Endocervical
Endometrial
Extrauterine
NOS

Other malignant neoplasms (specify)

SIL and CIN
Epithelial cell abnormality –
Squamous cell
 Atypic
 ASCUS

 ASCH

 SIL
 LSIL

 HSIL

 Carcinoma (invasif)
 Non keratinizing
 Keratinizing
ASCUS (Atypical Squamous
Cells of Undetermined
Significance)
 Criteria :
 Nuclear enlargement is (2,5-3) x of a normal
intermediate squamous cell nucleus with a slight
increase in nuclear/cytoplasmic ratio
 Variation
in nuclear size and shape, binucleation
may be observed
 Mild hyperchromasia may be present but the
chromatin remains evenly distributed without
granularity
 Nuclear outline usually smooth and reguler. Very
limited irregularity may be observed
ASCUS (Atypical Squamous
Cells of Undetermined
Significance)
 ASCUS associated with atrophy :
 Both nuclear enlargement (at least two times normal) and
significant hyperchromasia
 Irregularities in nuclear contour or chromatin distribution
 Marked pleomorphism in the form of tadpole or spindle cells.
 Atypical metaplasia :
 Nuclear enlargement : 1,5-2x normal metaplastic cells or 3x
normal intermediate squamous cells.
 DD/ HSIL
ASCUS
 Diagnosis of exclusion that are not
sufficiently to permit a more spesific
diagnosis
 Most often : Nuclear enlargement in
squamous cells with matur, superficial or
intermediate type cytoplasm.
 DD/ - Benign cellular change (reactive
change)
- LSIL
ASCUS
ASCUS associated with atrophy
& Atypical metaplasia
SIL (Squamous intraepithelial Lesion)
 Non invasive cervical epithelial abnormality
 Encompass :
 Low grade SIL (LSIL) :
 Cellular
change associated with HPV cytopathic effect
(Koilocytotic atypia)
 Mild dysplasia / CIN I
 High grade SIL (HSIL) :
 Moderate dysplasia / CIN II
 Severe dysplasia/ CIN III
 Carcinoma in situ
LSIL
 Criteria :
 Cells occur in singly or in sheets
 Nuclear abnormalities are generally confined to cells with
“matur” or superficial type cytoplasm
 Nuclear enlargement is at least 3x the area of normal
intermediate nuclei, resulting in increased
nuclear/cytoplasmic ratio
 Moderate variation in nuclear size and shape
 Binucleation or multinucleation often is present
 Hyperchromasia is present and the chromatin is uniformly
distributed
 Nucleoli are rarely present or inconspicious
 “Koilocytotic atypia” (optically clear perinuclear cavity and
a peripheral dense rim of cytoplasm, with nuclear
abnormalities)
LSIL
Koilocytotic atypia–HPV infection
HSIL
 Criteria :
 Cells usually occur singly, in sheets, or in a syncitial like
aggregates
 Nuclear abnormalities occur in predominantly in
squamous cells with “immature”, dense metaplastic
cytoplasm. Occasionally, the cytoplasm is “mature” and
densely keratinized
 Nuclear enlargement is in the range that seen in LSIL but
the cytoplasmic area is decreased , leading in marked
increase in the nuclear/cytoplasmic ratio.
 HSIL cells are smaller than in LSIL
 Hyperchromasia is evident, chromatin may be finely or
coarsely granular with an even distribution
 Nucleoli are generally absent
 Nuclear outlines are irreguler
HSIL
HSIL
Squamous cell carcinoma

 A malignant invasive tumor composed of

squamous cells
 Divided into :
 Non keratinizing squamous cell carcinoma
 Keratinizing squamous cell carcinoma
Squamous cell carcinoma
 Non keratinizing squamous cell carcinoma
 Criteria :
 Cells occur singly or in syncitial aggregates
 Cells display all the features of HSIL, but contain
prominent macronucleoli and markedly ireguler
distribution of chromatin, including: Coarse chromatin
clumping, and parachromatin clearing.
 Tumor diathesis : Necrotic debris, old blood
 Squamous cell carcinoma
 Keratinizing squamous cell carcinoma
 Criteria :
 Cells occur singly, less commonly in agregates
 Marked variation in cellular size and shape, is seen with
caudate and spindle cell that frequently contain dense
orangeophilic cytoplasm
 Nucleialso vary markedly in size and configuration, with
numerous dense opaque nuclear form
 Chromatin (when discernible) is coarsely granular and
iregularly distributed with ‘parachromatin clearing’
 Macronucleoli may be seen
 Tumor diathesis may be present
Squamous cell carcinoma
Epithelial cell abnormality
– Glandular cells
 Atypic :
 Favor reactive
 Favor neoplasm
 Endometrial cells
 Endocervical cells
 Adenocarcinoma in situ
 Adenocarcinoma invasif
Atypical Glandular cells of
Undetermined significance
(AGUS)
 Cells showing either endometrial or endocervical
differentiation, displaying nuclear atypia that
exceeds obvious reactive/reparative change,
but lack unequivocal features of
adenocarcinoma

 Atypical endometrial cells

 Atypical endocervical cells
 Favor reactive
 Favor neoplasm
Atypical endocervical
cells- Favor reactive
 Criteria :
 Cellsoccur in sheets with minor degree of
nuclear overlapping
 Nuclear enlargement, up to 3 - 5 x the area
of normal endocervical nuclei
 Mild variation in nuclear size and shape
 Slight hyperchromasia frequently is evident
 Nucleoli often are present
AGUS-Favor
reactive
Atypical endocervical cells-
Favor neoplasm
 Criteria :
 Abnormal cells occur in sheets, strips, and rosettes, with nuclear
crowding and overlap, when in sheets, a honeycoomb pattern
is lost, diminished cytoplasm, and ill defined cell border
 A Pallisading nuclear arrangement with nuclei protruding from
the periphery of cell clusters (“feathering”) is a characteristic
features
 Nuclear enlargement, elongation, and stratification are evident
in most cases
 Variation in nuclear size and shape
 Hyperchromasia is evident
 Nucleoli are small or inconspicious
 Mitotic figures may be seen
AGUS – Favor neoplasm
Endocervical
adenocarcinoma
 Criteria :
 Cytologic criteria include those outlined for
‘atypical endocervical cells favor neoplasm’
 Single cells, sheets, or clusters may be seen
 Enlarged nuclei demonstrate irreguler chromatin
distribution and parachromatin clearing
 Macronucleoli may be present
 Necrotic tumor diathesis may be present
Endocervical adenocarcinoma
Question ???