Latest revision as of 21:46, 13 August 2024

A cytology specimen with LSIL. Pap stain. (WC/Nephron)

Gynecologic cytopathology is a subset of cytopathology. Gynecologic usually refers to Pap test specimens, i.e. uterine cervix, vaginal vault; other gynecologic specimens are considered non-gynecologic.

This article deals only with cervical cytopathology. An introduction to cytopathology is in the cytopathology article.

Cervical cytology redirects to this article.

Preparation

The standard for Pap test is the Papanicolaou stain. It is described in the staining article and discussed in the context of cytopathology in the cytopathology article.

Slide marking conventions

Conventions are important for facilitating communication between various team members. They are discussed in the cytopathology article.

Normal cells

Squamous cell types:^[1]

Intermediate cells:
- In clusters or single.
- 30-50 micrometres in diameter.
- Associated with progesterone - (light) blue.
- This is the cell of reference in Pap test, i.e. other cells are measured against this cell when assessing a Pap test.
  - Nucleus ~ 7-8 micrometers.
    - Slightly smaller than a neutrophil.
Parabasal cells:
- Blue-grey.
- Associated with atrophy.
Basal cells:
- Small cells.
- Rarely seen.
Superficial cell:^[2]
- Nucleus smaller than for intermediate cell.
- Cytoplasm red.
  - Orange staining superficial cells are hypermature - suggests (abnormal) keratinization.

Glandular cells:^[3]

Sheets of cells with regular spacing.
Relatively high NC ratio (when compared to intermediate cells).
Nucleoli (like most glandular cells).
Nucleus approximately the size of an intermediate cell nucleus.

Images

Endocervical epithelium - high mag. (WC)
Endocervical epithelium - very high mag. (WC)
Endocervical epithelium - high mag. (WC)
Endocervical epithelium - very high mag. (WC)
Endocervical epithelium - high mag. (WC)
Endocervical epithelium - very high mag. (WC)

Endocervical cells and LSIL. (WC)

Mix of cells

The mix of cells is dependent on age and hormones:^[4]

Progesterone - makes the Pap test blue... more intermediate cells.
Yonger patients have a mix of cells.
Menopausal patients... more parabasal cells.
Older patients... more estrogen, glycogen.

Less common non-malignant cells

Clue cells.
Squamous metaplastic cells.
Endometrial cells.
Atrophic cells.
Tingible body macrophages.
Navicular cells.

Clue cells

Features:

Purple squamous cell covered with rod-shaped bacteria.

Notes:

The cytologic finding of bacterial vaginosis.

Image:

Clue cell (atsu.edu).

Squamous metaplastic cells

Features:

"Dense" cytoplasm.
Nucleus ~2X the size of an intermediate cell nucleus.
- Nucleolus (small) - important.
- Regular/smooth nuclear membrane.

Note:

Squamous metaplastic cells have a similar appearance to parabasal cells; they cannot be differentiated on morphologic grounds.
Squamous metaplastic cells have a high NC ratio - they are differentiated from HSIL via nuclear features (dark staining + irregular nuclear contour = HSIL).
- Slight nuc. contour irregularies are accepted, may be darker staining.

Images

SM - high mag. (WC)
SM - very high mag. (WC)
SM - very high mag. (WC)

Endometrial cells

Features:^[5]

Cluster of cells with a well-defined border that is bilayered, i.e. a clump of (epithelioid) stromal cells surrounded by (flatted) glandular cells. Classically described as a cluster with a double contour; known as exodus pattern.^[6]
Scant cytoplasm.
Chromatin clumping.
Raisin-like nuclei - approximately the size of an intermediate cell nucleus.
- Nuclei can be considered normal if nucleus less than 2X the size of an intermediate cell nucleus.

Notes:

Endometrial cells may appear irregular in the context of an intrauterine device (IUD); abnormalities in the context of an IUD are often ignored.
- Cytology: cytoplasmic vacuolization, +/-multinucleation.
  - May be signet ring cell-like.
The presence of endometrial cells on a Pap test on a woman >=40 years old (per Bethesda guidelines) should be noted in the pathology report^[7] - this prompts an endometrial biopsy.
- The practise of reporting benign endometrial cells in premenopausal women is not backed by evidence that demonstrates a significant benefit.

Images

Endometrial cells - very high mag.
Endometrial cells - very high mag.
Endometrial cells - very high mag.
Endometrial cells - very high mag.

Endometrial cells - high mag.
Endometrial cells - very high mag.
Endometrial cells - very high mag.

www:

Atrophic cells

Features:^[8]

Cells smaller.
Cytoplasm grey/blue.
No "dancing"/"sparkling" chromatin.
+/-"Dirty" background - degenerated cells, inflammatory cells (neutrophils, histiocytes).
- May mimic "dirty" background of tumour, i.e. 'tumour diathesis'.

Notes:

Usually older women.
May be a cellular cluster.

DDx:

HSIL - chromatin pattern irregular.

Tingible body macrophages

Features:

Abundant cytoplasm with vacuolization.
May be seen in the context of chlamydia.

Navicular cells

Main article: Navicular cell

Features:

Intermediate cells with:
1. Folded edges.
2. Abundant cytoplasmic glycogen - central yellow.

Images

NC - very high mag.
NC - very high mag.
NC - extremely high mag.
NCs - extremely high mag.

