Bethesda classification.3rd edition(2015) برای بزرگنمایی عکسها کلیک را روی ان نگه دارید..... ■■■【1】Specimen adequacy Fig. 1.1 Unsatisfactory due to scant squamous cellularity. Endocervical cells are seen in a honeycomb arrangement (LBP, ThinPrep at 10x magnification) Fig. 1.2 Unsatisfactory - scant cellularity (LBP, SurePath). Although this image cannot be directly compared to a microscopic field, this SurePath slide had fewer than 8 cells per 40x field. A SurePath specimen with this level of cellularity throughout the preparation would have fewer than 5,000 cells Fig. 1.3 Satisfactory, but borderline squamous cellularity (LBP, SurePath). At 40x, 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 Fig. 1.4 Satisfactory, but borderline squamous cellularity (LBP, ThinPrep): 10x fields of a ThinPrep specimen should have at least this level of cellularity to be considered satisfactory. At 40x magnifica- tion of this ThinPrep specimen, there were approximately four cells per field, which would correspond to slightly over 5,000 cells. Note that this level of cell density would be unsatisfactory in a SurePath LBP (see Fig. 1.2), corresponding to less than 5,000 cells because of the smaller preparation diameter Fig. 1.5 Squamous cellularity is satisfactory in this LBP from a 70-year-old woman with an atro- phic cell pattern (LBP, SurePath). LBPs may show less nuclear enlargement than conventional preparations due to fixation in the suspended state. The transformation zone component(s) may be difficult to assess in atrophy Fig. 1.6 Unsatisfactory specimen reprocessing. Original preparation (a, left) from a 54-year-old woman was unsatisfactory due to scant squamous cellularity and excessive blood (LBP, ThinPrep). Reprocessing with glacial acetic acid resulted in a satisfactory sample (b, right) Fig. 1.7 Satisfactory vaginal cytology from a 56-year-old, status post total hysterectomy (with no cervix remaining) for endometrial adenocarcinoma (LBP, ThinPrep). Cellularity was estimated to be <5,000 but it was considered satisfactory since the source was vaginal Fig. 1.8 (a, b) Low-cellularity but satisfactory specimen in woman with history of radiation (LBP, ThinPrep; contributed by Fang Fan, MD) Fig. 1.9 Low-cellularity but satisfactory specimen from a woman with history of pelvic radiation (LBP, SurePath) Fig. 1.10 Atrophy: borderline cellularity in LBP preparations from two different postmenopausal women (LBP, ThinPrep). Parabasal cells can be seen isolated (a, left) or in clusters (b, right). It may be difficult to distinguish parabasal-type cells from squamous metaplastic cells in specimens showing atrophy due to a variety of hormonal changes including menopause, postpartum changes, and progestational agents Fig. 1.11 Unsatisfactory specimen from a 39-year-old woman (LBP, ThinPrep). Abundant endocervical cells and mucus are seen; however, the squamous component is inadequate Fig. 1.12 Squamous cellularity: this image depicts the appearance of a 4x field of a conventional preparation with approxi- mately 75 cells. The specimen is unsatisfactory if all fields have this level, or less, of cellularity. It is to be used as a guide in assessing the squamous cellularity of a conventional smear (Used with permission, © George Birdsong, 2003) Fig. 1.13 Squamous cellularity: this image depicts the appearance of a 4x field of a conventional preparation with approxi- mately 150 cells. If all fields have this level of cellularity, the specimen will meet the minimum cellularity criterion, but by only a small margin (Used with permission, George Birdsong, 2003) Fig. 1.14 Squamous cellularity: this image depicts the appearance of a 4x field of a conventional preparation with approxi- mately 500 cells. A minimum of 16 fields with similar (or greater) cellularity are needed to call the specimen adequate (Used with permission, © George Birdsong, 2003) Fig. 1.15 Squamous cellularity: this image depicts the appearance of a 4x field of a conventional preparation with approxi- mately 1,000 cells. A minimum of eight fields with similar (or greater) cellularity are needed to call the specimen adequate (Used with permission, © George Birdsong, 2003) Fig. 1.16 Squamous cellularity: this image depicts the appearance of a 4x field of a conventional preparation with approximately 1,400 cells. A minimum of six fields with similar (or greater) cellularity are needed to call the specimen adequate (Used with permission, George Birdsong, 2003) Fig. 1.17 Endocervical cells (CP). Distinct cytoplasmic borders are seen in the cluster of cells on the left, giving a "honeycomb" appearance. The cell cluster on the right is seen from a side view, giving the "picket fence" appearance Fig. 1.18 Endocervical cells (LBP, SurePath). Cellular dissociation is more frequent in liquid-based preparations than in conventional smear preparations Fig. 1.19 Endocervical cells (LBP, SurePath). Routine screening, 27-year-old woman, NILM on follow-up. Normal endocervical cells may appear in large hyperchromatic fragments, often in the center of some LBPs. The thickness of the fragment may give the appearance of architectural disar- ray; however, note normal appearing cells at the periphery of the fragment. Additionally, focusing up and down through the fragment reveals normal spacing of cells, distinct cytoplasmic borders, and bland nuclear chromatin. Normal endocervical cell groups with this appearance should not be confused with neoplastic clusters that show more crowding (even within a single layer of cells), nuclear enlargement, nuclear membrane irregularity, and abnormal chromatin pattern Fig. 1.20 Transformation zone component (LBP, SurePath). Normal endocervical cells from the upper region of the endocervical canal can closely mimic squamous metaplastic cells Fig. 1.21 Normal squamous metaplastic cells (LBP, SurePath). Routine screening. Twenty-eight-year-old woman Fig. 1.22 Atrophy (CP). Degenerated cells in mucus and parabasal-type cells should not be counted in assessing transformation zone sampling. It may be difficult to distinguish parabasal-type cells from squamous metaplastic cells in specimens showing atrophy due to a variety of hormonal changes including menopause, postpartum changes, and progestational agents. In such cases, the laboratory may elect to make a comment about the difficulty of assessing the transformation zone component Fig. 1.23 Unsatisfactory due to obscuring