Module 7 - Gynae Cytopathology Flashcards
What is Diagnostic Cytopathology?
The interpretation of cellular changes related to benign, inflammatory and neoplastic conditions
Assessment of single cells or cell aggregates without the typical architectural landmarks usually observed
When should a Cervical Smear be conducted?
Midcycle
Absence of inflammation
1st smear depends on the age of initial sexual activity or at 25 years
Symptomatic women
- family history of cervical cancer
- abnormal looking cervix (discoloured, uclerated, tumor etc.)
- abnormal bleeding
When should a Cx Screening Test be Done?
Women with history of low risk HPV will have screening test every 5 years
Women with current or previous abnormality
Cervical screening can cease after 74 years of age if a women has had at least 2 negative oncogenic HPV tests
Women aged 70-74 who have opposite oncogenic variant, should be referred for colposcopic assessment with reflex LBC
Reflex Cytology
Done after detection of oncogenic HPV in primary screening
Cytology after detection of HPV in collect sample
Reflex LBC after detection of oncogenic HPV in FU HPV test
Cytology at colposcopy where:
- LBC unsat
- unconfirmed/untreated HSIL with gynae surveillance
What is considered Primary Screening?
Colposcopy today normal/unsat PV discharge Contact bleeding/heavy bleeding Menorrhagia/amenorrhoea/dysmenorrhoea Ectropion Inflamed cervix Endometrial thickening
What do you need for a Cervical Test?
Bivalve vaginal specimen Adjustable light Cervex sampler or endocervical spatula/broom Microscope slide with a frosted tip LBC collection system
Techniques for taking Cervical Samples
Cx sampler broom - rotate 3-5 times
and
Endocervical brush - insert into os, make sure can see lower row of bristles, make a quarter rotation
Cervix-Brush combi - insert central part of the brush into os and rotate clockwise twice
Spatula - rotate once or twice, be sure to keep in contact with ecto-cervix
and
Endocervical brush - insert into os, make sure can see lower row of bristles, make a quarter rotation
ThinPrep Sample Preparation Process
- Dispersion - rotation of filter in sample to separate debris and mucous
- Cell collection - vacuum is created which collects the cells on the exterior surface of the membrane
- Cell transfer - cells collected on membrane adhere to slide resulting in even distribution in an area
Anatomy - Vulva
Labia majora
Labia minora
- many sebaceous and apocrine sweat glands
Keratinising squamous eptihelium
Anatomy - Vagina
Fibromuscular structure extends from the cervix to the external genitalia
Does not contain glands
Lined by stratified squamous epithelium
Its wall consists of an inner mucosa, a middle muscularis layer and an
outer connective tissue adventitia
It is subjected to cyclical changes under influence of sex hormones
Anatomy - Cervix
Located in the lower part of the uterus and projects into the vaginal canal as the portio vaginalis.