Glycogen halos versus HPV effect

	HPV effect (koilocyte)	Glycogen halo
Discolouration of halo	Clear	Yellow
Nuclear changes	Associated with nuc. changes	Normal nuclei
Cell-to-cell variability	No - all clear	Yes - some yellow some clear

Gynecologic pathology in tables

Normal cells

Cell	Architecture	Cell borders	Cytoplasm	DNA	DDx
Intermediate cell (IC)	Single cells	Irregular	Blue, abundant	Small nucleus (~ size of PMN), no nucleolus	-
Superficial cell (SC)	Single cells	Irregular	Red, abundant	Small nucleus, 1/2 size of IC nucleus, no nucleolus	-
Squamous metaplastic cell	Single cells/clumps of cells	Smooth/oviod shape	Dense, dark blue	2X IC nucleus, nucleolus, no membrane irreg., no chromatin changes	DDx: HSIL, basal cell
Endometrial cell	Well-circumscribed clump/ball of cells with squamoid covering cells; referred to as "exodus" pattern^[9]	Indistinct within cluster	Blue, small/very scant	Small, dark, nuclear moulding, degenerative changes (chromatin clumping)	DDx: HSIL, basal cell.
Glandular (endocervical) cell	Sheets of cells with regular spacing, columnar morphology may be apparent, +/-palisading at edge of clump	Often distict	Blue, scant-to-moderate	Nucleus ~ size of an IC nucleus, no membrane irreg., no chromatin changes	DDx: endometrial cell
Atrophy	Single cells/groups	Well-circumscribed	Grey/blue dense, may be scant	Large NC ratio, nuc. membrane irregularities, NO chromatin clumping^[10]	DDx: HSIL
Radiation changes	Single cells/groups	Well-circumscribed	vacuolated, usu. abundant	Normal NC ratio, enlarged nucleus, no nuclear membrane irregularies, +/-multinucleation	DDx: LSIL, vitamin B12 def.

Note:

If only normal cells are present the diagnosis is negative for intraepithelial lesion and malignancy (NILM).

Abnormal cells

Cell	Architecture	Cell borders	Cytoplasm	DNA	Other	Image
Low-grade squamous intraepithelial lesion (LSIL)	Single cells/groups	Irregular or moderately-circumscribed	Blue, abundant - NC ratio ~ 1:3	Large nucleus (3-4X IC nuc. - see Note 1), perinuclear clearing, nuc. membrane irregularities, chromatin clumping	DDx: HSIL, reactive changes	LSIL (WC)
High-grade squamous intraepithelial lesion (HSIL)	Often single cells, may be groups	Well-circumscribed	Dark blue, scant - NC ratio ~ 1:2	Large nucleus (3-4X IC nuc. - see Note 1), nuc. membrane irregularities, clumping of coarse chromatin, dark nuc. staining, +/- small nucleoli	DDx: squamous metaplasia, atrophy with atypia, superficial endometrial cells	HSIL (WC)
Atypical squamous cells of undetermined significance (ASC-US)	Single cells/groups	Irregular or moderately-circumscribed	Blue, abundant cytoplasm	Moderately enlarged nucleus (~2.5-3.0X IC nuc.), minimal changes in nuclear membrane and chromatin	DDx: LSIL, reactive changes
Atypical squamous cells, cannot exclude HSIL (ASC-H)	Often single cells, may be groups	Irregular or moderately-circumscribed	Blue, moderate-to-scant cytoplasm	Moderately enlarged nucleus (~1.5-2.0X IC nuc.), minimal changes in nuclear membrane and chromatin	DDx: HSIL, AIS
Atypical glandular cells (AGC)	Usu. groups of cells	Usually well-circumscribed (?)	Dark blue dense, scant	Moderately enlarged nucleus (~2X IC nuc.), nuc. membrane irregularities, chromatin clumping, dark nuc. staining, nucleoli	DDx: AIS, HSIL
Adenocarcinoma in situ (AIS)	groups; rosette formation	Usually well-circumscribed	Dark blue dense, scant	Large nucleus (>=2X IC nuc.), nuc. membrane irregularities, chromatin clumping, dark nuc. staining, nucleoli (very common), pseudostratification (as in endocervical AIS)	DDx: AGC, HSIL	Endocervical AIS (WC)
Features of SCC (see Note 2)	Large clusters of cells with irreg. edge and "streaming", +/-blood, necrotic debris	Poorly seen	Dark blue dense, scant	Large NC ratio, nucleolus, nuc. membrane irregularities, chromatin clumping	DDx: HSIL

Note 1:

LSIL/HSIL nucleus - at least 3X IC nucleus.
- ASCUS nucleus - at least 2.5X IC nucleus.
  - 3X is not an absolute requirement to call SIL, i.e. SIL may be called with a smaller nucleus in circumstances where other nuclear features are at the extremus of malignant.
Large nuclear size, membrane irregularities, "clumpy" chromatin and dark nuc. staining - are the key features.
- Perinuclear clearing is quite subjective.
  - The best perinuclear halos have a sharp punched-out edge.

Note 2:

By definition, it is not possible to diagnose squamous cell carcinoma (SCC) on a pap test as one cannot demonstrate stromal invasion.

HSIL versus LSIL

	HSIL	LSIL
NC ratio^[11] - see Note 1	~1:2	~1:3
Nuclear membrane irregularities	Marked - distinct notches	Moderate
Chromatin granularity	Coarse, clumped, +/-nucleolus (red)	Coarse, no nucleolus
Cytoplasmic staining	Dark	Light
Perinuclear clearing	Usually absent	Often present
Binucleation	Uncommon	May be present
Maturity of squamous cell	Normal maturity	Hypermature (orangeophilic cell present)
Images (example)	HSIL (WC) HSIL (WC)	LSIL (WC) LSIL & endoCx (WC)

Note 1:

The single most useful feature is NC ratio but it is not definitive; NC ratio should be evaluated in the context of nuclear irregularities (nuclear membrane smoothness, chromatin pattern, presence of nucleolus).^[11]
It may be easier to think in terms of cell size - approximate values are:
- HSIL cells: < 1/2 size of IC.
- LSIL cells: classically the size of IC.

