Maj Liv Eide Non-neoplastic gynaecological cytology

Non‐neoplastic
gynaecological cytology
Maj Liv Eide, Dep. of Pathology and Medical Genetics,
Trondheim University Hospital ans Dep. of Biomedical Science,
Soer‐Troendelag University College, Norway

Agenda
Satisfactory smear
Normal cells in cervical specimens
Inflammatory conditions in general
Persistent irritation
o Metaplasia, tissue repair, tubal metaplasia, parakeratosis,
radiation therapy, IUD changes, reactive endocervical cells
and chronic inflammation
Specific infections
o Bacterial vaginosis, Candida albicans, Actinomyces Israeli,
Trichomonas vaginalis and Herpes simplex virus

Satisfactory smear
Conventional cytology
Conventional smear should
have a minimum of approx.
8000 – 12000 well‐preserved
and well‐visualized squamous
cells.
The number shall be
estimated, not counted
Liquid based cytology
Liquid based preparations
should have at least 5000
well‐visualized and well‐
preserved squamous cells.
A minimum of 10 fields
should be counted along a
diameter of the circle
including the centre

Minimum squamous cellularity in LBC
Counting 10 fields: The average cell number per microscopic field to achieve 5000 cells
is shown in the following table
FN 20 ocular/
10X objective
FN 20 ocular/
40X objective
FN 22 ocular/
10X objective
FN 22 ocular/
40 X objective
Preparation
diameter (mm)
cells/fields cells/fields cells/fields cells/fields
13 mm (SurePath) 118,3 7,4 143,2 9,0
20 mm (ThinPrep) 50 3,1 60,5 3,8
This method of strict criteria must not be applied to cell clustering, atrophy and cytolysis

Cervix: Normal cytology and hormones
• Papanicolaous staining method
• Estrogen and progesterone

Superficial squamous cells
Polygonal cells with pink,
transparent cytoplasm and
centrally placed small, dark
(pycnotic) nuclei
N/C ratio approx 1:30
Influenced by estrogen
Ovulation

Intermediate squamous cells
Polygonal cells with light
blue/turqoise cytoplasm and a
centrally placed, vesicular nuclei
Nuclear size equals polymorphs
Glycogen
N/C ratio approx 1 : 20
Influenced by progesteron
2.half of menstrual cycle
Pregnancy

Lactobacillus and cytolysis
• Lactobacillus –rod shaped
bacteria
• Able to lyse glycogen‐ rich
intemediate cells
• Converts glycogen to lactic
acid
• Second half of menstrual
cycle and pregnancy

Parabasal squamous epithelial cells
Round cells with bluegreen
cytoplasm and rund to oval nuclei
N/C ratio: 1 : 5
Atrophy
Postmenopause
Postpartum, when breast feeding
(some parabasal cells with
glycogen)
Oral contraceptive pills
(progesteron)

Endocervical columnar cells
Columnar shaped cells when
viewed from the side
Either secretory or ciliated cells
Secretory cells with mucin vacuoles
(one single or many)
Ciliated cells have denser
cytoplasm (bluegreen)
N/C ratio: approx. 1 : 3
Single, strips or in sheets
(honeycomb pattern)

Endometrial cells
•Epithelial and stromal cells
•The nuclei of epithelial cells are the size of
intermediate squmaous cells with
coarse chromatin due to degeneration
•Scant cytoplasm, often finely vacuolated
•Spontanously shedded endometrial cells: A
double contour cell ball with centrally placed
stroma surrounded by epithelium
•Endometrial cells shed after day 10‐14 or in
the menopause is considered abnormal

Metaplasia – normal physiologic process
Squamoucolumnar
junction
Transformation zone
‐ histology
Metaplastic cells ‐
cytology
Metaplastic process: Reserve cell hyperplasia, immature squamous metaplasia and
mature squamous metaplasia. Replaces damaged endocervical, columnar cells.

Squamous metaplastic cells
Immature
Parbasal‐like cells
Cobblestone pattern or single
Thick, dense blue‐green
cytoplasm with thicker
ectoplasm
”Spider cells” due to forcibly
scarped cells
LBC: Can look like endocervical
cells or HSIL
Mature
Intermediate squamous‐like
cells
Rounded cell outlines
Slightly, dense cytoplasm
Remnants of cobblestone

Squamous metaplasia
Conventional LBC

Euplasia –normal activity
Round to oval nuclei
Finely granulated chromatin
Evenly distributed and thin and even
chromatinic rim
Uniform nuclei

Fra Compendium in Clinical Cytology, R.Mecsei

Cell damage
Inflammatory reaction with
degenerative changes,
thereafter
regenerative/reactive changes
or cell death

Retroplasia
• Variation in nuclear size
• Loss of water control
• Swelling of nuclei due to increased water intake
• Wrinkled nuclear membrane due to loss of water
• Blurred or clumped chromatin
• Eosinophilia
• Amphophilia
• Vacuolisation
• Halo

Infection > decreased activity
Degenerative changes:
Blurred or clumped chromatin
Halo
Amphophilia
False eosinophilia
Vacuolisation

Necrosis
Irreversibel exogene cell damage > death
Karyopycnosis Karyorrhexis Karyolysis
The cells burst in the end and the cell content leaks into
the tissue, creating an inflammatory response unlike
apoptosis.

