Gynecologic Cytopathology Flashcards
What is the minimum amount of cells for most women in a liquid based pap preparation? What kind of cells should these be?
How many cells should be present in a conventional cervical preparation?
5000, well preserved, well visualized squamous cells for most women (some women post hysterectomy and with atrophy may be accepable with fewer cells
8000-12000 well preserved, well visualized squamous epithelial cells
What are the rules regarding the transformation zone and cervical cytology specimens?
You do not have to have cervical glandular cells, only squamous cells. However, cervical glandular cells should be reported.
What percentage of obscured squamous cells is considered unsatisfactory for cervical cytology specimens?
Greater then 75% of squamous cells obscured
How soon should a women will an unsatisfactory cervical cytology specimen get a repeat procedure?
When should a colposcopy be performed in women with unsatisfactory cervical cytology?
2-4 months
If she has two consecutative unsatisfctory tests
In what condition would you expect a pap to have many superficial cells?
What do you see lots of intermediate cells?
Parabasal cells?
High estrogen states, at the time of ovulation/midcycle peak
The secretory phase or when the women is lactating
Atrophy (post-menopausal), and young girls before menses
Identifiy these cells in cervical cytology…..
What condition is associated with an abdundance of these cells?
Superficial squamous cells
High estrogen states, such as the mid-cycle estrogen peak during ovulation
Identifiy these cells in a cervical cytology specimen?
In what condition(s) would you see an abundnce of these cells?
Intermediate squamous cells
Secretory phase endometrium, during lactating
Identifiy these cells in a cervical cytology specimen?
What condition(s) are associated with an abundance of these cells?
Pre-menopausal, post-menopausal (atrophy)
Identify these cells in context of a cervical cytology specimen? What is their special name?
When are they usually found?
Endometrial cells forming an “exodus ball”. These represent the last remenants of endometrial shedding.
Days 6-10 of the menstrual cycle.
What are these cells in context of cervical cytology?
What two special terms are used to describe these?
Metaplastic squamous cells
“Cookie cutter” cytoplasmic borders with “spider-like” cytoplasmic processes
What do these cells represent in the context of cervical cytology?
Reactive changes associated with an intrauterine device , cytoplasmic vacuoles displacing nuclei
Identify this in context of cervical cytology? What is it associated with?
Ferning, high estrogen states such as mid-cycle
What does this represent in context of pap cytology?
Radiation effect (multinucleation, vacuolization)
What is this in context of cervical cytology?
syncytiotrophoblast, pregnancy
Identify in context of cervical cytology?
Herpes (Margination, multinucleation)
What does this represent in context of urine cytology?
Atrophic vaginitis.
We see lots of parabasal cells, inflammation, and a “grundgy” background
What does this represent?
In what condition would you commonly see this?
A “blue blob”
Atrophic vaginitis
Identifiy in context of cervical cytology?
Describe features….
Trich
Pear-shaped with ecentric nucleas and eosinophillic cytoplasmic granules
What does this represent in context of cervical cytology?
Cocco-baccili, shift in vaginal flora
Name features of LSIL cells
Nuclear chromicity?
Nuclear size?
Chromatin pattern?
Nuclear membrane contour?
Nucleoli?
Cytoplasmic changes?
Often hyperchromatic, may be normochromatic
3 times larger then an intermediate squamous cell
Coursely granular to smudgy
Can be smooth or irregular
Nucleoli usually absent
Perinuclear cavitation with a clear, perinuclear zone and a peripheral rim of more “bunched up” densely staining cytoplasm. Is not mandatory for a diagnosis of LSIL!
How are women under 25 managed clinically with a diagnosis of LSIL?
Older then 25 with HPV negative test? HPV positive Unknown HPV status?
Follow up cytology in 12 months
Over 25 and LSIL with negative HPV test- HPV and cytologic testing in 3 years
Over 25 and LSIL with positive HPV test- Colposcopy
Over 25 and unknown HPV status- Repeat cytology in 12 months
Describe the cytologic features of HSIL….
Cell size?
N/C ratio compared to LSIL?
Nuclear size compared to LSIL?
Nuclear chromicity?