Infectious organisms

Disease	Organism	Group	Dx features	Associated features	Clinical	Reference	Image
Trichomoniasis	Trichomonas vaginalis	Protozoan	Pear-shaped pale-grey fluffy cytoplasm with well-defined nucleus, approx. 30 μm.	Acute inflammation (PMNs), may be seen with Leptothrix (hair-like appearance ~0.5 x 20 μm)	Sexually transmitted	^[12]	T. vaginalis - Pap stain (WC) Trichomonas - Pap stain (WC)
Candidiasis	Candida albicans	Fungi	Branching hyphae ~= 1/2 the dia. of IC nucleus, red	PMNs	?	?	Candida on Pap test (WC)
Herpes	Herpes simplex virus (HSV 1 - less commonly, HSV 2 - more commonly)	Virus	Large ground glass nuclei then multinucleation with moulding & inclusions with clear halo	?	Sexually transmitted	?	HSV (WC) HSV (WC)
Actinomycetes	Actinomycetes	Gram-positive bacteria	Clusters of cocci in chains - hyphae-like appearance	low power: pom-pom or fuzzy ball-like appearance	Should prompt removal of IUD, if present.	^[12]	Actinomycetes (gfmer.ch), Actinomycetes (quizlet.com)
Bacterial vaginosis (see Note 1)	Gardnerella vaginalis	Gram-variable rod	"Clue cell": bacterial clusters attached to a purple squamous cell	? Assoc.	Fishy smell	?	Bacterial vaginosis (WC) Clue cell (atsu.edu)

Note 1:

Usually not reported.

Adequacy of specimens

There is a generally accepted standard for cervical (liquid-based) cytology specimens:^[13]

>5000 squamous cells/slide, if no abnormality is present.
- If abnormal cells are present, any number of cells is acceptable.
  - This works-out to approx. 4 cells/HPF.
    - Where: HPF = area seen at 400X with an eye piece diameter is ~22 mm.
  - 10 HPFs are counted and a table is used to see whether the sample is adequate.

Note:

The standard for conventional pap smears is: 8000-12000 (well-visualized) squamous cells.^[14]

Transformation zone (TZ)

The presence of the TZ should be commented on:^[15]

An adequate TZ is 10 cells - endocervical cells or squamous metaplastic cells (per Bethesda).

Difficulties in obtaining a TZ may arise in the following populations:

Pregnant (endocervical canal not sampled).
Menopausal.
Young nulliparous.

Specific entities - infectious

Candida

Main article: Candidiasis

General

Common.
May be asymptomatic.
Usually Candida albicans.

Cytology

Features:

Typically in clusters - lead to darkened clusters of squamous cells (at low power).
May appear to "shish kabob" the cell; may appear to puncture the cell membrane (as they overlie it).
Red staining hyphae; width of hyphae ~= 1/2 the diameter of an intermediate cell nucleus; branches.

Notes:

Presence should be noted in the pathology report.

Images

Candida on Pap test - example 1. (WC)
Candida on Pap test - example 2. (WC)

Candida - high mag. (WC)
Candida - very high mag. (WC)

www

Candida on Pap test (flickr.com).

Trichomoniasis

General

Caused by Trichomonas vaginalis - a protozoa.
Sexually transmitted.
Common.
Occasionally found in urine cytology specimens.^[16]

Cytopathology

Features:

Low power: grey blob with a nucleus, may be pear-shaped:
- Size: approximately 30 micrometres.^[12]
- Shape: usually oval, may have teardrop-shaped.
- Flagellum - hair-thin locomotive stucture, usu. barely visible at 200X - diagnostic feature.

Cytopathological associations:

Acute inflammation (neutrophils), often marked - key feature at low power.
Reactive squamous cells with:
- Nucleoli,
- Perinuclear halos, and
- Moth-eaten cytoplasm; cytoplasm that has multiple vacuoles with star-like spaces.

Notes:

Trichomonas is tricky - it is easy to miss if one is not suspicious, in the context of inflammation.
May vaguely resemble a neutrophil:
- Flagellum useful to differentiate.
- Neutrophil has multiple lobulations of the nucleus.
May be seen in association of Leptothrix.
- Appearance: long, hair-like.
- Size: ~0.5 x 20 micrometres.

Images

T. vaginalis - Pap stain. (WC)
T. vaginalis - Pap stain. (WC)
Trichomonas vaginalis - Giemsa stain. (WC)

Trichomonas - high mag.
Trichomonas - very high mag.

Trichomonas - high mag.
Trichomonas - very high mag.

www

Herpes simplex virus

Main article: Herpes simplex virus

General

May be HSV1 or HSV2.
- Classically HSV2 based on epidemiology and location.

Cytology

Features:^[12]

Early: Large "ground-glass" nuclei - nuclei with hazy & uniformly dull appearance.
Late: multi-nucleation with moulding of nuclei and nuclear inclusions surrounded by a clear halo.

DDx:

Reactive endocervical cells - may be multinucleated.

Image

HSV on pap test. (WC)

Actinomycetes

Main article: Actinomycetes

General

Presence should prompt removal of intrauterine device (IUD), if present.^[12]
Gram-positive bacteria.
Microorganism part of the large Actinobacteria group.

Cytopathology

Features:^[12]

Clusters of filamentous bacteria.
- Hyphae-like appearance/"filamentous".

Notes:

Mycete = fungus.^[17]

DDx - sulfur granule:^[18]

Hematoidin (cockleburr) crystal - radiating crystal, refractile, classically golden-brown.

Bacterial vaginosis

General

Benign.
Very common.
Classically associated with Gardnerella vaginalis.^[19]^[20]

Clinical:

Fishy odor.

Treatment:

Antibiotics (metronidazole or clindamycin).^[20]

Cytopathology

Features:

Purple squamous cell covered with rod-shaped micro-organisms.

Image:

Clue cell (atsu.edu).

Stains

Gram stain +ve/-ve.
- Gardnerella vaginalis is a gram variable rod.^[21]

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Usually not reported.

Squamous intraepithelial lesions

Abbreviated SIL.

General:

The nucleus makes it SIL.
The cytoplasm determines the grade (LSIL vs. HSIL).

Management (in short):

LSIL = repeat Pap test in 6 months.
HSIL = referral for coloposcopy.

