1. pap smear seminar

Pap smear cytology, screening and reporting

1. PAP SMEAR CYTOLOGY SCREENING REPORTING Presenter : Dr G Santhi priya Moderator : Dr Prashanth R 7/19/2017 1 Seminar

2. Contents Introduction Cervical cancer screening Sampling and preparation Bethesda system of reporting Normal cytology Abnormal cytology 7/19/2017 2 Seminar

3. Dr George N. Papanicolaou 7/19/2017 3 Seminar

4. Method of cervical screening used to detect potentially pre-cancerous and cancerous processes Embraced as an ideal screening test for preinvasive lesions , which , if treated would be prevented from developing into invasive cancer 7/19/2017 4 Seminar

5. Cervical cancer screening guidelines given by ACOG and ACS/ASCCP/ASCP Age to begin screening – 21yrs ‹21 yrs -should not be screened Women aged 21 to 29 – Every 3 yrs with cytology alone 7/19/2017 5 Seminar

6. Women aged 30 to 65 – Every 3 yrs --cytology alone , Or Every 5yrs -- cotesting Discontinuation - 65yr with adequate prior screening and no history of CIN 2 or higher Screening after total hysterectomy – Not recommended 7/19/2017 6 Seminar

7. INSTRUCTIONS Schedule - 2 weeks after the first day of the last menstrual period Avoid examination during menses Not to use vaginal medication, vaginal contraceptives,or douches for 48 hours before the appointment Intercourse to be avoided before 24 hours 7 7/19/2017 Seminar

8. Speciment collection Key portion : squamo -columnar junction Most likley site of dysplasia The sample should be obtained before the application of acetic acid or lugol iodine The spatula is rotated atleast 360 degrees An optimal sample includes cells from the ectocervix and endocervix 7/19/2017 8 Seminar

9. PREPARATION METHODS Conventional smears Liquid – Based Cytology 7/19/2017 9 Seminar

10. CONVENTIONAL SMEAR S amples are smeared directly into a microscopic slide after collection Smears often obtained using spatula and brush Immediate fixation is critical to prevent air drying artifacts 10 7/19/2017 Seminar

11. 11 7/19/2017 Seminar

12. Lateral wall of vagina for hormonal assessment Posterior cul-de-sac is the original papanicolaus method. May contain endometrial cells and cells from upper reaches of genital tract 7/19/2017 12 Seminar

13. LIQUID BASED CYTOLOGY Manual/automated [Thin Prep/Sure Path/Mono Prep] Involves rinsing all the material into a fixative fluid Creats cell suspension , red blood cells are lysed by the transport medium Processed in labouratory 7/19/2017 13 Seminar

14. 14 Thinprep method 7/19/2017 Seminar

15. Overcoming the inherent limitations of the conventional pap smear Conventional pap smear Liquid based cytology Majority of cells not captured Non-representative transfer of cells Clumping and overlapping of cells Obscuring material Virtually all cells of sample are collected Ramdamized , representative transfer of cells Even distribution of cells Minimizes obscuring material 7/19/2017 15 Seminar

16. THE BETHESDA SYSTEM Is a complete diagnostic system that recognizes the cytopathological report as a medical consultation The first workshop was held in 1988 Earlier versions of bethesda include 3 categories of adequacy: Satisfactory Unsatisfactory Borderline. The 2001 Bethesda system eliminates the borderline category 7/19/2017 16 Seminar

17. The 2014 Bethesda System 1. SPECIMEN TYPE Indicate conventional smear (Pap smear) vs. liquid-based preparation vs. other 2. SPECIMEN ADEQUACY Satisfactory for evaluation Unsatisfactory for evaluation . . . ( specify reason) • Specimen rejected/not processed ( specify reason) • Specimen processed and examined, but unsatisfactory for evaluation of epithelial abnormality because of ( specify reason) 7/19/2017 17 Seminar

18. 3. GENERAL CATEGORIZATION ( optional) Negative for Intraepithelial Lesion or Malignancy(NILM) Other Epithelial Cell Abnormality The 2014 Bethesda System 7/19/2017 18 Seminar

19. 4. INTERPRETATION/RESULT NEGATIVE FOR INTRAEPITHELIAL LESION OR MALIGNANCY Non- Neoplastic Findings (optional to report) Non- neoplastic cellular variations • Squamous metaplasia • Keratotic changes • Tubal metaplasia • Atrophy • Pregnancy-associated changes 7/19/2017 19 Seminar