white blood cells (CP). If 50-75 % of the epithelial cells are covered, obscuring inflammation should be mentioned in the Quality Indicators section of the report (>75% obscuring is considered unsatisfactory if no abnormal cells are identified). In assessing the adequacy of a slide with respect to obscuring factors and cellularity, one should keep in mind that the minimum cellularity criteria outlined above refer to well-visualized cells Fig. 1.24 Satisfactory for evaluation; extensive air-drying artifact present. Atypical squamous cells cannot exclude high-grade squamous intraepithelial lesion (ASC-H) (CP). Enlarged, pale nuclei with indistinct chromatin. The nuclei are crowded and lack an orderly architectural arrange- ment. Note that if the interpretation is atypical cells or worse, then the specimen cannot be consid- ered "unsatisfactory" regardless of specimen squamous cellularity or overall quality. Histologic follow-up in this case was HSIL/CIN 2 Fig. 1.25 Unsatisfactory due to excess lubricant; 59-year-old woman (LBP, ThinPrep). Lubricant may mimic blood or mucus at low magnification (a, left). On higher magnification, the material is granular and lysed RBC or RBC "ghosts" are not seen (b, right). Practitioners who have a high unsatisfactory rate due to lubricant interference should be advised of manufacturer recommenda- tions regarding lubricant usage as part of laboratory quality assurance ■■■【2】Non-neoplastic findings Fig. 2.1 Superficial squamous cells (LBP, ThinPrep). Admixture of superficial and intermedi- ate squamous cells. The superficial cells have smaller condensed (pyknotic) nuclei. Light brown glycogen is present in the cytoplasm of both cell types. The inset reveals a characteristic superfi- cial cell at high magnification. Note the polygonal cytoplasmic profile, cytoplasmic keratohyaline granules, and pyknotic nucleus with a cross-sectional area of approximately 10 μm2. The dense nucleus is opaque to light Fig. 2.2 Intermediate squamous cell (LBP, ThinPrep). A typical intermediate cell with a polygo- nal cytoplasmic profile. The nucleus possesses finely granular chromatin with a longitudinal groove. The cross-sectional area of the intermediate nucleus is approximately 35 μm2 and is gener- ally used as the internal reference for size comparison. Light can pass through the intermediate nucleus due to the chromatin being more open than that of a superficial cell Fig. 2.3 Parabasal cell (LBP, ThinPrep). A parabasal cell is contrasted with an intermediate cell. The parabasal cell exhibits typical features with an oval nucleus, fine chromatin, and a cross- sectional area of approximately 50 μm2. The cytoplasm is dense relative to the intermediate cell, because the intermediate cell cytoplasm flattens out next to the nucleus, whereas in the parabasal cell, the cytoplasm is heaped up. If the cells were viewed from the side, an intermediate cell would be a flattened saucer with a central nuclear heap. The parabasal cell would resemble a hill with sloping sides Fig. 2.4 Endocervical cells (LBP, ThinPrep). Endocervical cells may be seen en face in a typical "honeycomb" arrangement of benign glandular epithelium (a). Alternatively, endocervical cells when viewed from the side present in a "picket-fence" configuration (b). There is normal nuclear polarity and ample evidence of apical mucin in these columnar cells Fig. 2.5 Endometrial cells (LBP, SurePath). A tight cluster of endometrial glandular cells with nuclei having cross-sectional areas slightly smaller than the 35 μm2 of intermediate cells. Endometrial cell nuclear to cytoplasmic ratios are high and the cells tend to form three-dimensional groups. The small and monotonous nuclear size should prevent overinterpretation as a squamous, or glandular abnormality Fig. 2.6 Endometrial cells, exodus (LBP, ThinPrep). Collections of peripheral glandular and cen- tral stromal endometrial cells (exodus ball) are typically seen between day 6 and 10 of the men- strual cycle. These clusters are among the last remnants of endometrial shedding and the cells may show degenerative changes. Both images show exodus balls from two different cases. On the left (a) is an intermediate magnification from a conventional preparation. More nuclear structure is observed in cells on the periphery of the exodus ball. In (b), from a liquid based preparation, physical forces have accentuated the rounding up of cells during fixation. The resultant three dimensional cell ball obstructs more light, is darker and may be over interpreted as a glandular abnormality Fig. 2.7 Lower uterine segment sampling (CP). Lower uterine segment sampling with ill-defined glandular cells near the upper left aspect and stromal cells loosely adherent to the glandular cells. Several blood vessels can be seen protruding from the group. Stromal and glandular components are not always easy to distinguish on cervical cytology Fig. 2.8 Lower uterine segment sampling (CP). A well-preserved endometrial gland presenting as a tubular structure. A stromal component is also visible at the lower right side of the epithelial tube. The inset shows columnar endometrial glandular cells that have round to oval, variably hyperchromatic nuclei, with moderately coarse but evenly distributed chromatin and smooth nuclear borders (CP) Fig. 2.9 Lower uterine segment sampling (CP). Endometrial stromal cells adherent to blood vessels and flattened against the slide in a fanlike pattern Fig. 2.10 Squamous metaplasia (LBP, SurePath). A characteristic metaplastic cell is found in the center of the field. The nucleus is round to oval with fine, evenly distributed chromatin. The nuclear to cytoplasmic ratio is variable, and in this instance, it approaches one to one. These cells should not be overinterpreted as ASC-H or HSIL Fig. 2.11 Squamous metaplasia (CP). Routine screening from a 27-year-old woman, day 8 of menstrual cycle shows reactive metaplastic cells with "spidery" cytoplasmic processes, a feature that is seen more often in conventional smears. Follow-up cytology was NILM Fig. 2.12 Squamous metaplasia (histology, H&E). (a, left) Early squamous metaplasia in an endocervical sample. A variety of stimuli can trigger an altered pathway of differentiation in the stem cell population that was committed to generating endocervical cells. The cells underneath the mucus secreting epithelial cells have rounded up, lost their ability to secrete