ATLAS Citologie

7CITOLOGIE
NILM: NEGATIVE FOR INTRAEPITHELIAL LESION OR MALIGNANCY

NILM is used when there is no cellular evidence of neoplasia; this may include organisms and/or other non-
neoplastic findings such as reactive/ reparative changes
Endometrial cells in a woman 40 years of age or older. (Specify if ‘negative for squamous intraepithelial lesion’)
In TBS 2001, only exfoliated, intact endometrial cells should be reported in women 40 years or older. Abraded
endometrial cells or lower uterine segment (LUS) fragments, stromal cells and histiocytes, when seen in the
absence of exfoliated endometrial cells, are not associated with increased risk of endometrial cancer and
therefore do not generally warrant reporting. If the endometrial cells appear “atypical” then they should be
interpreted as a glandular cell abnormality- atypical endometrial cells.
ASC-US: Atypical squamous cells of undetermined significance

Cells are usually the size of intermediate or superficial squamous cells and have nuclear changes that are
suggestive but not diagnostic of LSIL or SIL not otherwise specified
ASC-H: Atypical squamous cells cannot exclude HSIL

Cells are usually the size of metaplastic cells and may be seen singly or in clusters; they are suggestive but not
diagnostic of HSIL.
LSIL: Low grade squamous intraepithelial lesion

Encompassing: HPV cytopathic effect/ mild dysplasia/ CIN 1
HSIL: High grade squamous intraepithelial lesion

Encompassing: moderate dysplasia/ CIN 2 and severe dysplasia/CIS/ CIN 3 and HSIL with features suspicious
for invasion
1
Citologie Vaginală Celule scuamoase.
Type of Preparation: Conventional
Magnification: High
Clinical History: Premenopausal woman
Interpretation: NILM vs ASC-US
Cytomorphologic Criteria: Mature
squamous cells showing mild nuclear enlargement,
bi-nucleation, and even chromatin. Note benign
endocervical cells at bottom of field.

Magnification: Medium
Interpretation: ASC-US
Cytomorphologic Criteria: Three
dimensional plaque of keratinized cells with
orangeophilic cytoplasm and minimally irregular,
hyperchromatic nuclei.
Explanatory Notes: Such cells may form
the surface layers of reactive epithelium or SIL. In
this case the findings are not sufficient for a firm
interpretation of SIL.

Type of Preparation: SurePath/ LBP
Magnification: High
Clinical History: 32 year old, routine
cervical screening
Interpretation: ASC-US (Low end)
Cytomorphologic Criteria: Multinucleated
cells with small perinuclear halo.
Explanatory Notes: Features are
insufficient for an interpretation of LSIL.
Follow-up: HPV typing not done
2
Magnification: High
Clinical History: 22 year old female LMP -
4 weeks
Cytomorphologic Criteria: Cells with
perinuclear halos suggestive of HPV associated
cellular changes.
Explanatory Notes: Cells with central
cytoplasmic clearing; findings suggest either LSIL
(HPV effect) or glycogenation.
Follow-up: Cervix biopsies and
endocervical curettage 6 months ago showed chronic
cervicitis and squamous metaplasia

Clinical History: 21 year old female
Interpretation:ASC-US
Cytomorphologic Criteria: Binucleation
and slight nuclear enlargement in some cells.
Follow-up: F/U was mild dysplasia (CIN 1)

Magnification: High
Interpretation: ASC-H
Cytomorphologic Criteria: Loosely
cohesive metaplastic cells with increased N:C ratio.
Explanatory Notes: Differential includes
reactive/reparative metaplastic cells, and HSIL.
Follow-up: Repeat cytology was ASC-US;
Colpo biopsy showed CIN2 and LEEP was CIN3
3
Clinical History: 27 year old, Day 8.
History of "abnormal Pap"
Interpretation: NILM vs ASC-H
Cytomorphologic Criteria: Less mature
squamous cells/metaplastic cells with polygonal
shape, and slightly enlarged nuclei with occasional
nuclear contour irregularities.
Explanatory Notes: Boundary of ASC-US
and ASC-H; differential includes CIN 2.

Cytomorphologic Criteria: Metaplastic
cells with enlarged nuclei and nuclear contour
irregularities showing variation in size, shape, and
ratio of nuclear to cytoplasmic area.
Explanatory Notes:Differential includes
reactive/reparative metaplastic cells and HSIL.

Type of Preparation: ThinPrep/ LBP
Magnification: High
Clinical History: 27 year old woman. LMP
two weeks ago
Interpretation: ASC-H versus HSIL
cells with increased N:C ratios and nuclear contour
irregularities.
Follow-up: HSIL on repeat Pap; CIN3 on
LEEP
4
Magnification: High
Cytomorphologic Criteria: Thick
aggregate of loosely cohesive, overlapping cells
containing enlarged nuclei with even chromatin,
variation in size and shape and obscured cell
boundaries. The cluster demonstrates poor
preservation/ staining.
Explanatory Notes: Possible interpretations
include reactive endocervical and / or metaplastic
squamous cells, HSIL, and AIS.

Clinical History: 69 year old
postmenopausal female. S/P TAH/BSO for Stage 2
endometrial adenocarcinoma. H/O VAIN 10 years
ago. Vaginal ThinPrep
Cytomorphologic Criteria: Atypical
multinucleated cell.
Explanatory Notes: Atypical cells may be
seen in atrophy, but the differential includes a high
grade lesion. Repeat sampling following a course of
estrogen may clarify the findings.
Follow-up: Vaginal cuff biopsies and repeat
Pap test 2 months later showed severe dysplasia/CIS
(CIN 3)

Magnification: High
postmenopausal woman, prior abnormal Pap
elsewhere
Cytomorphologic Criteria: Atypical
keratinized cells with smudged chromatin present in
an atrophic background. Cells are suggestive of a
high grade lesion however poor preservation
precludes definitive interpretation.
Follow-up:Moderate dysplasia on repeat
Pap smear and cervical biopsy after topical estrogen
therapy
Citologie Vaginală Celule scuamoase. Type of Preparation: Conventional

5
Magnification: High
Clinical History: Post-Menopausal
Cytomorphologic Criteria: Immature cells
have high N:C ratios and irregular nuclear contours.
Explanatory Notes: Such cells may be seen
in atrophy, but the differential includes a high grade
lesion. Repeat sampling following a course of

Magnification: High
Clinical History: 32 year old with prior
abnormal Pap test
Interpretation: ASC-US vs LSIL
Cytomorphologic Criteria: Clusters of
abnormal squamous cells may be seen in ?spike-like?
aggregates. These clusters should be classified as
NILM, ASC, or SIL based on the degree of nuclear
abnormalities. This patient had an LSIL interpretation
on a conventional smear, two months prior to this
LBP, that was interpreted as ASC-US (atypical PK).
Explanatory Notes: Limited personal
experiences suggest that this pattern is more frequent
in liquid based preparations. It has been hypothesized
that it may represent the Pap Test equivalent of a
histologic "condylomatous spike". Limited
correlation with HPV testing suggests that cases
showing this pattern (and without obvious SIL
elsewhere in the Pap test) can be positive for high-
risk HPV.

Cytomorphologic Criteria: Nuclei are
hyperchromatic with fine chromatin and smooth
membranes. Nuclear features are borderline between
those required for ASC-US and LSIL.. Cell sizes
vary with the smallest cell resembling a benign
metaplastic cell.
Explanatory Notes: Some cells contain
enlarged nuclei but chromatin is similar in all cells.
While there is some "atypia" , clear cut evidence for
an interpretation of LSIL is lacking.
6
Magnification: High
(Borderline)
Cytomorphologic Criteria: Several cells in
this group exhibit changes suggestive of koilocytes.
Nuclei are only slightly enlarged and do not meet the
criteria for LSIL (3 times larger than an intermediate
nucleus). Nuclear features are borderline between
those required for ASC-US and LSIL.
Explanatory Notes: Some of these cellular
alterations can be seen in a reactive process;
however, due to the slight nuclear enlargement,
hyperchromasia, and cytoplasmic changes, an
interpretation ASC-US may be more appropriate.
Follow-up: Follow-up was CIN 1 (mild
dysplasia)

Magnification:High
Cytomorphologic Criteria: Single small
cell with abnormal nuclear chromatin and high N:C
ratio surrounded by mature squamous cells.
Follow-up: Patient was subsequently found
to have squamous cell carcinoma

Magnification: High
cells with slightly enlarged nuclei and binucleation.
Explanatory Notes: Findings may suggest
either nuclear irregularity or bi-nucleation. Focusing
"up and down" may be necessary to appreciate
binucleation.
7
Interpretation: NILM vs. ASC-H
cells, some with enlarged or slightly irregular nuclei.
Follow-up: High grade CIN was found on
biopsy

Magnification: High
Clinical History: Routine Pap smear 24
year old. Also had Trichomonas vaginalis and mixed
bacteria on this smear
Cytomorphologic Criteria: Mild nuclear
enlargement and binucleation.
Explanatory Notes: Nuclear changes may
be reactive due to Trichomonas, however a low grade
lesion cannot be entirely excluded.

Magnification: High
Clinical History: 25 year old, Day 14
and small perinuclear halos.
Follow-up: ECC was NILM
8
Magnification: High
Clinical History: 20 year old, postpartum
Cytomorphologic Criteria: Cell with
enlarged nucleus and small perinuclear halo.
Follow-up:LEEP showed extensive CIN1

and subtle koilocytosis are displayed in the absence
of nuclear changes; features are not supportive of an
interpretation of LSIL.
Explanatory Notes: Nuclear abnormalities
consistent with LSIL must be present an
interpretation of LSIL.

Magnification: High
Cytomorphologic Criteria:
Multinucleation and slightly enlarged nuclei.

9
Magnification: High
Clinical History: Post-Menopausal
Cytomorphologic Criteria: Single cells
with marked nuclear enlargement.
Explanatory Notes: Such cells may be seen
in atrophy, but the differential includes a high grade
lesion. Repeat sampling following a course of

slight nuclear enlargement/ hyperchromasia and
keratinized cytoplasm.
Explanatory Notes: These cells minimally
exceed "typical parakeratosis".

Interpretation: ASC-H versus NILM
cells with enlarged hyperchromatic nuclei.
10
Magnification: High
Interpretation: NILM vs. ASC-US
Cytomorphologic Criteria: Slight nuclear
enlargement and mild hyperchromasia.
Explanatory Notes: These changes are
insufficient for a definitive interpretation of LSIL.

Magnification: High
Cytomorphologic Criteria: A
hyperchromatic cells cluster, the nature of which may
be difficult to ascertain in this atrophic specimen.
Follow-up: F/U was severe dysplasia (CIN
3)

Magnification: High
cell with nuclear enlargement and mild chromatin
granularity. Air drying present.
11
Magnification: High
Cytomorphologic Criteria: Enlarged
hyperchromatic nucleus versus binucleation.

Magnification: High
Cytomorphologic Criteria: Poorly
preserved, atypical small cell with high N:C ratio.
Follow-up: ECC performed one month after
Pap test was negative

Magnification: High
cells with increased N:C ratio.
reactive/reparative metaplastic cells and HSIL.
Follow-up: Biopsy and ECC performed one
month later were negative
12
Clinical History: 33 year old female. No
history provided
Cytomorphologic Criteria: Mature and
metaplastic cells showing abnormal, hyperchromatic,
enlarged nuclei, suggestive of mild dysplasia.
Explanatory Notes: Nuclear changes are
not consistent with LSIL.

Magnification: High
Interpretation: ASC-H vs reactive
endocervicals
Cytomorphologic Criteria: Main panel
shows columnar and polygonal cells with dense
cytoplasm and high ratio of nuclear to cytoplasmic
area. Nuclear chromatin is granular with small
chromocenters or nucleoli. Occasional nuclear
grooves are seen. The insert on the lower left corner
contains cells from another specimen that appear
similar, but possess cytoplasm that is scant and less
dense.
reactive endocervicals and/or repair and HSIL.
Follow-up: HPV negative

Magnification: High
Clinical History: 23 year old woman with a
previous Pap test interpreted as ASC-US
cells with increased N:C ratios and some nuclear
contour irregularities.
LEEP
13
Citologie Vaginală TRICHOMONAS
VAGINALIS
Magnification: High
Clinical History: 32 year old with "vaginal
discharge"
Interpretation: NILM: Trichomonas
vaginalis
Cytomorphologic Criteria: Trichomonas is
a pear-shaped, oval to round, cyanophilic organism
that ranges in size from 15-30 microns. The nucleus
is pale, vesicular and centrally located. Eosinophilic
granules are often visible in the cytoplasm. In LBPs,
the organisms tend to be smaller due to rounding,
nuclei and cytoplasmic granules are better visualized
and flagellae are often better preserved.
Explanatory Notes: Good example of a
flagella. Flagella are usually not seen in conventional
Pap smears. Also seen in this image (left lower inset)
is a "kite shaped" trichomonad- another finding noted
in liquid based preparations.

VAGINALIS
Magnification: High
vaginalis
Cytomorphologic Criteria: Trichomonas is
a pear shaped, oval, or round cyanophillic organism.
Nuclei are pale and eccentrically located.
Eosinophilic cytoplasmic granules may be visible.
Explanatory Notes: It is essential to
identify one or more of the following- nucleus,
eosinophilic granules, flagella (less often seen in
conventional smears) in order to distinguish
trichomonads from cytoplasmic fragments.