20. Reactive cellular changes associated with: • Inflammation (includes typical repair) • Lymphocytic (follicular) cervicitis • Radiation • Intrauterine contraceptive device (IUD) Glandular cells status post hysterectomy 7/19/2017 20 Seminar

21. Organisms • Trichomonas vaginalis • Fungal organisms - Candida spp. • Shift in flora - bacterial vaginosis • Bacteria - Actinomyces spp. • Cellular changes consistent with herpes simplex virus • Cellular changes consistent with cytomegalovirus 7/19/2017 21 Seminar

22. OTHER Endometrial cells ( in a woman ≥45 years of age) ( Specify if “negative for squamous intraepithelial lesion”) EPITHELIAL CELL ABNORMALITIES SQUAMOUS CELL Atypical squamous cells • of undetermined significance (ASC-US) • cannot exclude HSIL (ASC-H) 7/19/2017 22 Seminar

23. Low-grade squamous intraepithelial lesion (LSIL) ( encompassing: HPV/mild dysplasia/CIN 1) High-grade squamous intraepithelial lesion (HSIL) ( encompassing: moderate and severe dysplasia, CIS; CIN 2 and CIN 3) • with features suspicious for invasion ( if invasion is suspected) Squamous cell carcinoma 7/19/2017 23 Seminar

24. GLANDULAR CELL Atypical • endocervical cells (NOS or specify in comments) • endometrial cells (NOS or specify in comments) • glandular cells (NOS or specify in comments) Atypical • endocervical cells, favor neoplastic changes • glandular cells, favor neoplastic changes Endocervical adenocarcinoma in situ Adenocarcinoma • endocervical • endometrial • extrauterine • not otherwise specified (NOS) 7/19/2017 24 Seminar

25. 5.OTHER MALIGNANT NEOPLASMS: (specify) 6.ADJUNCTIVE TESTING 7.COMPUTER-ASSISTED INTERPRETATION OF CERVICAL CYTOLOGY 8. EDUCATIONAL NOTES AND COMMENTS APPENDED TO CYTOLOGY REPORTS ( optional) 7/19/2017 25 Seminar

26. Normal cervical cells 7/19/2017 26 Seminar

27. Superficial cells Intermediate cells Parabasal cells Metaplastic cells MICROSCOPIC APPEARANCE Basal cells 7/19/2017 27 Seminar

28. Superficial Cells M ature squamous cells L arge polygonal T ransparent pink cytoplasm S mall, pyknotic nucleus 5 to 6 μm in diameter. 7/19/2017 28 Seminar

29. Intermediate cells Cyanophilic cytoplasm P yknotic nucleus G ranular chromatin Nucleus measuring 8 μ m in diameter. 7/19/2017 29 Seminar

30. Parabasal cell Basal cell Immature squamous cells Common at the transformation zone Round or oval rather than polygonal Variably sized nucleus 7/19/2017 30 Seminar

31. Lactobacilli Lactobacilli are observed in about 50% of normal healthy adult female population. Mainly affect intermediate and superficial cells. Parabasal cells are generally spared

32. Mucin producing columnar Eccentrically placed nucleus Chromatin texture is finely granular Abundant vacuolated cytoplasm Arranged in cohesive sheets Honey comb appearance- sheets Picket fence appearance-strips Endocervical cells 7/19/2017 32 Seminar

33. NON NEOPLASTIC CELLULAR VARIATIONS Composed of parabasal cells (immature squamous cells) Interlocking parabasal type cells represents squamous metaplasia of the endocervix Squamous metaplasia 7/19/2017 33 Seminar

34. Hyperkeratosis Anucleate squamous cells Protective response of the stratified squamous epithelium-chronic mucosal irritation Parakeratosis Appears as plaques or as isolated cells Keratinized squamous cells with dense orangeophilic cytoplasm & small pyknotic nucleus 7/19/2017 34 Seminar

35. Tubal metaplasia Benign alteration of the endocervical epithelium Atrophy Hyperchromatic parabasal cells Flat monolayer sheet Preserved nuclear polarity 7/19/2017 35 Seminar

36. Inflammation SQUAMOUS EPITHELIAL CELLS Cytoplasm vacuolation perinuclear halo abnormal keratinisation Nucleus wrinkling of nuclear membrane multinucleation chromatin degeneration ENDOCERVICAL CELLS Cytoplasmic degeneration Nuclear variation 7/19/2017 36 Seminar