mucin, and assumed a protective role, increasing the thickness of barrier between the stimulus and the underlying tissue. (b, right) A later stage in squamous metaplasia where multiple layers of metaplastic cells are seen under the surface epithelium Fig. 2.13 Squamous metaplasia (CP). Squamous metaplastic cells show nuclear size similar to parabasal cells. This cohesive group of cells also shows some modest nucleolar prominence that is consistent with reactive/reparative changes Fig. 2.14 Keratotic cellular changes (LBP, ThinPrep). Intermediate squamous cells showing prominent cytoplasmic keratohyaline granules, a precursor to full keratinization Fig. 2.15 Keratotic cellular changes (CP). Keratotic cellular changes, "typical parakeratosis." On the left side (a), note the "squamous pearl" formation in this specimen from a 49-year-old woman being followed up after treatment for SIL. On the right side (b) is a small cluster of miniature squamous cells. Both are examples of "typical parakeratosis" showing miniature squamous cells with small bland, pyknotic nuclei Fig. 2.16 Keratotic cellular changes. Keratotic cellular changes, "typical parakeratosis”. On the left (a, CP) is an orangeophilic cluster, and on the right (b, LBP, ThinPrep) are more eosinophilic squamous cells with small, opaque nuclei. Human papillomavirus (HPV) testing, performed as part of co-testing on the liquid-based specimen, was negative Fig. 2.17 Keratotic cellular changes, "hyperkeratosis." On the left (a, LBP, ThinPrep) is a group of anucleate squames at low power. On the right (b, LBP, ThinPrep) are anucleate, mature polygo- nal squamous cells with ghostlike "nuclear holes" ("b" is reprinted with permission from Williamson et al. [15]) Fig. 2.18 Tubal metaplasia (histology, H&E). Endocervical gland with tubal metaplasia amid cervical stroma. The ciliated cells of tubal metaplasia show prominent terminal bars at the base of the cilia Fig. 2.19 Tubal metaplasia (CP). Ciliated cells derived from tubal metaplasia. Note terminal bar and cilia at left edge (arrow). Tubal metaplasia shows prominent pseudostratification and can have enlarged nuclei that make it a look-alike for endocervical adenocarcinoma in situ Fig. 2.20 Tubal metaplasia (LBP, Thin Prep). A linear array of cells showing tubal metaplasia Fig. 2.21 Tubal metaplasia (CP). Ciliated columnar endocervical cells. A goblet cell is seen at the center with its nucleus closer to the top of the image (arrow) Fig. 2.22 Atrophy (histology, H&E). The cervical squamous epithelium is remarkably thinned and made up entirely of parabasal cells. This is a consequence of waning hormonal support. In such cases, p16 immunostain would be negative Fig. 2.23 Atrophy (LBP, ThinPrep). Note flat, monolayer sheet of parabasal-type cells, with preserved nuclear polarity Fig. 2.24 Atrophy with inflammation (“atrophic vaginitis") (CP). Note the classic finding of granular debris in background, degenerating parabasal cells, and polymorphonuclear leukocytes. (a) "Blue blobs" and pseudoparakeratosis are also seen in atrophic vaginitis, the former being more prominent in conventional preparations (b) Fig. 2.25 Atrophy with inflammation (atrophic vaginitis) (LBP, ThinPrep). In liquid-based preparations, the granular debris is often clumped and adheres to atrophic cell clusters in a pattern that may mimic "clinging tumor diathesis" (see Fig. 5.58). Attention to cellular features is crucial to avoid overinterpretation Fig. 2.26 Atrophy (LBP, SurePath). Note more dissociation of parabasal cells in a relatively clean background Fig. 2.27 Atrophy with multinucleated giant cells (CP). Multinucleated histiocytic giant cells are a nonspecific finding and are often seen in postmenopausal and postpartum specimens. They differ from other giant cells such as syncytiotrophoblast (Fig. 2.29b) and multinucleated cells in herpes infection (Fig. 2.63) Fig. 2.28 Pregnancy-related hormonal changes - navicular cells. In pregnant patients, squamous cells become laden with glycogen, and have a vaguely "boatlike" shape referred to as "navicular" cells (a) left, LBP, ThinPrep, and (b) right, LBP, SurePath Fig. 2.29 (a) Pregnancy-related cellular changes, decidua. Decidual change involving the cervical stroma can be sampled and resemble epithelial cell abnormalities, both LSIL and HSIL (See Fig. 5.53). On the upper left (LBP, ThinPrep) are cells that are loosely cohesive, approximately the size of mature squamous cells, with soft, ill-defined cytoplasm, and nuclei that have nucleoli and pale, finely granular, evenly distributed chromatin. They can be misinterpreted as reactive squamous cells or LSIL if one is not aware of the history of pregnancy or recent delivery. On the upper right (histology, H&E) is the corresponding histology showing decidual change. Note the resemblance to the cytology on the upper left. Pregnancy-related cellular changes, syncytiotrophoblast (CP). (b) The placental-derived syncytiotrophoblast is a unique cell that can have 50 or more nuclei and tends to be elongated with granular cytoplasm. Other multinucleated cells that can be seen in cervical cytology include multinucleated histiocytes in postmenopausal and postpartum women and cells infected with herpes virus Fig. 2.30 Pregnancy-related cellular changes, Arias-Stella reaction. The upper and lower left images (a, b, LBP, SurePath) show groups of stimulated endometrial glandular epithelium that could be mistaken for a glandular epithelial abnormality. The histology (c, right, H&E) demon- strates the exuberant variation in epithelial nuclear morphology due to hormonal stimulation during pregnancy Fig. 2.31 Reactive-reparative cellular changes (CP). These reactive squamous epithelial cells display mild nuclear enlargement without any significant chromatin abnormalities (Reprinted with permission from Kurman RJ. [39]) Fig. 2.32 Reactive-reparative cellular changes: reactive endocervical cells (LBP, SurePath). Thirty-two-year-old woman. Variation in nuclear size, prominent nucleoli, and rare intracytoplas- mic polymorphonuclear leukocytes are seen; these features are consistent with endocervical repair. Follow-up cytology was NILM Fig. 2.33 Reactive-reparative cellular changes: reactive endocervical cells (CP). A 22-year-old woman status post loop electrosurgical excision procedure (LEEP) 6 months earlier for high-grade cervical intraepithelial neoplasia (CIN). Endocervical cells show