Low-grade squamous intraepithelial lesion

Abbreviated LSIL.

Main article: Low-grade squamous intraepithelial lesion

General

Usually regress, i.e. will disappear on their own.
Low inter-rater concordance.^[22]

Cytopathology

Features:

Nuclei 3x size of intermediate cell - key feature. †
Irregular nuclear border.
+/-Perinuclear 'cavity' (clearing).
- The best perinuclear halos have a sharp punched-out edge.
Chromatin clumping/irregular & granular.

Note:

† Nucleus diameter ~21-24 μm.
In the context of exams: 2 of criteria 1-3 is enough to call LSIL.^[23]

Images

LSIL with HPV effect. (WC)
LSIL. (WC)
LSIL. (WC)

www:

Possible LSIL (flickr.com).

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Low grade squamous intraepithelial lesion (LSIL).

Cannot exclude HSIL

At least low grade squamous intraepithelial lesion; CANNOT EXCLUDE high-grade squamous intraepithelial lesion.

High-grade squamous intraepithelial lesion

Abbreviated HSIL.

Main article: Squamous intraepithelial lesion of the uterine cervix

General

Often progress to cervical cancer.

Cytopathology

Features:

Often single cells, may be in clusters.
Blue cells - nucleus and cytoplasm.
Increased NC ratio - key feature.
- Irregular nuclear border.
- Chromatin clumping.

Note:

Nucleoli uncommon - should prompt consideration of squamous carcinoma.

DDx:

Images

HSIL. (WC)
HSIL. (WC/Nephron)

Squamous cell carcinoma

Abbreviated SCC.

Main article: Squamous cell carcinoma

Some believe that one can diagnosis SCC on a pap test.
- This is nonsense, as SCC implies invasion which cannot be seen on a pap test.

Features suggestive of invasion:

Loose clumps of ovoid-to-spindled cells with:
- +/-Orange/red cytoplasm (orangeophilic cytoplasm).
- Nucleoli - key feature.
- Coarse chromatin.
- Nuclear hyperchromasia.
Necrotic debris - often obscures cell borders:
- Anucleate, fragmented cells - cytoplasm-like material.
- Neutrophils.

Note:

Nucleoli DDx:
- Reactive changes.
- Glandular lesions (adenocarcinoma in situ, atypical glandular cells).

Image:

HSIL with features suggestive of invasion (WC)

Glandular lesions

Adenocarcinoma in situ

Abbreviated AIS.

Adenocarcinoma in situ on Pap test is classically divided into:

Endocervical.
Uterine.
Extra-uterine.

Adenocarcinoma vs. squamous carcinoma:

Adenocarcinoma:
- Mucin vacuole.
- Eccentric nucleus.
Endocervical adenocarcinoma in situ:
- "Feathering" - seen in adenocarcinoma^[24] more commonly on smears.^[25]
- "Birdtails" - seen on liquid preparations.
Squamous carcinoma:
- Orangeophilic cytoplasm.
- Central nucleus.

Images

www:

Endocervical adenocarcinoma in situ

Main article: Endocervical adenocarcinoma in situ

AKA adenocarcinoma in situ of the endocervix.

General

Associated with HPV.
- May be seen in conjunction with a SIL.
Management - like AGC and other types of AIS: coloscopy +/- endometrial biopsy.

Cytopathology

Features:

Cluster of small cells with:
- Moderate nuclear enlargement.
- Coarse chromatin.
- Nucleoli - prominent - key feature.
- +/-Mitoses.
"Feathering" - picket fence-like arrangement of the cells at the edge of the cell cluster.
Apoptotic/necrotic cells.

Negatives:

Lack cilia.
- Cilia on cells is a feature of benignancy and should sway the pathologist away from adenocarcinoma.

DDx:

AGC - no prominent nucleoli, not 3-dimensional.
Endometrial adenocarcinoma in situ.
Metastatic colorectal adenocarcinoma.
Lower uterine segment epithelium^[26] - esp. proliferative phase endometrium - mitoses rare, NC ratio normal.

Image

ECAIS - high mag. (WC)
ECAIS - very high mag. (WC)
ECAIS - very high mag. (WC)
ECAIS - high mag. (WC)
ECAIS - very high mag. (WC)

Endocervical AIS. (WC/euthman)

Endometrial adenocarcinoma in situ

AKA adenocarcinoma in situ of the endometrium.

General

Management - like AGC and other types of AIS: coloscopy + endometrial biopsy.

Cytopathology

Features:

Single cells or cluster of small cells with:
- Moderate nuclear enlargement ~2x intermediate cell nucleus.
- Nuclear hyperchromasia.
- Coarse chromatin.
- Nucleoli - prominent - key feature.
- +/-Mitoses.
- +/-Intracytoplasmic neutrophils.
Apoptotic/necrotic cells.
+/-Psammoma bodies.
- Suggestive of serous carcinoma of the endometrium.

DDx:

AGC - no prominent nucleoli, not 3-dimensional.
Endocervical adenocarcinoma in situ.

Waffle categories

Like all waffle diagnoses, these should be used sparingly.

Atypical squamous cells of undetermined significance

Abbreviated ASC-US or ASCUS.

General

This is a waffle category that should be used sparingly.
- The ASCUS/LSIL rate is used as a quality measure^[27] - the specific ratios are dependent on how they specimens are processed.^[28]
Diagnosis may be an indication for HPV testing.

Cytology

Features:

Squamous differentiation:
- Central nucleus.
- Dense/solid-appearing cytoplasm.
Nuclear size >2.5X IC nucleus, but <3X IC nucleus.
+/-Orange/red cytoplasmic (orangeophilic cytoplasm).^[29]

Note:

One should not see nucleoli.
- Nucleoli are seen in reactive changes and squamous cell carcinoma of the uterine cervix.
The IC nucleus is ~ 8 μm.^[30]

DDx:

NILM.
LSIL.

