Cytology Training Program:Cytology Training Program:Gyn Cytology Revision Exercise Gyn Cytology Revision Exercise

by Tony Chanby Tony ChanReference:Reference:

THE BETHESDA SYSTEM WEBSITE ATLTHE BETHESDA SYSTEM WEBSITE ATLAS AS

American Society of CytopathologyAmerican Society of Cytopathology

Select Your Interpretation Select Your Interpretation from below:from below:

NILM: Negative for Intraepithelial Lesion or Malignancy NILM: Negative for Intraepithelial Lesion or Malignancy Endometrial cells in a woman >= 40 Endometrial cells in a woman >= 40 ASC-US ASC-US ASC-H ASC-H LSIL LSIL HSIL HSIL Invasive Squamous Cell Carcinoma Invasive Squamous Cell Carcinoma Atypical Endocervical Cells Atypical Endocervical Cells Atypical Endometrial Cells Atypical Endometrial Cells Adenocarcinoma in situ (AIS), Endocervical Adenocarcinoma in situ (AIS), Endocervical Adenocarcinoma, EndocervicalAdenocarcinoma, Endocervical Adenocarcinoma, EndometrialAdenocarcinoma, Endometrial

27 year old woman, colposcopy vi27 year old woman, colposcopy visitsit

NILM: Fungal organisNILM: Fungal organisms consistent with Cms consistent with Candida sppandida spp

Pseudohyphae and rPseudohyphae and reactive changes in theactive changes in the squamous epithelie squamous epithelial cells.al cells.

31 year old31 year old

HSILHSIL

Important features of hiImportant features of high grade squamous intrgh grade squamous intraepithelial lesions are eaepithelial lesions are enlarged and/or high N/C nlarged and/or high N/C ratio, centrally placed nratio, centrally placed nuclei, hyperchromasia, auclei, hyperchromasia, and irregular nuclear mend irregular nuclear membranes.mbranes.

40 year old woman, history of squ40 year old woman, history of squamous cell carcinoma of the cerviamous cell carcinoma of the cervi

x. x. NILM: Reactive cellular changNILM: Reactive cellular chang

es associated with Radiationes associated with Radiation

Enlarged nuclei with abundaEnlarged nuclei with abundant polychromatic cytoplasm nt polychromatic cytoplasm with vacuolization. Mild nuclwith vacuolization. Mild nuclear hyperchromasia without ear hyperchromasia without coarse chromatin, prominent coarse chromatin, prominent nucleoli (coexisting repair). Nnucleoli (coexisting repair). Note multinucleation (upper riote multinucleation (upper right corner insert).ght corner insert).

What is your interpretation?What is your interpretation?

NILMNILM Pseudokoilocytosis: Pseudokoilocytosis:

cytoplasmic vacuolizcytoplasmic vacuolization without nucleaation without nuclear change of HPV effecr change of HPV effect.t.

67 year old woman with postmen67 year old woman with postmenopausal bleedingopausal bleeding

Adenocarcinoma, endometriAdenocarcinoma, endometrialal

Three-dimensional papillary Three-dimensional papillary cluster of abnormal cells with cluster of abnormal cells with irregular nuclear membranes irregular nuclear membranes and nucleoli. No evidence of fand nucleoli. No evidence of featheringeathering

Follow-up:Follow-up: adenocarcinoma of the endoadenocarcinoma of the endometrium, FIGO Grades I-IImetrium, FIGO Grades I-II

Just this cell seen. What’s your Just this cell seen. What’s your interpretation?interpretation?

ASC-US ASC-US Enlarged nuclei with Enlarged nuclei with

small perinuclear halsmall perinuclear haloo

Features are insufficiFeatures are insufficient for an interpretatent for an interpretation of LSIL.ion of LSIL.

27 year old woman. LMP two 27 year old woman. LMP two weeks agoweeks ago

ASC-H ASC-H Metaplastic cells witMetaplastic cells wit

h increased N:C ratioh increased N:C ratios and nuclear contous and nuclear contour irregularities.r irregularities.

HSIL on repeat Pap; HSIL on repeat Pap; CIN3 on LEEPCIN3 on LEEP

26 year old woman, LMP 2 weeks, mild 26 year old woman, LMP 2 weeks, mild vaginal dischargevaginal discharge

NILM: Reactive squaNILM: Reactive squamous cellular changmous cellular changes associated with Tres associated with Trichomonas vaginalisichomonas vaginalis

Trichomonas also seTrichomonas also seen. Where?en. Where?

What is your interpretation?What is your interpretation?

LSILLSIL

Binucleation and koilBinucleation and koilocytes in mildly dyspocytes in mildly dysplastic mature cells is lastic mature cells is consistent with HPV consistent with HPV effect.effect.

What is your interpretation?What is your interpretation?

