Cervical Cytology Morphology Flashcards
In cytology what is the main stain used to identify and visualise cells?
The Papanicolaou stain.
Describe the Papanicolaou stain including its constituents.
The Papanicolaou stain is a combination of cytoplasmic and nuclear stains which allows the identification of various types of epithelial cells.
The cytoplasmic stains are eosin, light green and orange G.
Eosin stains superficial cells pink, light green stains less mature cells blue/green, orange G stains keratinised cells orange.
The nuclear stain is haematoxylin and this stains the nuclei blue/black.
What are the cytoplasmic stains contained in the Papanicolaou stain?
Eosin, light green and orange G.
What are the nuclear stains contained in the Papanicolaou stain?
Haematoxylin.
What does eosin stain?
Eosin stains superficial cells pink.
What does light green stain?
Light green stains less mature cells blue/green.
What does orange G stain?
Orange G stains keratinised cells orange.
What does haematoxylin stain?
Haematoxylin stains nuclei blue/black.
How can epithelial cells be identified? How do we distinguish normal and abnormal epithelial cells?
Epithelial cells can be identified by their morphology and staining properties.
The distinction between normal and abnormal epithelial cells is based primarily on nuclear morphology.
The following features may be used to distinguish normal from abnormal cells:
Nuclear size, Nucleocytoplasmic ratio, Chromatin pattern (granular/smooth), Nuclear shape (round/oval/irregular), Intensity of nuclear staining (in abnormal cells you tend to get darker staining).
Name the 4 layers of the squamous epithelium.
1) . Basal layer (1 cell thick)
2) . Parabasal layer (4-5 cells thick)
3) . Intermediate layer (stain blue)
4) . Superficial layer ( oldest cells, stain pink)
What hormone are superficial cells under the influence of?
Oestrogen. Increased oestrogen leads to increased superficial cell production.
What hormone are intermediate cells under the influence of?
Progesterone. Increased progesterone leads to increased levels of intermediate cells.
Describe superficial cells.
Superficial cells are angular polygonal cells that have an eosinophilic (pink) cytoplasm and a low N/C ratio (small nuclei).
Describe intermediate cells.
Polygonal cells with a cyanophilic (blue/green) cytoplasm.
Have a round/oval nucleus with a low N/C ratio and fine vesicular chromatin. The nucleus tends to be slightly longer than in superficial cells.
Describe parabasal cells.
Parabasal cells are round/oval cells that tend to be 12-30um in diameter.
They have a dense green/blue cytoplasm and a round/oval nucleus occupying half the cell.
They have evenly distributed vesicular chromatin.
What 2 types of cells is the glandular epithelium made up of?
Endocervical epithelium and endometrial epithelium.
Describe the glandular endocervical epithelium.
It is a simple columnar epithelium. A single layer of endocervical epithelial cells with all the nuclei at the basement membrane.
It secretes mucin which acts as a lubricant and a protective barrier.
Movement of mucin is assisted by ciliated cells.
Describe the endocervical cells of the endocervical epithelium.
Endocervical cells are columnar cells with cilia occasionally visible at one end.
They have a finely vacuolated cyanophilic cytoplasm and an oval nucleus with fine chromatin.
Occasionally they may have more than one nucleus.
They may be seen arranged in a honeycomb shape or in palisades.
Describe the glandular endometrial epithelium.
The epithelial lining of the uterus is called the endometrium. It consists of a single layer of cuboidal cells called endometrial cells.
Describe endometrial cells.
Endometrial cells are normally present up to day 12 of the cycle.
They are round/oval cells that are 8-10um in diameter and have little cytoplasm. They have crumpled, hyperchromatic nuclei.
They are seen as dense tight blue clusters. They may be observed as a dense core of stromal cells and a periphery of larger epithelial cells often referred to as a top hat formation or a wreath. They are tight groups of disorganised cells.
What is metaplasia?
Metaplasia is the transformation of one cell type to another.
Give an example of where metaplasia takes place in the cervical canal.
In the cervix the endocervical glandular epithelium transforms into squamous epithelium when it is exposed to the acidic pH of the vagina.
This is the region of the cervix that is most susceptible to metaplastic change and it is termed the transformation zone (TZ).
The transformation zone is the area where precancerous and cancerous lesions of the cervix usually arise. Cervical samples must be taken from this area.
Metaplastic cells have cyanophilic cytoplasm. They have cytoplasmic projections giving rise to the term spider cells. Their nuclei are vesicular, and variable in size with small nucleoli. Morphology can depend on the degree of maturation.
What influence do hormone levels have on the cervical epithelium after menopause?
After the menopause oestrogen levels decrease. This induces atrophy of the cervical epithelium which leads to a drop in the number of superficial cells and an increase in the numbers of parabasal cells. This is known as the post menopausal atrophic pattern.
What hormonally influenced changes take place in the cervical epithelium after birth?
The changes that take place after birth depend on the levels of oestrogen and progesterone which depend on whether or not the mother breast feeds.
During breast feeding the lack of oestrogen causes atrophy and the sample consists mainly of parabasal and intermediate cells. This is known as the lactating pattern.
What non-epithelial elements may be found at the cervical epithelium?