Images

ASCUS - high mag. (WC)
ASCUS - very high mag. (WC)
ASCUS - high mag. (WC)
ASCUS - very high mag. (WC)
ASCUS - very high mag. (WC)

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Atypical squamous cells of undetermined significance (ASC-US).

Atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion

Abbreviated ASC-H.

General

This is a waffle category that should be used very rarely.
Higher HPV positivity vs. ASC-US.^[31]
Management - like HSIL: colposcopy.

Cytology

Features:

Atypia that falls short of diagnosing HSIL:
- Increased NC ratio.
Architecture: cell clusters or rare single cells.

DDx:^[32]

HSIL.
NILM - atrophy, parabasal cells.
LSIL.

Atypical glandular cells

Abbreviated AGC.
Previously atypical glandular cells of undetermined significance, abbreviated AGUS.

General

Waffle diagnosis.
Clinical management, like AIS: coloscopy +/- endometrial biopsy.

May represent either:

Endocervical cells, i.e. atypical endocervical cells (AEC).
Endometrial cells, i.e. atypical endometrial cell (AEM).

Microscopic

Features:

Atypical glandular cells:
- Cell cluster with cells with a diameter <= 2x intermediate cell nucleus.
- Some features of nuclear atypia, e.g. irregular nuclear membrane, granular chromatin, nuclear hyperchromasia, nuclear enlargement.

DDx:

Adenocarcinoma in situ.

Uncommon stuff

Follicular cervicitis

General

Uncommon. (???)
Finding may be associated with Chlamydia trachomatis.^[33]

Cytology

Features:^[34]

Discohesive clusters of small (lymphoid) cells with interspersed:
- Tingible-body macrophages.
- Plasma cells.

DDx:

AGC - nuclei larger, more cohesive

Image:

Follicular cervicitis (nih.techriver.net).

Hematoidin crystal

AKA hematoidin cockleburr.
AKA cockleburr.

General

Rare.
Benign.
Associated with hemorrhage in pregnancy.^[35]

Note:

Overlap with crystalline bodies. (???)
- Crystalline bodies associated with pregnancy, and OCP use.^[35]

Cytology

Features:^[18]^[36]

Radiating crystal.
Refractile.
Classically golden-brown.
+/-Surrounded by macrophages.

DDx:

Sulfur granule of Actinomycetes.

Images:

Carpet beetle larval parts

General

Uncommon distinctive contaminant.^[37]
Fragment of a beetle.
Benign.

Cytology

Features:

Slender long structure - fern-like.

Note:

One may have a complete insect.^[38]

Image:

Carpet beetle (archivesofpathology.org).

Radiation changes in cervical cytology

Main article: Radiation changes

General

Radiation is used to treat cervical cancer.

Cytology

Features:^[39]

Architecture: single cells/groups.
Cell borders: well-circumscribed.
Cytoplasm: vacuolated, usually abundant.
Nucleus:
- Enlarged nucleus - but normal NC ratio.
- No nuclear membrane irregularies.
- Chromatin: "smudgy".
- +/-Multinucleation.

DDx:

LSIL.
Vitamin B12 deficiency.

Images:

Cornflaking artifact

General

Processing artifact - due to air under the cover slip.^[40]

Cytology

Features:^[40]

Central brown discolourization in squamous cells.

Images:

Endocervical repair

General

Benign.

Cytology

Features:

Cluster of (2-dimensional) glandular cells with:
- Streaming (school of fish-appearance).
- Prominent nucleoli.
- Neutrophils.

Image:

Reactive endocervical cells (nih.techriver.net).

Historical

Maturation index

Abbreviated MI.

General

Based on vaginal wall scrape.

Definition

$MI=P:I:S$ .

Where:

P = number of parabasal cells / 300 squamous cells * 100 %.
I = number of intermediate cells / 300 squamous cells * 100 %.
S = number of superficial cells / 300 squamous cells * 100 %.

Interpretation

Common patterns:

Superficial predominant, no parabasal = high estrogen effect.
Parabasal predominant, no superficial = atrophy.

Examples:

70 : 30 : 0 is an atrophic pattern.
0 : 30 : 70 is a high estrogen pattern.

Note:

Significant inflammation distorts the result.

