DIGISCAN HAS LAUNCHED A VERY AMBITIOUS ON LINE DERMATOPATHOLOGY LECTURE SERIES

Digiscan has launched a very ambitious On Line Dermatopathology Lecture Series project in collaboration with Indian Association of Dermatologists, Venereologists and Leprologists and financially supported by MSD.
In this lectures series eminent, distinguished speakers and faculty of highly acclaimed institutions of the country will be giving lectures on various important topics. It is planned to have 24 lectures to cover most of the topics. These lectures will be highly valuable for post-graduate students and residents of Dermatoloy as well as Pathology.
These lecture will be available free on the website www.digiscan.co.in to all and can be accessed 24×7 .
Those desirous of learning dermatopathology with the help of annotated/labeled Digital Pathology slides can in addition subscribe the dematopathology digital slide set at nominal cost.
Dermatopathology set for postgraduate students and residents in pathology & young practicing pathologists consists of large number of lesions including all the topics of dermatopathology . Digital slides have been annotated for ease of understanding and self study.
Special smaller set of dermatopathology slides for dermatologists has been prepared keeping the requirement of Dermatology post-graduates and residents in mind which consists of selected skin lesions commonly encountered in the clinics and about which they are expected to know. Slides have been labeled for ease of understanding.
For subscription ,one may contact us at digiscanvm@gmail.com

DVD OF DIGITAL WSI (WHOLE SLIDE IMAGE)

DVD of Digital WSI (Whole Slide Image)/ Online Access Digital (WSI) Images on the Web Server of the slides to be offered to the Patients and Global Reporting Pathologist.

Technological advances are making rapid strides in every aspect of health care and medical diagnostics. Today with the easy access to internet across the globe, people are not only aware but more demanding than ever before. Patients and their families wish to seek opinion from experts about the diagnosis of their ailment and the treatment offered to them.

It is now a common practice in radio diagnosis to provide DVD of the images and interpretation of images to the patient providing them freedom to seek opinion from other experts globally. This practice is lacking in pathology laboratories so far but time has come when pathology laboratories also will have to adopt new technologies and will have to offer solutions to their problems of seeking second opinion from the expert pathologists of their choice globally.

For the first time in India, we are providing the facility of digitizing glass slides and preparing DVD of Digital whole slide images / online access to digital (WSI) images of the glass slides so that patient has the freedom to seek opinion from other doctors.

This technological advancement is going to enhance the prestige of pathology. This can be achieved by adopting the practice of issuing the DVD of the digital whole slide image of pathology slide along with the surgical pathology report just as a CD is issued with CT, MRI and Pet Scan image or giving access of online images on the web server to the patient and their consultant pathologists.

We strongly recommend adopting this to serve patients better and have an edge over your competitors in practice.

We offer the following packages to your laboratory for your patients.

Package A – Cost of Package – Rs.550/- (Per Case)

DVD of Digital WSI (Whole Slide Image)/ online Digital (WSI) Images of the slides to be offered to the Patients along with your surgical pathology report.

Package B – Cost of Package – Rs.750/- (Per Case)

DVD of Digital WSI (Whole Slide Image)/ online Digital (WSI) Images of the case.
Report from a renowned surgical Pathologist and Oncopathologist on the case.
Package C – Cost of Package – Rs.950/- (Per Case)

Complete Report of the case including.

Processing and section preparation of the tissue.
Report from renowned Surgical Pathologist and Oncopathologist.
DVD of Digital WSI (Whole Slide Image) / online Digital (WSI) Images of the case.

Package D – Cost of Package: Rs.350/- (Per Case)

Digitization of Glass Slides (Whole Slide Images) with Uploading the web server and providing link, user name and password to National and International Pathology experts for second opinion

We also provide the facility of obtaining Second opinion on the cases from National and International Pathology Experts at nominal rates. Using online digital images on web server and providing link to the global reporting pathologist.

For more Details, Please Contact:
Dr. Mithilesh Chandra, M.D. FIMSA, FIC (Path)

digiscanvm@gmail.com

Please visit:
www.digiscan.co.in

CYTOLOGY-BETHESDA SYSTEM

BETHESDA SYSTEM (2011) FOR REPORTING CERVICAL CYTOLOGIC DIAGNOSIS
establish an effective communication with the referring Bethesda system (Table 16.2) considered cervico- vaginal smear as a medical consultation and stressed it to be reported in clear, unambiguous language so as to consultant and facilitate cyto-histologic correlation.