VAGINALIS
Magnification: High
Clinical History: Not provided
vaginalis and Leptothrix
Cytomorphologic Criteria: Leptothrix are
slender, long bacteria that may be seen in association
with Trichomonas.
Explanatory Notes: The finding of
Trichomonas and leptothrix together has been
referred to as "spaghetti and meatballs" The
leptothrix should be distinguishable from Doderlein
bacilli, that are normally seen. When leptothrix are
seen, one should search for the possible presence of
trichomonads. In liquid based preparations, the
leptothrix organisms may tend to clump (as seen in
this image) as opposed to conventional smears.
14
VAGINALIS
Magnification: High
vaginalis
Cytomorphologic Criteria:Trichomonas is
a pear-shaped, oval to round, cyanophilic organism
that ranges in size from 15-30 microns. The nucleus
is pale, vesicular and centrally located. Eosinophilic
granules are often visible in the cytoplasm.
Explanatory Notes: Seen in this image are
numerous trichomonads adhering to a squamous cell.
Identification of one or more of the following- the
organisms nucleus, cytoplasmic eosinophilic
granules, or flagella (less often seen in conventional
smears) is necessary in order to distinguish
trichomonads from cytoplasmic fragments.

VAGINALIS
Magnification: High
Interpretation: NILM: Reactive squamous
cells associated with Trichomonas vaginalis
Cytomorphologic Criteria: Minimal
nuclear enlargement, cytoplasmic polychromasia.

VAGINALIS
Magnification: High
Clinical History: 45 year old female.
routine pap
vaginalis and Leptothrix
Explanatory Notes: Leptothrix may be seen
in association with T. vaginalis; this finding alone is
not diagnostic but suggests the presence of
trichomonads.
15
VAGINALIS
Clinical History:34 year old, high risk
female presented with vaginal discharge
Interpretation: NILM: Leptothrix and
Trichomonas vaginalis
Explanatory Notes:Leptothrix may be seen
in association with Trichomonas. It is a long
"spaghetti-like" bacteria.
Citologie Vaginală CANDIDA SP.

Magnification: High
Clinical History: 27 year old woman,
colposcopy visit
Interpretation: NILM: Fungal organisms
consistent with Candida spp
Cytomorphologic Criteria: Pseudohyphae
and reactive changes in the squamous epithelial cells.
Follow-up: None

Magnification: High
Interpretation: NILM: Fungal organisms,
consistent with Candida spp.
formed by elongated budding yeast showing
constrictions along their length. There is also
spearing of epithelial cells and an inflammatory
background.
Explanatory Notes: Pseudohyphae should
be distinguished from mucus strands.
16
Clinical History:45 year old woman
Interpretation: NILM: Fungal organisms,
consistent with Candida spp.
Cytomorphologic Criteria: Spearing of
epithelial cells by candida pseudohyphae ("shish
kebob" effect).
Explanatory Notes: Spearing is more
common on LBP, and this may be a clue to Candida
even when pseudohyphae are not obvious.
Follow-up: No abnormal follow-up

Type of Preparation:Conventional
Magnification: High
Clinical History: 63 year old female routine
Pap test.
morphologically consistent with Candida spp.
(Torulopsis Glabrata)
Cytomorphologic Criteria: Small, uniform,
round budding yeast.
Explanatory Notes: Fungus related to
candida. Do not form pseudohyphae in vivo or in
culture. Torulopsis organisms may have a
surrounding capsule with the yeast in the center
giving a "halo appearance".

Magnification: High
Pap test.
(Torulopsis Glabrata)
Cytomorphologic Criteria: Small,
uniform ,round budding yeast forms, c/w candida
species.
Explanatory Notes: Note the capsule with
the yeast in the center giving a "halo appearance"
which is characteristic of Torulopsis glabrata. Unlike
other candida species, Torulopsis does not form
pseudohyphae in vivo or in culture.
17
of Candida formed by elongated budding.
Constrictions are seen along length.
Explanatory Notes: Spearing of epithelial
cells is also observed, and this is more common in
LBPs.

Magnification: High
Cytomorphologic Criteria: Lactobacilli,
Cytolysis, and fungal organisms are seen in this
image. Abundant lactobacilli with intermediate
squamous cells, many of which show cytolysis (bare
nuclei with partial or complete stripping of
cytoplasm). The nuclei are bland and well-preserved.
Explanatory Notes: In determining
specimen adequacy, nuclear preservation and
visualization are of key importance, and changes
such as cytolysis and partial obscuring of cytoplasmic
detail may not necessarily interfere with specimen
evaluation. Abundant cytolysis(>~50%) may be
mentioned as a quality indicator, but most such
specimens do not qualify as unsatisfactory unless
nearly all of the nuclei are devoid of cytoplasm.

Magnification:HighInterpretation: NILM:
Fungal organisms morphologically consistent with
Candida
Cytomorphologic Criteria: Candida:
Pseudohyphae, formed by elongated budding, with
spearing of epithelial cells--"shish kebob" effect.
Explanatory Notes: Spearing of epithelial
cells is more common on liquid preparations. This
may be a clue even when pseudohyphae are not
obvious are not prominent.
18
Citologie Vaginală ACTINOMYCES SP.
Magnification: High
Clinical History: 41 year old. No history
provided
Interpretation: NILM: Bacteria
morphologically consistent with Actinomyces spp.
Cytomorphologic Criteria: Tangled
clumps of filamentous organisms, often with acute
angle branching, sometimes showing irregular wooly
appearance. Swollen filaments may be seen with
clubs at periphery. A cotton ball like acute
inflammatory response is common.
Explanatory Notes: Actinomyces is often
associated with intrauterine device (IUD) usage.
Organisms may alert clinician to look for evidence of
pelvic infection.
Citologie Vaginală ACTINOMYCES SP.

Magnification: High
Clinical History: Routine Pap test
Interpretation: NILM: Bacteria
morphologically consistent with Actinomyces spp.
Cytomorphologic Criteria: The center of
this sulfur granule shows amorphous material, while
the periphery exhibits thin filamentous bacilli
radiating outwards. Branching may be evident in
these bacilli (not seen here). Only a few
polymorphonuclear cells are seen accompanying this
particular colony.
Explanatory Notes: Actinomyces is often
associated with intrauterine device (IUD) usage.
Organisms may alert clinician to look for evidence of
pelvic infection.
Follow-up: None
Citologie Vaginală HEPES VIRUS SIMPLEX

Interpretation: NILM: Cellular changes
consistent with Herpes simplex virus
Cytomorphologic Criteria: Nuclei showing
"ground-glass" appearance. Multinucleation, nuclear
molding, and dense eosinophilic intranuclear
inclusions surrounded by a halo are also seen.
Explanatory Notes: "Ground-glass"
appearance is due to intranuclear viral particles and
enhancement of nuclear envelope caused by
peripheral chromatin margination.
19
Magnification:High
Cytomorphologic Criteria: The
multinucleated squamous epithelial cell (top) shows
degeneration of nuclei, whereas the multinucleated
squamous cell (below center) shows the typical
molded nuclei of HSV infection (pomegranate seed
appearance). Faint nuclear inclusions are evident in
this cell and a uninucleate cell beneath.
Explanatory Notes: Nuclei have "ground
glass" effect due to intranuclear viral particles and
enhancement of the nuclear envelope caused by
peripheral margination of the chromatin.
Multinucleated cells are not always present.

Cytomorphologic Criteria: Cellular
changes consistent with Herpes simplex virus. Note
the intranuclear, ?Cowdry type? inclusions.
Explanatory Notes: The „ground-glass”
appearance of the nuclei is due to accumulation of
viral particles leading to peripheral margination of
chromatin.

Magnification:Low
Cytomorphologic Criteria:Dense
intranuclear inclusions which are often eosinophilic,
surrounded by a halo or clear zone. Multinucleation
is also present.
Explanatory Notes: Multinucleated cells
and inclusions are not always seen. Nuclei with
"ground-glass" features are the most common change
identified with Herpes.
20
Magnification: High
Cytomorphologic Criteria: Large
multinucleated epithelial cell with molded nuclei.
Note ground glass appearance due to intranuclear
viral particles and enhancement of the nuclear
envelope caused by peripheral margination of the
chromatin.
Explanatory Notes: Multinucleated
epithelial cells are not always present--mononucleate
cells with viral changes may be the only finding.
Citologie Vaginală VAGINOZĂ

Magnification: High
Interpretation: NILM: Shift in Flora
suggestive of bacterial vaginosis
Cytomorphologic Criteria: Individual
squamous cells covered by a layer of bacteria that
obscures the cell membrane (clue cells). Background
is usually clear in liquid based preparations.
Explanatory Notes: Contrast with
appearance in conventional smear.
Citologie Vaginală VAGINOZĂ

Magnification: Interpretation: NILM:
Shift in Flora suggestive of bacterial vaginosis
Cytomorphologic Criteria: Filmy
background of small coccobacilli. Individual
squamous cells covered by a layer of bacteria.
Conspicuous absence of lactobacilli.
Explanatory Notes: Note the ?clue cell?
and filmy background due to the coccobacilli.
21
Citologie Vaginală Modificări Epiteliale Reactive:
Clinical History: Routine Pap Test, 28 year
old female
Adequacy Description: NILM: Squamous
metaplasia
Cytomorphologic Criteria: Normal
polygonal squamous metaplastic cells with round to
oval nuclei and bland chromatin pattern. On liquid
based preparations cells may appear more rounded,
and nuclei may appear smaller. This would be
interpreted as "NILM".
Explanatory Notes: The presence of
squamous metaplastic cells indicates that the
transformation zone has been sampled (a minimum of
10 well-preserved endocervical or metaplastic cells is
required for this quality indictor).

Magnification: High
cells
Cytomorphologic Criteria: Reactive
squamous cells showing mild nuclear enlargement
without any significant chromatin abnormalities

Magnification: High
Clinical History: 26 year old woman, LMP
2 weeks, mild vaginal discharge
cellular changes associated with Trichomonas
vaginalis
Explanatory Notes: Trichomonas also seen.
Follow-up: Follow-up Paps negative
22
Magnification: High
routine exam, LMP 18 days
Interpretation: NILM: Squamous
metaplasia
squamous metaplastic cells.
Explanatory Notes: Note the spidery
cytoplasmic processes, a feature that may be seen in
metaplastic cells on conventional smears.

Clinical History: 32 year old woman
Interpretation: NILM: Endocervical cells:
reparative
Cytomorphologic Criteria: Monolayer
sheet of endocervical cells with orderly arrangement.
Streaming effect is observed. Nuclei are enlarged
with nucleoli but have smooth borders and are not
hyperchromatic.
Explanatory Notes: Repair is characterized
by cohesive cell groups with few or no single cells. In
liquid preparations, the groups may appear more
rounded with less streaming.

Clinical History: 67 year old woman with
uterine prolapse
Interpretation: NILM: Reactive cellular
changes, Repair
Cytomorphologic Criteria: Flat monolayer
sheets with distinct cytoplasmic outlines, streaming
nuclear polarity, prominent nucleolus in almost every
cell.
23
Interpretation: NILM: Repair
Cytomorphologic Criteria: Squamous cells
in flat monolayer sheet with maintenance of nuclear
polarity and a prominent nucleolus in almost every
cell.
Explanatory Notes: If marked
anisonucleosis, irregularities in the chromatin
distribution, or variation in size and shape of nucleoli
are present, so-called "atypical repair", the changes
should be categorized as atypical glandular cells or
atypical squamous cells.

Type of Preparation:
ThinPrep/ LBP
Clinical History: 32 year old; routine Pap
test
cell
squamous cell.
Explanatory Notes: While there is nuclear
enlargement in the cells on the right side, the smooth
nuclear contours and finely distributed chromatin
favor reactive change over ASC-US.

Magnification: High
Interpretation: NILM: Atrophy with
inflammation (atrophic vaginitis)
Parabasal cells with mostly bland nuclei
(some showing air drying). Some degenerated cells
with pyknosis also present. Basophilic granular
background with inflammation also present.
Explanatory Notes: This photo does not
show significant atypia, but an interpretation of ASC
may be indicated if degenerated cells show
significant atypia.
24
Magnification: High
Cytomorphologic Criteria: Parabasal cells
with some nuclear degeneration. Background shows
granular debris which can mimic tumor diathesis, i.e.
by 'clinging' to cell groups.
Explanatory Notes: Overall background is
usually cleaner in liquid preparations, but clinging
debris may be observed. Nuclei are usually smaller
with less air drying artifact.

Magnification: High
squamous cells showing mild nuclear enlargement,
bi-nucleation, and even chromatin. Note benign
endocervical cells at bottom of field.

Clinical History: 32 year old female.
Cytomorphologic Criteria: Changes are
similar to those seen on conventional smears, but cell
streaming may be less apparent due to rounding of
cell clusters. Note the intracytoplasmic
polymorphonuclear leucocytes, another feature seen
in repair.
25
Magnification: High
cells with slightly enlarged nuclei and binucleation.
Explanatory Notes: Findings may suggest
either nuclear irregularity or bi-nucleation. Focusing
"up and down" may be necessary to appreciate
binucleation.

Magnification: High
Adequacy Description: NILM. Squamous
metaplasia
Cytomorphologic Criteria: Squamous
metaplastic cells with a polygonal to elongated
cellular appearance, dense cytoplasm and benign
nuclei.
squamous metaplastic cells indicates that the
transformation zone has probably been adequately
sampled. This is one of the quality indicators for
specimen adequacy (a minimum of 10 well-preserved
endocervical or metaplastic cells is required: cells do
not need to be in groups).

