PAP SMEAR.pptx with gynae and pathology correlation

pap smear testing in gynae pathology

1. PAP SMEAR It is a system of reporting cervical or vaginal cytology (used for reporting Pap smear results). The Papanicolaou test (also called Pap smear, pap test, cervical smear or smear test) is a screening test used to detect potentially pre-cancerous and cancerous process in the cervix.

2. Patient preparation Women should be tested two weeks after the first day of their last menstrual period.(Day 14 of cycle is optimal). Women should not use any vaginal medication, contraceptive during the 48 hrs prior to sample collection. Sexual abstinence is recommended the night before the test. dr. monika nema

3. Squamo -Columnar Junction • Junction between the stratified squamous epithelium and columnar epithelium of the endocervix • Sampling target • TZ—Vulnerable to HPV infection; SCC cervix; surveillance of the area imp. to detect early cases of dysplasia

4. Collection of sample: Sample collection : Optimal sample include cells from the ectocervix and endocervix . Squamo -columnar junction (Most likely site of dysplasia).

5. Superficial squamous cell : Mature , polygonal Derived from outermost layer of cervical epithelium Seen in proliferative phase of menstrual cycle and in presence of irritation C ytoplasm : abundant and e osinophilic N ucleus : pyknotic and cross- sectional area of 10-15µm 2

6. Intermediate squamous cell : P resent in the middle or intermediate layer of squamous epithelium Prominent in pregnancy and with use of progestational agents. N ucleus - L arger than that of superficial cell i.e. cross-sectional area 35µ 2 ; Fine granular chromatin pattern. The intermediate cell nucleus serves as the basic size reference for other cells in cervical cytology specimens

7. Parabasal / Basal squamous cells : Small , oval , round immature Predominate in postmenopausal and postpartum states. N ucleus – oval ; larger than in intermediate cells with an area of 50μm 2 ; fine chromatin

8. Endometrial cells : A ppea r as rounded clusters . Smaller than endocervical cells

9. ENDOCERVICAL CELLS HONEY COMB PICKET FENCE

10. SQUAMOUS METAPLASIA

11. TUBAL METAPLASIA

12. Metaplastic phenomenon in which normal endocervical epithelium is replaced by an epithelium that recapitulates that of the normal fallopian tube.  This metaplastic epithelium includes ( ciliated cells, peg cells, and goblet cells) Nuclei are round to oval ,enlarged, pleomorphic, and often hyperchromatic . Chromatin evenly distributed and nucleoli not seen . The cytoplasm may show discrete vacuoles or goblet cell change Tubal metaplasia is among the most common benign processes to be misinterpreted as endocervical atypia or neoplasia .

13. The 2014 BETHESDA SYSTEM FOR REPORTING CERVICAL CYTOLOGY 1)SPECIMEN TYPE: Indicate conventional smear (Pap smear) vs. liquid-based preparation vs. other 2)SPECIMEN ADEQUACY : • Satisfactory for evaluation ( describe presence or absence of endocervical /transformation zone component and any other quality indicators, e.g., partially obscuring blood, inflammation, etc. ) • 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 )

14. 3)GENERAL CATEGORIZATION ( optional ) • Negative for Intraepithelial Lesion or Malignancy • Other: See Interpretation/Result ( e.g., endometrial cells in a woman ≥45 years of age ) • Epithelial Cell Abnormality: See Interpretation/Result ( specify ‘squamous’ or ‘glandular’ as appropriate ) 4)INTERPRETATION/RESULT I)NEGATIVE FOR INTRAEPITHELIAL LESION OR MALIGNANCY: When there is no cellular evidence of neoplasia , state this in the General Categorization above and/or in the Interpretation/Result section of the report -- whether or not there are organisms or other non-neoplastic findings

15. A)NON-NEOPLASTIC FINDINGS ( optional to report; list not inclusive ) • Non-neoplastic cellular variations – Squamous metaplasia – Keratotic changes – Tubal metaplasia – Atrophy – Pregnancy-associated changes • Reactive cellular changes associated with: – Inflammation (includes typical repair) - Lymphocytic (follicular) cervicitis – Radiation – Intrauterine contraceptive device (IUD) • Glandular cells status post hysterectomy

16. B)ORGANISMS • Trichomonas vaginalis • Candida spp. • B acterial vaginosis • Actinomyces spp. • Herpes simplex virus • cytomegalovirus C)OTHER • Endometrial cells ( in a woman ≥45 years of age ) ( Specify if “negative for squamous intraepithelial lesion” )

17. II)EPITHELIAL CELL ABNORMALITIES SQUAMOUS CELL • Atypical squamous cells – of undetermined significance (ASC-US) – cannot exclude HSIL (ASC-H) • 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 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 – glandular cells, favor neoplastic

18. Endocervical adenocarcinoma in situ • Adenocarcinoma – endocervical – endometrial – extrauterine – not otherwise specified (NOS) OTHER MALIGNANT NEOPLASMS: (specify) 5)ADJUNCTIVE TESTING : Provide a brief description of the test method(s) and report the result so that it is easily understood by the clinician. 6)COMPUTER-ASSISTED INTERPRETATION OF CERVICAL CYTOLOGY: If case examined by an automated device, specify device and result. 7)EDUCATIONAL NOTES AND COMMENTS APPENDED TO CYTOLOGY REPORTS (optional): Suggestions should be concise and consistent with clinical follow-up guidelines published by professional organizations (references to relevant publications may be included)

19. The Bethesda system 1)SPECIMEN TYPE Indicate Conventional smear (Pap smear) vs. liquid-based preparation vs. other.

20. Unsatisfactory specimen from a 39-year-old woman (LBP, ThinPrep ). Abundant endocervical cells and mucus are seen; however, the squamous component is inadequate

21. Satisfactory cellularity (LBP). At 40×, there were approximately 11 cells per field when ten microscopic fields along a diameter were evaluated for squamous cellularity; this would give an estimated total cell count between 5,000 and 10,000

22. LOW GRADE SQUAMOUS INTRA-EPITHELIAL LESIONS(LSIL) Cells occur singly, in clusters, and in sheets. Cytologic changes occurs in squamous cells with “mature” intermediate or superficial squamous cell. cell size is large, & “mature ” well-defined cytoplasm. Nuclear enlargement > 3times the area of normal intermediate nuclei Nuclei hyperchromatic but may be normochromatic & anisonucleosis .

23. Chromatin uniformly distributed Binucleation and multinucleation are common. Nucleoli absent or inconspicuous Koilocytosis or perinuclear cavitation Cells show Increased keratinization with dense, eosinophilic cytoplasm Cells with koilocytosis or dense orangeophilia must also show nuclear abnormalities to be diagnostic of LSIL

24. HIGH GRADE SQUAMOUS INTRA-EPITHELIAL LESIONS(HSIL) C ells are smaller and show less cytoplasmic maturity than cells of LSIL Cells occur singly, in sheets, or in syncytial-like aggregates,result in hyperchromatic crowded groups of immature cells Degree of nuclear enlargement is more variable Cytoplasmic area is decreased, leading to increase in N:C ratio . N:C ratio is higher in HSIL compared to LSIL. Nuclei hyperchromatic to normochromatic & chromatin fine or coarsely granular , evenly distributed . N uclear membrane irregular and have prominent indentations or grooves . Nucleoli absent .

25. The dysplastic cells are seen here in a syncytial cluster or hyperchromatic crowded group

26. There is variation in nuclear size and shape, and the cells have delicate cytoplasm