Cervix cyto

detailed decription of bethesda Cervical cytology, 3rd edition

1. CERVICAL CYTOLOGY Dr. Rajesh Deo Resident Department of Pathology

2. A screening test for detection of cervical cancer and precancerous conditions. Dr. George Papanicolaou - introduced cervical cytology in clinical practice (1940)

3. Whom to screen S hould start at the age of 21 regardless of the onset of sexual activity Women (21-29 yrs ) should have pap test every 3 yrs Women (30-65 yrs ) should have co-test (Pap test and HPV test) every 5 yrs or pap test alone every 3 yrs.

4. When to stop routine screening Age 65 and above if - no history of dysplasia or cancer - 3 negative pap test in a row or 2 negative co-tests in a row in past 10 years (most recent tests - within 5 years) Total hysterectomy (No CIN II/III, Ca)

5. Not applicable to: History of cervical cancer HIV infected, with weak immune system DES exposure in utero

6. NHSCSP guidelines Under 24.5  no invitation. 24.51 st invitation. 25 to 49every 3 yrs 50 to 64every 5 yrs 65+for those who had abnormal tests.

7. THE BETHESDA SYSTEM OF REPORTING CERVICAL CYTOLOGY Started 3 decades back in 1988 Profound effect on cervical cytology for pathologists and clinicians. Updated in 2014

8. TBS: 2001 SPECIMEN TYPE: Conventional smear vs LBC   SPECIMEN ADEQUACY -Satisfactory for evaluation -Unsatisfactory for evaluation

9. INTERPRETATION/RESULT 1.NEGATIVE FOR INTRAEPITHELIAL LESION OR MALIGNANCY -No cellular evidence of neoplasia Organisms Trichomonas vaginalis Fungal organisms morphologically consistent with  Candida   spp Shift in flora suggestive of bacterial vaginosis Bacteria morphologically consistent with  Actinomyces   spp Cellular changes consistent with Herpes simplex virus

10. Non-neoplastic findings  (Optional to report) - Reactive cellular changes associated with : Inflammation and Radiation Glandular cells status post hysterectomy - Atrophy

11. 2. OTHER Endometrial cells   >= 40 years of age Negative for squamous intraepithelial lesion should be specified.

12. 3 .EPITHELIAL CELL ABNORMALITIES Squamous cell Atypical squamous cells -Of undetermined significance (ASC-US) -Cannot exclude HSIL (ASC-H ) Low grade squamous intraepithelial lesion (LSIL ) High grade squamous intraepithelial lesion (HSIL ) Squamous cell carcinoma

13. Glandular cell Atypical - Endocervical cells -Endometrial cells A denocarcinoma   in situ Adenocarcinoma - Endocervical -Endometrial - Extrauterine -NOS

14. OTHER MALIGNANT NEOPLASMS  (specify) ANCILLARY TESTING AUTOMATED REVIEW   EDUCATIONAL NOTES AND SUGGESTIONS  (optional)   

15. SPECIMEN ADEQUACY Satisfactory for evaluation Presence /absence of endocervical /transformation zone component should be mentioned. 2. At least 10 well preserved endocervical or squamous metaplastic cells singly or in clusters 3. Other quality indicators/qualifiers- partially obscuring blood, inflammation ) 4.Specimen with abnormal cells ( ASC-US, AGC)

16. Unsatisfactory for evaluation(processed/unprocessed) Scenarios: No identification B roken slide 3. More than 75 % of squamous cells obscured-no abnormal cells are identified

17. Organisms Trichomonas vaginalis : Pear- shaped, oval or round cyanophilic organisms ranging from 15-30 micron Nucleus is pale, vesicular,and eccentrically located. Flagella seen in liquid based preparation. Leptothrix may be seen in association with the organism.

18. Fungal organisms morphologically consistent with  Candida   spp Budding yeasts Pseudohyphae

19. Shift in flora suggestive of bacterial vaginosis Individual squamous cells - covered by a layer of bacteria that obscures the cell membrane- clue cells. C onspicuous absence of lactobacilli.