Interpretation: NILM vs. ASC-H
cells, some with enlarged or slightly irregular nuclei.
Follow-up: High grade CIN was found on
biopsy
26
Magnification: High
Clinical History: Routine Pap smear 24
year old. Also had Trichomonas vaginalis and mixed
bacteria on this smear
Cytomorphologic Criteria: Mild nuclear
enlargement and binucleation.
Explanatory Notes:Nuclear changes may
be reactive due to Trichomonas, however a low grade
lesion cannot be entirely excluded.

Magnification: High
Cytomorphologic Criteria: The cell cluster
shows inter-cellular windows (school-of-fish
appearance) and a streaming pattern. Nuclei are
uniformly large, and contain prominent nucleoli.
Chromatin abnormalities are absent.

Magnification: High
metaplasia
Cytomorphologic Criteria: Small round or
polygonal metaplastic cells with slightly enlarged
N/C ratio. Smooth nuclear membranes. Chromatin
pattern is finely granular and evenly distributed.
Small round nucleoli are commonly seen.
27
changes associated with IUD
Cytomorphologic Criteria: Glandular cells
in small clusters with increased N/C ratio and
cytoplasmic vacuoles. Nuclear degeneration and
prominent nucleoli present.
Explanatory Notes: The cells may be shed
as clusters or singly. Clusters such as these may
mimic cells from adenocarcinoma. One should
diagnose adenocarcinoma with caution in the
presence of an IUD. If in doubt, consider repeat
sampling after removal of the IUD. Single cells may
also mimic high grade SIL. One needs to look for the
morphologic spectrum of abnormalities associated
with SIL.

Magnification: High
Cytomorphologic Criteria: Increased
nuclear size and prominent nucleoli. Cells in
monolayer sheet with nuclei oriented in the same
direction (streaming).
Explanatory Notes: Absence of single cells
with nuclear changes and lack of marked
anisonucleosis or irregularities in chromatin
distribution or variation in size and shape of nuclei
indicates this is typical repair (as opposed to "atypical
repair") which would be categorized as atypical
glandular cells or atypical squamous cells.

Clinical History: 40 year old woman s/p
squamous cell carcinoma of the cervix. Completion
of radiation therapy 8 weeks ago
changes associated with Radiation
Cytomorphologic Criteria: Enlarged nuclei
with abundant polychromatic cytoplasm with
vacuolization. Mild nuclear hyperchromasia without
coarse chromatin, prominent nucleoli (coexisting
repair). Note multinucleation (upper right corner
insert).
28
Cytomorphologic Criteria: Note small
cluster of glandular cells with cytoplasmic vacuoles
displacing nuclei. The cytoplasmic vacuoles may
displace the nucleus, creating a signet-ring
appearance.
Explanatory Notes: The cells may be shed
as clusters or singly. Clusters such as these may
mimic cells from adenocarcinoma. One should
diagnose adenocarcinoma with caution in the
presence of an IUD. If in doubt, consider repeat
sampling after removal of the IUD.

Cytomorphologic Criteria: Single partially
degenerated epithelial cells with increased nuclear
size and high N/C ratio.
Explanatory Notes: Single cells may also
mimic high grade SIL; however the morphologic
spectrum of abnormalities usually present with
squamous intraepithelial lesions is absent in cases
with single atypical cells due to IUD effect. Also the
presence of nucleoli in isolated cells with a high N/C
ratio (right) are not typical of HSIL.

Interpretation: ASC-H versus NILM
cells with enlarged hyperchromatic nuclei.
29
Magnification: High
Interpretation: NILM vs. ASC-US
Cytomorphologic Criteria: Slight nuclear
enlargement and mild hyperchromasia.
Explanatory Notes: These changes are
insufficient for a definitive interpretation of LSIL.

metaplasia
Cytomorphologic Criteria: Higher N/C
ratio than mature cells. Nuclear membranes smooth
and chromatin finely granular and evenly distributed.
Small round nucleoli/chromatin centers present.
Explanatory Notes: Note the "spidery"
cytoplasmic processes, a feature that may be seen in
conventional smears.

Interpretation: NILM: Endocervical cells,
reactive
Cytomorphologic Criteria: Nuclear
enlargement with some bi- and multinucleation.
Nuclear outlines are smooth and uniform. Chromatin
is fine with small nucleoli. Cells are present in flat
orderly sheet.
30
Magnification: High
IUD
Interpretation: NILM: Reactive Cellular
Cytomorphologic Criteria: Small cluster of
glandular cells with cytoplasmic vacuoles displacing
nuclei in a clean background.
Explanatory Notes: The amount of
cytoplasm varies and frequently large vacuoles may
displace the nucleus, creating a signet -ring
appearance. The cells may be shed as clusters or
singly. Clusters such as these may mimic cells from
adenocarcinoma. One should diagnose
adenocarcinoma with caution in the presence of an
IUD. If in doubt, consider repeat sampling after
removal of the IUD. Single cells may mimic high
grade SIL. One needs to look for the morphologic
spectrum of abnormalities associated with SIL.

Magnification: High
metaplasia
Cytomorphologic Criteria: Enlarged nuclei
in metaplastic cells but fine uniform chromatin. N/C
ratio is usually 50% or less.

Metaplasia
Cytomorphologic Criteria: Rounded up
cells with somewhat higher N/C ratio but smooth
nuclear contours and even distribution of chromatin.
Explanatory Notes: Squamous metaplastic
cells round up in liquid based preparations. Instances
in which there is a higher N/C ratio (>50%) in
conjunction with hyperchromasia and/or nuclear
contour irregularities such as notching or grooving
could prompt the consideration of HSIL or ASC-H.
31
Magnification: High
Interpretation: NILM: Reactive
endocervical cells
Cytomorphologic Criteria: Cohesive
orderly sheet of endocervical cells with enlarged
nuclei and nucleoli. There is some variation in
nuclear size. Nuclei are generally round and smooth
without significant hyperchromasia.

Magnification: High
Interpretation: ASC-H vs reactive
endocervicals
Cytomorphologic Criteria:Main panel
shows columnar and polygonal cells with dense
cytoplasm and high ratio of nuclear to cytoplasmic
area. Nuclear chromatin is granular with small
chromocenters or nucleoli. Occasional nuclear
grooves are seen. The insert on the lower left corner
contains cells from another specimen that appear
similar, but possess cytoplasm that is scant and less
dense.
reactive endocervicals and/or repair and HSIL.
Follow-up: HPV negative

Magnification: High
Cytomorphologic Criteria: Nuclear and
cytoplasmic enlargement, smooth nuclear outlines
with mild hyperchromasia but chromatin is finely
granular. Cytoplasmic polychromasia and
vacuolization.
32
Magnification: High
pap smear
inflammation
Cytomorphologic Criteria: Partly air dried
parabasal and abundant inflammation present.
Explanatory Notes: Decreased mucus leads
to increased air drying problems with conventional
smears.

Magnification: High
cell. Abundant polychromatic cytoplasm;
cytoplasmic vacuoles.
Explanatory Notes: Acute radiation
changes.

Magnification: High
cells associated with Trichomonas vaginalis
Cytomorphologic Criteria: Minimal
nuclear enlargement, cytoplasmic polychromasia.
33
Magnification: High
enlarged nuclei, abundant vacuolated polychromatic
cytoplasm, mild nuclear hyperchromasia without
course chromatin, prominent nucleoli.
Explanatory Notes: Prominent single or
multiple nucleoli may be seen if coexisting repair is
present.

Magnification: High
Clinical History: 42 year old female status
post LEEP for cervical dysplasia; 2nd follow up Pap.
Previous Pap smear showed reactive endocervical
cells
endocervical cells
Cytomorphologic Criteria: Increased N/C
ratio. Prominent nucleoli but delicate chromatin and
no nuclear membrane abnormalities.
Explanatory Notes: Such changes should
not be over interpreted as atypical endocervical cells.

Magnification: High
Clinical History: 22 year old female status
post LEEP 6 months ago for cervical dysplasia
Interpretation: NILM: Endocervical cells:
Reactive s/p LEEP
Cytomorphologic Criteria: Slight increase
in nuclei size, variation in size and shape of nuclei
with prominent nucleoli, fine chromatin.
Explanatory Notes: Cells are present in a
cohesive relatively orderly sheet without significant
number of single cells showing similar changes.
Follow-up: Concurrent cervical biopsy was
benign
34
endocervical cells
Cytomorphologic Criteria: Increased N/C
ratio. Prominent nucleoli but delicate chromatin and
even nuclear membranes.
Explanatory Notes: Endocervical repair.

Magnification: High
Clinical History: History of radiation for
cervical cancer
Cytomorphologic Criteria: Abundant
cytoplasm. Smudgy chromatin with mild nuclear
enlargement.

Magnification: High
endocervical cells
Cytomorphologic Criteria: Reactive
endocervical cells showing nuclear enlargement and
prominent nucleoli. A few intracytoplasmic
polymorphonuclear leukocytes are visible
35
history of squamous cell carcinoma of the cervix who
completed radiation treatments 6 months ago
Cytomorphologic Criteria: Mild reactive
changes associated with radiation including enlarged
nuclei but increase in cytoplasm as well. Chromatin
is still fine with slight prominence of nucleoli in
some cells.
Explanatory Notes: The radiation
associated changes in this picture are mild.

Magnification: High
Cytomorphologic Criteria: Squamous cells
in flat monolayer sheet with maintenance of nuclear
polarity and prominent nucleoli in most cells
Explanatory Notes: If marked
anisonucleosis, irregularities in the chromatin
distribution, or variation in size and shape of nucleoli
are present, so-called "atypical repair", the changes
should be categorized as atypical glandular cells or
atypical squamous cells
Citologie Vaginală – Atrofie

Magnification: High
with mostly bland nuclei (some showing air drying).
Some degenerated cells with pyknosis also present.
Basophilic granular background with inflammation
also present.
Explanatory Notes: This photo does not
show significant atypia, but an interpretation of ASC
may be indicated if degenerated cells show
significant atypia.
36
postmenopausal woman, being evaluated for possible
Squamous cell carcinoma of vulva
Interpretation: NILM: Atrophy
Cytomorphologic Criteria: Sheets of
uniform orderly parabasal cells are observed
representing deep parabasal cells. Some nuclei show
grooves, but chromatin pattern is fine. Atrophic cells
may have nucleoli (lower right insert).
Explanatory Notes: Differentiate from
HSIL by uniform bland nuclei and orderly cell
arrangement. Background clues may be helpful.

with occasional pyknotic degenerated cells.
Clumping of granular background produces a cleaner
background. Globular collections of basophilic
amorphous material (blue blobs) present.
Explanatory Notes: Blue blobs reflect
either degenerated parabasal cells or inspissated
mucus. Air drying and nuclear enlargement are also
less frequently noted with liquid based preparations.

Magnification:High
with some nuclear degeneration. Background shows
granular debris which can mimic tumor diathesis, i.e.
by 'clinging' to cell groups.
Explanatory Notes: Overall background is
usually cleaner in liquid preparations, but clinging
debris may be observed. Nuclei are usually smaller
with less air drying artifact.
37
Type of Preparation: Histology
Clinical History:Postmenopausal woman
Explanatory Notes: Histologic section
showing atrophic cervical epithelium

Magnification: High
Interpretation: NILM. Atrophy
which resemble metaplastic cells in atrophy. Nuclei
are usually well preserved with liquid fixation.
Explanatory Notes: The transformation
zone component may be difficult to assess in atrophy.
Laboratories may choose to append a note indicating
this in such cases.

Magnification: High
Clinical History: 27 year old, post-partum,
routine Pap smear.
Interpretation: NILM: Atrophy, post-
partum
Cytomorphologic Criteria: A sheet of
parabasal cells is present without any evidence of
more advanced maturation.
Explanatory Notes: Parabasal cells and
metaplasia may be difficult to distinguish from
squamous metaplasia and can appear occasionally as
"hyperchromatic clusters". The background cells and
history provide clues.
38
Magnification: Low
Clinical History: Postmenopausal woman
Adequacy Description: NILM. Atrophy
Cytomorphologic Criteria: Sheets of
parabasal cells with slight air drying. Interpretation is
NILM.
Explanatory Notes: Atrophic parabasal
cells can be confused with squamous metaplasia. The
background and cell pattern may be useful in
distinguishing the two.
Follow-up: The transformation zone
component may be difficult to assess in atrophy. In
such cases, the laboratory may elect to make a
comment about the difficulty of assessing the
transformation zone component (does not apply for
vaginal smears)

Magnification: High
Cytomorphologic Criteria: Generalized
nuclear enlargement is present in parabasal cells but
without significant hyperchromasia. Nuclei show fine
chromatin and appear uniform and bland. They are
present in a sheet with a microbiopsy appearance.
Explanatory Notes: This is a more difficult
example of atrophy. Background findings may be
useful. Nuclei within atrophy tend to look similar,
while different populations are present in ASC and
SIL.