variable increase in nuclear size, prominent nucleoli, and fine chromatin. Concurrent biopsy was benign Fig. 2.34 Reactive-reparative cellular changes: reactive squamous cells (CP). A 26-year-old woman, day 14 of menstrual cycle with mild vaginal discharge. Squamous cells show mild nuclear enlargement with nuclear hypochromasia, perinuclear halos, and cytoplasmic polychromasia resulting in a "moth-eaten" appearance. Trichomonads are seen in the background. Follow-up was NILM Fig. 2.35 Reactive-reparative cellular changes: reactive squamous cells (LBP, ThinPrep). Routine screen of a 32-year-old woman. Although there is nuclear enlargement in the cells on the right side, the smooth nuclear contours and finely distributed chromatin favor reactive change over ASC-US Fig. 2.36 Reactive-reparative cellular changes: inflammatory halos. Examples of reactive perinuclear halos induced by organisms/inflammation such as seen in trichomonas infection. The images demon- strate reactive squamous cells showing small perinuclear halos that should be differentiated from koilocytic clearing seen in HPV cytopathic effect. On the left (a) is a low power from an LBP, ThinPrep and on the right (b) is a higher-power image obtained from a conventional preparation Fig. 2.37 Reactive-reparative cellular changes: repair (CP). A 67-year-old woman with uterine prolapse. Flat, monolayer sheet of reparative cells with distinct cytoplasmic borders, streaming nuclear polarity, and a prominent nucleolus in almost every cell. Reactive group of endocervical cells seen at top center Fig. 2.38 Reactive-reparative cellular changes: repair (LBP, SurePath). Thirty-two-year-old woman. Changes are similar to those seen on CPs, but cell streaming may be less apparent due to rounding of cell clusters. Note the intracytoplasmic polymorphonuclear leukocytes, another feature seen in repair. Compare to Figs. 2.39 and 2.40 Fig. 2.39 Reactive-reparative cellular changes: repair (LBP, ThinPrep). Cohesive group of reactive endocervical cells stimulated by factors related to inflammation and infection. Nucleoli are prominent Fig. 2.40 Reactive-reparative cellular changes: repair (CP). Example of cytoplasmic cohesion and streaming in repair. Note intracytoplasmic polymorphonuclear leukocytes. The streaming and interdigitation of cells has been likened to a "school of fish." Also seen in Fig. 2.37 Fig. 2.41 Reactive-reparative cellular changes: lymphocytic (follicular) cervicitis (LBP, ThinPrep). Note polymorphous population of lymphoid cells and tingible body macrophages; the lymphoid cells may clump on liquid-based preparations Fig. 2.42 Reactive-reparative cellular changes: lymphocytic (follicular) cervicitis (CP). Abundant lymphoid cells with a tingible body macrophage located centrally Fig. 2.43 Reactive-reparative cellular changes: radiation (CP). Reactive cellular changes associ- ated with radiation (CP). A 40-year-old woman with history of squamous cell carcinoma of the cervix who completed radiation therapy 8 weeks earlier. Cells with enlarged nuclei, abundant vacuolated polychromatic cytoplasm, mild nuclear hyperchromasia without coarse chromatin, and prominent nucleoli. Note multinucleation (upper right corner inset) Fig. 2.44 Reactive-reparative cellular changes: radiation. Low-power image of radiation changes in a squamous cell (a, CP). Note the irregularly shaped abundant cytoplasm and the streaming or "windblown" edges of the cell in a conventional preparation. Nuclei are typically enlarged and may be pale or become hyperchromatic as nuclear material condenses. Nucleoli are typically seen. In this case, numerous polymorphonuclear leukocytes are seen in the background. On the left (b, LBP, ThinPrep) radiated cells in liquid-based preparations do not tend to show the streaming and the cytoplasm is typically more dense. Nuclear degeneration and cytoplasmic vacuolization are common in both preparation types Fig. 2.45 Reactive-reparative cellular changes: IUD (CP). Reactive cellular changes associated with intrauterine contraceptive device (IUD). Note small cluster of glandular cells with cytoplasmic vacuoles displacing nuclei Fig. 2.46 Reactive-reparative cellular changes: IUD (LBP, Thin Prep). In liquid-based prepara- tions, cellular groups tend to be tighter but the same features of cytoplasmic vacuolization and reactive nuclear changes are present as are noted in CP Fig. 2.47 Reactive-reparative cellular changes: IUD (CP). Epithelial cells with a high nuclear to cytoplasmic ratio may mimic high-grade squamous intraepithelial lesion (HSIL) (left, a); however, the morphologic spectrum of abnormalities usually present with squamous intraepithelial lesions is absent. Presence of nucleoli in isolated cells with a high N/C ratio as seen in this cell (right, b) is not typical of HSIL. Obtaining a history of the presence of an IUD is important in the face of this type of abnormal morphology Fig. 2.48 Glandular cells status post hysterectomy (CP). Vaginal smear from a 49-year-old woman status post total hysterectomy for squamous cell cancer of the cervix, showing benign, endocervical- like cells. If benign-appearing, these are of no clinical consequence and reporting is optional Fig. 2.49 Glandular cells status post hysterectomy (LBP, ThinPrep). Columnar glandular cells are seen in a vaginal sample from a 68-year-old woman status post hysterectomy (a). She had a recto- vaginal fistula; however, a cell block (b) was made and the glandular cells were negative for CDX2 immunostain, making colonic origin unlikely Fig. 2.50 Trichomonas vaginalis (CP): trichomonads. Pear-shaped organism with eccentrically located nucleus and eosinophilic cytoplasmic granules. Presence of a nucleus and cytoplasmic granules distinguishes trichomonads from cytoplasmic fragments Fig. 2.51 Trichomonas vaginalis and Leptothrix. Leptothrix (a, left, CP) may be seen in associa- tion with T. vaginalis; finding Leptothrix alone is not sufficient for a diagnosis of Trichomonas, but suggests the presence of trichomonads. On the right (a) is an example from a liquid-based (SurePath) preparation Fig. 2.52 Trichomonas vaginalis (LBP, ThinPrep): "polyballs." A clue to the presence of trichomonads in a sample is the presence of aggregates of neutrophils or "polyballs." These are seen here along with a few trichomonads in the background Fig. 2.53 Trichomonas vaginalis (LBP, SurePath): a 32-year-old woman with vaginal