20. Bacteria morphologically consistent with  Actinomyces   spp Tangled clumps of filamentous organisms recognizable as “ cotton ball” clusters Associated with IUCD use

21. Cellular changes consistent with Herpes simplex virus Nuclei have a “ ground glass” appearance Large multinucleated epithelial cells with molded nuclei

22. Other non neoplastic findings Reactive cellular changes associated with inflammation Nuclear enlargement (1/1.5-2 times more) Occasional binucleation or multinucleation Nuclear outlines smooth, round and uniform, vesicular nuclei Prominent single or multiple nucleoli Cytoplasm : polychromasia , vacuolization, perinuclear halos without peripheral thickening

23. Reactive cellular changes associated with radiation: Cell size is markedly increased without increase in N:C ratio i.e cytoplasm n nucleus is proportionately increased Prominent single or multiple nucleoli is coexisting repair Cytoplasmic vacuolization and/or polychromatic staining Bizzare cell shape may occur

24. Reactive cellular changes associated with intrauterine contraceptive device May be present singly or in small clusters, mimicking a signet ring appearance

25. Atrophy: Flat, monolayer sheets or dispersed parabasal cells Blue blobs Multinucleated giant cells

26. Endometrial cells Exfoliated endometrial cells in ball like clusters Normal during first half of menstrual cycle Endometrial cells (>= 40years of age)

27. Epithelial cell abnormalities Squamous cell: Atypical squamous cells(ASC) of undetermined significance(ASC-US) cannot exclude HSIL(ASC-H)

28. Atypical squamous cells Refer to cytological changes, suggestive of SIL which are qualitatively or quantitatively insufficient for definitive interpretation. Doesnot represent a single biological entity 50% with ASC are infected with HPV Remaining may mimic numerous non neoplastic condition- inflammation, air drying artefacts, atrophy with degeneration, radiation

29. ASCUS > 90 % of ASC s/o LSIL but are quanititatively or qualitatively insufficient for definite interpretation. Cells resemble superficial or intermediate cells 2.5-3 times increase in nuclear size with minimal nuclear irregularities 2 times size of squamous metaplastic cells Repeat after 6 months or HPV test(LBC) or colposcopy.

30. ASC-H Cells resemble parabasal and basal cells nuclei 1.5 to 2.5 larger than normal Hyperchromatic nuclei with irregularities Management - colposcopy

31. Squamous Intraepithelial lesion ( SIL) Low grade squamous intraepithelial lesion (LSIL)  HPV(low risk)/mild dysplasia/CIN 1 High grade squamous intraepithelial lesion (HSIL)  Moderate and severe dysplasia/CIS/CIN 2 & 3 /HPV(high risk)

32. HPV Low risk HPV: HPV 6, 11 High risk HPV: HPV 16( most common), 18, 31, 33 HPV are associated with both low and high grade SIL. LSIL & HSIL -2 different biological entities (LSIL)Transient infections: regress over a period of 1 to 2 years (HSIL)Persistent infections associated with increased risk of precancerous lesions/ invasive carcinoma

33. HPV 15 high risk HPVs currently identified, HPV-16  60% of cervical cancer cases, and HPV-18 accounts for another 10% of cases On average, 50% of HPV infections are cleared within 8 months, and 90% of infections are cleared within 2 years. HPVs infect immature basal cells of the squamous epithelium in areas of epithelial breaks, or immature metaplastic squamous cells present at the squamocolumnar junction.

34. PATHOGENESIS viral proteins E6 and E7 INHIBITS activity of tumor suppressor proteins that regulate cell growth and survival. Viral E7 binds RB ( hypophosphorylated form) degradation by proteasome pathway Binds and inhibits p21 and p27(CDKI) enhances cell cycle progression and inhibit DNA damage repair .

35. PATHOGENESIS.. contd viral E6 proteins of high-risk HPV subtypes binds to the tumor suppressor protein p53 and promote its degradation by the proteasome . In addition, E6 up-regulates the expression of telomerase, which leads to cellular immortalization. The net effect is increased proliferation of cells that are prone to acquire additional mutations that may lead to cancer development.

36. LSIL Cells occur singly and in sheets Cytological changes confined to cells with “ mature” intermediate or superficial type cytoplasm. >3x intermediate nuclei with slightly increased N:C ratio Hyperchromatic to normochromatic Smooth to irregular nuclear membrane Nucleoli absent or inconspicuous Koilocytosis : cells with enlarged hyperchromatic nuclei, irregular contour with perinuclear halo

37. LSIL does not progress directly to invasive carcinoma and in fact most cases regress spontaneously; only a small percentage progress to HSIL. LSIL is not treated like a premalignant lesion. LSILs are ten times more common than HSILs. More than 80% of LSILs are a/w HPV .