Nuclear contrours?
Usually smaller then LSIL cells
Higher N/C ratio
Nuclear size is the same to decreased compared to LSIL
Usually hyperchromatic but variable
Often irregular contours
What types of HPV are known for association with endocervical dysplasia?
HPV 16 and 18
What does the following image represent in the context of cervical cytology?
Tubal metaplasia, should not be overcalled as malignant or atypical, look for the cillia and terminal bar
What are the features of atypical endocervical cells…
In terms of how the cells group?
In terms of nuclear size?
Sheets or strips of cells with some cell crowding and overlapping
Nuclei enlarged, 3-5X larger then typical endocervical cells
Name some features of atypical cervical cells, favor malignant?
How the cells grouped?
Nuclear size?
Chromatin?
Mitotic activity?
N/C ratio?
In sheets and strips with nuclear crowding, overlap, and possibly pseudostratification. The cell groups can sometimes form rosettes and can have feathering (individual cells hanging out of the main cluster)
Nuclei are enlarged and sometimes elongated
The chromatin should be course
Occasional mitosis can be present
N/C ratio is increased
How would you diagnose this? (cervical cytology)
Atypical endocervical cells, this later turned out to be tubal metaplasia according to the book, but the cilia and terminal bars were difficult to visualize
How would you diagnose this? (cervical cytology)
Atypical endocervical cells. LIkely from a reactive process, follow-up showed no epithelial cell abnormality
We have nuclear enlargement, increased N/C ratio, prominant nucleoli, and mitotic activity.
How would you diagnose this? (cervical cytology)
Atypical endocervical cells, favor neoplastic
We have feathering at the edges, mitosis (?), and crowded cells
F/u showed endocervical AIS.
How would you diagnose this? (cervical cytology)
Describe features
Atypical endocervical cells, favor neoplastic
We have atypical endocervical cells with crowding, disorganization, and some nucleoli
F/U showed endocervical AIS
How would you diagnose this? (cervical cytology)
Atypical endocervical cells, favor neoplastic
Enlarged elongated nuclei with pseudostritification
Identifiy in context of cervical cytology?
Describe features….
Repairative change
Streaming, “school of fish” appearence. We can have variation in nuclear size, with prominant nucleoli and rare intracytoplasmic PMNs.
Small cell carcinoma of the cervix is associated with which HPV type?
HPV 18
Identify in the context of cervical cytology…..
Describe features
Cellularity/architecture?
Nuclear features?
Small cell carcinoma
Uniform cells with scant cytoplasm, occuring singly and in small loosely cohesive groups. Often nuclear molding, crush artifact, and finely stippled chromatin.
Identify in the context of cervical cytology…..
Describe features
Squamous cell carcinoma
Marked variation in size and shape, cytoplasmic keratinization, tumor diathesis (necrosis, hemorrhage, inflammatory cells), cytoplasmic keritinization
How would you diagnose this? (cervical cytology)
Describe features
Endocervical adenocarcinoma in situ
Elongated crowded nuclei with overlapping and hyperchromasia. This one has a rosette formation.
How would you diagnose this? (cervical cytology)
Describe features
Endocervical adenocarcinoma in situ
Elongated crowded nuclei with overlapping, hyperchromasia, peripheral feathering
Name some features of endocervical adenocarcinoma in situ
Architectural arrangement?
Nuclear size?
Nucleoli?
Chromicity?
Mitotic activity?
N/C ratio?
Sheets, clusters, strips, and rosettes with nuclear crowding and overlap.Can have “feathering” with cytoplasmic tags protruding from the cluster.
Enlarged nuclei
Nucleoli are small or inconspicuous (in contrast to adenocarcinoma)
Hyperchromicity
Mitosis are common
N/C ratio increased
Name some features of endocervical adenocarcinoma
Architectural arrangement?
Nuclear size?
Nucleoli?
Can be single cells or 3D clusters
Enlarged and pleomorphic nuclei
Macronucleoli, in contrast to adenocarcinoma in citu
Also remember we can have clinging tumor diathesis
How would you diagnose this? (cervical cytology)
Describe features
Adenocarcinoma, endocervical
Large nuclei, macronucleoli
How would you diagnose this? (cervical cytology)
Describe features
Adenocarcinoma, endocervical
Large nuclei, macronucleoli
Some tumor diathesis is seen clinging at the edges
Name some features of endometrial adenocarcinoma?