Macrophages,
Giant histiocytes,
Neutrophils,
Red Blood Cells.
Describe the appearance of macrophages.
They vary in size. The cytoplasm may contain vacuoles or is lace-like. The nucleus is often kidney bean shaped and located off centre.
Describe the appearance of giant histiocytes.
They are multinucleated large cells. They are often present in post menopausal women.
Describe the appearance of polymorphs (neutrophils).
They group together in bunches, indicate infection and can be observed in the blood.
How might red blood cells appear on a slide?
Not singular, they get bunched together by sample processing.
What two types of cells is the cervical epithelium comprised of?
Squamous epithelium and glandular epithelium cells.
What kinds of injury may inflammation be a response to?
Physical (heat, cold, irradiation)
Chemical (acids, alkalis, drugs)
Microbiological (bacteria, fungi, viruses, protazoa)
What four things may make up an inflammatory response?
Redness, swelling, pain, heat.
You would likely see an increase in polymorphonuclear neutrophils in what stage of cervicitis?
Acute phase
You would likely see an increase of lymphocytes and plasma cells in what stage of cervicitis?
Chronic phase.
Describe degenerative inflammatory changes that may occur in epithelial cells in response to inflammation.
Degenerative changes will affect the nucleus and the cytoplasm.
The nucleus may show enlargement, multinucleation, vacuolation, condensation of chromatin at nuclear membrane, fragmentation, shrinkage and nuclear lysis.
The cytoplasm may display vacuolation, ingestion of leukocytes, cytolysis, peri nuclear halo and eosinophila.
Describe regenerative inflammatory changes that may occur in epithelial cells in response to inflammation.
The nucleus may show enlargement, multinucleation and unlike in degenerative changes - hyperchromasia, evenly distributed chromatin clumping and enlarged nucleoli.
The cytoplasm may display vacuolation and unlike in degenerative changes - increase in the N:C, sheet formation of repair cells, hyper/para-keratosis.
List the six most common infections associated with cervical inflammatory changes.
Candida albicans, Trachomonas vaginalis, Bacterial vaginosis, Actinomyces, Herpes, HPV
Why can it be difficult to distinguish inflammation from neoplasia cytologically?
The morphological features overlap.
List some feature of inflammatory changes to cervical cells.
Nuclear enlargement, Peri-nuclear halos, Increased amount and injestion of polymorphs, Vacuolation of cytoplasm, Cell degeneration, Cell death
Describe the appearance of candida on smears.
Candida is a fungi. It appears as tangled filaments, often with hyphae. Cells can form a kebab skewer shape. It can also exist in a population of red spores (dormant stage).
What are the symptoms of Candida albicans infection?
Thick white discharge,
Itching and redness of the vagina,
Pain during intercourse,
May have no symptoms.
What is the treatment for Candida albicans infection?
Anti fungal treatments including medications and creams.
If no symptoms are apparent then no treatment may be necessary.
Describe the cytologically appearance of herpes simplex virus.
In cytology shows smooth chromatin and ground glass appeared.
May see multinucleated cells which often appear moulded together.
What are the symptoms of Herpes?
None in the latent phase.
In active state 90% of patients experience cold sores, blistering, pain, itching, dysuria, discharge, enlarged lymph nodes, fever, headache and muscle pains.
What is the treatment for heroes simplex virus?
HSV cannot be completely cleared up but can be inhibited by antivirals that interfere with viral replication.
Painkillers and anaesthetic ointments ease symptoms.
How does HPV appear cytologically?
There are more than 100 different subtypes of HPV. Some low risk and associated with warts and low grade CIN, others high risk and associated with high grade CIN.
On a cervical sample HPV can cause multinucleation, enlarged nuclei, coarse chromatin an dyskeratosis.
For HPV to be reported in a smear koilocytes must be present. Koilocytes are squamous cells with a large clearing around the nuclei and a thick, irregular rim of cytoplasm around the edge.
What are the symptoms of HPV?
There may be none or genital warts may be present that cause bleeding during intercourse.
What are the treatments for HPV?
There are currently none.
It is often cleared up by the immune system.
Vaccination against high risk subtypes is available.
What is actinomyces?
A bacteria that colonises IUCD’s.
How does actinomyces present cytologically?
They can show up as blue clusters of bacteria that have a dense centre with filaments radiating out.
Occasionally have a bottle brush appearance.
Generally cause no problems.
What are the symptoms of actinomyces?
On rare occasions can cause PID causing intramenstual bleeding, pain in the lower abdomen and discharge.
What are the treatments for actinomyces?
For PID caused by actinomyces may advice antibiotics or removal of IUCD.
What is the cytologically appearance of trachomonas vaginalis?
Trachomonas vaginalis is a protazoa.
It appears pear shaped with flagella and a faintly visible nucleus.
It stains a blue/grey colour.
Sometimes red granules can be seen in the cytoplasm.
It is difficult to see in cervical samples because it blends in with cervical material. An inflamed appearance of the rest of the slide including peri nuclear halos and two-toned colours of squamous cells could indicate that trachomonas is present.
Sometimes trachomonas can be seen clustered around squamous in a nursery or marina effect.