38. MANAGEMENT OF LSIL < 25yrs and LSIL+ve  follow up with cytology at 12months >25 yr, HPV – ve follow up after 3yrs >25yr, HPV+ve  colposcopy >25yrs, HPV unknown Repeat cytology in 12months

39. Koiocyte

40. HSIL Cytological changes involve smaller and less mature cells than LSIL. Cells occur singly or in syncytial like aggregates Nuclear hyperchromasia with greater nuclear irregularities N:C ratio higher than LSIL Chromatin fine or coarsely granular Nucleoli absent but occasionally seen Cytoplasm is immature, lacy and delicate or densely metaplastic or occasionally mature and densely keratinized Immediate LEEP or colposcopy

41. HSIL, there is a progressive deregulation of the cell cycle by HPV  increased cellular proliferation, decreased or arrested epithelial maturation, and a lower rate of viral replication, as compared with LSIL. Derangement of the cell cycle in HSIL may become irreversible and lead to a fully transformed malignant phenotype, and thus all HSILS are considered to be at high risk for progression to carcinoma. More than 100% HSIL a/w HPV.

42. MANAGEMENT OF HSIL >25 YRS and + ve HSIL Immediate excisional procedure at the time of colposcopy if lesion is identified. If biopsy confirmed HSIL not identified at the time of colposcopyp16 IHC to be done.

43. Squamous cell carcinoma Malignant tumor showing differentiation towards squamous cells D oes not subdivide squamous cell carcinoma Tadpole cells, tumor diathesis

44. KERATINIZING SCC Mostly singly and less commonly cellular Variation in shape and size caudate to spindle Dense orangeophilic cytoplasm Dense opaque nuclei with irrregular nuclear membrane Coarsely granular to irregular with chromatin clearing Less commonly tumor diathesis

45. NON-KERATNIZING SCC Occur singly or in clusters Smaller than HSIL Coarsely clumped chromatin with chromatin clearing Prominent nucleoli Tumor diathesis common  necrotic debris and broken blood elements

46. Bethesda system 2014: changes increased use of liquid-based preparations addition of co-testing (Pap and HPV testing) primary HPV testing as additional screening options further insights into HPV biology approval and implementation of prophylactic HPV vaccines and updated guidelines for cervical cancer screening and clinical management.

47. What has changed? 1.Reporting of benign-appearing endometrial cells is now recommended for women aged ≥45 years. - to increase the predictive value of this category.

48. No new category was created for squamous lesions with LSIL and few cells s/o concurrent HSIL . LSIL in addition to ASC-H(LSIL is present with possibility of HSIL.)

49. LIQUID BASED CYTOLOGY Is a monolayer slide preparation technology introduced to overcome shortcomings of conventional pap smear Produces a sample fully representative of the material

50. Advantages of LBC over conventional pap smear Provides a more representative cervical sampling Reduces obscuring factors Lower unsatisfactory rates Less screening time Fewer artefacts in cellular morphology Cells are deposited on slide in a monolayer Provides representative residual material that can be used for additional test like HPV test Immunohistochemical analysis

51. FDA approved 1.Surepath Centrifugation and sedimentation through a density gradient 2.ThinPrep Filtration and collection of vacuum-packed cells on a membrane and transferring to the glass slide

52. Processing: SurePath Works on principle of density gradient. The vials are vortex mixed to re-suspend cells. An aliquot is treated with a density reagent and centrifuged. This produces a concentrated pellet of cells

53. Cells sediment to form a thin layer and excess fluid is discarded. Staining is an integrated part of the process

54. Disadvantages of LBC Cost Not suitable for smaller centers dealing with fewer samples Some studies show equal specificity in detecting HSIL and carcinoma as conventional

55. HPV VACCINE Currently used in UK is Gardasil . Protects against 4 types of HPV (16,18,6 and 11) 99% effective against cancer caused by HPV 16 and 18. 1 st dose 12 -13 yrs older 2 nd dose12 months or 6months gap between the doses. For aged>15yrs or older who have not vaccinated at 12-13 yrs 3 doses to be taken.

56. Thank you!! 