CYTOLOGY- SAMPLE SUBMISSION

Areas of smear are to be examined and sometimes multiple smears are prepared. Examination is time consuming and tiring which may lead to missing of abnormal cells due to fatigue. Liquid-based cytology has the advantages of reduction in the smear screening time, uniform spread of cells (Fig. 16.6), with reported increase in detection of HSIL in LBC smears as compared to conventional Pap smears, and the facility of conducting ancillary studies on the same sample. However, some pathologists feel there may be interpretation errors due to alteration in cellular cytology caused by suspension of cells in the liquid medium; absence of intercellular relationship and absence of mucus deprives the screener with vital clues for interpretation. Moreover, it is expensive as compared to conventional Pap smear and preparation of smears is more time consuming.

SAMPLE SUBMISSION

The glass slide/specimen vial must be labeled with patient’s name and identification no. and packaged carefully to prevent breakage or leakage and transported to the laboratory for processing. All specimens should be submitted to the laboratory accompanied with completed laboratory requisition forms. Laboratory requisition form should include the following clinical details written clearly or typed
•Patient’s Name, Age, Address, Identification No., Telephone No.
•Date of procedure, referring Doctor with contact details
•Source and site of origin of specimen with identifying symbols
•Method of collection
•Clinical symptoms and signs
•Date of Last Menstrual Period
•Special situations-pregnancy, postmenopausal, oral contraceptive/ other hormonal use
•Provisional clinical diagnosis
•Prior abnormal cytology/histology report
•Prior treatment if any.

Causes for rejection of specimen or limited reports:
•Incomplete and/ or improper labeling
•Insufficient pertinent clinical history
•Specimen not fixed on slide immediately
•Obscuring inflammation, debris, or excessive air drying
•A broken slide will be rejected and discarded as a biohazard.

SCHEDULE FOR REPEAT SMEARS

In general, all repeats should not be performed within 6-8 weeks. It is because the scraped surface may not have re-epithelialized and the chance of a false negative result is increased. If colposcopic investigation is performed within this period upon a report of possible or definite abnormality, a concurrent cytology sample is not recommended.

CYTOLOGY- TYPES OF CELLS

TYPES OF CELLS SEEN ON CERVICAL CYTOLOGY

Normal Findings

Basal Cells
Basal cells are small (10 u) in size and possess blue cytoplasm. Nuclei are large about 8 u in size. N:C ratio is high. Basal cells generally do not shed, but may be seen in smears obtained from vigorous endocervical brushing and present as sheets of small endocervical cells with uniform dense nuclei. Basal cell hyperplasia may occur in early metaplasia

Parabasal Cells
Parabasal cells are round cells, 10-15 u in size and show cyanophilic cytoplasm (Fig. 16.7), with centrally located vesicular nuclei. Cytoplasm is more abundant than basal cells.

Intermediate Cells
Intermediate cells are large (15-40 u), polyhedral in shape, and possess abundant cytoplasm and central vesicular nuclei. Cytoplasm is amphophilic to light basophilic in col or (Fig. 16.8).

Navicular Cells
Navicular cells are a variant of intermediate cells. Cells become oval or boat-shaped and show folding of cytoplasm (Fig. 16.9). Glycogen deposits stain yellow. These are seen is pregnancy and early menopause,however, are not diagnostic of pregnancy. Thus it is importance to mention the age of the woman and clinical history of amenorrhoea, if present.

Superficial Cells
Superficial cells are large (40-60 u), polyhedral cells with abundant eosinophilic cytoplasm and small dense pyknotic nuclei, with small perinuclear halo in many cells (Fig. 16.10). In abnormal conditions, these cells are keratinized and are seen as anucleate, polygonal, pink, transparent cells.

DIGITAL SLIDES

Why digital slides are standard in slide seminars?

Digital slides have many benefits over glass slides for conducting slide seminars which make them widespread choice as in comparison with glass slides.

1.Speaker on the seminar has to arrange a number of sections of the slides for demonstration beneath the microscope. That is time consuming ,technically demanding and never possible in lots of circumstances the place tissue block just isn’t obtainable. Digital slides simply wants one slides for preparation and that’s typically the digital slides on which ultimate analysis was made.

2. In circumstances of endoscopic biopsies and core biopsies,making further sections for demonstration is probably not potential. In such conditions ,digital slides are the one device to show the small biopsy interpretation to the residents.
three. In instances the place IHC was essential to arrive on the prognosis,it’s not attainable to take IHC slides for demonstration, Digital slides develop into a boon for making analysis by the individuals of the seminar four.

Individuals don’t get adequate time to view the slides stored for microscopy as usually microscopy classes are held for half a day to 1 day and members are too many.-Digital slides will be uploaded on the server and hyperlink despatched to the individuals eight-10 days earlier than the slide seminar. Contributors get ample time to view the slides and skim concerning the potential analysis. Seminars grow to be extra attention-grabbing and interactive and academically extra rewarding.

Digital slide is an entire slide picture ready by scanning beneath the scanning microscope. . Digiscan, an organization devoted to offer on line materials for e-studying has huge materials in pathology, histology, oral pathology ,oral histology within the type of digital slides units obtainable on line on subscription.

GRANULOMATOUS LESIONS

Invited as faculty for slide discussion and presented “Granulomatous lesions” using digital slides and gave presentation on “Virtual Microscopy” during International Dermatopathology Conference organized by Dermatopathology Society of India and International society of Dermatopathology held at Father Muller College of Medical Sciences, Mangalore, Karnataka on 31st Aug,-2nd September, 2012.