Endocervical canal connects the body of the uterus at the internal os with the vagina at the external os
Ectocervix is the outer aspect of the cervix covered by squamous epithelium
Endocervical canal contains tall columnar cells with inconspicuous reserve cell layer underneath it
Squamo-columnar junction is where the squamous epithelium of the cervix meets the endocervical canal
Histology of the Cervix
All below are layers of the squamous epithelium
Germinal layer adheres to basement membrane
- single layer of small regular cells called basal cells
Parabasal layer is immature and crowded
- 2-3 cells deep
Intermediate layer shows variable thickness
- cells held together by intercellular bridges
Superficial layer has weaker cell bonds
- cells are dead or dying
- cell exfoliate spontaneously
Keratinsing layer
- layer of keratinised cells with a nucleus showing karyorrhexis and karyolysis
Histology of the Endocervical Canal
Part of the cervix might I add
Lined with tall, mucous secreting columnar epithelium
Lines highly branched and tubular cervical glands that extend into the cervical canal and into the lamina propria
Principle of the Papanicolaou Stain
Polychromatic stain with multiple dyes
Nuclei stained blue with Harris Hematoxylin
- Harris Hx is natural dye that has a high affinity for chromatin, attaching itself to sulphate groups on the DNA molecule
- Hx is not a stain, it is the oxidation product, haematein which is produced naturally or chemically using sodium iodate
Orange green 6 stains cytoplasm of mature and keratinised squamous cells
- OG6 is the first acidic counterstain used and structures stain orange with different intensities
Eosin Azure gives mature squamous cells the pink colour
- light green in EA50 stain the cytoplasm of metabolically active cells, like parabasal cells, intermediate squamous cells and columnar cells
Morphology of Basal Cells
Small cells that give rise to squamous cells Rarely recognised in a Pap smear Seen in short rows Sparse green cytoplasm Oval nuclei High N/C ratio Fine granular chromatin pattern Small chromocentres
Morphology of Parabasal Cells
Round to oval cells Dense green (cyanophilic cytoplasm) May stain pink (orangeophilic) if not well preserved Nucleus occupies ½ of cell Fine chromatin pattern May present in sheets, singly Commonly found in post menopausal women/post partum Indicates oestrogen deficiency
Morphology of Intermediate Cells
Polygonal in shape
Larger than parabasal cells
Cytoplasm in well preserved cells stain blue/green
Nucleus is round to oval
Nucleus is vesicular
Nucleus during pregnancy referred to as navicular
Fine chromatin pattern
Cells appear crowded or clumped or folded
Accumulate glycogen deposits in cytoplasm
- glycogen appears pale yellow
Morphology of Superficial Cells
Large, flat and polygonal in shape Mature squamous cells Slightly larger than intermediate cells Cytoplasm stain light pink to orange Nuclei are small often pyknotic with no definite internal structures
Morphology of Anucleate Squamous Cells
Mature superficial squamous cells without a nucleus
If found in a Cervical smear, may indicate:
- the smear was taken in the distal 1/3 of the vagina
- the specimen was taken from an ectocervix that contained an area of leukoplakia (hyperkeratosis)
- the specimen was taken from a pregnant patient whose fetal membranes had ruptured with secretions containing anucleate squames
Morphology of Endocervical Cells
Present in small strips, flat sheets, singly and in groups
Cytoplasm is cyanophilic and translucent or finely vacuolated
Nuclei are basal, round to oval
Fine chromatin pattern
1-2 nucleoli may be present
Cilia may be present
Mucin secreting goblet cells
Bare degenerate cells may be present in background mucous
Variation in size of cells
May be multinucleated
Morphology of Squamous Metaplasia
Normal constituent of transformation zone
As they mature they resemble intermediate and superficial squamous cells
Size of parabasal cells
Cytoplasmic projections “spinous processes’
Cytoplasm is normally cyanophilic and delicate
May show cytoplasmic polychromasia
Vesicular round to oval nuclei
Nucleoli may be present
Degenerative changes such as vacuolisation, intracytoplasmic polymorph ingestion, karyorrhexis and karyopyknosis may be present
Morphology of Endometrial Cells
Found in the superficial stroma and deep stroma
Central core of stromal cells, peripheral rim of epithelial cells
Appear in 3 dimensional clusters or singly
Cell ball pattern with moulding
Often show degenerative changes
Cytoplasmic vacuoles with neutrophils
Hyperchromatic nuclei
May appear no larger than a inflammatory cells
Superficial vs Deep Stromal Cells
Superficial - rounded to oval cells - scant to moderate amounts of cytoplasm - central, round vesicular nuclei Deep - oval to spindle shaped cells - scanty cytoplasm - oval nucleus - granular chromatin pattern - longitudinal grooves
What causes an Unsatisfactory Smear?
Poor sampling Poor fixation Poor collection technique Formalin vapour artefact Heavily blood stained Marked inflammation
Unsatisfactory Smear - Cytologically
May be a result of 7 factors:
- Poor squamous representation
- Marked inflammation obscuring cellular detail
- Heavily bloodstained obscuring cellular detail
- Insufficient cellular material
- Poorly preserved cellular material
- Lubricant/mucous limiting adequacy of sq component
- Formalin vapour artefact