37. Trichomonas vaginalis P ear-shaped 15 to 30 µm long Pale , eccentriacally placed nucleus Red cytoplasmic granules ORGANISMS 7/19/2017 37 Seminar

38. Candida Fungal species – vulva , cervix and vagina Pink Yeast forms – 3 to 7 µm diameter Long pseudohyphae and true hyphae Tangles and skewers of sq epithelial cells around pseudohyphae (spaghetti and meatballs or shish kebabs effect) 7/19/2017 38 Seminar

39. Bacterial vaginosis Steep reduction in proportion of lactobacilli with concomitant predominance of coccobacilli Short bacilli- coccobacilli,curved bacilli,or mixed bacteria L ayer of bacteria that obscures the cell membrane (clue cells) Absence of inflammatory cells with filmy appearance 7/19/2017 39 Seminar

40. Actinomyces Long filamentous organism Tangled clumps of bacteria -cotton ball appearance or dust bunnies C enter sulfur granule shows amorphous material P eriphery exhibits thin filamentous bacilli radiating outwards I ntrauterine device (IUD) usage. 7/19/2017 40 Seminar

41. HERPES SIMPLEX Multinucleation Molding of nulcei Margination of chromatin Ground-glass nuclei Eosinophilic intranuclear inclusions 7/19/2017 41 Seminar

42. Epithelial cell abnormalities Epithelial cell abnormalities 7/19/2017 42 Seminar

43. 7/19/2017 43 Seminar

44. 1.ASCUS : Atypical squamous cells of undetermined significance Minimal hyperchromasia Bi-nucleation Even chromatin & enlarged nucleus Multinucleated cells with small perinuclear halo. -Mild nuclear enlargement 7/19/2017 44 Seminar

45. 2.ASC-H : ATYPICAL SQUAMOUS CELLS - CANNOT EXCLUDE HSIL Small cells with high N/C ratio Smooth nuclear contour and delicate chromatin 7/19/2017 45 Seminar

46. 3.LSIL : low grade squamous intraepithelial lesion Includes HPV / mild dysplasia / CIN1 Intermediate sized cells Nuclear atypia - enlargement irregular contour hyperchromasia slight chromatin coarseness Cytoplasmic cavities ( koilocytes ) Keratinizing variant-deeply orangeophilic cytoplasm and squamous pearls Koilocyte 7/19/2017 46 Seminar

47. 4.HSIL:High grade squamous intraepithelial lesion High N/C ratio than LSILs as the cells are smaller usually parabasal sized cells Discrete cells or syncytium like groups- hyperchromatic crowded groups Nuclear atypia - enlargement marked irregularity in countour marked hyperchromasia marked chromatin coarseness Karatinizing variant 7/19/2017 47 Seminar

48. 5.Squamous cell carcinoma Most common malignant tumor of cervix HPV 16 & 18 HSIL features ,plus macronucleolus irregular chromatin distribution tumour diathesis- granular , amorphous precipitate with nuclear debris and RBC Tad pole cells- bizzare elongated spindle shaped cells Fiber cells –keratinizing type 7/19/2017 48 Seminar

49. 6.Adenocarcinoma in situ (AIS) Hyperchromatic crowded groups Glandular differentiation columnar cells strips and rosettes feathering Neoplastic nucleus hyperchromasia crowding,stratification inconspicuous nucleolus apoptosis mitoses no tumour diathesis 7/19/2017 49 Seminar

50. 7.Endocervical Adenocarcinoma Tumor diathesis- one half of cases Large,round nucleus Prominent nucleolus Abundant cytoplasm 7/19/2017 50 Seminar

51. Conclusion The mortality rate from cervical cancer fell dramatically after screening was introduced There was a direct correlation between the intensity of screening and decrease in mortality Implementing Liquid Based Cytology will increase oppurtunity to detect early signs of abnormality The Bethesda System (TBS) improve the predictive value of the screening process 7/19/2017 51 Seminar

52. Thank you ‼ 7/19/2017 52 Seminar

53. References Cibas E S, Ducatman B S.Cervical and vaginal cytology.In: Cytology : diagnostic principles and clinical correlates, 3rd ed.Elseiver;2008 p1-60. Solomon D, Nayar R. The Bethesda System for Reporting Cervical Cytology.2 nd ed.springer;2004 Nayar a R, Wilbur B D C. The Pap Test and Bethesda 2014 . Acta Cytologica . 2015;59:121–132 7/19/2017 53 Seminar