Tissue repair
Repair is visualised as regenerative cells
Often seen in patients with recurrent
cervicitis or after biopsies and laser therapy
Nuclear variation in size, shape and
enlargement
Prominent nucleoli and finely granulated,
evenly distributed chromatin, but not
hyperchromatic
Abundant cytoplasm and cohesive cells in
sheet‐like arrangements
Leukocyte infiltration in groups

Tubal metaplasia (TM)
Benign, nonneoplastic replacement of columnar cells
(endocervical or endometrial)
Cells characteristic of the fallobian tube
Usually occurs high up in the endocervical canal and
common finding due to use of endocervical brush
Hyperchromatic crowded groups and stratified strips
with high N/C ratio and dark, but finely granular, even
chromatin
The finding of terminal bars and cilia is most helpful
in recognising tubal metaplasia

Radiation damage
http://nih.techriver.net/atlas.php
The cytological changes due to
radiation can be transitory, last
for 1‐2 years or persist.
Both tumour cells and normal
cells are affected but tumour cells usually
clear rapidly (6‐8 weeks)
>Cytological criteria
Enlarged nuclei often multiple, pale or
dark with N/C ratio relatively unchanged.
Cytoplasm with amphophilia
Vacuolated cytoplasm (acute radiation
change)
Repair/regeneration is common

IUD changes
The Pap Test by RM DeMay, ASCP Press 2005
Chronic irritation due to IUD tail and body
affecting the tissue
> Cytological criteria
Reactive glandular (endocervical or
endometrial cells) or metaplastic cells with
prominent nucleoli and hypervacuolisation
(“bubble‐gum cells”).
Hyperplastic endocervical, columnar cells may
form papillary tissue fragments.
A few, atypical appearing, single endometrial
cells (IUD cells) or shed in clusters.
Clean background

Parakeratosis
The Pap Test by RM DeMay, ASCP Press 2005
Benign keratotic reaction, but
may conceal underlying
lesion, most often associated
with condyloma or SIL.
> Cytological criteria
Single, flat cells, layered strips
of cells or concentrically
arranged “pearls”. Usually
orange stained cytoplasm
and centrally, pycnotic and
hyperchromatic nuclei.

Reactive endocervical cells
The Pap Test by RM DeMay, ASCP Press 2005
Reactive endocervical cells are
common (hyperplasia, polyps,
cervicitis)
>Cytological criteria
•Cells ”lay flat” with enlarged,
round to oval nuclei up to 4‐5
times the normal area
•Fine chromatin
•Bi‐ and multinucleation
•Prominent nucleoli
•Maintained N/C ratio
•Well defined cell borders

Chronic (follicular) cervicitis
Follicular cervicitis, synonymous with lymphoid cervicitis is an
inflammatory condition involving lymphoid follicles in
subepithelial areas.
Associated with Chlamydia infection
> Cytological criteria:
Mature and immature lymphoid cells along with tingible body
macrophages, which must be identified. Follicular cervicitis is easier
to interpret in conventional smears than LBC due to lymhocytic
dispersion in the latter.
DD: Lymphoma, endometrial cells, histiocytes, metastatic tumor
cells.

Chronic (follicular) cervicitis
Conventional LBC

Bacterial vaginosis
• Thin, homogenous discharge
• Vaginal ph > 4,5 due to lack of
lactobacilli
• Gardnerella vaginalis, one of the
major species assosiated with
bacterial vaginosis
> Cytological criteria
1. Clue cells: Coccobacillus sticked to
squamous cells
2. Lack of inflammatory cells and
lactobacilli

Fungal infection > due to Candida
Conventional LBC
Pseudohyphae (sticks) and yeast (stones), which may look like “balloon dogs”.
Budding may be seen. The pseudohyphae usually stain pale pink or blue and are
surrounded by a small, clear halo.
> Cytological criteria: Mildly enlarged nuclei, with slight hyperchromasia and
hyperkeratosis: Lysed neutrophils are common. DD: ASC‐US

Actinomyces israeli
Conventional LBC
Actinomyces is associated with IUD usage
Actinomyces are branching, filamentous bacteria and in Pap test the
bacteria live symbiotically with colonies of bacteria forming dark‐blue
masses with spidery legs (actinomyces)

Trichomonasinfection
Conventional LBC
Trichomonas vaginalis is an oval or pear‐shaped protozoan. The nucleus of the
trichomonas is thin, pale and eccentrically located and must be seen to identify
this organism. Flagella may be seen in LBC.
Cytological changes: Pseudokeratinization, amphophilia and false eosinophilia.
Slight nuclear enlargement, hyperchromasia and perinuclear halos are common.

Herpes simplex virus infection
Conventional LBC
http://nih.techriver.net/atlas.php
Multinucleated cells with enlarged nuclei and molding. The chromatin marginates
due to viral particles filling the nuclei, resulting in ground glass appearance. The
nuclear membrane appears thickened due to condensed chromatin. Intranuclear
inclusions are highly characteristic when present, but is found only in half of the
cases.

Workshop
Cases with both Conventionals and LBC (ThinPrep)and a
number of cases with LBC Surepath only and ThinPrep
only
NILM –negative for intraepithelial lesion or malignancy
Please follow the arrows when passing the slides around