discharge. The organism's nucleus, cytoplasmic granules, and flagella (right) may be better visualized on liquid-based preparations. Note the kite shape and granules (bottom right inset) Fig. 2.54 Candida species. (LBP, ThinPrep): pseudohyphae. Fungal organisms morphologically consistent with Candida spp. Note pseudohyphae and modest number of yeast forms Fig. 2.55 Candida species. (LBP, ThinPrep): spearing. Fungal organisms morphologically con- sistent with Candida spp. Forty-five-year-old woman. Note "spearing" or a "shish kebab" appear- ance of squamous cells. This feature is readily appreciated at low power, even when the pseudohyphae are not prominent. Follow-up cytology was NILM Fig. 2.56 Candida species (CP): Torulopsis. Routine screening of a 63-year-old woman. Fungal organisms morphologically consistent with Candida glabrata (previously known as Torulopsis glabrata). Note clear halos surrounding the yeast forms (left). Bacteria, not pseudohyphae, are also seen in the background. This organism does not form pseudohyphae and may be pathogenic in immunocompromised individuals Fig. 2.57 Bacteria - coccobacilli (CP). Shift in flora suggestive of bacterial vaginosis. Note the "clue cell" and filmy background due to large numbers of coccobacilli Fig. 2.58 Bacteria - coccobacilli (LBP, SurePath). Shift in flora suggestive of bacterial vaginosis. Twenty-five-year-old woman. Note clue cell and the relatively clean background compared to that in CPS (see also Fig. 2.57) Fig. 2.59 Bacteria: lactobacilli and cytolysis (a, left, CP). Lactobacilli are typically seen on the cell surfaces in liquid-based preparations and not dispersed in the background as in conventional prepa- rations. Contrast with coccobacilli in Figs. 2.57 and 2.58 in b, right, LBP, ThinPrep) note the pres- ence of a cytolytic background with cell debris and numerous stripped nuclei of intermediate cells Fig. 2.60 Bacteria morphologically consistent with Actinomyces (CP). Forty-one-year-old woman. Low power shows "cotton ball" appearance of tangled clumps of filamentous organisms. An acute inflammatory response is also apparent Fig. 2.61 Bacteria morphologically consistent with Actinomyces (LBP, ThinPrep). Note that the clumps of protein usually seen in conventional preparations tend to be washed away in liquid- based preparations leaving only fine thin bacterial filaments. These are much thinner than the pseudohyphae of Candida spp Fig. 2.62 Bacteria: lactobacilli (LBP, ThinPrep). In liquid-based preparations, lactobacilli may aggre- gate to form "clumps" that may resemble Actinomyces species and should be distinguished by the presence of similar isolated bacilli in the background and absence of characteristic features of actinomyces Fig. 2.63 Cellular changes consistent with herpes simplex virus (CP). Note the eosinophilic intranu- clear "Cowdry A-type" inclusions. The "ground-glass" appearance of the nuclei is due to accumulation of viral particles leading to peripheral margination of chromatin. The inset shows a SurePath liquid-based preparation with a typical multinucleated herpetic cell showing "ground-glass" appearance of the nuclei Fig. 2.64 Cytomegalovirus (CMV). The histologic image on the left (a, H&E) shows CMV cyto- pathic effect in an endocervical cell with the typical lilac-red-colored large intranuclear inclusion. Smaller basophilic cytoplasmic inclusions adjacent to the nucleus are also apparent. On the right (b, CP) CMV inclusions are seen in an endocervical cell. CMV infection is usually not seen in squamous cells; however, it can infect a wide range of other epithelial, mesenchymal, lymphoid, and hematopoietic cells ■■■【3】Endometrial cells Fig. 3.1 Exfoliated endometrial cells (conventional preparation, CP). Cells are arranged in three- dimensional clusters. Nuclei are small and similar in size to an intermediate squamous cell nucleus. Nucleoli are inconspicuous. Cytoplasm is scant, and cell borders are indistinct Fig. 3.2 Exfoliated endometrial cells (liquid-based preparation (LBP), ThinPrep) Fig. 3.3 Double-contoured cluster of exfoliated endometrial cells (LBP, ThinPrep). Endometrial glandular cells surround a dark core of stromal cells. Note the cleaner background typical of LBP menstrual specimens Fig. 3.4 Exfoliated endometrial cells (LBP, SurePath). Single cell necrosis (apoptosis) can be seen in exfoliated endometrial cell clusters (arrow) Fig. 3.5 Abraded lower uterine segment (LUS) fragment (CP). A large fragment of epithelium is associated with vascular stroma composed of tightly packed spindle-shaped cells. Abraded LUS/ endometrium does not carry the same implications as exfoliated endometrial cells Fig. 3.6 Histiocytes (CP). Histiocytes have a round to reniform nucleus and a moderate amount of finely vacuolated cytoplasm. They are often seen in association with exfoliated endometrial cells. Histiocytes alone have no significance in predicting the presence of endometrial carcinoma Fig. 3.7 "Small blue cells" (LBP, ThinPrep). Naked nuclei are clustered and demonstrate mold- ing. The insert (lower right) shows a higher magnification of a grapelike cluster of nuclei with finely textured chromatin. Such clusters should not be mistaken for endometrial cells Fig. 3.8 Follicular cervicitis (LBP, ThinPrep). The lymphocytes of a lymphoid follicle may aggregate into three-dimensional clusters. Tingible body macrophages (arrow) mimic the apoptosis of exfoliated endometrial cells. In contrast to exfoliated endometrial cell clusters, lymphoid aggregates are looser and more irregularly shaped, and small mature lymphocytes have coarser chromatin than endometrial cells ■■■【4】ASC-US/ASC-H Fig. 4.1 ASC-US (LBP, ThinPrep). A 32-year-old woman. Atypical intermediate squamous cells with a nucleus 2-3× the area of a normal intermediate squamous cell nucleus and mild irregularity of nuclear contour. This isolated cell has some features suggestive of HPV infection. hrHPV was positive. Follow-up biopsy revealed LSIL (CIN1) Fig. 4.2 ASC-US (LBP, ThinPrep). A 28-year-old woman. An intermediate squamous cell with an enlarged nucleus and slight nuclear membrane irregularity. The atypical features do not meet the criteria for LSIL. hrHPV was positive. Follow-up biopsy revealed LSIL (CIN1) Fig. 4.3 ASC-US (LBP, SurePath). Routine screen from a 32-year-old woman. Single atypical squamous cell with ill-defined cytoplasmic halo in a background of inflammation. Adjacent