Magnification: High
and blue blobs.
Explanatory Notes: Blue blobs are globular
collections of basophilic amorphous material
reflecting either degenerated parabasal cells or
inspissated mucus.
39
Magnification: High
Adequacy Description: Satisfactory
squamous cellularity. NILM (Atrophy).
Cytomorphologic Criteria: Satisfactory
squamous cellularity is present in this SurePath
specimen. Liquid based preparations with atrophy
show less nuclear enlargement than conventional
smears due to improved fixation and cleaner
background than in conventional smears. An
adequate liquid based preparation should have an
estimated minimum of 5,000
well-visualized/preserved squamous cells.
Explanatory Notes: The transformation
zone component(s) may be difficult to assess in
atrophy, as parabasal cells may resemble metaplastic
cells. In such cases, the laboratory may elect to make
a comment about the difficulty of assessing the
transformation zone component.

Magnification: High
pap smear
inflammation
Cytomorphologic Criteria: Partly air dried
parabasal and abundant inflammation present.
Explanatory Notes: Decreased mucus leads
to increased air drying problems with conventional
smears.

Magnification: High
Cytomorphologic Criteria: Parabasal and
intermediate cells are seen with a basophilic granular
background. Occasional blue blobs are seen.
Explanatory Notes: Blue blobs represent
either degenerated parabasal cells or inspissated
mucus.
40
Citologie Vaginală LSIL
Magnification: High
Interpretation: LSIL
features of LSIL without cytoplasmic HPV changes.).
Nuclear enlargement and hyperchromasia is of
sufficient degree for the interpretation of LSIL. HPV
associated cytoplasmic changes are not seen in this
image.
Explanatory Notes: Demonstration of HPV
cytopathic effect is not necessary for an interpretation
of LSIL, if required nuclear changes are present.

Magnification: High
Clinical History: 32 year old female, LMP-
2 weeks ago
Cytomorphologic Criteria: Large,
multinucleated dysplastic cells with "mature"
cytoplasm and distinct cell borders. Nucleus shows
enlargement which is > 3X intermediate nuclei,
hyperchromasia, pleomorphism of size and shape. No
nucleoli seen.
Explanatory Notes: Note the overall large
cell size, well-defined cytoplasm and
multinucleation. .

Magnification: High
Clinical History: 26 year old, prior
"abnormal" Pap
features are consistent with LSIL. HPV cytopathic
effect or ?koilocytosis? is also seen. .
Explanatory Notes: Morphologic criteria
for LSIL are similar to those on conventional
preparations. The depth of field for SurePath
preparations with clusters may require focusing up
and down for adequate visualization.
41
Magnification: High
Clinical History: 32 year old, LMP: 20
days, routine screening
Interpretation: LSIL Cytomorphologic
Criteria: HPV nuclear and cytoplasmic changes
(binucleation and koilocytosis) are consistent with
LSIL. Note that in addition to perinuclear cavitation,
nuclear abnormalities as seen here are required to
make an interpretation of LSIL.
Explanatory Notes: Nuclear size is only 2
times larger than intermediate nuclei, but chromatin
pattern is granular and nuclear membranes are
irregular.

keratinized cytoplasm, slight nuclear enlargement
and hyperchromasia ("atypical parakeratosis")
interpretation as LSIL is based on nuclear features.
Explanatory Notes: "Parakeratosis" is a
descriptive term used for abnormal keratinization of
the cytoplasm but it is not an interpretation and is not
part of the Bethesda terminology. "Parakeratotic"
changes may be seen in cells without nuclear
abnormalities and in SIL.

Clinical History: 24 year old, routine
screening Pap Test
Interpretation: NILM
Cytomorphologic Criteria: Glycogen in
squamous cells can give the appearance of
"pseudokoilocytosis". Nuclear abnormalities required
for an interpretation of ASC-US/ LSIL are absent.
Explanatory Notes: Glycogen can cause
"pseudokoilocytosis". This may be more prominent
on ThinPrep.
42
squamous cells displaying enlarged nuclei with a
granular chromatin distribution meet the criteria for
interpretation as LSIL. Binucleation and koilocytosis
are consistent with HPV cytopathic effect.
Explanatory Notes:Nuclei are 3 to 4 times
the size of normal intermediate cell nuclei. Nuclear
hyperchromasia may not be as obvious in LBP?s as
compared to conventional smears, however other
criteria for interpretation of SIL are present.
Follow-up: Follow-up: CIN 1

Cytomorphologic Criteria: Nuclei are
hyperchromatic with fine chromatin and smooth
membranes. Nuclear features are borderline between
those required for ASC-US and LSIL.. Cell sizes
vary with the smallest cell resembling a benign
metaplastic cell.
Explanatory Notes: Some cells contain
enlarged nuclei but chromatin is similar in all cells.
While there is some "atypia" , clear cut evidence for
an interpretation of LSIL is lacking.

Magnification: High
Interpretation:ASC-US vs LSIL
(Borderline)
Cytomorphologic Criteria: Several cells in
this group exhibit changes suggestive of koilocytes.
Nuclei are only slightly enlarged and do not meet the
criteria for LSIL (3 times larger than an intermediate
nucleus). Nuclear features are borderline between
those required for ASC-US and LSIL.
Explanatory Notes: Some of these cellular
alterations can be seen in a reactive process;
however, due to the slight nuclear enlargement,
hyperchromasia, and cytoplasmic changes, an
interpretation ASC-US may be more appropriate.
Follow-up: Follow-up was CIN 1 (mild
dysplasia)
43
Magnification: High
3 weeks, routine exam
Interpretation: LSIL/HSIL (Borderline)
Cytomorphologic Criteria: Borderline
LSIL/ HSIL. The abnormal cells characterizing
moderate dysplasia have a fair amount of cytoplasm
compared to severe dysplasia/ CIN3, but less than
that in LSIL cells. These cells are at the borderline of
what may be interpreted as LSIL by some and HSIL
by others.
Explanatory Notes: While the majority of
SIL cases can be classified as HSIL or LSIL, in
occasional cases, the distinction between LSIL and
HSIL may not be possible. However note that mildly
dysplastic cells are often seen in slide preparations
diagnostic of more severe lesions. Histologic follow-
up of such cases is LSIL or if HSIL, it tends to be
CIN 2 (moderate dysplasia).

squamous cells display enlarged nuclei with granular
chromatin and large cytoplasmic cavitations
consistent LSIL and human papillomavirus
cytopathic effect.
Explanatory Notes: Cytoplasmic clearing
consistent with koilocytotic change is evident in
some cells. A sharp inner edge of the cavitation
characterizes koilocytes.

Cytomorphologic Criteria: LSIL with
keratinized cytoplasm and ?smudgy? nuclei
44
Magnification: High
Cytomorphologic Criteria: Dysplastic
nuclei and abundant mature cytoplasm are consistent
with mild dysplasia (LSIL).
Explanatory Notes: It is the amount of
cytoplasm and not the degree of nuclear atypia that
determines the grade of a dysplastic lesion.

Magnification: High
and koilocytes in mildly dysplastic mature cells is
consistent with HPV effect.
Explanatory Notes: Dysplastic nuclear
changes in koilocytes warrant a diagnosis of LSIL.

Magnification: High
Interpretation: LSIL/HSIL
nuclei are similar; however, the amount of cytoplasm
varies – Mild to moderate dysplasia.
Explanatory Notes: The more severe lesion
should be mentioned in the diagnosis.
45
Clinical History: 19 year old female, 38
weeks pregnant
Cytomorphologic Criteria: A large,
multinucleated cell showing mild dysplasia, along
with four cells with a higher nuclear to cytoplasmic
ratio consistent with moderate dysplasia or HSIL.
Explanatory Notes: Cells consistent with
HSIL may be interpreted as mild dysplasia by some,
especially in a pregnant patient.

Clinical History: 33 year old female. No
history provided
Cytomorphologic Criteria: Mature and
metaplastic cells showing abnormal, hyperchromatic,
enlarged nuclei, suggestive of mild dysplasia.
Explanatory Notes: Nuclear changes are
not consistent with LSIL.

Magnification: High
Cytomorphologic Criteria: Possible
equivalent of "condylomatous spike" in a liquid
based Pap test, based on limited personal experience.
Explanatory Notes: Such cell patterns
should be classified as NILM, ASC, or SIL based on
the degree of nuclear abnormality.
46
Magnification: High
Cytomorphologic Criteria: cluster of
Koilocytes.
Explanatory Notes: Nuclear abnormalities
seen here distinguish these cells from
"pseudokoilocytosis" due to excess glycogen
accumulation.

Pseudokoilocytosis: cytoplasmic vacuolization
without nuclear change of HPV effect.
Explanatory Notes: Cytoplasmic
vacuolization alone without nuclear atypia is a benign
cellular change (sometimes referred to as
pseudokoilocytosis) and should not be classified as
LSIL or ASCUS. Pseudokoilocytosis may be seen
with increased glycogen in the cytoplasm.
Citologie Vaginală HSIL

Magnification: High
Clinical History: 27 year old woman. LMP
two weeks ago
Interpretation: ASC-H versus HSIL
cells with increased N:C ratios and nuclear contour
irregularities.
LEEP
47
Magnification: High
Interpretation: HSIL
Cytomorphologic Criteria:Loose aggregate
of HSIL cells with some variation in cell size and
N/C ratios, irregular nuclear membranes and granular
chromatin. Note that some of the metaplastic cells
still show mucin/ endocervical features.
Explanatory Notes: Single dysplastic cells
in a streaming pattern, especially at low power may
mimic histiocytes A cluster such as this may raise the
differential diagnosis of squamous metaplastic cells
under lower magnification. Attention to nuclear
details is essential to make these distinctions.
Follow-up: Biopsy was CIN 3 (carcinoma in
situ/ sever dysplasia)

Magnification: High
Cytomorphologic Criteria: Severely
dysplastic cells on the left display a high nuclear to
cytoplasmic ratio and irregular nuclear membranes.
Moderately dysplastic cells on the right have similar
nuclei and more cytoplasm.
Explanatory Notes: Note the nuclear
membrane irregularities and abnormally distributed
chromatin. In liquid based preparations,
hyperchromasia may not be as prominent as in

Magnification: High
2 weeks
Cytomorphologic Criteria: This large
cluster of cells exhibits a loss of polarity, nuclear
enlargement and coarsely granular chromatin.
Together with a high nuclear to cytoplasmic ratio, a
diagnosis of HSIL is warranted. Some nuclei display
discrete nucleoli.
Explanatory Notes: Although uncommon,
nucleoli may be seen in HSIL, especially with
extension into endocervical gland spaces. The
chromatin may also appear less coarsely granular in
these cases. Thus the presence of nucleoli in
dysplastic squamous cells in itself is not a specific
morphologic indicator of "invasion" in a squamous
epithelial abnormality.
48
Magnification: High
Cytomorphologic Criteria: Syncytial
arrangement (loss of polarity and cell borders)
suggests carcinoma in situ . The cytoplasm is "non-
metaplastic" Note also that the abnormal nuclei
contain grooves- a feature that is not infrequently
seen in HSIL.

Magnification: High
Clinical History: 29 year old, from "high-
risk" clinic
Cytomorphologic Criteria: In liquid-based
preparations, cells from HSIL are often isolated,
small in size and have nuclei that are slightly larger
than an intermediate cell nucleus. Dense cytoplasm
and centrally placed nuclei are consistent with a
squamous origin.
Explanatory Notes: Close attention to
isolated cells is required when screening liquid based
preparations since the abnormal cells tend to be
isolated and may not be as apparent as clusters of
HSIL cells. Additionally, these isolated cells may lie
between benign cell clusters or in ?empty spaces? on
the preparation. When the criteria for HSIL are met,
such cells should be interpreted as HSIL and not
ASC-H.

Magnification: High
Cytomorphologic Criteria: A cluster of
HSIL cells. Important features of high grade
squamous intraepithelial lesions are enlarged,
centrally placed nuclei, hyperchromasia, and irregular
nuclear membranes.
koilocytes in other cells on the smear supports an
interpretation of squamous intraepithelial lesion. In
this case HSIL is present, and the highest grade of
abnormality present in the smear is what should be
reported.
Follow-up: Biopsy- CIN 3
49
Magnification: High
3 weeks, routine exam
Interpretation: LSIL/HSIL (Borderline)
Cytomorphologic Criteria: Borderline
LSIL/ HSIL. The abnormal cells characterizing
moderate dysplasia have a fair amount of cytoplasm
compared to severe dysplasia/ CIN3, but less than
that in LSIL cells. These cells are at the borderline of
what may be interpreted as LSIL by some and HSIL
by others.
Explanatory Notes: While the majority of
SIL cases can be classified as HSIL or LSIL, in
occasional cases, the distinction between LSIL and
HSIL may not be possible. However note that mildly
dysplastic cells are often seen in slide preparations
diagnostic of more severe lesions. Histologic follow-
up of such cases is LSIL or if HSIL, it tends to be
CIN 2 (moderate dysplasia).