Table 16.2: The 2001 Bethesda system for reporting cervical cytologic diagnosis

I. Specimen type

Indicate conventional smear (Pap smear) vs. liquid-based

II. Specimen adequacy

Satisfactory for evaluation

(presence/absence of endocervical/transformation zone component and any other quality indicators, e.g. partially

obscuring blood and inflammation)

Unsatisfactory for evaluation … (specify reason)

Specimen rejected/not processed (specify reason)
Specimen processed and examined, but unsatisfactory for evaluation of epithelial abnormality (specify reason)
III. General categorization (optional)

Negative for intraepitheliallesion or malignancy-see interpretation/result

Epithelial cell abnormality (specify ‘squamous’ / ‘glandular’)-see interpretation/result
Other (e.g. endometrial cells in a woman> 40 years of age)-see interpretation/result

IV. Interpretationlresult

Negative for intraepithelial lesion or malignancy

(State whether or not there are organisms or other non-neoplastic findings)

Organisms:

Trichomonas vaginal is
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
Other non-neoplastic findings (optional to report):

Reactive cellular changes associated with inflammation (includes typical repair) radiation intrauterine contraceptive
device (IUD)
Glandular cells status post-hysterectomy
Atrophy
Epithelial cell abnormalities
Squamous cell
Atypical squamous cells (ASC):

ASC of undetermined significance (ASC-US)
ASC-cannot exclude HSIL (ASC-H)
Low grade squamous intraepitheliallesion (LGSIL)
Encompassing: HPV, mild dysplasia, and CIN 1
High grade squamous intraepitheliallesion (HGSIL)

Encompassing: Moderate and severe dysplasia, CIS, CIN 2, and CIN 3

Squamous cell carcinoma

Glandular cell

Atypical glandular cells (AGC)

Specify endocervical, endometrial, or gladular cells not otherwise specified
Atypical glandular cells, favor neoplastic

Specify endocervical cell or not otherwise specified
Endocervical adenocarcinoma in situ (AIS)
Adenocarcinoma

Other:

Endometrial cells (in a woman> 40 years of age-specify if ‘negative for squamous intraepitheliallesion’)

Automated review and ancillary testing (include if appropriate)

Educational notes and suggestions (optional)

CYTOLOGY-EDUCATIONAL NOTES

INVASIVE ENDOCERVICAL ADENOCARCINOMA

Columnar cells possess cytoplasmic vacuoles, nuclear enlargement, eccentric nuclei, large eosinophilic nucleoli, multiple nucleoli and papillary spherical clusters. There is overlapping of nuclei and clusters may have a lumen (rosette or glands). Such cells are seen in adenocarcinoma, squamous cell carcinoma and HGSIL.

It is difficult to differentiate between dysplastic and malignant endocervical cells. However, in adenocar- cinoma, smear shows necrotic and bloody background.

Signet ring cells may be present. Mitotic figures and apoptotic nuclei are present. A few dysplastic squamous cells may be seen (Fig. 16.38).

OTHER

This category is created for reporting normal or abnormal endometrial cells in women who are 40 years or older, as the presence of even benign-appearing endometrial cells on cervical cytology in women who are at least 45 years of age is more often associated with endometrial adenocarcinoma and endometrial hyper- plasia than with benign endometrium. However, since cervical cytology is primarily a screening test for squamous epithelial lesions and squamous cancer, it is not reliable for detection of endometrial lesions.

ANCILLARY TESTING AND EDUCATIONAL NOTES

If slides are scanned by automated computer systems, the type of system used should be reported with the result. Ancillary testing such as HPV DNA is performed, if appropriate, and reported with the cytology results.

Written comments regarding the interpretation of a cytologic specimen are optional and may be conveyed to the clinician by the pathologist as a means of clarification and information.

CYTOLOGY-SPECIMEN ADEQUACY

SATISFACTORY FOR EVALUATION

Cervicovaginal smear should be representative of epithelia of ectocervix, endocervix and should include transformation zone as aim of cervical smear examination is detection of abnormal cells which generally arise in the transformation zone. Therefore, ideally the smear should contain squamous cells, metaplastic cells (TZ) and/ or endocervical cells, and should not be obscured by the presence of blood/ inflammation, etc. However, since the absence of endocervical cells/presence of partially obscuring factors have not shown to increase the risk of a false negative report; TBS 2001 considers such specimens to be reported as “satisfactory for evaluation”, but the comments about the TZ components/ partially obscuring factors are placed in the narrative report which should be read carefully by the clinician to note that the trans- formation zone was not sampled and to improve the specimen adequacy henceforth. In conventional Pap smears, cervical mucus itself is evidence of smear adequacy in absence of endocervical cells. However, in liquid-based preparations, this valuable resource is lost. Since only a part of sample aliquot is used in smear preparation, 5000 well preserved squamous cells per smear and 10 endocervical cells form the basis of adequacy. In older women, TZ may be situated within endocervix canal and is much more difficult to sample and presence of endocervical cells or mucus is not necessary for adequacy. Any smear containing abnormal cells is considered satisfactory for evaluation irrespective of the number of cells present.

