Gyn Cytology Revision

							 Cytology Training Program:
Gyn Cytology Revision Exercise
        by Tony Chan
              Reference:
   THE BETHESDA SYSTEM WEBSITE
                ATLAS
   American Society of Cytopathology
      Select Your Interpretation
             from below:
   NILM: Negative for Intraepithelial Lesion or Malignancy
   Endometrial cells in a woman >= 40
   ASC-US
   ASC-H
   LSIL
   HSIL
   Invasive Squamous Cell Carcinoma
   Atypical Endocervical Cells
   Atypical Endometrial Cells
   Adenocarcinoma in situ (AIS), Endocervical
   Adenocarcinoma, Endocervical
   Adenocarcinoma, Endometrial
27 year old woman, colposcopy
             visit

                  NILM: Fungal
                   organisms consistent
                   with Candida spp

                  Pseudohyphae and
                   reactive changes in
                   the squamous
                   epithelial cells.
31 year old

         HSIL

         Important features of
          high grade squamous
          intraepithelial lesions are
          enlarged and/or high N/C
          ratio, centrally placed
          nuclei, hyperchromasia,
          and irregular nuclear
          membranes.
 40 year old woman, history of
squamous cell carcinoma of the
             cervix.
                  NILM: Reactive cellular
                   changes associated with
                   Radiation

                  Enlarged nuclei with abundant
                   polychromatic cytoplasm with
                   vacuolization. Mild nuclear
                   hyperchromasia without coarse
                   chromatin, prominent nucleoli
                   (coexisting repair). Note
                   multinucleation (upper right
                   corner insert).
What is your interpretation?
                 NILM
                 Pseudokoilocytosis:
                  cytoplasmic
                  vacuolization without
                  nuclear change of
                  HPV effect.
 67 year old woman with
postmenopausal bleeding
               Adenocarcinoma, endometrial

               Three-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
Just this cell seen. What’s your
         interpretation?
                   ASC-US
                   Enlarged nuclei with
                    small perinuclear halo
                    Features are
                    insufficient for an
                    interpretation of LSIL.
27 year old woman. LMP two
         weeks ago

                ASC-H
                Metaplastic cells with
                 increased N:C ratios
                 and nuclear contour
                 irregularities.

                HSIL on repeat Pap;
                 CIN3 on LEEP
26 year old woman, LMP 2 weeks, mild vaginal
                 discharge


                         NILM: Reactive
                          squamous cellular
                          changes associated
                          with Trichomonas
                          vaginalis

                         Trichomonas also
                          seen. Where?
What is your interpretation?
                 LSIL

                 Binucleation and
                  koilocytes in mildly
                  dysplastic mature
                  cells is consistent with
                  HPV effect.
What is your interpretation?
                 HSIL

                 "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.
What is your interpretation?
                 NILM: Shift in Flora
                  suggestive of bacterial
                  vaginosis

                 Filmy background of
                  small coccobacilli.
                  Individual squamous cells
                  covered by a layer of
                  bacteria. Conspicuous
                  absence of lactobacilli.
58 year old woman, LMP 8 years,
   postmenopausal bleeding
                  Adenocarcinoma, Endometrial

                  Large aggregate of small cells
                   with irregular chromatin
                   distribution, small nucleoli,
                   poorly defined finely
                   vacuolated cytoplasm in a
                   watery background.

                  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.

                  Follow-up: Adenocarcinoma of
                   the endometrium
What is your interpretation?
                 NILM: Cellular changes
                  consistent with Herpes simplex
                  virus

                 Note the intranuclear
                  inclusions Vs nucleoli

                 The ground-glass appearance
                  of the nuclei is due to
                  accumulation of viral particles
                  leading to peripheral
                  margination of chromatin.
45 year old

         Squamous cell carcinoma

         Dysplastic squamous cells
          with anisocytosis and
          anisonucleosis including
          keratinization and tadpole
          cells are diagnostic of
          invasive squamous cell
          carcinoma.
41 yrs old, routine exam
               NILM: Endometrial
                cells in a woman >=
                40
               Three-dimensional
                cluster with slightly
                larger nuclei and
                nucleoli.
39 year old woman, routine Pap
   smear, no LMP date given
                  Atypical endocervical cells,
                   NOS
                  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.
 63 year old woman with
postmenopausal bleeding
               Atypical endometrial cells

               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
32 years old, mother of 3 children
                    NILM: Reactive cellular
                     changes associated with IUD

                    Note small cluster of glandular
                     cells with cytoplasmic vacuoles
                     displacing nuclei. The
                     cytoplasmic vacuoles may
                     displace the nucleus, creating
                     a signet-ring appearance.
What is your interpretation?
                 Squamous Cell
                  Carcinoma-clinging
                  diathesis

                 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.
41 year old. No history provided

                   NILM: Bacteria morphologically
                    consistent with Actinomyces
                    spp.

                   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.
What is your interpretation?
                 NILM: Tubal metaplasia
                 Cell group demonstrating
                  crowding,
                  pseudostratification and
                  oval or elongated nuclei.
                  Note the presence of cilia
                  in some cells.
What is your interpretation?
                 Endocervical adenocarcinoma
                  in situ (AIS)

                 Cluster of cells with crowded
                  overlapping oval nuclei that
                  show hyperchromasia and
                  evenly distributed by coarsely
                  granular chromatin. Smear
                  background is clean.

                 Nuclear crowding and
                  overlapping, hyperchromasia
                  and evenly distributed granular
                  chromatin are classic features
                  of AIS.
39 year old female, Day 12 of cycle

                     Adenocarcinoma,
                      Endocervical

                     Cluster of cells
                      enlarged nuclei,
                      macronucleoli and
                      some nuclear
                      membrane
                      irregularities; poorly
                      defined, finely
                      vacuolated cytoplasm;
What is your interpretation?
                 HSIL

                 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.
32 year old, LMP now, abnormal
        cervix on exam
                  Adenocarcinoma, endocervical

                  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.

                  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.

                  Follow up: Endocervical
79 year old postmenopausal woman, being
   evaluated for possible Squamous cell
            carcinoma of vulva
                       NILM: Atrophy

                       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).
              End of Exercise

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