HSILHSIL

"Keratinizing dysplasia". "Keratinizing dysplasia". The dysplastic cells in thThe dysplastic cells in this field display enlarged is field display enlarged nuclei with coarsely granuclei with coarsely granular chromatin and kernular chromatin and keratinized cytoplasm. Occatinized cytoplasm. Occasional cells have pyknoasional cells have pyknotic or opaque nuclei with tic or opaque nuclei with sharp, angled edges and sharp, angled edges and abnormal cell shapes arabnormal cell shapes are seen. e seen.

What is your interpretation?What is your interpretation?

NILM: Shift in Flora suggNILM: Shift in Flora suggestive of bacterial vaginestive of bacterial vaginosisosis

Filmy background of smFilmy background of small coccobacilli. Individuall coccobacilli. Individual squamous cells coveral squamous cells covered by a layer of bacteria. ed by a layer of bacteria. Conspicuous absence of Conspicuous absence of lactobacilli.lactobacilli.

58 year old woman, LMP 8 years, pos58 year old woman, LMP 8 years, postmenopausal bleeding tmenopausal bleeding

Adenocarcinoma, EndometrialAdenocarcinoma, Endometrial

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

In conventional smears, endomeIn conventional smears, endometrial adenocarcinoma tends to btrial adenocarcinoma tends to be associated with a thin watery de associated with a thin watery diathesis in contrast to the bloody,iathesis in contrast to the bloody, necrotic background often seen necrotic background often seen with endocervical adenocarcinowith endocervical adenocarcinoma.ma.

Follow-up: Adenocarcinoma of tFollow-up: Adenocarcinoma of the endometriumhe endometrium

What is your interpretation?What is your interpretation?

NILM: Cellular changes consisNILM: Cellular changes consistent with Herpes simplex virutent with Herpes simplex viruss

Note the intranuclear inclusiNote the intranuclear inclusions Vs nucleolions Vs nucleoli

The ground-glass appearancThe ground-glass appearance of the nuclei is due to accue of the nuclei is due to accumulation of viral particles leamulation of viral particles leading to peripheral marginatioding to peripheral margination of chromatin.n of chromatin.

45 year old45 year old

Squamous cell carcinomSquamous cell carcinomaa

Dysplastic squamous celDysplastic squamous cells with anisocytosis and ls with anisocytosis and anisonucleosis including anisonucleosis including keratinization and tadpokeratinization and tadpole cells are diagnostic of le cells are diagnostic of invasive squamous cell cinvasive squamous cell carcinoma.arcinoma.

41 yrs old, routine exam41 yrs old, routine exam

NILM: Endometrial NILM: Endometrial cells in a woman cells in a woman >= 40 >= 40

Three-dimensional Three-dimensional cluster with slightly cluster with slightly larger nuclei and larger nuclei and nucleoli.nucleoli.

39 year old woman, routine 39 year old woman, routine Pap smear, no LMP date givenPap smear, no LMP date given

Atypical endocervical cells, NAtypical endocervical cells, NOSOS

Sheet of cells with enlarged rSheet of cells with enlarged round or oval nuclei with proound or oval nuclei with prominent nucleoli. Chromatin is minent nucleoli. Chromatin is finely granular and evenly disfinely granular and evenly distributed but occasional chrotributed but occasional chromocenters are seen. Cell bormocenters are seen. Cell borders are well-defined. Mitotic ders are well-defined. Mitotic figures are noted.figures are noted.

63 year old woman with 63 year old woman with postmenopausal bleedingpostmenopausal bleeding

Atypical endometrial cellAtypical endometrial cellss

Aggregate of small cells Aggregate of small cells with slightly enlarged rouwith slightly enlarged round or oval nuclei, small nnd or oval nuclei, small nucleoli and finely vacuolaucleoli and finely vacuolated cytoplasm.ted cytoplasm.

Follow-up:Follow-up: Adenocarcinoma of the eAdenocarcinoma of the endometrium, grade Indometrium, grade I

32 years old, mother of 3 32 years old, mother of 3 childrenchildren

NILM: Reactive cellular changNILM: Reactive cellular changes associated with IUDes associated with IUD

Note small cluster of glandulNote small cluster of glandular cells with cytoplasmic vacar cells with cytoplasmic vacuoles displacing nuclei. The cuoles displacing nuclei. The cytoplasmic vacuoles may disytoplasmic vacuoles may displace the nucleus, creating a place the nucleus, creating a signet-ring appearance.signet-ring appearance.

What is your interpretation?What is your interpretation?

Squamous Cell CarcinoSquamous Cell Carcinoma-clinging diathesisma-clinging diathesis

Tumor diathesis, variatiTumor diathesis, variation in cell size and shape, on in cell size and shape, evidence of keratinizatioevidence of keratinization, and nuclear abnormaln, and nuclear abnormalities are all demonstrateities are all demonstrated in this image from a sqd in this image from a squamous cell carcinoma.uamous cell carcinoma.

