Pap smear

1. PAP SMEAR IN CERVICAL CYTOLOGY PRESENTED BY : DR. BISWAJEETA SAHA PG STUDENT,DEPT. OF PATHOLOGY, KIMS,BHUBANESWAR

2. HISTORY DR.GEORGE PAPANICOLAOU

3. BETHESDA SYSTEM The first workshop was held in 1988, to reduce widespread confusion among laboratories and clinicians created by the use of multiple classification systems and inconsistently defined numerical grading conventions. Earlier versions of bethesda include 3 categories of adequacy: Satisfactory Unsatisfactory Borderline. The 2001 bethesda system eliminates the borderline category. To provide a clearer indication of adequacy specimens are now designated as “satisfactory” or “unsatisfactory”.

4. Cytological identification of epithelial cells

5. Transformation zone and squamocolumnar junction Area of metaplastic epithelium proximal to the original squamocolumnar junction is referred to as transformation zone since it is an area of epithelial instability.

6. OTHER COMPONENTS OF CERVICAL SMEAR Endometrial cells Neutrophils,basophils,eosinophils,lymphocytes Macrophages Spermatozoa Contaminants.

7. PREPARATION OF PAP SMEAR . Conventional pap smear Liquid based preparations

8. SPECIMEN ADEQUACY Minimum squamous cellularity criteria Conventional smear-8000 to 12000 well preserved, well visualised squamous cells. Liquid based prep-min 5000. Endocervical zone component Atleast 10 well preserved endocervical or squamous metaplastic cells ,singly or in clusters. If high grade cancer is present,it is not necessary to report presence or absence of transformation zone component.

9. SATISFACTORY: Describes presence or absence of endocervical /transformation zone component and any other quality indicators. Any specimen with abnormal cells (ASC-US,AGC or worse)is by definition satisfactory for evaluation. UNSATISFACTORY: Rejected specimen-not processed because(specimen not labelled,slide broken, patient particulars not mentioned etc.) Fully evaluated, unsatisfactory specimen-specimen processed and examined, but unsatisfactory for evaluation of epithelial abnormality because of-obscuring blood, inflammatory cells,etc . Specimens with more than 75% of squamous cells obscured should be termed unsatisfactory. When 50-75% cells are obscured,a statement describing the specimen as partially obscured should be made.

10. DIAGNOSTIC CATEGORIES Non neoplastic neoplastic Organisms: Trichomonas Candida Chlamydia HSV HPV CMV Other: Reactive- *inflammation *radiation *IUD Glandular cells post hysterectomy Atrophy. Epithelial cell abnormality Squamous cell: Atypical squamous cells(ASC) *ASCUS *ASC-H Squamous intraepithelial lesion *LSIL *HSIL Squamous cell ca * keratinising *non- keratinising Glandular cell abnormalities: Atypical * endocervical *endometrial *glandular Atypical * endocervical cells favour neoplastic . *glandular cells favor neoplastic Endocervical ca in situ Adenooca * endocervical *endometrial * extrauterine * nos

11. ATYPICAL SQUAMOUS CELLS(ASC) Interpretation af ASC requires that cells demonstrate 3 features- Squamous differentiation Increased N/C ratio Minimal nuclear hyperchromasia,chromatin clumping,irregularity,smudging or multinucleation

12. ATYPICAL SQUAMOUS CELLS OF UNDETERMINED SIGNIFICANCE Nuclei approx 2 and 2.5 times area of nucleus of intermediate cells Slightly increased N/C ratio. Minimal hyperchromasia,irregilarity in chromatin distribution or nuclear shape.

13. ATYPICAL SQUAMOUS CELLS-CANNOT EXCLUDE HSIL Include 2 categories Small cells with high N/C ratio-atypical metaplasia *cells occur singly or in small fragments of less than 10 cells. *cells size of metaplastic cells,nuclei about 1.5 to 2.5 times larger than normal. Crowded sheet pattern- *crowded cells,nuclei show loss of polarity or difficult to visualize. *dense cytoplasm, polygonal cells and fragments with sharp linear edges generally favor squamous over glandular differentiation.

14. LSIL Mature type cytoplasm Large cell size,increased N/C ratio. Nuclear enlargement more than 3 times the area of normal intermediate nuclei Bi and multinucleation Chromatin uniformly distributed. Nucleoli generally absent Nuclear membrane slightly irreguilar distinct cytoplasmic borders. Koilocytosis .