squamous cell shows adherent lactobacilli. HPV testing was not performed on this sample Fig. 4.4 ASC-US (LBP, ThinPrep). A 28-year-old female. An atypical binucleated intermediate cell with molded nuclei and orangeophilic cytoplasm suggestive but not diagnostic of LSIL. hrHPV was positive. Follow-up biopsy revealed LSIL (CIN1) Fig. 4.5 Negative for intraepithelial lesion or malignancy (NILM) versus atypical squamous cells – undetermined significance (ASC-US) (CP). Perimenopausal woman. Mature squamous cells show mild nuclear enlargement, binucleation, and even chromatin distribution. Note benign endocervical cells at bottom of field Fig. 4.6 ASC-US (CP). Cells with multinucleation, nuclear enlargement, and air-drying artifact, possibly representing LSIL (CIN1) Fig. 4.7 ASC-US (LBP, SurePath). A 21-year-old woman. Thick cohesive sheet of cells with focal nuclear enlargement, orangeophilic cytoplasm, poorly formed cytoplasmic vacuoles, and binucleation. Follow-up biopsy was LSIL (CIN1) Fig.4.8 ASC-US (LBP, ThinPrep). A 35-year-old woman. A group of cells featuring mild nuclear enlargement, slight nuclear membrane irregularity and mild hyperchromasia in a clean background. The cytologic features do not meet the criteria for LSIL. hrHPV was positive. Follow-up biopsy revealed LSIL (CIN1) Fig. 4.9 ASC-US (LBP, ThinPrep). A 25-year-old woman. Intermediate cells with nuclear enlargement x2-3 that of normal intermediate squamous cell nucleus. There are rare binucleated cells. Slight nuclear irregularity and hyperchromasia are present that do not meet the diagnostic criteria for LSIL. A repeat cervical cytology showed similar findings. Follow-up biopsy revealed LSIL (CIN1) Fig. 4.10 ASC-US (LBP, ThinPrep). A 40-year-old woman. Binucleated atypical intermediate squamous cell with slightly enlarged irregular nuclei in an inflammatory background. hrHPV was positive. Follow-up biopsy showed LSIL (CIN1) Fig. 4.11 ASC-US (LBP, ThinPrep). A 40-year-old woman. A single atypical intermediate squa- mous cell with a nucleus that is 2 to 3 times the area of a normal intermediate squamous nucleus and an irregular nuclear contour. The background shows acute inflammation. The cytologic fea- tures do not meet the criteria for LSIL Fig. 4.12 ASC-US (LBP, SurePath). Routine screening in a perimenopausal woman. Several cells showing slightly increased nuclear hyperchromasia and nuclear to cytoplasmic ratios. Occasional bi-nucleation and cytoplasmic halos are seen. These features may be seen in a reactive/infectious process; however, given the absence of organisms and lack of history, an interpretation of ASC-US was rendered. Repeat cervical cytology was negative; hrHPV testing was also negative Fig. 4.13 ASC-US (LBP, ThinPrep). A 23-year-old woman. An atypical intermediate squamous cell with a mildly enlarged nucleus and a poorly-formed perinuclear halo. The atypical features are suggestive but not diagnostic of LSIL. hrHPV was positive. Follow-up biopsy revealed LSIL (CIN1) Fig. 4.14 ASC-US (LBP, ThinPrep). A 30-year-old woman. A metaplastic cell with dense cytoplasm, slightly enlarged nucleus and mild nuclear membrane irregularity is seen in the center. Below it is a binucleated intermediate squamous cell with irregular nuclear contour. The cytologic features are suggestive but do not meet the criteria for LSIL. hrHPV was positive. Follow-up biopsy revealed LSIL (CIN1) Fig. 4.15 ASC-US - atypical keratinized cells (LBP, ThinPrep). A 25-year-old woman. A cohesive sheet of spindled keratotic cells with nuclear enlargement, hyperchromasia and orangeophilic cytoplasm. hrHPV was positive. Follow-up biopsy revealed LSIL with prominent keratinization Fig. 4.16 ASC-US - atypical keratinized cells (LBP, ThinPrep). A 32-year-old woman. Cohesive sheet of atypical squamous cells with orangeophilic cytoplasm and elongated, hyperchromatic crowded nuclei. hrHPV was positive. Follow-up biopsy revealed HSIL (CIN 2) with prominent keratinization Fig. 4.17 ASC-US - atypical repair (CP). In this image, cells are arranged in two-dimensional sheet with abundant cytoplasm showing a "pulled-out" or streaming effect. Nuclei show pleomor- phism of size and shape with some cells having multiple nuclei. Most nuclei show prominent nucleoli. These changes, while indicative of a reparative reaction, may be classified as ASC-US because of the nuclear pleomorphism noted. In favor of a reactive process is the generally fine granularity of the chromatin pattern Fig. 4.18 ASC-US - atypical repair (CP). Group of cells with features of repair; however, the presence of irregular chromatin distribution and the increased nucleus to cytoplasmic ratio are not typical (see Figs. 2.38 and 2.39). Atypical reparative squamous cells may be classified as ASC-US, or sometimes as ASC-H if invasive carcinoma is a morphologic consideration Fig. 4.19 Postmenopausal atypia (LBP, SurePath). Postmenopausal woman with an atrophic cell pattern, predominantly comprised of parabasal cells. The presence of occasional enlarged nuclei is a characteristic feature of postmenopausal atypia and is often overcalled as ASC-US. hrHPV testing is usually negative in such cases Fig. 4.20 ASC-H (LBP, ThinPrep). A 27-year-old woman. (a) On the left are isolated small cells with variable N/C ratios and some cells displaying prominent nuclear irregularity. (b) On the right is a high-magnification view of six small cells with enlarged and irregular, but degenerated, nuclei. Follow-up was HSIL (CIN 3) Fig. 4.21 ASC-H (LBP, SurePath). Routine cytology for a 30-year-old woman. Rare metaplastic cells with dense cytoplasm and nuclear enlargement with hyperchromasia are present in a background of scattered acute inflammation. An interpretation of ASC-H was rendered. Follow-up cervical biopsies revealed immature squamous metaplasia. Immature squamous metaplasia is one of the most common mimics of HSIL. An interpretation of ASC-H is appropriate, especially when only rare abnormal cells with "metaplastic" cytoplasm and high nuclear to cytoplasmic ratio are present Fig. 4.22 ASC-H (LBP, SurePath). Perimenopausal woman with history of LSIL. Unremarkable slide with only a single large atypical cell in a clean background. The nuclear irregularity and hyperchromasia were worrisome but not definitive for SIL. Cervical biopsies were performed and showed tubal metaplasia but no intraepithelial neoplasia. A solitary cell of this nature