References

↑ Half-day. 10 November 2008.
↑ SM. 14 January 2010.
↑ SM. 14 January 2010.
↑ GR. 4 February 2010.
↑ SM. 14 January 2010.
↑ URL: http://nih.techriver.net/view.php?patientId=78. Accessed on: 31 March 2012.
↑ Thrall MJ, Kjeldahl KS, Savik K, Gulbahce HE, Pambuccian SE (August 2005). "Significance of benign endometrial cells in papanicolaou tests from women aged >=40 years". Cancer 105 (4): 207-16. doi:10.1002/cncr.21156. PMID 15900572.
↑ DeMay, RM. The Art & Science of Cytopathology: Exfoliative Cytology. 1996. ISBN 0-89189-322-9. PP.116-7.
↑ URL: http://nih.techriver.net/view.php?patientId=221. Accessed on: 26 November 2011.
↑ DeMay, RM. The Art & Science of Cytopathology: Exfoliative Cytology. 1996. ISBN 0-89189-322-9. PP.116-7.
↑ ^11.0 ^11.1 Slater, DN.; Rice, S.; Stewart, R.; Melling, SE.; Hewer, EM.; Smith, JH. (Aug 2005). "Proposed Sheffield quantitative criteria in cervical cytology to assist the diagnosis and grading of squamous intra-epithelial lesions, as some Bethesda system definitions require amendment.". Cytopathology 16 (4): 168-78. doi:10.1111/j.1365-2303.2005.00264.x. PMID 16048503. http://www3.interscience.wiley.com/journal/118661591/abstract?CRETRY=1&SRETRY=0.
↑ ^12.0 ^12.1 ^12.2 ^12.3 ^12.4 ^12.5 Humphrey, Peter A; Dehner, Louis P; Pfeifer, John D (2008). The Washington Manual of Surgical Pathology (1st ed.). Lippincott Williams & Wilkins. pp. 446. ISBN 978-0781765275.
↑ UHN PCY50001.08 P.10.
↑ Sheffield, MV.; Simsir, A.; Talley, L.; Roberson, AJ.; Elgert, PA.; Chhieng, DC. (Mar 2003). "Interobserver variability in assessing adequacy of the squamous component in conventional cervicovaginal smears.". Am J Clin Pathol 119 (3): 367-73. PMID 12645338.
↑ GR. 4 February 2010.
↑ Doxtader EE, Elsheikh TM (January 2017). "Diagnosis of trichomoniasis in men by urine cytology". Cancer Cytopathol 125 (1): 55–59. doi:10.1002/cncy.21778. PMID 27636204.
↑ URL: http://en.wiktionary.org/wiki/-mycete#English. Accessed on: 14 September 2011.
↑ ^18.0 ^18.1 ^18.2 URL: http://www.cytology-asc.com/cec/normal/index.htm#cockle. Accessed on: 10 April 2012.
↑ Scott TG, Smyth CJ, Keane CT (February 1987). "In vitro adhesiveness and biotype of Gardnerella vaginalis strains in relation to the occurrence of clue cells in vaginal discharges". Genitourinary medicine 63 (1): 47–53. PMC 1194007. PMID 3493202. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1194007/.
↑ ^20.0 ^20.1 Polatti, F. (Feb 2012). "Bacterial vaginosis, Atopobium vaginae and nifuratel.". Curr Clin Pharmacol 7 (1): 36-40. PMID 22082330.
↑ Taylor-Robinson D (1984). "The bacteriology of Gardnerella vaginalis". Scand J Urol Nephrol Suppl 86: 41–55. PMID 6399409.
↑ Bigras, G.; Wilson, J.; Russell, L.; Johnson, G.; Morel, D.; Saddik, M. (Feb 2013). "Interobserver concordance in the assessment of features used for the diagnosis of cervical atypical squamous cells and squamous intraepithelial lesions (ASC-US, ASC-H, LSIL and HSIL).". Cytopathology 24 (1): 44-51. doi:10.1111/j.1365-2303.2011.00930.x. PMID 22007754.
↑ Chan, S. 26 April 2012.
↑ URL: http://www.cytology-asc.com/cec/endocx/. Accessed on: 13 September 2011.
↑ Belsley, NA.; Tambouret, RH.; Misdraji, J.; Muzikansky, A.; Russell, DK.; Wilbur, DC. (Apr 2008). "Cytologic features of endocervical glandular lesions: comparison of SurePath, ThinPrep, and conventional smear specimen preparations.". Diagn Cytopathol 36 (4): 232-7. doi:10.1002/dc.20782. PMID 18335553.
↑ Nucci, Marisa R.; Oliva, Esther (2009). Gynecologic Pathology: A Volume in Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 167. ISBN 978-0443069208.
↑ Duggan, MA. (Mar 2000). "Cytologic and histologic diagnosis and significance of controversial squamous lesions of the uterine cervix.". Mod Pathol 13 (3): 252-60. doi:10.1038/modpathol.3880046. PMID 10757336.
↑ URL: http://www.cap.org/apps/docs/proficiency_testing/CYP07600.pdf. Accessed on: 2 May 2012.
↑ Owens, CL.; Ali, SZ. (Dec 2005). "Atypical squamous cells in exfoliative urinary cytology: clinicopathologic correlates.". Diagn Cytopathol 33 (6): 394-8. doi:10.1002/dc.20344. PMID 16299739.
↑ URL: http://www.curran.pwp.blueyonder.co.uk/cytology.htm. Accessed on: 5 November 2012.
↑ Srodon, M.; Parry Dilworth, H.; Ronnett, BM. (Feb 2006). "Atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion: diagnostic performance, human papillomavirus testing, and follow-up results.". Cancer 108 (1): 32-8. doi:10.1002/cncr.21388. PMID 16136595.
↑ Chivukula, M.; Shidham, VB. (2006). "ASC-H in Pap test--definitive categorization of cytomorphological spectrum.". Cytojournal 3: 14. doi:10.1186/1742-6413-3-14. PMC 1524979. PMID 16686950. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1524979/.
↑ Hare, MJ.; Toone, E.; Taylor-Robinson, D.; Evans, RT.; Furr, PM.; Cooper, P.; Oates, JK. (Feb 1981). "Follicular cervicitis--colposcopic appearances and association with Chlamydia trachomatis.". Br J Obstet Gynaecol 88 (2): 174-80. PMID 6893939.
↑ Halford, JA. (Dec 2002). "Cytological features of chronic follicular cervicitis in liquid-based specimens: a potential diagnostic pitfall.". Cytopathology 13 (6): 364-70. PMID 12485172.
↑ ^35.0 ^35.1 Minassian, H.; Schinella, R.; Reilly, JC.. "Crystalline bodies in cervical smears. Clinicocytologic correlation.". Acta Cytol 37 (2): 149-52. PMID 8465632.
↑ Zaharopoulos, P.; Wong, JY.; Keagy, N.. "Hematoidin crystals in cervicovaginal smears. Report of two cases.". Acta Cytol 29 (6): 1029-34. PMID 3866455.
↑ Bechtold, E.; Staunton, CE.; Katz, SS.. "Carpet beetle larval parts in cervical cytology specimens.". Acta Cytol 29 (3): 345-52. PMID 3859134.
↑ URL: http://www.cytology-asc.com/cec/normal/index.htm#dustmite. Accessed on: 10 April 2012.
↑ Gupta, S.; Mukherjee, K.; Gupta, YN.; Kumar, M. (Aug 1987). "Sequential radiation changes in cytology of vaginal smears in carcinoma of cervix uteri during radiotherapy.". Int J Gynaecol Obstet 25 (4): 303-8. PMID 2887465.
↑ ^40.0 ^40.1 ^40.2 URL: http://www.cytology-asc.com/cec/normal/index.htm#cornflake. Accessed on: 10 April 2012.