UNSATISFACTORY FOR EVALUATION

When the smear does not contain adequate cellular material for reliable interpretation, it is reported as “unsatisfactory for evaluation”. The report would specify, whether the specimen was rejected and not processed (with reason); or whether it was processed and examined, but found unsatisfactory for evaluation of epithelial abnormalities. The causes of unsatisfactory smears could be:

  1. Heavy inflammation obscuring cells (Fig. 16.14)
  2. Air drying artifact (Fig. 16.15)
  3. Excessive cytolysis (Fig. 16.16)
  4. Bloody smear with only few cells
  5. Uniformly thick smear
  6. Scanty cellular material
  7. Lubricant contaminant
  8. Inadequate fixation
  9. Unrepresentative material
  10. Menstrual cells

HISTOPATHOLOGY OF PRECANCEROUS LESIONS

HISTOPATHOLOGY OF PRECANCEROUS LESIONS

Histological features that are used to establish diagnosis of precancerous lesions are cellular differentiation and maturation, organization, polarity, nuclear abnormalities and mitotic activity.7,8,26
In normal epithelium, squamous cells are arranged in well defined layers of basal, parabasal, intermediate \ and superficial cells with increasing cytoplasm and a more organised arrangement towards the surface as cells mature. These features are disturbed in CIN and cells lack differentiation with retention of features of parabasal cells, lack organization and polarity as cells in upper layers do not remain parallel to the surface, rather arrange vertically or haphazardly.
The proportion of epithelium showing disturbance of maturation and differentiation reflects the severity of abnormality.
Nuclear abnormalities are characterized by increased nuclear cytoplasmic ratio, hyperchromasia, irregularity in size and shape (pleomorphism and anisonucleosis), coarse chromatin clumping and multinucleation. Severity of these changes will determine the grade of the lesion (Figs. 9.1 and 9.2).
Generally there is a good correlation between the proportion of epithelium showing disturbance of maturation and degree of nuclear abnormality. However, when there is lack of correlation, degree of nuclear abnormality is more reliable for grading.
Abnormality in mitotic activity is assessed by the number, location and type of mitotic figures.Normally mitotic figures are infrequent and are seen only in parabasal layer. In precancerous lesions, the number of mitotic figures increases and these may be found higher up in the epithelium. Mitotic activity is an expression of immaturity of the cells. HPV’ infection increases the number of mitotic figures and may result in attributing an erroneously high grade to the lesion. In CIN, mitotic figures may have abnormal configuration and are important criteria in grading of the lesion. The most common aberration is the three group metaphase (triaster). Mitotic figures with more than two spindles (quadraster or multipolar mitotic figures) and/ring mitotic figures are also frequently seen.
Keratinization can sometimes be seen on the surface of CIN generally of higher grade (Fig. 9.3).

LOW GRADE CIN/SIL (CIN I)

Abnormal cellular changes are mild and are confined to the lowest one third of the epitheliurn.Y? There is usually good maturation of upper layers. Nuclear abnormalities are mild and are confined to the deeper layers of epithelium. However, some abnormalities persist at the surface also; otherwise cytological recognition of low grade lesions will not be possible. Mitotic figures are increased in number, confined to deeper layers and abnormal configurations are not present. HPV cytopathic effects characterized by perinuclear cytoplasmic vacuolation, nuclear hyperchromasia and wrinkling, binucleate cells, increased number of mitotic figures may be present in the upper layers of epithelium (Fig. 9.4).
Involvement of upper layers by HPV changes should not lead to diagnosis of higher grade of lesion.

HIGH GRADE CIN/SIL (CIN 11, ILL)

Maturation and stratification may be present in the upper .1-2 layers of the epithelium or may be completely lacking. Nuclear abnormalities are more marked and extend to the upper layers even up to surface. Marked anisonucleosis and bizarre nuclear forms may be seen. Mitotic figures are markedly increased in number and abnormal forms are frequent. It is to be borne in mind that all epithelia will not show the changes to the same degree. While some epithelia may show marked nuclear pleomorphism and hyperchromasia but low mitotic activity, other cases may show numerous mitotic figures with abnormal forms but little nuclear abnormality (Fig. 9.5). Sometimes intermediate grades of lesions or lesions with mixed picture may be difficult to classify (Fig. 9.6).