Magnification: High
Interpretation: HSIL, r/o invasion
Cytomorphologic Criteria: Keratinized
dysplastic cells with nucleoli, and angulated or ?
carrot? shaped nuclei that may raise suspicion for
invasion and qualify for an interpretation of HSIL,
cannot rule out invasion.
CIS are generally round to oval and of similar size.
When the lesion is "keratinizing" it is often more
difficult to classify the degree of abnormality present
with certainty.
Follow-up: Biopsy- CIN 3 (severe
dysplasia, keratinizing)

Magnification: High
Interpretation: HSIL in Mucus Strand
Cytomorphologic Criteria: Isolated HSIL
cells in a stream of mucus (lower power in upper
right inset). The pattern of HSIL cells streaming
within mucus can mimic histiocytes and
endocervical/ metaplastic cells. At high power, HSIL
can be readily distinguished from benign cellular
elements.
Explanatory Notes: This is a pattern that is
important to be aware of to avoid false negatives.
50
Interpretation: Endocervical
adenocarcinoma in situ (AIS) /HSIL
Explanatory Notes: Co-existing glandular
and squamous lesions should always be considered
when making an interpretation of endocervical
adenocarcinoma in situ.
Follow-up: HSIL (moderate dysplasia) and
endocervical adenocarcinoma in situ occurring at the
transformation zone

postmenopausal woman with hx of abnormal Pap test
elsewhere
Hyperchromatic crowded group of AIS (upper right)
and small aggregate of HSIL (lower left).
Follow-up: Endocervical adenocarcinoma in
situ with invasive adenocarcinoma and HSIL

Magnification: High
Clinical History: 47 year old female,
HIV+Interpretation: HSIL, features suspicious for
invasion
Cytomorphologic Criteria: Numerous
abnormal cells are present in varying sizes and
shapes. Nuclei vary from round to oval to spindle
shaped. This type of pleomorphism suggests invasive
carcinoma. However, the absence of nucleoli and
necrosis are consistent with CIS.
Explanatory Notes: The distinction
between CIS and invasive carcinoma may be difficult
when cells are numerous and display variation in
nuclear size and shape.
Follow-up: CIS with gland involvement; no
invasion
51
Magnification: High
Cytomorphologic Criteria: Unequivocal
nuclear "dysplastic" changes are present in these
relatively small squamous cells. The nuclear to
cytoplasmic ratio suggests moderate dysplasia
(CIN2).
Explanatory Notes:For mild dysplasia
(LSIL), more abundant and mature cytoplasm and a
lower N/C ratio is expected. In this case chromatin
changes suggest HSIL; however the N/C ratio is on
the low end for HSIL.

Magnification: High
Cytomorphologic Criteria: Isolated
abnormal cells with evenly distributed coarse
chromatin, centrally placed enlarged nuclei, and
dense / "metaplastic" cytoplasm are consistent with
HSIL. A mitotic figure is evident.

Cytomorphologic Criteria: This lower
magnification calls to mind a "pavement-like
arrangement" of squamous metaplastic cells.
However these are dysplastic cells with nuclear
abnormalities and "metaplastic"/dense, scant
cytoplasm, c/w HSIL.
52
Magnification: High
Cytomorphologic Criteria:Histologic
section demonstrating "full thickness" involvement of
the epithelium by dysplastic cells without significant
maturation. Note mitoses in upper third of the
epithelium and apoptotic bodies.
Explanatory Notes: Histologic appearance
of CIN 3 (severe dysplasia/ carcinoma in situ),
apoptosis.

Magnification: High
Cytomorphologic Criteria: HSIL (CIS)
cells are seen in a syncytial arrangement of cells with
hyperchromatic nuclei and a high nuclear to
cytoplasmic ratio. The loss of polarity and dense
cytoplasm are consistent with CIS .
Explanatory Notes: CIS can be seen in a
syncytial pattern as demonstrated here or in smaller
groups or as isolated cells. Additionally the
cytoplasm in HSIL cells maybe dense (metaplastic),
immature/ lacy/ non-metaplastic or keratinized.
Compare this pattern of CIS with images showing
endocervical gland involvement by HSIL.

Cytomorphologic Criteria: "Keratinizing
dysplasia". The dysplastic cells in this field display
enlarged nuclei with coarsely granular chromatin and
keratinized cytoplasm. Occasional cells have
pyknotic or opaque nuclei with sharp, angled edges
and abnormal cell shapes are seen. Nuclear size and
degree of abnormality exceed the cytomorphology of
"atypical parakeratosis" yet are not supportive of an
invasive lesion.
Explanatory Notes: The criteria of N/C
ratio and degree of nuclear abnormalities used for
grading SIL may be more difficult to apply to
keratinizing lesions. The extent of abnormality here
qualifies for an interpretation of HSIL.
53
Magnification: High
Cytomorphologic Criteria: Highly
magnified, irregular nuclear membranes are readily
visualized in these cells diagnostic for CIS/HSIL.
Explanatory Notes: Chromocenters are
commonly seen in the nuclei of severely dysplastic
cells.

Magnification: High
Cytomorphologic Criteria: When
examining hyperchromatic crowded groups, it is
important to study the cells at the edges. In this case,
nuclear enlargement and chromatin abnormalities
consistent with CIS are evident.
Explanatory Notes: This type of cellular
arrangement suggests glandular extension.
Follow-up: Biopsy- CIN 3 (severe dysplasia
with endocervical gland involvement)

Magnification: High
Cytomorphologic Criteria: Such ?
hyperchromatic crowed groups? may raise a wide
differential diagnosis under low magnification;
attention to architectural pattern and cellular detail
are necessary for correct interpretation. In this image,
the enlarged nuclei with hyperchromatic/granular
chromatin, dense cytoplasm and high N/C ratio cells
arranged in a syncytial cluster such as this warrant an
interpretation of HSIL/CIS.
Explanatory Notes: The nuclei in this
tightly arranged group are too large to be endometrial
cells. Other differential diagnosis of such
"hyperchromatic clusters" include atrophy/ parabasal
cells, lower uterine segment, glandular epithelial
abnormalities and HSIL extension into endocervical
gland spaces.
Follow-up: Biopsy- CIN 3 (severe
dysplasia/CIS)
Citologie Vaginală HSIL Type of Preparation: SurePath/ LBP
54
Magnification: High
dysplastic cells with a fair amount of cytoplasm
represent a moderate dysplasia - HSIL.
Explanatory Notes: For LSIL, abundant
mature cytoplasm is expected.
Follow-up: Biopsy-CIN 2 (moderate
dysplasia)

Cytomorphologic Criteria: On low
magnification, this large "hyperchromatic" cluster of
cells displays enlarged nuclei and a high nuclear to
cytoplasmic ratio. The dense cytoplasm suggests a
squamous origin. The pattern is consistent with CIS.
Explanatory Notes: As in conventional
smears, crowded hyperchromatic cell groups should
be examined with care. If a squamous abnormality is
suspected, a thorough search for single dysplastic
cells in the background is warranted. SIL
occasionally presents morphologically as spindle
cells.
Follow-up: Biopsy-CIN 3 (severe
dysplasia/carcinoma in situ)

Magnification: High
dysplastic cells with high nuclear to cytoplasmic
ratio, hyperchromasia, and irregular nuclear
membranes are consistent with HSIL. Scant
cytoplasm is dense and well-defined.
Explanatory Notes: Although cytoplasmic
features are similar to that seen in squamous
metaplasia, nuclear abnormalities are consistent with
HSIL.
Citologie Vaginală HSIL Magnification: High

Type of Preparation: ThinPrep/ LBP Interpretation: HSIL
55
Cytomorphologic Criteria: The dysplastic
cells in this field display several criteria for HSIL:
high nuclear to cytoplasmic ratio, hyperchromasia,
and granular, hyperchromatic chromatin. Combined
with the irregular nuclear membranes, these cells are
pathognomonic for HSIL.
Explanatory Notes: The degree of nuclear
atypia exhibited precludes the diagnosis of squamous
metaplasia or reactive cellular changes.
Follow-up: Biopsy-CIN 3

Magnification: High
weeks pregnant
squamous cells display varying degrees of maturity
and dysplastic nuclei. They range from mild to
moderate to severe dysplasia warranting a diagnosis
of HSIL.
Explanatory Notes: It is important to base
the diagnosis on the cells showing the most severe
abnormality.

Clinical History: 27 year old, LMP
unknown. no prior history of abnormal Paps
Cytomorphologic Criteria: Two
metaplastic, moderately dysplastic cells seen in this
field. They have enlarged, hyperchromatic nuclei,
high N/C ratio and dense cytoplasm. Two mature
intermediate cells are also seen in the field.
56
Magnification: High
Cytomorphologic Criteria: HSIL with
extension into gland space. Note that in addition to
the abnormal cells themselves, there is flattening of
cells at the edge of the cluster, lack of columnar
shape and loss of polarity (central whorling). These
features favor HSIL extending into endocervical
glands over a glandular lesion.
Explanatory Notes: The differential
diagnosis of such clusters includes HSIL with gland
extension and AGC/ endocervical neoplasia.

Magnification: High
Cytomorphologic Criteria: On low power,
the group of cells in the center may appear to be
glandular and small. On closer inspection, large
abnormal nuclei are evident; single lying cells are
similar and consistent with HSIL.
Explanatory Notes: When screening, it is
important to distinguish abnormal squamous cells
from endometrial or endocervical cells.

Magnification: High
dysplastic cells with a high nuclear to cytoplasmic
ratio, enlarged nuclei (3 times normal intermediate
nucleus), and irregular nuclear membranes are
consistent with HSIL.
Explanatory Notes: Nuclear size and
abnormality are classic for HSIL.
57
Citologie Vaginală HSIL Follow-up: HSIL extending into glands with focal epithelial cell
Interpretation: HSIL necrosis within occluded glands but no invasion
dysplastic cells are small and round to oval with scant
cytoplasm. Cellular changes are consistent with HSIL
and correlate well with a biopsy showing CIS
Explanatory Notes: Isolated, small,
dysplastic cells should not be confused with
histiocytes or endometrial cells. The presence of
similar cells consistent with moderate dysplasia
provides a clue as to the nature of the lesion.
Follow-up: CIS

postmenopausal woman on HRT
Hyperchromatic crowded groups seen at low power
require careful examination at higher magnification.
Under close scrutiny, this hyperchromatic crowded
group show at the edge loosely cohesive cells that are
morphologically consistent with HSIL.
Explanatory Notes: Nuclear overlap,
hyperchromasia and dense cytoplasm are consistent
with a squamous origin. Note the "flattening" of cells
at the periphery of the group on the upper right side
of the cluster. Flattening at the edge of the cell cluster
and whorling in the center are suggestive of HSIL
over a glandular epithelial abnormality. Careful
appraisal of the remaining smear for overall cell
pattern and single dysplastic cells is also extremely
important.

postmenopausal woman
Interpretation: HSIL with some features
suspicious for invasion
Cytomorphologic Criteria: Small
squamous cells with irregular hyperchromatic nuclei
and high N/C ratios. There is some necrotic cellular
debris in the background, which raises the question of
possible invasion.
Explanatory Notes: HSIL involving
endocervical glands may undergo central necrosis
when those glands become occluded. In conventional
smears, necrotic cellular debris may be seen as focal
aggregates of debris (usually associated with
abnormal epithelial cells) in an otherwise clean
background. This differs from the necrotic debris
admixed with broken down blood and inflammation
that usually seen in diathesis with invasive lesions.
This is an unusual and difficult pattern on Pap tests.
58
Magnification: High
postmenopausal woman
Cytomorphologic Criteria: Due to the
presence of elongate cells and much nuclear
overlapping, the abnormal cells in this specimen may
be misinterpreted as glandular in origin. Most nuclei
are round to oval and consistent with HSIL.
Explanatory Notes: Spindling of squamous
cells in conventional preparations is often an artifact
of smearing.
Follow-up: HSIL

Magnification: High
Cytomorphology is that of both LSIL and HSIL, the
distinction being the nuclear to cytoplasmic ratio
which is much higher in HSIL.
Explanatory Notes: If both LSIL and HSIL
features are present, the more severe interpretation
(HSIL) is reported.
Follow-up: Biopsy showed CIN1 and CIN2

Magnification: High
nuclei are similar; however, the amount of cytoplasm
varies - Mild to moderate dysplasia.
Explanatory Notes: The more severe lesion
should be mentioned in the diagnosis.
59
weeks pregnant
Cytomorphologic Criteria: A large,
multinucleated cell showing mild dysplasia, along
with four cells with a higher nuclear to cytoplasmic
ratio consistent with moderate dysplasia or HSIL.
HSIL may be interpreted as mild dysplasia by some,
especially in a pregnant patient.

Magnification: High
Cytomorphologic Criteria: Conventional
smears containing cells consistent with HSIL often
display dysplastic cells in a strand of mucus.
Explanatory Notes: This type of
presentation is unusual in liquid-based preparations.
Citologie Vaginală Carcinom Scuamos

Magnification: High
Interpretation: Squamous cell carcinoma
squamous cells with anisocytosis and anisonucleosis
including keratinization and tadpole cells are
diagnostic of invasive squamous cell carcinoma.
60
Magnification: High
Cytomorphologic Criteria: Cells on the
left with scant cytoplasm display nuclei with
irregularly distributed, coarsely granular chromatin
and prominent nucleoli. On the right, lysed blood and
a stripped nucleus, tumor diathesis, is evident.
Explanatory Notes: Invasive carcinoma
with prominent nucleoli may suggest
adenocarcinoma; however, in this case centrally
located nuclei and flat arrangement of cells is
consistent with squamous cell carcinoma.