41 year old. No history 41 year old. No history providedprovided

NILM: Bacteria morphologicaNILM: Bacteria morphologically consistent with Actinomyclly consistent with Actinomyces spp.es spp.

Tangled clumps of filamentoTangled clumps of filamentous organisms, often with acutus organisms, often with acute angle branching, sometimee angle branching, sometimes showing irregular wooly aps showing irregular wooly appearance. Swollen filaments pearance. Swollen filaments may be seen with clubs at permay be seen with clubs at periphery. A cotton ball like acutiphery. A cotton ball like acute inflammatory response is ce inflammatory response is common.ommon.

What is your interpretation?What is your interpretation?

NILM: Tubal metaplasiaNILM: Tubal metaplasia Cell group demonstratinCell group demonstratin

g crowding, pseudostratg crowding, pseudostratification and oval or eloification and oval or elongated nuclei. Note the ngated nuclei. Note the presence of cilia in some presence of cilia in some cells.cells.

What is your interpretation?What is your interpretation?

Endocervical adenocarcinoma Endocervical adenocarcinoma in situ (AIS)in situ (AIS)

Cluster of cells with crowded oCluster of cells with crowded overlapping oval nuclei that shverlapping oval nuclei that show hyperchromasia and evenlow hyperchromasia and evenly distributed by coarsely grany distributed by coarsely granular chromatin. Smear backgrular chromatin. Smear background is clean.ound is clean.

Nuclear crowding and overlapNuclear crowding and overlapping, hyperchromasia and eveping, hyperchromasia and evenly distributed granular chromnly distributed granular chromatin are classic features of AIS.atin are classic features of AIS.

39 year old female, Day 12 of cycl39 year old female, Day 12 of cyclee

Adenocarcinoma, EndocervicalAdenocarcinoma, Endocervical

Cluster of cells enlarged nuclei, Cluster of cells enlarged nuclei, macronucleoli and some nucleamacronucleoli and some nuclear membrane irregularities; poorr membrane irregularities; poorly defined, finely vacuolated cytly defined, finely vacuolated cytoplasm; ghost of RBC's and cell oplasm; ghost of RBC's and cell debris noted at the edge of the debris noted at the edge of the cluster ("clinging diathesis").cluster ("clinging diathesis").

Follow-up:Follow-up: Endocervical adenocarcinomaEndocervical adenocarcinoma

What is your interpretation?What is your interpretation?

HSILHSIL

HSIL with extension HSIL with extension into gland space. Note into gland space. Note that in addition to the that in addition to the abnormal cells abnormal cells themselves, there is themselves, there is flattening of cells at flattening of cells at the edge of the cluster, the edge of the cluster, lack of columnar shape lack of columnar shape and loss of polarity. and loss of polarity.

32 year old, LMP now, 32 year old, LMP now, abnormal cervix on examabnormal cervix on exam

Adenocarcinoma, endocervicalAdenocarcinoma, endocervical

Large group of abnormal cells witLarge group of abnormal cells with round to elongated hyperchromh round to elongated hyperchromatic nuclei and granular chromatiatic nuclei and granular chromatin. Note pseudostratified strips witn. Note pseudostratified strips with feathering at the edges. Nuclear h feathering at the edges. Nuclear crowding and overlap are promincrowding and overlap are prominent. Smear background is bloody.ent. Smear background is bloody.

The cytologic features of endocerThe cytologic features of endocervical adenocarcinoma may overlavical adenocarcinoma may overlap with those of endocervical adenp with those of endocervical adenocarcinoma in situ, but features oocarcinoma in situ, but features of invasion, such as tumor diathesif invasion, such as tumor diathesis, are seen.s, are seen.

Follow up: Follow up: Endocervical adenocarcinEndocervical adenocarcinomaoma

79 year old postmenopausal woman, bein79 year old postmenopausal woman, being evaluated for possible Squamous cell cag evaluated for possible Squamous cell ca

rcinoma of vulvarcinoma of vulva NILM: AtrophyNILM: Atrophy

Sheets of uniform orderlSheets of uniform orderly parabasal cells are obsy parabasal cells are observed representing deep erved representing deep parabasal cells. Some nparabasal cells. Some nuclei show grooves, but uclei show grooves, but chromatin pattern is finchromatin pattern is fine. Atrophic cells may have. Atrophic cells may have nucleoli (lower right ine nucleoli (lower right insert).sert).

End of ExerciseEnd of Exercise

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Self-test:Self-test:http://nih.techriver.net/diagnosis.phphttp://nih.techriver.net/diagnosis.php