LOCATION AND SPREAD (CRYPT INVOLVEMENT)

Preneoplastic lesions develop in the transformation zone, the field of columnar epithelium that undergoes squamous metaplasia. It follows the contours of original columnar epithelium and affects the surface of ectocervix and cervical canal as well as glands/crypts (Fig. 9.7). Very rarely it may involve original squamous epithelium.
Generally higher grade of CIN is seen in proximal location in cervical canal and lower grade caudally towards vagina thereby indicating the importance of endocervical brush or curettage for detection of higher and more severe lesions. As is obvious, cytology of surface lesion or lower end of cervical canal by Ayre’s spatula may miss the CIN lesion or may reveal low grade of lesion only.
Crypt involvement is quite high and was reported in 88.6% of cone biopsies examined for CIN in a study.” Few crypts or only a part of crypt may be involved and uninvolved crypts can be recognized lying alongside (Figs. 9.8 and 9.9). Maximum depth up to 5.2 mm is involved which is the depth \JP to which normal crypts are present. Area and depth of crypt involvement increases with severity of CIN.I
Crypt involvement can sometimes be confused with early invasive carcinoma (Fig. 9.7). Recognition of basement membrane around the cross-section of crypts, circumferential fibrous thickening of stroma surrounding crypts, absence of loose stroma or lymphocytic reaction in the stroma and presence of uninvolved crypts nearby help in differential diagnosis.

DNA PLOIDY AND HPV DNA IN PRENEOPLASIA

It is possible to objectively classify CIN by nuclear DNA ploidy patterns using static or flow cytometry.Condylomas and majority of CIN I have predominantly diploid and occasionally polyploid pattern. 10,24
Aneuploid pattern is seen in one third of CIN I, more than three fourth cases of CIN Il and almost all cases of CIN Ill.
Diploid and polyploid lesions are more likely to regress or persist in contrast to aneuploid lesions which have more propensity for progression.Morphologically abnormal mitotic figures form useful marker of aneuploidy.P Diploid or polyploid lesions are likely to retain polarity; nuclei are relatively uniform and lack abnormal mitotic activity. CIN,with aneuploid DNA in general reveal high cellularity,cellular disorganization, nuclear pleomorphism and high mitotic activity including abnormal forms (Fig. 9.10). 85% of CINs with aneuploid DNA pattern contain abnormal mitotic figures, while less than 20% of CIN with diploid DNA have abnormal mitoses. Aneuploidy increases with severity of the lesion.24.54
Abnormal mitotic figures are also linked to high risk HPV 16 in 80% of cases.25,54 Kadish et al. (1992) demonstrated that abnormal mitotic figures in 12.5% of CINs were related to HPV type 6/11, 78.3% to type 16, 20% to type 18, 21.4% to type 31 and 100% to type 33.37 Lesions associated with high risk HPV types are likely to progress while lesions with type 6/11 regress or persist.s”
Thus from viewpoint of clinical outcome, study of DNA ploidy and HPV typing is important in CIN lesions from the point of management since histology alone cannot always predict biologic behavior of the lesion and the type of associated HPV.

NOMENCLATURE OF PRECANCEROUS SQUAMOUS LESIONS OF CERVIX

NOMENCLATURE OF PRECANCEROUS SQUAMOUS LESIONS OF CERVIX

The nomenclature of precancerous lesions of the cervix has undergone several changes. in the past four decades. No classification is free of drawbacks and universally accepted. However, attempts are being made to bring about a uniformity of terminology which can be interpreted and understood by the colposcopists, cytologists and the histopathologists.

Reagan et al. (1953) introduced the term “dysplasia” for atypical hyperplasia of cervical epithelium.Later Reagan et al. (1957) divided dysplasia into four categories of mild, moderate and severe dysplasia for early lesions depending upon the severity and “carcinoma-in-situ” (CIS) for lesions that showed alteration of full thickness of epithelium.P This nomenclature was widely accepted and recommended by WHO (1973).60 However, this classification implied that dysplastic lesions were not premalignant; only CIS meant preneoplasia, indicating two separate processes. Therefore, it did not convey the concept of continuum of change in carcinogenesis according to our present understanding. It also created problems in patient management since sometimes dysplasias were not treated.

Cervical intraepithelial neoplasia (CIN) is a more appropriate terminology. It is subdivided into CIN 1, CIN Il and CIN III according to the severity of cellular alterations.V This terminology has been widely accepted around the world but has its drawbacks because neither all early lesions are premalignant nor all advanced lesions progress to neoplasia. Some object to the term “neoplasia” as a given lesion at a given time may not be neoplastic and may have only neoplastic potential. “Neoplasia” also has sinister connotation and scares the patients.