Magnification: High
Interpretation: Squamous Cell Carcinoma-
clinging diathesis
Cytomorphologic Criteria: Tumor
diathesis, variation in cell size and shape, evidence of
keratinization, and nuclear abnormalities are all
demonstrated in this image from a squamous cell
carcinoma.
Explanatory Notes: In liquid-based
preparations, tumor diathesis may be more subtle and
often tends to collect at the periphery of cell groups;
a pattern that has been referred to as ?clinging
diathesis?.
Follow-up: Follow-up- squamous cell
carcinoma

Magnification: High
Interpretation: Squamous cell carcinoma,
non-keratinizing
Cytomorphologic Criteria: Non-
keratinizing squamous cell carcinoma, "large cell
variant," shows a fair amount of cyanophilic
cytoplasm, granular chromatin, and prominent
nucleoli.
Explanatory Notes: Dense cytoplasm, well-
defined cell borders, and flat cellular arrangements
characterize squamous cell carcinoma.
61
Magnification:High
Interpretation: Squamous cell carcinoma -
non keratinizing
isolated cells display nuclei with irregular
membranes, uneven chromatin distribution,
hyperchromasia, and irregular membranes. While the
cells display all the features of HSIL, they also
contain nucleoli, and markedly irregular distribution
of chromatin. An associated tumor diathesis is often
present, but is not pictured.
Explanatory Notes: It has been suggested
that large numbers of isolated cells may be a clue as
to the severity a squamous epithelial lesion.

Cytomorphologic Criteria: Keratinized
cells with pleomorphism of size and shape. The
nuclei also show marked variation in size and dense,
opaque nuclear forms are seen in which chromatin
may be difficult to discern. However in other cells,
the chromatin is irregularly distributed with
parachromatin clearing
Explanatory Notes: Chromatin may be
difficult to discern in keratinized cells and
macronucleoli are seen less commonly seen as
compared to non-keratinizing squamous carcinoma

Magnification: High
Cytomorphologic Criteria: Tumor
diathesis and lysed blood provide the background for
numerous small, hyperchromatic malignant cells.
Two large nuclei with coarsely granular chromatin
and prominent nucleoli are consistent with squamous
cell carcinoma.
Explanatory Notes: Pleomorphism of shape
and size is a feature of invasive squamous cell
carcinoma, and is usually more obvious in the
keratinizing type.
62
Magnification: High
Cytomorphologic Criteria: At low
magnification, nuclear abnormalities such as
irregularly distributed coarse chromatin,
hyperchromasia, and high nuclear to cytoplasmic
ratio can be appreciated.
Explanatory Notes: Ragged borders favor
carcinoma, not SIL.

Magnification: High
Cytomorphologic Criteria: Highly atypical
cluster of cells with loss of polarity, variable N/C
ratios, nuclear membrane irregularities (better
appreciated by focusing up and down), and
prominent nucleoli. Intracytoplasmic nuclear debris
and mitosis are also present.
Explanatory Notes: Both repair and
invasive carcinoma have prominent nucleoli;
however the atypia seen in carcinoma, as well as
isolated malignant cells and diathesis were useful in
making the correct interpretation. The malignant cell
clusters show more rounding on liquid preparations
and in an individual cell group distinction between a
squamous and glandular lesion may be difficult.
Attention should be given to looking for isolated
dysplastic cells in the background.

Magnification:High
Cytomorphologic Criteria: "Litigation
Cell"; shown as an example of single cell that can be
missed or misclassified as "atypical parakeratosis".
Explanatory Notes: When cells such as this
are encountered a detailed assessment for other
abnormal cells and the background features
(diathesis) should be performed.
63
Citologie Vaginală Celule endometriale
1. Explanatory Notes: Endometrial cells are only reported in women 40 or over if the glandular component is
present. In this case the age is 36 years and the patient is menstruating: thus the endometrial cells do not need to be
reported. Endometrial cells on liquid based preparations may look more worrisome than conventional Pap smears
because nuclear details are preserved and more easily detected.
2. Explanatory Notes: Exfoliated glandular endometrium may be seen when evaluating Pap tests. When
endometrial cells are encountered in a woman 40 or older, they are uncommonly associated with significant pathology.
Rarely, typical endometrial cells may be associated with an asymptomatic endometrial carcinoma in this age group.
Because of this association, all glandular endometrial cells are reported in women 40 years and over.
3. Explanatory Notes: The lower uterine segment (LUS) can easily be sampled if the endocervical sampling
device is pushed into the endocervical canal far enough to reach the LUS. In isolation, the epithelial fragments may be
mistaken for endocervical adenocarcinoma, endocervical adenocarcinoma in situ, tubal metaplasia or reactive
endocervical cells. The spindle cells alone may also appear as "hyperchromatic groups" and cause concern. Abraded
LUS does not carry the same significance as exfoliated endometrial cells and should not be reported.
4. Explanatory Notes: Endometrial cells may be encountered when evaluating Pap tests. Prior to age 40,
exfoliated endometrial cells are not associated with significant endometrial pathology. In women 40 years or older, a
small number of women may have uterine abnormalities and usually have symptoms of bleeding. Because menstrual
history, menopausal status, clinical symptoms, and endometrial cancer risk factors are often unknown to the laboratory,
endometrial glandular cells are reported in all women 40 years and older.
5. Explanatory Notes: Exfoliated glandular endometrium may be seen when evaluating Pap tests. When
endometrial cells are encountered in a woman 40 or older, they are uncommonly associated with significant pathology.
Rarely, cytologically "typical or benign appearing" endometrial cells may be associated with an asymptomatic
endometrial carcinoma in this age group. Because of this association, all glandular endometrial cells are reported in
women 40 years and over.
6. Explanatory Notes: In women 40 or over (or if the age is not provided) exfoliated endometrial cells should
be reported. A comment stating "negative for squamous intraepithelial lesion" should be made if applicable. An
educational note is recommended explaining the possible significance of exfoliated endometrial cells in women 40 years
or older. Such cases are considered "Other" in the General Categorization.
64
Magnification: High
routine exam, onset menses
Interpretation: NILM: menstrual smear
Cytomorphologic Criteria: Three-
dimensional cluster with slightly larger nuclei and
nucleoli.
Follow-up: Two follow-up Pap tests have
been normal

Magnification: High
Clinical History: 43 year old whose LMP
not available. She has no symptoms of bleeding
Interpretation: Endometrial cells are
present in a woman >= 40 years of age. Negative for
squamous intraepithelial lesion. (See Note) Note:
Endometrial cells after age 40, particularly out of
phase or after menopause may be associated with
benign endometrium, hormonal alterations and less
commonly, endometrial /uterine abnormalities.
Clinical correlation is recommended
Cytomorphologic Criteria: Three
dimensional groups with depth of focus. Dark
stromal cells are present internally. Epithelial cells
surround the cluster in a "double contour." Nuclear
features of epithelial and stromal cells are more
readily apparent in ThinPrep specimens than
Follow-up: No symptoms for 3 years
following this Pap preparation. Subsequent Pap tests
have been negative

Clinical History: A 45 year old female for a
routine visit
Cytomorphologic Criteria: Lower uterine
segment (LUS). Large tissue fragments with a
biphasic pattern of glands and spindle cells. Densely
packed spindle cells are seen with glands embedded
within. Glands are simple, nonbranching, with
indistinct cytoplasm and round uniform nuclei.
Follow-up: Normal follow up for 5 years
65
Clinical History: A 50 year old woman. No
clinical history available
Clinical correlation is recommended.
Cytomorphologic Criteria: Cells occur in
small clusters. Small, round nuclei similar in size to a
normal intermediate cell nucleus. Inconspicuous or
absent nucleoli. Cytoplasm is scant, basophilic and
sometimes vacuolated. Cell borders are ill-defined.

Clinical History: 50 year old female with
no menstrual history available
Cytomorphologic Criteria: Exodus pattern
is characterized by a double contour pattern of
external glandular epithelium with internal stromal
cells. The stroma in this group is slightly eccentric.
Nuclear features are easily appreciated, despite this
being a conventional Pap smear. The nuclei have
delicate even chromatin. Histiocytes are often seen in
association with the double contour fragments of
exodus.

Clinical History: 42 year old female,
menstruating at time of office visit
Cytomorphologic Criteria: Cells are in a
three dimensional "above the plane" of squamous
cells. Nuclei are larger and vacuoles are seen at the
periphery of the cell group. Apoptosis is seen easily
as dark nuclear material (individual cell necrosis).
66
receiving hormone therapy. No symptoms of
bleeding
squamous intraepithelial lesion. (See Note). Note:
Cytomorphologic Criteria: Endometrial
glandular group "above" the squamous cell plane of
focus. Apoptotic cell centrally. A single vacuolated
cell at group edge. The endometrial cell nuclei are the
same size as the intermediate squamous cell nucleus.
Explanatory Notes: Endometrial glandular
cells are reported in women of 40 years or older
because of the association of asymptomatic
endometrial carcinoma in a small number of patients.

routine exam, menses at the time of office visit
Endometrial cells correlate with the menstrual
history provided.
dimensional cluster of cells. The nuclei are larger
than the endometrial nuclei seen on conventional
smears. Nuclei appear more pleomorphic in size and
appear darker than conventional smears.
preparations, shed/menstrual endometrium may show
more pleomorphism than is seen in conventional
smears.
Follow-up: Two follow-up Pap tests have
been normal

routine exam, LMP 7 days
Cytomorphologic Criteria: Endometrial
cells seen as single cells with abundant eccentric
cytoplasm and indented or reniform nuclei
characteristic of superficial stromal cells/histiocytes.
At the lower left, a glandular cluster is also seen.
Explanatory Notes: Exodus pattern seen in
a woman whose LMP is Day 7.
67
Clinical History: The patient is a 52 year
old with abnormal uterine bleeding
Clinical correlation is recommended
Cytomorphologic Criteria: In this field,
single cells with abundant eccentric cytoplasm and
indented or reniform nuclei characteristic of
superficial stromal cells/histiocytes are seen.
Histiocytes are often associated with and
indistinguishable from superficial stromal cells.
Explanatory Notes: Endometrial glandular
cells were seen in other field(s), and thus endometrial
cells were reported. Pap test with only
histiocytes/superficial stromal cells should be
reported as "Negative for intraepithelial lesion or
malignancy." Histiocytes/superficial stromal cells
alone do not have independent diagnostic
significance and should NOT be reported in the same
context as exfoliated glandular cells.
Follow-up: Endometrial carcinoma in a
background of endometrial hyperplasia

Explanatory Notes: Endometrial stromal
cells are present.

Magnification: High
Clinical History: Routine Pap smear in a 43
year old
Cytomorphologic Criteria: Round to
spindle shaped deep stromal cells. Small oval nuclei.
Scant cytoplasm.
Explanatory Notes: Exfoliated glandular
endometrial cells are the endometrial cells that may
have clinical significance as a harbinger of
endometrial pathology. Histiocytes and stromal cells
do not have independent significance. Their presence
should not be reported in the same context as the
exfoliated glandular epithelium. Frequently, stromal
cells such as these may represent abraded, not
exfoliated, endometrium.
68
Clinical History: The patient is a 49 year
old female without symptoms, routine visit
Cytomorphologic Criteria: Large clusters
of spindle cells with inconspicuous cytoplasmic
borders.
Explanatory Notes: Sometimes fragments
of lower uterine segment are abraded and do not
contain simple tubular glands. Close attention to the
large fragments and delicate spindled nuclei suggests
abraded endometrial stroma. Abraded endometrium
does not carry the same implication of risk for
endometrial carcinoma that exfoliated endometrium
does. LUS should be reported as "NILM.".
Follow-up: Free of abnormality for 10 years

Clinical History: 54 year old receiving
hormone replacement therapy
Cytomorphologic Criteria: Loose
aggregates of naked nuclei. There is nuclear molding
and absent cytoplasm.
Explanatory Notes: Small naked nuclei
may be seen in a variety of conditions, including
atrophy, hormone therapy and Tamoxifen therapy.
They are most likely naked squamous cell nuclei. In
women taking hormone therapy or nonsteroidal
antiestrogen compounds, these cells "stand out"
against the background keratinized epithelial cells.
They should not be reported as endometrial cells.
Follow-up: No symptoms of endometrial
abnormality and negative follow up for 3 years

Clinical History: Post menopausal breast
cancer patient receiving Tamoxifen therapy, routine
examination
aggregates of "naked" nuclei. Nuclear molding is
seen, without cytoplasm.
Explanatory Notes: Naked nuclei should
not to be mistaken for endometrial cells. They are
seen in a variety of conditions (atrophy, hormone
therapy, antiestrogen therapy.) They are most likely
naked squamous cell nuclei. In women taking
hormone therapy or nonsteroidal antiestrogen
compounds, these cells "stand out" against the
background keratinized epithelial cells.
Follow-up: Asymptomatic after 3 years
Citologie Vaginală Celule endocervicale atipice Type of Preparation: Conventional

69
routine Pap smear, no LMP date given
Interpretation: Atypical endocervical cells,
NOS
Cytomorphologic Criteria: Sheet of cells
with enlarged round or oval nuclei with prominent
nucleoli. Chromatin is finely granular and evenly
distributed but occasional chromocenters are seen.
Cell borders are well-defined. Mitotic figures are
noted.
Explanatory Notes: In some cases, atypical
glandular cells associated with benign processes may
be difficult to differentiate from neoplastic processes,
especially when mitotic activity is prominent.
Follow-up: ECC and multiple follow-up
Pap smears over three years were negative and the
patient have no other gynecologic findings. In view
of the benign follow-up, the cytologic atypia and
mitotic activity are thought to represent endocervical
repair
Citologie Vaginală Celule endocervicale atipice