Architectural arrangement?
Nuclear size?
Nucleoli?
Cytoplasmic features?
Intracytoplasmic neutrophils?
How does the tumor diathesis look?
Sinigly or small clusters
Both nuclear size and nucleoli increase with higher-grade tumors, and are smaller with more well differentiated tumors
The cytoplasm is scant and blue, often vaculoated
Present
“Watery” tumor diathesis, especially in conventional preps
Compare the cytologic features of endocervical vs endometrial CA…
Cellularity?
Cell size?
Cell shape?
Archtecture?
PMNs associated?
Endocervical is more cellular, has larger cells
Endocervical has columnar cells, endometrial has round cells
Endocervical and rosettes and crowded sheets, endometrial cancer has balls of cells
Endocervical is not usually associated with PMNs, endometrial usually is
What is associated with this in terms of cervical cytology? 4
Benign AND malignant conditions including IUDs, Endosalpingosis, TB endometritis, Benign endometrial and ovarian lesions, serous papillary carcinoma and other malignancies
Identifiy this lesion in context of cervical cytology?
Features common with this lesion?
Metastatic colonic adenocarcinoma
Some features are a dirty background, elongated cigar shaped nuclei
Identify in context of cervical cytology?
What is this associated with?
Follicular cervicitis (you can see the diverse populatin of lymphocytes with tingible body macrophages)
Chlamydia
Identify in context of cervical cytology?
Chlamydia
Identify in context of cervical cytology?
Pinworm (enterobius vermicularis)
What is routine screening for women 21-29?
30-64?
Pap every 3 years
Pap every 5 years
How should women 30+ be managed with a negative cytology but positive HPV test? (2 options)
Repeat cotesting at 1 year or DNA typing (with DNA typing move to colposcopy if 16 or 18 positive, 1 year cotesting if negative fpr 16 and 18)
How should ASC-US be managed? (Women 24+)
Women 21-24?
Repeat Cytology in 1 year or HPV cotesting (preferred, if positive, move to colposcopy)
For women 21-24 preferred method is repeat cytology in 12 months
LSIL with negative HPV management?
LSIL with no HPV test management?
HPV with postive HPV test management?
Repeat cotesting in 1 year (preferred)
LSIL with no HPV test and with positive test should both get colposcopy
Pregnant women with LSIL management?
Colposcopy is preferred
Management of women with ASC-H (excluding women age 21-24 and pregnant) ?
Colposcopy no matter HPV status
Management of women 21-24 with ASC-H or HSIL?
Colposcopy (NOT YET LEEP)
Management of women with HSIL (except 21-24 and pregnant)?
2 options
Immediate LEEP or Colposcopy
What situtation would qualify for Atypia of Undetermined Significance for thyroid in terms of….
Microfollicles?
Hurthle cells?
Follicular cell atypia?
Features of papillary carcinoma?
Lymphoid cells?
Sparsely cellular but the cells that are present form microfollicles
Sparsely cellular with mainly Hurtle cells
Atypia uncertain due to possible artifact (larger due to airdrying, smudgy chromatin, etc..)
Features of PTC (pale chromatin, grooves, enlarged nuclei) but the vast majority of the sample has benign follicular cells and/or abdundant colloid
Lymphoid cells are atypical but not so much so that a malignant diagnosis can be reached
Does convential or liquid based pap specimens need less cells to be adequate? What are the numbers?
Conventional: 8,000 at least
Liquid: 5,000 at least
A liquid based pap is found to have less then 5000 cells but is still considered adqquate, why?
The women had radiation, chemotherapy, or is post-menopausal
What are the primary HPV oncogenes and what proteins are they associated with?
E6 and E7. E6 with p53, E7 with rb.
(E)6 with 5(3)
or 53 before rb
Do intracytoplastic neutrophils favor endocervical or endometrial adenocarcinoma?
Endometrial