CERVICAL CYTOLOGY REPORTING

Abnormal Findings

The term” dyskaryosis” meaning’ abnormal nucleus’ is used to describe cells with nuclear abnormalities and maturity of cytoplasm and is still used in UK. The term” dysplasia” is also used to describe the same, mainly in USA. Both these terms can be used interchangeably.

Dysplastic (Dyskoryotic) Cells

Dysplastic (dyskaryotic) cells show slight to moderate nuclear abnormalities (enlargement and hyperchro- masia) in well differentiated squamous or glandular
lesions. More advanced lesions show nuclear enlarge- ment, hyperchromasia, along with high N:C ratio, coarse chromatin and thickened nuclear membrane.

Dysplastic squamous cells are of 3 types:

1. Intermediate dysplastic cells seen in LGSIL.

2. Parabasal dysplastic cells resemble closely parabasal or metaplastic cells in size and shape but have atypical nuclei. Cells lie singly or in clusters or strings or files. These cells are seen in HGSIL or cancer.
3. Small parabasal and basal dysplastic cells. These cells indicate more aggressive lesion. Cells lie scattered loose or in loose clusters or in syncitia.

Dysplastic Endocervical Cells

Dysplastic endocervical cells are uncommon and difficult to recognize. They may be seen in HGSIL or early adenocarcinoma, and are seen as columnar cells with enlarged hyperchromatic or pale nuclei and large nucleoli.

Koilocytes

Koilocytes are mature squamous cells of intermediate type with abnormal enlarged hyperchromatic nuclei that are smudged, homogenous, and are surrounded

by sharply demarcated perinuclear halo. Sometimes binucleation/multinucleation may be seen. Koilocytes are characteristic of HPV infection and are seen with
both low-risk and high-risk types of HPV infection and form the criteria for the diagnosis of LGSIL.

Leukoplakia

White discoloration or abnormal keratinization of cervical surface is called leukoplakia. This is because of keratinization of superficial cells which are seen as anucleate, olygonal, transparent cells with pink or yellow cytoplasm. Brown cytoplasmic granules may be present and ghost nuclei are seen.

Parakeratosis/Pseudoparakeratosis

Also presents as white patch clinically. Small nucleated squmaous cells present in sheets. Cause is not known. But such cells can be seen in HPV infection, low grade and high-grade squamous lesions.

CERVICAL CYTOLOGY REPORTING

Terminologies/Classifications Papanicolaou, the founder of contemporary diagnostic cytology, proposed a classification in 1943 (Table 16.1), but it did not reflect current understanding of cervical neoplasia, classes had no equivalents in histopathologic terminology, and did not reliably communicate clinically relevant information. Over the years, different systems and terminologies evolved to overcome the deficiencies of the previous ones. WHO and CIN classifications had the drawbacks of lack of reproduci- bility in assigning lesions to different categories and the biological behavior of the lesions did not correspond with the cytological categories. Terminology for reporting cervicovaginal smears was further standar- dized by The Bethesda System (TBS) in 1988. Since the goal of any screening program is to detect the precursor lesions and treat them early in order to halt their progress to frank cancer, it is of utmost importance for the clinicians and the pathologists to be familiar with the terminology, morphology and management protocols of the precancerous lesions.

Table 16.1: Evolution of reporting system precancerous
lesions of cervix

Papanicolaou!s classification

Class I: Absence of atypical or abnormal cells

Class II: Atypical cytology but no evidence of malignancy

Class III: Cytology suggestive of but not conclusive for malignancy

Class IV: Cytology strongly suggestive of malignancy

Class V: Cytology conclusive for malignancy

WHO classification proposed by Reagen and Patten in 1962:

Mild dysplasia
Moderate dysplasia
Severe dysplasia
Carcinoma in situ
CIN classification: Proposed by Richart in 1967 to further
improve upon the concept of disease continuum.

CINI
CIN II
CINIII
The Bethesda system: Standardized in 1988, revised twice there
after current system developed in 2001

CYTOLOGY- NORMAL PAP SMEAR

Normal Pap Smear

In child bearing age, predominantly superficial cells and intermediate cells are seen (Fig. 16.13). Parabasal cells are seen only occasionally in normal smears but are seen in certain situations which will be described later. Basal cells are seen rarely. Endocervical cells form an important constituent of the Pap smear. Neutrophils may be present.

In menopausal women, cytology findings are affected by withdrawal of estrogenic activity. In early meno-pause, estrogen deficiency is mild. There is reduction in the number of superficial and predominance of intermedia te cells and some large parabasal cells (Fig. 16.14). As estrogen deficiency increases, thick crowded and large clusters of intermediate large parabasal cells are seen. Some cells may resemble navicular cells. In advanced stage of menopause, estrogen levels are markedly low. Yield of cellular material is poor due to dryness of genital tract. Dominant cell is para basal type; there is enhanced eosinophilia of the cytoplasm and pyknosis of nuclei, nuclear breakup and marked variation in cell size. Sometimes there is enlargement of nuclei of parabasal cells and such cells may be mistaken for dysplastic cells. Occasionally sheets of spindle cells may be seen which may be mistaken for malignant cells. Endocervical cells are few or absent.

It is now almost established that carcinoma cervix is preceded by cellular abnormality of surface epithelium. Most high grade lesions start de novo though some low grade lesions may develop into cancer. Transformation zone is the site of initiation in most cases.