Interpretation:Atypical endocervical cells,
NOS, HSIL
Cytomorphologic Criteria: Cluster of cells
showing crowding and overlapping of nuclei, nuclear
enlargement, chromocenters, and small nucleoli.
Explanatory Notes: HSIL involving gland
spaces may present as contoured clusters that mimic
the appearance of glandular lesions. Note the absence
of elongated nuclei, feathering, rosettes, and
pseudostratified strips, features that are typically
associated with endocervical AIS.
Follow-up: High grade squamous
intraepithelial lesion only
Citologie Vaginală Celule endometriale atipice

Magnification: High
postmenopausal bleeding
Interpretation: Atypical endometrial cells
Explanatory Notes: Atypical endometrial
cells may be associated with the presence of a wide
variety of processes, including polyps, chronic
endometritis, hyperplasia, and carcinoma.
Follow-up: adenocarcinoma of the
endometrium, grade 1
Citologie Vaginală Celule endometriale atipice Magnification: High

Type of Preparation: ThinPrep/ LBP Clinical History: 63 year old woman with postmenopausal bleeding
70
Cytomorphologic Criteria: Aggregate of
small cells with slightly enlarged round or oval
nuclei, small nucleoli and finely vacuolated
cytoplasm.
Follow-up: Adenocarcinoma of the
endometrium, grade I

Clinical History: 52 year old female on
estrogenic hormone therapy.
dimensional group of small cells with crowded round
or oval nuclei.
preparations, the evaluation of individual cell features
may be difficult in the dense three-dimensional
clusters.
Follow-up: Endometrial hyperplasia

Magnification: High
Clinical History: 54 year old woman 4
months s/p radiation therapy for Stage I cervical
cancer
Interpretation: Atypical endocervical cells
Cytomorphologic Criteria: Sheet of
abnormal cells with markedly pleomorphic nuclei
(vary widely in size and shape) and prominent
nucleoli. Chromatin is finely granular and cell
borders are fairly distinct. Occasional cytoplasmic
vacuoles are noted.
Explanatory Notes: Ionizing radiation
therapy may produce striking atypias in the
endocervical epithelium that can mimic residual
carcinoma. This degree of atypia usually resolves
within 18 months after completion of therapy.
Follow-up: Changes became less severe
over time on follow-up Pap smears. Findings are
compatible with post radiation atypia
Citologie Vaginală Celule endometriale atipice Type of Preparation: Conventional

71
Magnification: High
Clinical History: Left: 82 year old woman
with postmenopausal spotting
dimensional groups of small cells with
hyperchromatic nuclei, small nucleoli and
occasionally vacuolated cytoplasm.
Follow-up: Endometrial hyperplasia

Magnification: High
NOS
dimensional cluster of crowded glandular cells with
round or oval nuclei.
preparations, the cells are often seen in three-
dimensional clusters that make visualization of cells
in the center difficult.
Follow-up: Benign

Magnification: High
Cytomorphologic Criteria: Cell group
demonstrating crowding, pseudostratification and
oval or elongated nuclei. Note the presence of cilia in
some cells.
Explanatory Notes: Tubal metaplasia is a
significant pitfall in the interpretation of glandular
changes. Cells may show features that overlap with
those of AIS.
Follow-up: These findings are most likely
related to tubal metaplasia
72
Magnification: High
Clinical History: Routine Pap test, 45 year
old with an IUD in place
Cytomorphologic Criteria: Cells
demonstrate nuclear enlargement, nucleoli and
cytoplasmic vacuolization.
Explanatory Notes: IUD-related changes
may mimic some cytologic features seen in glandular
neoplasia.
Follow-up: IUD-related changes

Magnification: High
with crowding and overlapping of nuclei. Note the
presences of a variety of cell types (goblet, ciliated,
peg). Some cells demonstrate relative hypochromasia
or a "washed-out" appearance.
Explanatory Notes: Cell groups from tubal
metaplasia may raise the differential diagnosis of
endocervical adenocarcinoma in situ. However the
hyperchromatic elongated nuclei of AIS are absent.
Follow-up: Cells are probably derived from
tubal metaplasia

Magnification: High
Citologie Vaginală Celule endocervicale atipice Type of Preparation: Conventional

73
dimensional groups of glandular cells with
pseudostratification and crowding of cells. Note the
presence of cilia in some cells.
Explanatory Notes: Tubal metaplasia is a
significant pitfall in the interpretation of glandular
changes. Cells may show features that overlap with
those of AIS and interpretation may be difficult when
cilia are not readily appreciated.
Follow-up: Tubal metaplasia

Magnification: High
NOS
Cytomorphologic Criteria: Cells are
characterized by disordered arrangement and
enlarged round or oval nuclei with occasional
nucleoli.
Explanatory Notes: Atypical endocervical
cells typically show features that exceed those of
obvious reactive/reparative changes but do not fulfill
the criteria for endocervical adenocarcinoma in situ.
Follow-up: Adenocarcinoma in situ (AIS)

Magnification: High
Cytomorphologic Criteria: Cluster of
small cells with fairly uniform nuclei and
inconspicuous nucleoli. Note cytoplasmic vacuoles
with ingested neutrophils.
Follow-up: Complex endometrial
hyperplasia with extensive mixed metaplasia
74
Magnification: High
postmenopausal woman with history of prior atypical
Pap test
small cells with slightly enlarged nuclei, small
nucleoli and vacuolated cytoplasm.
endometritis, hyperplasia, and carcinoma. Patient had
a prior Pap test that showed atypical endometrial
cells. The Pap test was the first indication of
endometrial disease.
Follow-up:Endometrial hyperplasia

Magnification: High
favor neoplastic
Pseudostratified strip of endocervical cells with
enlarged, elongated nuclei and some chromatin
granularity.
Explanatory Notes: Some features of
endocervical adenocarcinoma in situ are present but
they fall just short of an unequivocal diagnosis.

Magnification: High
adenocarcinoma in situ (AIS)
Cytomorphologic Criteria: Intact
endocervical gland lined by pseudostratified
glandular cells with enlarged, elongated,
hyperchromatic nuclei. Note "gland-in-gland"
arrangement. Mitotic figures are numerous.
75
Magnification: High
Interpretation: Atypical glandular cells,
favor neoplastic
aggregate of cells with round or oval variably-sized
nuclei, granular evenly distributed chromatin,
nucleoli, and nuclear membrane irregularities. The
cytoplasm is scant and poorly defined.
Explanatory Notes: The most common
significant pathology associated with atypical
glandular cells (NOS or endocervical origin) is
squamous neoplasia, especially HSIL.
Follow-up: Squamous cell carcinoma, non-
keratinizing
Citologie Vaginală AIS

with enlarged, hyperchromatic nuclei, increased N/C
ratios and feathering at the periphery of the sheet.
Explanatory Notes: Note the monotony of
the hyperchromasia in the nuclei in contrast to the
more variable nuclear changes seen in tubal
metaplasia.
situ

Type of Preparation: ThinPrep
history of an abnormal Pap test at another institution
referred for workup
abnormal cells with elongated hyperchromatic nuclei
arranged in glandular strips that have nuclear
pseudostratification and suggestion of a gland lumen.
There is some suggestion of feathering at the
periphery.
Explanatory Notes: Cells with elongated
nuclei and nuclear pseudostratification are classic
features of endocervical AIS. Feathering at the
periphery of cells sheets may be more subtle in
liquid-based preparations.
Follow-up: endocervical adenocarcinoma in
situ with a small component of invasive
adenocarcinoma and a co-existing HSIL
76
Magnification: High
Cytomorphologic Criteria: Rosette-like
arrangement of cells with enlarged oval or elongated
nuclei, nuclear hyperchromasia and granular, evenly
distributed chromatin. Smear background is clean.
Explanatory Notes: Rosette arrangements,
oval or elongated nuclei, hyperchromasia and evenly
distributed granular chromatin are classic features of
AIS.
situ

Magnification: High
abnormal glandular cells arranged singly, in small
aggregates and pseudostratified strips. Nuclei are
round, oval or elongated with irregular nuclear
membranes and small nucleoli. Note the mitotic
figure.
Explanatory Notes:In liquid-based
preparations, AIS often presents with pseudostratified
strips of cells having short "bird-tail" arrangements.
situ

Magnification: High
Cytomorphologic Criteria: Intact
endocervical gland lined by pseudostratified
glandular cells with enlarged, elongated,
hyperchromatic nuclei. Note "gland-in-gland"
arrangement. Mitotic figures are numerous.
77
Magnification: High
adenocarcinoma in situ
with enlarged, variably-sized round or oval nuclei
with prominent nucleoli. A mitotic figure is also
noted.
Explanatory Notes: AIS may occasionally
show prominent nucleoli, raising the question of
invasive endocervical adenocarcinoma.
situ

Follow-up: HSIL (moderate dysplasia) and
endocervical adenocarcinoma in situ occurring at the
transformation zone

postmenopausal woman with hx of abnormal Pap test
elsewhere
Cytomorphologic Criteria:Hyperchromatic
crowded group of AIS (upper right) and small
aggregate of HSIL (lower left).
situ with invasive adenocarcinoma and HSIL
78
Magnification: High
Cytomorphologic Criteria: Gland-like
cluster of cells showing crowded, overlapping oval
nuclei and granular, evenly distributed chromatin.
Cytoplasm is finely vacuolated with some columnar
shapes. Smear background is clean.
situ

Magnification: High
Cytomorphologic Criteria:Cluster of cells
with crowded overlapping oval nuclei that show
hyperchromasia and evenly distributed by coarsely
granular chromatin. Smear background is clean.
Explanatory Notes: Nuclear crowding and
overlapping, hyperchromasia and evenly distributed
granular chromatin are classic features of AIS.
Follow-up:Endocervical adenocarcinoma in
situ

Magnification: High
Interpretation:Endocervical
Pseudostratified strip of cells demonstrating nuclear
enlargement and crowding and peripheral feathering.
Smear background is clean.
Explanatory Notes: Pseudostratification,
nuclear crowding and feathering are classic features
of AIS.
situ
79
clusters of abnormal glandular cells containing
crowded cells with elongated nuclei. Note
pseudostratification of cells and feathering at the
periphery of the clusters.
preparations, the pseudostratified strips of cells often
present as short "bird-tail" arrangements. (see linked
image).
situ

history of an abnormal Pap at another institution
Interpretation: endocervical
adenocarcinoma in situ, intestinal type (AIS)
Cytomorphologic Criteria:Cluster of
abnormal glandular cells with nuclear crowding and
overlap, elongated nuclei, and inconspicuous
nucleoli. Note numerous goblet-type cells.
Explanatory Notes: Although uncommon,
variant patterns of AIS exist (e.g., intestinal,
endometrioid, clear cell) and may show morphologic
features that differ from those seen in the "classic"
endocervical form.
situ, intestinal pattern
Citologie Vaginală Adk Endocervical

Magnification:High
Interpretation: Adenocarcinoma,
endocervical
with enlarged round or oval nuclei, irregular
chromatin distribution and prominent nucleoli.
Explanatory Notes: Irregular chromatin
distribution and prominent or macronucleoli are a
classic findings in invasive endocervical
adenocarcinoma.
80
Magnification:Medium
Clinical History: 39 year old female, Day
12 of cycle
Endocervical
enlarged nuclei, macronucleoli and some nuclear
membrane irregularities; poorly defined, finely
vacuolated cytoplasm; ghost of RBC's and cell debris
noted at the edge of the cluster ("clinging diathesis").
preparations, tumor diathesis may be seen as
coagulated necrosis or as debris clinging to the
periphery of clusters of abnormal cells.
Follow-up: Endocervical adenocarcinoma

Type of Preparation: Conventional/ Histol
Magnification: Low
villoglandular
Cytomorphologic Criteria: Large cohesive
group of endocervical cells with nuclear crowding
and loss of normal honeycomb pattern. Individual
cell atypia in minimal.
Explanatory Notes: Rare neoplasm of the
endocervix, often with true papillary clusters. It is
important to recognize the low power architectural
abnormalities seen in this neoplasm.
Follow-up: Adenocarcinoma, villoglandular
on histology (left side of image)

Magnification: High
now, abnormal cervix on exam
endocervical
Cytomorphologic Criteria: Large group of
abnormal cells with round to elongated
hyperchromatic nuclei and granular chromatin. Note
pseudostratified strips with feathering at the edges.
Nuclear crowding and overlap are prominent. Smear
background is bloody.
Explanatory Notes: The cytologic features
of endocervical adenocarcinoma may overlap with
those of endocervical adenocarcinoma in situ, but
features of invasion, such as tumor diathesis, are
seen.
81
Type of Preparation: SurePath / LBP
Magnification: Low
endocervical
Cytomorphologic Criteria: Large clusters
of crowded cells with hyperchromatic nuclei.
Occasional cytoplasmic vacuolization is noted.
preparations, cell groups may be large, thick and
three dimensional, making architecture difficult to
interpret and visualization of cell nuclei problematic.

Magnification: High
endocervical
abnormal cells with enlarged, variably-sized nuclei
with irregularly distributed chromatin and prominent
or macronucleoli.
Explanatory Notes: Irregular chromatin
distribution and prominent or macronucleoli are
classic findings in invasive endocervical
adenocarcinoma.

