Pap smear Examination

PAP smear examination and diagnosing various features ASCUS, LSIL,HSIL, ASH

1. PAP Smear examination Vikram Prabhakar (DCP,DNB Pathology)

2. Patient details Pt is a 39 yr female, a housewife HIV positive since 2001 Is on Regular ART

3. H/O present illness Pt visited gynecology OPD in December 2014 for a routine examination. No h/o dysmenrrhoea , white discharge p/v. No h/o irregular menstruation. No h/o chronic disease No h/o blood transfusion or surgery

4. Obstetric history: P1L1, FT ND, male child, 19 yrs back Menstrual history: Regular cycle of menstruation Menarche at 13 years

5. On Examination P/A– Soft, non tender, no organomegaly P/S– Cervix, Vagina healthy P/V– uterus normal size, AV, FF, NFT RS/CVS/CNS– NAD PAP smear was done

6. Low power Adequate Inflammatory smear

7. Low power view Inflammatory smear

8. High power High N:C ratio Irregular nuclei Coarse chromatin

9. High N:C ratio Irregular nucleus Hyperchromatic nucleus

10. Differential diagnosis ASC-h/HSIL ASCUS LSIL ASC-H mimic

11. Criteria for ASC-H Cells are the size of a metaplastic cells with nuclei 1.5 to 2 times the size of normal. Variable N:C ratio; may be very high Prominent nuclear irregularity Generally hyperchromatic nuclei but may be normo - or hypochromatic . Lack of nucleoli

12. ASCUS Nuclei are 2.5 to 3 times the nucleus of a normal intermediate S q cell or twice the size of a squamous metaplastic cell nucleus Slightly increased N:C ratio Minimal nuclear hyperchromasia

13. LSIL Mature squamous cells with enlarged nuclei Koilocytosis or perinuclear cavitation Binucleation / multinucleation is common Variable size nuclei

14. Final Impression ASC--H

15. Revisited the OPD on 30th May 2015. No specific gynecological complaints. On examination: P/A : soft, non-tender P/S : Cx , vagina healthy P/V : uterus normal size, FF, NFT.

16. USG: Normal study, No obvious mass/focal lesion in Cervix. PAP smear

17. Low power Adequate smear Moderate to dense inflammation

18. BB shots

19. Low power A syncytial cluster or hyperchromatic crowded group

20. High N:C ratio Nuclear irregularity Hyperchromatic No nucleolus

21. Variable nuclear enlargement High N:C ratio Irregular nuclear margin delicate cytoplasm

22. Isolated single abnormal cell

23. Abnormal, large stripped nuclei are seen that are considerably bigger than the intermediate cell nuclei.

24. Differential Diagnosis HSIL Non- keratinized Sq cell Ca Endocervical adenocarcinoma in situ (AIS) Mimics of HSIL

25. Criteria for HSIL Variable N:C ratio; may be very high Nuclear membrane notching and marked irregularity Generally hyperchromatic nuclei but may be normo - or hypochromatic Occasional mitosis Inconspicuous nucleoli In clusters-- Horizontal arrangement of cells at periphery

26. Sq cell Ca v/s HSIL

27. Endocervical Adeno Ca in situ Hyperchromatic crowded cells with: Glandular differentiation Columnar cells Strips and rosettes Psuedo stratification Snake eating an egg appearance Feathering

28. Rosettes are highly characterestic of AIS and are never seen with HSIL

29. Resemble HSIL but feathering at borders gives away the glandular nature

30. Impression HSIL Biopsy was advised

31. A cervical biopsy was sent for HPE (5325/15) on 20/6/15. Imp: Carcinoma in situ of Cervix

32. Low power The abnormal immature cells show minimal maturation from the base of the epithelium to the surface with nuclear size and shape variation

33. Low power

34. High power

35. Low power

36. Dysplasia Koilocytic changes

37. High power Koilocytic change Dysplastic cells

38. Impression Carcinoma in situ cervix

39. Mimics of HSIL/ASC-H

40. Immature squamous metaplasia :-- Nuclear uniformity, smooth nuclear borders, and fine and evenly distributed chromatin

41. Single benign endocervical cells are prone to cytoplasmic lysis

42. Tubal metaplasia with Cilia

43. HSIL in Atrophic smear HSIL in atrophy may be difficult to distinguish from clusters of benign atrophic squamous cells . Focusing in different planes allows one to better distinguish them from the parabasal cells in the background

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