External links

[1] Half-day. 10 November 2008.

[2] SM. 14 January 2010.

[3] SM. 14 January 2010.

[4] GR. 4 February 2010.

[5] SM. 14 January 2010.

[6] URL: http://nih.techriver.net/view.php?patientId=78. Accessed on: 31 March 2012.

[pmid15900572-7] Thrall MJ, Kjeldahl KS, Savik K, Gulbahce HE, Pambuccian SE (August 2005). "Significance of benign endometrial cells in papanicolaou tests from women aged >=40 years". Cancer 105 (4): 207-16. doi:10.1002/cncr.21156. PMID 15900572.

[8] DeMay, RM. The Art & Science of Cytopathology: Exfoliative Cytology. 1996. ISBN 0-89189-322-9. PP.116-7.

[9] URL: http://nih.techriver.net/view.php?patientId=221. Accessed on: 26 November 2011.

[10] DeMay, RM. The Art & Science of Cytopathology: Exfoliative Cytology. 1996. ISBN 0-89189-322-9. PP.116-7.

[pmid16048503-11] 11.0 ^11.1 Slater, DN.; Rice, S.; Stewart, R.; Melling, SE.; Hewer, EM.; Smith, JH. (Aug 2005). "Proposed Sheffield quantitative criteria in cervical cytology to assist the diagnosis and grading of squamous intra-epithelial lesions, as some Bethesda system definitions require amendment.". Cytopathology 16 (4): 168-78. doi:10.1111/j.1365-2303.2005.00264.x. PMID 16048503. http://www3.interscience.wiley.com/journal/118661591/abstract?CRETRY=1&SRETRY=0.

[Ref_WMSP446-12] 12.0 ^12.1 ^12.2 ^12.3 ^12.4 ^12.5 Humphrey, Peter A; Dehner, Louis P; Pfeifer, John D (2008). The Washington Manual of Surgical Pathology (1st ed.). Lippincott Williams & Wilkins. pp. 446. ISBN 978-0781765275.

[13] UHN PCY50001.08 P.10.

[pmid12645338-14] Sheffield, MV.; Simsir, A.; Talley, L.; Roberson, AJ.; Elgert, PA.; Chhieng, DC. (Mar 2003). "Interobserver variability in assessing adequacy of the squamous component in conventional cervicovaginal smears.". Am J Clin Pathol 119 (3): 367-73. PMID 12645338.

[15] GR. 4 February 2010.

[16] Doxtader EE, Elsheikh TM (January 2017). "Diagnosis of trichomoniasis in men by urine cytology". Cancer Cytopathol 125 (1): 55–59. doi:10.1002/cncy.21778. PMID 27636204.

[17] URL: http://en.wiktionary.org/wiki/-mycete#English. Accessed on: 14 September 2011.

[asc_cockle-18] 18.0 ^18.1 ^18.2 URL: http://www.cytology-asc.com/cec/normal/index.htm#cockle. Accessed on: 10 April 2012.

[pmid3493202-19] Scott TG, Smyth CJ, Keane CT (February 1987). "In vitro adhesiveness and biotype of Gardnerella vaginalis strains in relation to the occurrence of clue cells in vaginal discharges". Genitourinary medicine 63 (1): 47–53. PMC 1194007. PMID 3493202. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1194007/.

[pmid22082330-20] 20.0 ^20.1 Polatti, F. (Feb 2012). "Bacterial vaginosis, Atopobium vaginae and nifuratel.". Curr Clin Pharmacol 7 (1): 36-40. PMID 22082330.

[pmid6399409-21] Taylor-Robinson D (1984). "The bacteriology of Gardnerella vaginalis". Scand J Urol Nephrol Suppl 86: 41–55. PMID 6399409.

[pmid22007754-22] Bigras, G.; Wilson, J.; Russell, L.; Johnson, G.; Morel, D.; Saddik, M. (Feb 2013). "Interobserver concordance in the assessment of features used for the diagnosis of cervical atypical squamous cells and squamous intraepithelial lesions (ASC-US, ASC-H, LSIL and HSIL).". Cytopathology 24 (1): 44-51. doi:10.1111/j.1365-2303.2011.00930.x. PMID 22007754.

[23] Chan, S. 26 April 2012.

[24] URL: http://www.cytology-asc.com/cec/endocx/. Accessed on: 13 September 2011.

[pmid18335553-25] Belsley, NA.; Tambouret, RH.; Misdraji, J.; Muzikansky, A.; Russell, DK.; Wilbur, DC. (Apr 2008). "Cytologic features of endocervical glandular lesions: comparison of SurePath, ThinPrep, and conventional smear specimen preparations.". Diagn Cytopathol 36 (4): 232-7. doi:10.1002/dc.20782. PMID 18335553.

[Ref_GP167-26] Nucci, Marisa R.; Oliva, Esther (2009). Gynecologic Pathology: A Volume in Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 167. ISBN 978-0443069208.

[pmid10757336-27] Duggan, MA. (Mar 2000). "Cytologic and histologic diagnosis and significance of controversial squamous lesions of the uterine cervix.". Mod Pathol 13 (3): 252-60. doi:10.1038/modpathol.3880046. PMID 10757336.

[28] URL: http://www.cap.org/apps/docs/proficiency_testing/CYP07600.pdf. Accessed on: 2 May 2012.

[pmid16299739-29] Owens, CL.; Ali, SZ. (Dec 2005). "Atypical squamous cells in exfoliative urinary cytology: clinicopathologic correlates.". Diagn Cytopathol 33 (6): 394-8. doi:10.1002/dc.20344. PMID 16299739.

[30] URL: http://www.curran.pwp.blueyonder.co.uk/cytology.htm. Accessed on: 5 November 2012.