is difficult to classify. Cyto-histologic correlation favored this to be a reactive endocervical cell, although a ter- minal bar and cilia were not conclusively identified Fig. 4.23 ASC-H (LBP, SurePath). Perimenopausal woman with history of atypical cytology (ASC-US). Three small atypical metaplastic cells with hyperchromatic nuclei and irregular nuclear membranes are identified. The interpretive considerations included immature metaplasia; however, a high-grade lesion could not be excluded, thus an interpretation of ASC-H was rendered. Loop electrical excision procedure (LEEP) revealed focal areas of HSIL as well as immature metaplasia. Concomitant review of the cytology favored these cells to represent HSIL Fig. 4.24 ASC-H (LBP, SurePath). A group of atypical immature metaplastic cells with enlarged nuclei, high nuclear to cytoplasmic ratio, coarse chromatin and irregular nuclear contour. The cytologic features are worrisome but insufficient for an interpretation of HSIL. Follow-up biopsy revealed HSIL (CIN3) Fig. 4.25 ASC-H (LBP, ThinPrep). A 35-year-old woman. An isolated group of atypical imma- ture metaplastic cells with dense cytoplasm, high nuclear to cytoplasmic ratio, enlarged nuclei, irregular nuclear contour and nuclear grooves. Follow-up biopsy revealed HSIL (CIN2) Fig. 4.26 ASC-H (LBP, ThinPrep). Vaginal specimen obtained from patient with prior history of vaginal HSIL (VAIN 3) and endometrial carcinoma. Cells present show degenerated, markedly hyperchromatic nuclei, worrisome for HSIL. Follow-up histology was HSIL (VaIN 3) Fig. 4.27 ASC-H (CP). Thick aggregate of cohesive, air-dried, overlapping cells containing nuclei with even chromatin and regular borders. The thickness of the cluster makes it difficult to determine if the cells are squamous or glandular. The disorganization of the cells within the group is suggestive of a high-grade lesion; however, the individual nuclear features are insufficient for a definitive interpretation Fig.4.28 ASC-H (CP). Smear from postmenopausal patient containing ovoid cells with irregular poorly preserved nuclei. Possible interpretations include NILM (atrophy), ASC-H and HSIL Fig. 4.29 ASC-H (CP). A 50-year-old postmenopausal woman with prior abnormal cytology. Two cells with extremely hyperchromatic, degenerated nuclei, and orangeophilic cytoplasm, in a background of atrophy with lysed cells and debris. Follow-up demonstrated HSIL (CIN 2) Fig. 4.30 ASC-H (LBP, SurePath). Routine cervical cytology from a perimenopausal woman. A group of metaplastic cells with increased nuclear to cytoplasmic ratios is identified in a relatively clean background. In addition to slightly increased nuclear size, the cells also show some nuclear clearing. In the absence of a history of prior abnormalities, an interpretation of ASC-H was made. Follow-up cervical biopsy and endocervical curettage were negative. The atypical cells were iden- tified as degenerating endocervical cells on cyto-histologic correlation Fig. 4.31 ASC-H (LBP, SurePath). Perimenopausal woman with no significant medical history. Cervical cytology was unremarkable with the exception of a single enlarged cell with scant cyto- plasm, a distinct, regular nuclear membrane and evenly distributed chromatin. An interpretation of ASC-H was made. Cervical biopsy and endocervical curettage were negative. Cyto-histologic cor- relation favored this atypical cell to be a degenerated endocervical cell seen en face. Review of other fields with comparison of other endocervical cells showed similar nuclear features Fig.4.32 Endometrial cells mimicking HSIL (CP). A crowded group of poorly preserved endome- trial cells featuring small cells with hyperchromatic nuclei and high nuclear to cytoplasmic ratios Fig. 4.33 Histiocytes: appearance on liquid based and conventional preparations. (a) Left panel. NILM, histiocytes (LBP, ThinPrep). Routine screen from a 32-year-old woman. Cells possess eccentric oval and round nuclei and foamy cytoplasm. The rounder shape of most cells in LBP as compared to CP may lead to uncertainty about the cell type; however, definitive assessment is usually possible under high magnification. (b) Right panel. NILM, histiocytes (CP). Streaming pattern of single cells with round, ovoid, and bean-shaped nuclei. Cells possess fine cytoplasmic vacuoles that may resemble degenerative vacuoles sometimes found in normal metaplasia, ASC-H, and HSIL. By contrast, cells of squamous lineage typically are polygonal in shape and possess dense cytoplasm. Follow-up was NILM in both cases Fig. 4.34 NILM, Endocervical cell grouping (LBP, SurePath). Endocervical cells, when viewed on end, may mimic ASC-H, showing high nuclear to cytoplasmic ratios, and a configuration remi- niscent of metaplastic cells. Maintenance of a "honeycomb" structure, and a mucus cap when focusing above the nuclear plane is helpful in distinguishing this mimic ■■■【5】LSIL/HSIL Fig. 5.1 Nuclear area (LBP, ThinPrep). The nuclear area of an intermediate squamous cell is approximately 35 μm2. This is used as a reference to measure abnormal squamous cells such as ASC-US (approximately 100 μm2) and LSIL (approximately 150-175 μm2) Fig. 5.2 Low-grade squamous intraepithelial lesion (LSIL) (a, left: LBP, ThinPrep and b, right cervix, H&E stain). Nuclear enlargement and hyperchromasia are of sufficient degree for the inter- pretation of LSIL (a & b). HPV-associated cytoplasmic changes are not a prerequisite for LSIL Fig. 5.3 LSIL (LBP, ThinPrep). A 32-year-old woman, day 15, routine cervical cytology screening. Note the overall large cell size, "smudged" nuclear chromatin, well-defined cytoplasm, and multinucleation Fig. 5.4 LSIL (LBP, ThinPrep). Routine screen from a 32-year-old woman. Nuclear abnormalities are required to make an interpretation of LSIL. HPV cytopathic effect manifested by perinuclear cavitation often accompanies the nuclear abnormalities but is not required for an interpretation of LSIL Fig. 5.5 LSIL (LBP, SurePath). Cells with diagnostic koilocytic features of LSIL have a sharply defined perinuclear cavity, condensation of cytoplasm around the periphery, and abnormal nuclear features including enlargement and nuclear membrane irregularity. In liquid-based samples, nuclear hyperchromasia may be less evident Fig. 5.6 LSIL (LBP, ThinPrep). A 28-year-old woman with a history of ASC-US and positive hrHPV testing. LSIL on cytology is characterized by mature