15. ASCUS LSIL INFLAMMATION

16. HSIL Less mature than cells in LSIL. Nuclear hyperchromasia accompanied by variations in nuclear size and shape. Degree of nuclear enlargement more variable Nuclear membrane quite irregular with indentations and grooves Nucleoli absent,occassionally present cytoplasm immature,lacy,delicate or densely metaplastic

17. SQUAMOUS CELL CARCINOMA KERATINISING relatively few cells present. Marked variation in cell size and shape,wiith caudate , spindle cells and tadpole cells Marked variation in nuclear size, irregular nuclear membrane, numerous dense opaque nuclei. Coarsely granular chromatin with parachromatin clearing . Tumor diathesis may be present, less than non keratinizing .

18. NON KERATINISING- Cells occur singly or in syncitial aggregate with poorly defined cell borders. Smaller than HSIL. Marked irregular distribution of coarsely clumped chromatin. A tumour diathesis consisting of necrotic debris and old blood.

19. ATYPICAL ENDOCERVICAL CELLS NOS Cells in sheets and strips, cell crowding, nuclear overlap. Nuclear enlargement upto 3 to 5 times area of normal endocervical nuclei. Some variation in nuclear size and shape. Mild hyperchromasia Nucleoli may be present Mitosis rare Cytoplasm fairly abundant, N/C ratio increased Distinct cell border

20. ATYPICAL ENDOMETRIAL CELLS Cells occur in small groups ,usually 5-10 cells/group. Nuclei slightly enlarged Mild hyperchromasia Small nucleoli Scant cytoplasm,ocassionaly vacuolated Ill defined cell borders.

21. ENDOCERVICAL CARCINOMA IN SITU Cells occur in sheets,clusters,strips and rosettes with nuclear crowding and overlap, loss of honeycomb pattern. palisading nuclear arrangement with feathering Enlarged. Stratified nuclei. Hyperchromasia Nucleoli small, inconspicuous Mitosis and apoptosis seen N/C ratio increased,cytoplasm and mucin diminished Abnormal squamous cells may be present

22. ENDOCERVICAL ADENOCARCINOMA Abundant abnormal cells,typically with columnar configuration Single cells,2dimensional sheets or 3 dimensional clusters and syncitial aggregates commonly seen Enlarged pleomorphic nuclei,parachromatin clearing,nuclear membrane irregularities. Macronucleoli present Cytoplasm finely vacuolated Necrotic tumour diathesis may be seen

23. TRICHOMONAS Pear shaped,oval,cyanophilic organisms,15-30 μ Pale vesicular eccentrically located nucleus. Eosinophilic cytoplasm granules centrally. Inflammatory changes.

24. GARDNERELLA VAGINALIS Clue cells Mixed bacteria,mainly coccoid Neutrophilic satellitosis .

25. CANDIDA Double contoured pale pink hyphae and pseudohyphae Pseudohyphae appear septate Spores are eosinophilic Inflammatory changes variable

26. HERPES SIMPLEX Swollen nuclei with multinucleation . Ground glass chromatin with prominent nuclear membrane and nuclear inclusions(tombstones). Nuclear moulding .

27. HUMAN PAPILLOMA VIRUS Koilocytosis -superficial and intermediate cells Multinucleation Nuclear swelling and degeneration Keratotic spikes,pearls and rafts Single dyskeratotic cells.

28. INFLAMMATION CHANGES IN SQUAMOUS EPITHELIAL CELLS- Cytoplasmic abnormalities * vacuolation * perinuclear halo *altered staining *abnormal keratinisation Changes in nucleaus - *wrinkling of nuclear membrane * multinucleation *chromatin degeneration CHANGES IN ENDOCERVICAL CELLS- Cytoplasmic degeneration Nuclear variation

29. RADIATION Cell size markedly increased without increase in N/C ratio. Nuclei show degenerative changes Bi or multinucleation Prominent single or multiple nucleoli Cytoplasmic vacuolation

30. INTRAUTERINE DEVICES Endometrial shedding at any stage. Single and clustered enlarged vacuolated glandular cells. Neutrophilic exudate Actinomycotic colony

31. ATROPHY Flat monolayer sheets of parabasal cells with preserved nuclear polarity Parabasal cells may have hyprechromaisa Chromatin uniformly distributed Autolysis result in naked nuclei. Abundant inflammatory exudate .

32. OUTCOME ASC-US + ASC-H: *no immediate cancer risk. *most cases don’t progress to cancer. *perform HPV testing + ve ---- colposcopy - ve ---repeat PAP smear in 12m LSIL: *12-16% cases progress to cancer in 10years *50% cases regress in 2years. *HPV testing + ve-colposcopy LOOP - ve —repeat PAP smear at 6 and 12m HSIL: *20% progress to cancer in 10years. colposcopy

33. Bethesda system 2001 Specimen type-conventional smear Specimen adequacy * satisfactory *unsatisfactory General categorisation * NILM *epithelial cell abnormality *other Interpretation

34. Thank you