Magnification: High
endocervical
Cytomorphologic Criteria: Malignant cells
with columnar shapes, enlarged nuclei, irregular
chromatin distribution, and nucleoli.
82
Magnification: High
endocervical
with large round or oval nuclei, irregular chromatin
and prominent nucleoli. Cytoplasm is poorly defined
and finely vacuolated. Bloody smear background.
Explanatory Notes: Prominent or
macronucleoli and tumor diathesis are classic
findings in invasive adenocarcinoma of the
endocervix.
Citologie Vaginală Adk Endometrial

Clinical History: 61 year old female with
Endometrial
aggregate of small epithelial cells with slightly
enlarged nuclei, small nucleoli, and vacuolated
cytoplasm; "watery diathesis" and histiocytes also
noted.
Explanatory Notes: In conventional
smears, endometrial adenocarcinoma is more
commonly associated with a thin watery diathesis in
the smear background in contrast to the bloody,
necrotic background associated with endocervical
adenocarcinoma.
Follow-up: Endometrial adenocarcinoma,
Grade 1.

endometrial
dimensional papillary cluster of abnormal cells with
irregular nuclear membranes and nucleoli. No
evidence of feathering.
Follow-up: adenocarcinoma of the
endometrium, FIGO Grades I-II
83
Magnification: High
Clinical History: Post menopausal woman
endometrial
small cells with enlarged round or oval nuclei, small
nucleoli and vacuolated cytoplasm in a background
of "watery" diathesis.
Explanatory Notes: In cases of endometrial
adenocarcinoma on conventional smears, tumor
diathesis, if present, is watery and more difficult to
appreciate.
endometrium, serous

Magnification: High
endometrial
Cytomorphologic Criteria: Clusters of
small cells with variably-sized nuclei and small
nucleoli. The cytoplasm is vacuolated with ingested
neutrophils.
Explanatory Notes: Cytologic detection of
endometrial adenocarcinoma in cervical specimens is
limited by the low number of well-preserved
abnormal cells and the subtlety of their cellular
alterations.
Follow-up: Endometrial adenocarcinoma

Magnification: High
endometrial
Cytomorphologic Criteria: Small cluster of
cells with slightly enlarged nuclei, small nucleoli and
vacuolated cytoplasm.
Explanatory Notes: Cytologic detection of
endometrial adenocarcinoma in cervical specimens is
limited by the low number of well-preserved
abnormal cells and the subtlety of their cellular
alterations.
Follow-up: Endometrial adenocarcinoma
84
Magnification: High
Interpretation: Endometrial
adenocarcinoma
Cytomorphologic Criteria: Papillary
cluster with large cells and prominent nucleoli.
Explanatory Notes: These tumors may
resemble their counterparts in the ovary.
Follow-up: High grade papillary serous
carcinoma of the endometrium

Magnification: High
8 years, postmenopausal bleeding
Endometrial
Cytomorphologic Criteria: Large
aggregate of small cells with irregular chromatin
distribution, small nucleoli, poorly defined finely
vacuolated cytoplasm in a watery background.
Explanatory Notes: In conventional
smears, endometrial adenocarcinoma tends to be
associated with a thin watery diathesis in contrast to
the bloody, necrotic background often seen with
endocervical adenocarcinoma.
endometrium
Citologie Vaginală ADK Extrauterin /Alte tipuri

de carcinoame
Magnification: High
Clinical History: 48 year old woman 2+
years s/p resection, TAH and radiotherapy for colon
carcinoma now presents with posterior vaginal lesion
extrauterine (metastatic from colonic primary)
Cytomorphologic Criteria: This group of
atypical glandular cells with nuclear pleomorphism,
hyperchromasia, and cellular overlap is diagnostic of
adenocarcinoma. The tall columnar cells and
scattered goblet cells with distended mucin-filled
vacuoles are characteristic of colon carcinoma.
Explanatory Notes: Colon carcinoma is one
of the most common secondary tumor encountered in
cervical cytology samples. Although metastatic
carcinomas to the cervix lack tumor diathesis, direct
extension of this tumor from the rectum may be
associated with such diathesis.
Follow-up: Adenocarcinoma of the colon
Citologie Vaginală ADK Extrauterin /Alte tipuri de carcinoame
85
large pelvic mass and ascites
extrauterine
Cytomorphologic Criteria: Cells in
papillary configurations and psammoma bodies.
Explanatory Notes: Although most
commonly associated with ovarian carcinoma,
psammoma bodies may also be seen in fallopian tube
carcinoma and papillary serous carcinomas of the
endometrium. Note clean background, generally
typical of tumors not originating in the cervix.
Follow-up: Ovarian adenocarcinoma

de carcinoame
postmenopausal woman presents with a pelvic mass
and ascites
extrauterine
Cytomorphologic Criteria: Papillary three-
dimensional clusters of cells with enlarged nuclei and
very scant cytoplasm. Note nuclear molding and
overlap.
preparations, the three-dimensional nature of the
papillary clusters may make evaluation of the
component cells difficult.
Follow-up: Biopsy proven papillary
adenocarcinoma in omentum and peritoneal implants
- presumed ovarian primary

de carcinoame
Clinical History: 39 year old woman s/p
resection of colon carcinoma presents with lesion in
left fornix of vaginal
extrauterine (metastatic from colonic primary)
Cytomorphologic Criteria: The typical
columnar cells of metastatic colon carcinoma are
present in this cluster of cells. These features are
similar to those identified on conventional smears.
However this group lacks the distinctive goblet cells.
A mild degree of degeneration may be related to the
preparation method. As a comparison, the lower left
inset shows normal colonic mucosa.
Explanatory Notes: A granular cellular
debris is seen clinging to the periphery of the cellular
cluster; this is compatible with tumor diathesis.
Follow-up: Metastatic colon cancer
Citologie Vaginală ADK Extrauterin /Alte tipuri de carcinoame

86
Magnification: High
extrauterine
with prominent/macronucleoli. Smear background is
clean.
Explanatory Notes: When cells diagnostic
of adenocarcinoma are seen in a clean background or
with morphology unusual for tumors of the uterus or
cervix, an extrauterine origin should be considered.

de carcinoame
Magnification: High
extrauterine
with prominent/macronucleoli. Smear background is
clean.
Explanatory Notes: When cells diagnostic
of adenocarcinoma are seen in a clean background or
with morphology unusual for tumors of the uterus or
cervix, an extrauterine origin should be considered.

de carcinoame
Magnification: High
history of breast cancer.
extrauterine (Breast carcinoma)
Cytomorphologic Criteria: Group of
dissociated cells with malignant features including
high nuclear to cytoplasmic ratio, hyperchromatic,
slightly irregular nuclei and conspicuous nucleoli. A
finely vacuolated cytoplasm is consistent with
glandular differentiation.
Explanatory Notes: Presence of signet ring
cells and cell-in-cell arrangement may suggest breast
carcinoma. Typically the cervical preparation would
lack tumor diathesis in metastatic tumors. The
differential diagnosis includes metastatic gastric
carcinoma as well as other adenocarcinomas, NOS.
Follow-up: Metastatic breast cancer
87
de carcinoame
postmenopausal woman with hx of gastric carcinoma
and ascitesInterpretation: Other Malignant
Neoplasms: Metastatic gastric carcinoma
Cytomorphologic Criteria: A small cluster
of cells has malignant nuclear features and displays a
cell within cell arrangement commonly seen in
gastric carcinoma. A cytoplasmic vacuole is present
in one of the single cells.
Explanatory Notes: A clean background or
lack of tumor diathesis is a common finding
compatible in metastatic rather than primary tumors
of the cervix. The differential diagnosis based on the
cytologic features includes metastatic breast
carcinoma.

de carcinoame
perimenopausal woman with large firm mass in the
cervixInterpretation: Other Malignant Neoplasms:
Small cell undifferentiated carcinoma
overlapping small cells with scant cytoplasm,
hyperchromatic nuclei, shows prominent nuclear
molding characteristic of small cell undifferentiated
carcinoma. Background tumor diathesis is present.
The lower right hand side insert illustrates the finely
granular, stippled chromatin and inconspicuous
nucleoli as well as nuclear molding; features typical
of neuroendocrine carcinoma.
Explanatory Notes: It is important to
recognize this tumor as distinct from poorly
differentiated squamous carcinoma with small cells.
The interpretation of small cell undifferentiated
carcinoma should be reserved for tumors composed
of small cells in which squamous or glandular
differentiation is absent or minimal. In the cervix,
these tumors are strongly associated with HPV 18, a
feature not identified in other primary sites. The
differential includes: poorly differentiated squamous
carcinoma with small cells, poorly differentiated
adenocarcinoma, low-grade endometrial stromal
sarcoma and lymphoma. If a liquid based specimen is
used, immunostaining for neuroendocrine markers
(NSE, synaptophysin, chromogranin) may be useful
to demonstrate neuroendocrine features.
Follow-up: Small cell undifferentiated
carcinoma of the cervix confirmed on biopsy
88
Citologie Vaginală ADK Extrauterin /Alte tipuri adenocarcinoma. Granular debris consistent with tumor diathesis is noted at
de carcinoame the edges of the cluster.
Clinical History: 68 year old woman with Explanatory Notes: MMMT commonly exfoliate as poorly
postmenopausal bleeding and an enlarged uterus on preserved malignant cells in cervical cytology samples. Only epithelial
pelvic exam clusters may be found resulting in an overlap with endometrioid
Interpretation: Other Malignantadenocarcinoma on the cytologic preparation.
Neoplasms: MMMT (carcinosarcoma) Follow-up: MMMT of endometrium
Cytomorphologic Criteria: These spindle
cells with round or oval pleomorphic nuclei, slightly
irregular nuclear membranes, and multiple prominent
nucleoli constitute the sarcomatoid component of this
tumor. These cells are admixed with the more
obvious epithelial component of the tumor (left upper
corner). The bloody background and tumor diathesis
are also represented in this picture.
Explanatory Notes: Sarcomatoid elements
are usually spindle cells. they may appear stromal,
fibroblastic or leiomyosarcomatous. Occasional
heterologous elements may include
rhabdomyosarcoma, chondrosarcoma or
osteosarcoma. In a poorly differentiated tumor a
separate sarcomatous and epithelial component may
be difficult to identify. A uterine sarcoma should be
considered in the differential diagnosis. (combine as
split screen with Misc-c-st8).
Follow-up: MMMT of endometrium
(hysterectomy)

de carcinoame
postmenopausal woman with extensive Paget disease
of vulva that appears to extend into the vaginal.
Interpretation: Other Malignant
Neoplasms: Paget disease
Cytomorphologic Criteria: The vaginal
smear has loosely cohesive groups and single cells
with pleomorphic hyperchromatic nuclei, irregular
clumped chromatin, prominent nucleoli, and
moderate amounts of cytoplasm. A cytoplasmic
vacuole within the binucleated cell is suggestive of
glandular differentiation.
Explanatory Notes: The cytologic features,
although diagnostic of malignancy and consistent
with adenocarcinoma, are not specific for Paget
disease. History and comparison with primary tumor
support that interpretation.
Follow-up: Compared with prior tissue

de carcinoame
postmenopausal bleeding and an enlarged uterus on
exam
Neoplasms: MMT (carcinosarcoma)
Cytomorphologic Criteria: A three-
dimensional cluster of epithelial cells with enlarged
round nuclei, macronucleoli and moderate amount of
finely vacuolated cytoplasm has features of
89
Citologie Vaginală ADK Extrauterin /Alte tipuri Clinical History: 89 year old woman with hx of high grade
de carcinoame urothelial carcinoma diagnosed two years previously
Clinical History: 32 year old woman with Interpretation: Other malignant neoplasms: metastatic transitional
soft polypoid lesion of the cervix cell carcinoma
Interpretation: Other Malignant Cytomorphologic Criteria: Single and small aggregates of
Neoplasms: Spindle Cell Carcinoma malignant cells are diagnostic of a poorly differentiated carcinoma. A mitotic
Cytomorphologic Criteria:This looselyfigure and a bloody background are also noted. The findings are compatible
cohesive group of spindled non-keratinizing cells with the patient's previous high grade tumor.
display variability in nuclear size, nuclear membrane Explanatory Notes: Transitional cell carcinoma is one of the most
irregularity, coarse granular chromatin and commonly encountered secondary tumors in cytologic cervical samples, and
conspicuous nucleoli. The cytologic features are may involve the cervix/ vagina by direct extension or as a pagetoid spread to
compatible with a malignant spindle cell neoplasm. the vagina. Its cytologic features may overlap with squamous cell carcinoma.
Explanatory Notes:In the absence of
keratinized cells, the cytologic features of this spindle
cell neoplasm are not specific. The findings may be
compatible with spindle cell sarcoma or malignant
melanoma. If liquid based cytology is used,
performing immunostains (keratin and S-100 protein)
may help classify the tumor.
Follow-up: Spindle cell carcinoma
(hysterectomy)

de carcinoame
Clinical History:64 year old
postmenopausal woman with extensive Paget disease
of vulva that appears to extend into the vagina
Neoplasms: Paget disease
Explanatory Notes:This tissue section of
the primary tumor from the vulva shows an
adenocarcinoma with cytologic features similar to
those displayed in the vaginal smear. Note the
presence of cytoplasmic vacuoles and the nesting of
malignant cells to the left.

de carcinoame
90
91

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7CITOLOGIE

NILM: NEGATIVE FOR INTRAEPITHELIAL LESION OR MALIGNANCY

ASC-US: Atypical squamous cells of undetermined significance

ASC-H: Atypical squamous cells cannot exclude HSIL

LSIL: Low grade squamous intraepithelial lesion

HSIL: High grade squamous intraepithelial lesion

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