[pmid16136595-31] Srodon, M.; Parry Dilworth, H.; Ronnett, BM. (Feb 2006). "Atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion: diagnostic performance, human papillomavirus testing, and follow-up results.". Cancer 108 (1): 32-8. doi:10.1002/cncr.21388. PMID 16136595.

[pmid16686950-32] Chivukula, M.; Shidham, VB. (2006). "ASC-H in Pap test--definitive categorization of cytomorphological spectrum.". Cytojournal 3: 14. doi:10.1186/1742-6413-3-14. PMC 1524979. PMID 16686950. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1524979/.

[pmid6893939-33] Hare, MJ.; Toone, E.; Taylor-Robinson, D.; Evans, RT.; Furr, PM.; Cooper, P.; Oates, JK. (Feb 1981). "Follicular cervicitis--colposcopic appearances and association with Chlamydia trachomatis.". Br J Obstet Gynaecol 88 (2): 174-80. PMID 6893939.

[pmid12485172-34] Halford, JA. (Dec 2002). "Cytological features of chronic follicular cervicitis in liquid-based specimens: a potential diagnostic pitfall.". Cytopathology 13 (6): 364-70. PMID 12485172.

[pmid8465632-35] 35.0 ^35.1 Minassian, H.; Schinella, R.; Reilly, JC.. "Crystalline bodies in cervical smears. Clinicocytologic correlation.". Acta Cytol 37 (2): 149-52. PMID 8465632.

[pmid3866455-36] Zaharopoulos, P.; Wong, JY.; Keagy, N.. "Hematoidin crystals in cervicovaginal smears. Report of two cases.". Acta Cytol 29 (6): 1029-34. PMID 3866455.

[pmid3859134-37] Bechtold, E.; Staunton, CE.; Katz, SS.. "Carpet beetle larval parts in cervical cytology specimens.". Acta Cytol 29 (3): 345-52. PMID 3859134.

[38] URL: http://www.cytology-asc.com/cec/normal/index.htm#dustmite. Accessed on: 10 April 2012.

[pmid2887465-39] Gupta, S.; Mukherjee, K.; Gupta, YN.; Kumar, M. (Aug 1987). "Sequential radiation changes in cytology of vaginal smears in carcinoma of cervix uteri during radiotherapy.". Int J Gynaecol Obstet 25 (4): 303-8. PMID 2887465.

[asc_cornflake-40] 40.0 ^40.1 ^40.2 URL: http://www.cytology-asc.com/cec/normal/index.htm#cornflake. Accessed on: 10 April 2012.

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@@ Line 3: / Line 3: @@
 This article deals only with cervical cytopathology.  An introduction to cytopathology is in the ''[[cytopathology]]'' article.
+'''Cervical cytology''' redirects to this article.
 =Preparation=
@@ Line 151: / Line 153: @@
 *#Abundant cytoplasmic glycogen - central yellow.
-Images:
+====Images====
-*[http://www.flickr.com/photos/28287204@N02/3083659626/ Navicular cells (flickr.com)].
+<gallery>
-*[http://www.flickr.com/photos/28287204@N02/3112533994/ Cluster of navicular cells (flickr.com)].
+Image: Navicular cell -- very high mag.jpg | NC - very high mag.
+Image: Navicular cell - alt -- very high mag.jpg | NC - very high mag.
+Image: Navicular cell -- extremely high mag.jpg | NC - extremely high mag.
+Image: Navicular cells -- extremely high mag.jpg | NCs - extremely high mag.
+</gallery>
 ==Glycogen halos versus HPV effect==
@@ Line 473: / Line 480: @@
 *Sexually transmitted.
 *Common.
+*Occasionally found in [[urine cytology]] specimens.<ref>{{cite journal |authors=Doxtader EE, Elsheikh TM |title=Diagnosis of trichomoniasis in men by urine cytology |journal=Cancer Cytopathol |volume=125 |issue=1 |pages=55–59 |date=January 2017 |pmid=27636204 |doi=10.1002/cncy.21778 |url=}}</ref>
 ===Cytopathology===
@@ Line 616: / Line 624: @@
 www:
 *[http://www.flickr.com/photos/moorepix4u2c/1440144102/in/set-72157602113534479/ Possible LSIL (flickr.com)].
+===Sign out===
+<pre>
+Low grade squamous intraepithelial lesion (LSIL).
+</pre>
+====Cannot exclude HSIL====
+<pre>
+At least low grade squamous intraepithelial lesion; CANNOT EXCLUDE high-grade squamous intraepithelial lesion.
+</pre>
 ==High-grade squamous intraepithelial lesion==

Difference between revisions of "Gynecologic cytopathology"

Latest revision as of 21:46, 13 August 2024

Preparation

Slide marking conventions

Normal cells

Images

Mix of cells

Less common non-malignant cells

Clue cells

Squamous metaplastic cells

Images

Endometrial cells

Images

Atrophic cells

Tingible body macrophages

Navicular cells

Images

Glycogen halos versus HPV effect

Gynecologic pathology in tables

Normal cells

Abnormal cells

HSIL versus LSIL

Infectious organisms

Adequacy of specimens

Transformation zone (TZ)

Specific entities - infectious

Candida

General

Cytology

Images

www

Trichomoniasis

General

Cytopathology

Images

www

Herpes simplex virus

General

Cytology

Image

Actinomycetes

General

Cytopathology

Bacterial vaginosis

General

Cytopathology

Stains

Sign out

Squamous intraepithelial lesions

Low-grade squamous intraepithelial lesion

General

Cytopathology

Images

Sign out

Cannot exclude HSIL

High-grade squamous intraepithelial lesion

General

Cytopathology

Images

Squamous cell carcinoma

Glandular lesions

Adenocarcinoma in situ

Images

Endocervical adenocarcinoma in situ

General

Cytopathology

Image

Endometrial adenocarcinoma in situ

General

Cytopathology

Waffle categories

Atypical squamous cells of undetermined significance

General

Cytology

Images

Sign out

Atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion

General

Cytology

Atypical glandular cells