For these reasons another nomenclature was developed in 1988 at a meeting convened at the National Cancer Institute (NCI) in Bethesda’? where it was decided to delete the word “neoplasia” and replace it with the term “lesion”. This was called the Bethesda System (TBS) and was modified again in 199] .43 The entire spectrum of abnormalities from earliest to advanced lesions were included and were called Squamous Intraepithelial Lesions (SIL). Since many clinical and laboratory studies advoc~ted the two tier system of classification, SIL was divided into Low-grade SIL and High-grade SIL depending on the severity of cellular alterations. Low-grade SIL includes HPV changes, koilocytoatypia, condyloma, CIN 1. High-grade SIL includes qN Il, III and CIS.

Since CIN classification is well founded and accepted by most of the laboratories, Richart in 1990 acknowledging the concept of two tier system divided CIN into Low-grade CIN and High-grade CIN. Koss in 1992 devised yet another classification of precancerous lesions into Early Borderline Lesions for minimal changes and Well Developed Borderline Lesions for more advanced changes.

NOMENCLATURE OF PRECANCEROUS GLANDULAR LESIONS OF CERVIX

An increase in the incidence of adenocarcinoma of the cervix in young women below the age of 35 years in the last three decades has aroused an interest in precancerous glandular lesions of cervix. Helper et al. in 1952 for the first time described glandular lesions showing highly atypical endocervical glands adjacent to frankly invasive adenocarcinoma of cervix, Friedell and Makay in 1953 also found two similar cases and coined the term Adenocarcinoma-in-situ (AIS) for these abnormalities. However, subsequently it became apparent that not all cases had severe enough abnormalities to be labelled as AIS. Cases with less severe cellular abnormality have been called endocervicaldysplasia, 11 Endocervical glandular dysplasia (EGD) and atypical hyperplasia.Pc Brown
and Wells (1986) divided EGD into low grade and high grade EGD depending upon the severity of cellular alterations’”. Jaworsky (1990) however does not advocate the subdivision.P Gloor and Hurlimann (1986) on the analogy of squamous lesions classified abnormal glandular lesions as Cervical Intraepithelial Glandular Neoplasia (CIGN) and divided into three grades of I, Il and III depending upon the severity of cytologic abnormality and mitotic activity.” CIGN I and Il corresponded to atypical hyperplasia and CIGN III corresponded to AIS: Since there is no conclusive evidence based on scientific data to show that CIGN I and Il are truly neoplastic lesions and progress to invasive adenocarcinoma, Kurman et aJ. (1992) prefer to use the term Atypical Endocervical Hyperplasia for these lesions.

NATURAL HISTORY OF PREMALIGNANT LESIONS

Natural history of precancerous lesions is considered a dynamic process characterized by progression, persistence or regression. Several epidemiological studies have now established that high grade lesions are more likely to progress to invasive cancer than low grade lesions over a period of 5-15 years.t? Oster (1993) in his review using life table analysis found that for CIN I the likelihood of regression was 57%, of persistence 32%, of progression to CIN III 11 % and to invasive cancer 1 %49. Comparable figures for CIN Il are 43%, 35%, 22%, 5%; and for CIN Ill, 32% regress, 56% persist and 12% progress to invasive cancer. It is important however to note that it is not a must that all low grade lesions progress through high grade lesions to invasive cancer since many low grade CIN lesions may progress to cancer without intervening stages of II-III and many high risk lesions arise de novo .

The risk factors for the development of precancerous lesions are similar to those implicated in the carcinogenesis of invasive cancer, namely early age at marriage, multiple partners, promiscuity, smoking, tobacco chewing, oral contraceptives and genital infections particularly human papilloma virus infection.

HPV infectum has received much attention in the last two decades and the detection of HPV DNA in lesions has become an important adjunct to diagnosis of precancerous lesions.F It has been documented in many studies that the majority of low grade lesions are associated with low risk HPV 6, 11 and high grade lesions show high risk HPV types 16, 18, 30, 33, 35. HPV subtyping in abnormal Pap smears can be used in management of cases. The role of HPV infection in carcinogenesis has been dealt with in a separate chapter.

PRENEOPLASTIC LESIONS

INTRODUCTION
It is now well established that precancerous lesions of the cervix and invasive carcinoma of the cervix are a continuum of one disease process. It is possible to prevent deaths resulting from cervical cancer by early diagnosis and management of precursor lesions. Early diagnosis of preneoplastic lesions was ushered in as early as the 1950s by the use of smear examination

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