squamous cells with enlarged nuclei with variable chromatin and nuclear membranes. Koilocytosis or perinuclear cavitation in the cyto- plasm, a characteristic of HPV cytopathic effect is present, however it is not required for an inter- pretation of LSIL Fig. 5.7 Pseudokoilocytes (LBP, ThinPrep). Glycogen in squamous cells can give the appearance of "pseudokoilocytosis" (a). The halos associated with glycogen often have a yellow refractile appearance (b). The nuclear abnormalities required for an interpretation of LSIL are absent. Follow-up in both cases was NILM Fig. 5.8 ASC-US versus LSIL (a left CP, b Right LBP, ThinPrep). Atypical squamous cells with orangeophilic cytoplasm ("atypical parakeratosis"). These cells have some features of SIL; however, such keratinized lesions may be difficult to grade. hrHPV triage is helpful in determining follow-up Fig. 5.9 ASC-US versus LSIL (LBP, ThinPrep). A 32-year-old woman. Clusters of squamous cells may be seen in "spikelike" aggregates; such clusters should be classified based on the degree of nuclear abnormalities. This patient had an LSIL interpretation on a conventional smear 2 months before this cytology which was interpreted as ASC-US. hrHPV test was positive Fig. 5.10 ASC-US versus LSIL (CP). Nuclear features are borderline between those required for ASC-US and LSIL. Cases such as this will no doubt have poor interobserver reproducibility as demonstrated in various studies including the Bethesda 2001 BIRST project Fig. 5.11 ASC-US versus LSIL (LBP, ThinPrep). Abnormal nuclear enlargement without concomitant HPV cytopathic change is identified in this Pap test from a 32-year-old woman. The hallmark of LSIL is an enlarged nucleus, often as much as four to six times the area of a normal intermediate cell nucleus. The N/C ratio is low and hyperchromasia varies, especially in liquid- based preparations Fig.5.12 Herpes (LBP, ThinPrep). Routine cervical cytology. A 25-year-old woman. Endocervical cell (a) and intermediate cells (b) showing herpes virus cytopathic effect with clearing of chroma- tin. These cells can be mistaken for ASC-US or LSIL (b) or occasionally HSIL (a) when obvious nuclear changes associated with herpes virus infection are not seen. Looking elsewhere on the same slide will usually clarify that the changes are due to herpes cytopathic effect Fig.5.13 Radiation change versus squamous cell carcinoma (CP). (a) A 61-year-old woman with a history of squamous cell carcinoma and radiation. Mature squamous cell showing cytomegaly, low N/C ratios, intracytoplasmic vacuoles with neutrophils. The mild enlargement of the nucleus should not be mistaken for LSIL. (b) Patients radiated for squamous cell carcinoma may also show tumor cells with radiation effect. These changes should be distinguished from radiation changes in benign cells (a) Fig. 5.14 High-grade squamous intraepithelial lesion (HSIL) (LBP, ThinPrep). There is a mixture of dysplastic cells here, one large LSIL cell, and four adjacent, small, high N/C ratio cells with nuclear features consistent with HSIL Fig. 5.15 High-grade squamous intraepithelial lesion (HSIL) (CP). The dysplastic cells are seen here in a syncytial cluster or hyperchromatic crowded group Fig. 5.16 HSIL-syncytial cluster (LBP, SurePath). As in conventional smears, crowded hyper- chromatic cell groups should be examined with care. If a squamous abnormality is suspected, a thorough search for single dysplastic cells in the background is warranted. Follow-up showed HSIL (CIN 3) with endocervical gland involvement Fig. 5.17 HSIL (CP). A 58-year-old postmenopausal woman on hormone replacement therapy. Hyperchromatic crowded groups seen at low power require careful examination at higher magnification. Flattening at the edge of the cell cluster and whorling in the center are suggestive of HSIL over a glandular abnormality. Follow-up showed HSIL (CIN 3) with endocervical gland involvement Fig. 5.18 HSIL (CP). Nuclear changes are HSIL; however, the nuclear/cytoplasmic (N/C) ratio is on the low end for HSIL Fig. 5.19 HSIL (CP). There is variation in nuclear size and shape, and the cells have delicate cytoplasm Fig. 5.20 HSIL (CP). HSIL with "metaplastic" or dense cytoplasm, in contrast to that seen in the syncytial groups of HSIL (Fig. 5.19) Fig. 5.21 HSIL (CP). HSIL cells with some variation in cell size and N/C ratios. A cluster such as this may be misinterpreted as squamous metaplastic cells if examined only under lower magni- fication. Follow-up showed HSIL (CIN 3) Fig. 5.22 HSIL (a, b LBP, ThinPrep). HSIL that is markedly hypochromatic. A diligent search may reveal more classic cells elsewhere on the same slide. (a) On the left side, note syncytial arrangement and nuclear grooves. (b) On the right side, abnormal naked nuclei and a hyperchro- matic, high N/C ratio single HSIL cell are seen Fig. 5.23 HSIL (a, b LBP, SurePath). Note the nuclear envelope irregularities and abnormal chro- matin. As seen here in LBPs, hyperchromasia may not be as prominent as in conventional smears Fig. 5.24 HSIL (LBP, ThinPrep). Cells showing variably sized, ovoid nuclei with prominent nuclear grooves. In this case, the chromatin is not particularly hyperchromatic, and cytoplasm has ill-defined borders Fig. 5.25 HSIL (CP). A 42-year-old woman. Although uncommon, nucleoli may be seen in HSIL, especially with extension into endocervical gland spaces. The chromatin may appear less coarsely granular Fig. 5.26 HSIL-keratinizing lesion (CP). The criteria of nuclear to cytoplasmic ratio and degree of nuclear abnormalities used for grading SIL may be more difficult to apply to keratinizing lesions. The extent of abnormality here qualifies for an interpretation of HSIL (contrast with Figs. 5.8 and 5.9) Fig. 5.27 HSIL (a, b: LBP, ThinPrep). A 29-year-old woman from a high-risk clinic. Close attention to isolated cells is required when screening LBPs because the abnormal isolated cells may not be as apparent as clusters of HSIL cells and may lie between benign cell clusters or in "empty spaces" on the preparation. When the criteria for HSIL are met, such cells should be interpreted as HSIL and not ASC-H. Both images (a and b) demonstrate such cells. Follow-up showed HSIL (CIN 3) Fig. 5.28 HSIL (LBP, ThinPrep). Isolated single abnormal cells (arrow) are more often seen in LBPS. These small cells may be seen in the spaces between cells as seen here and may be easily missed on screening. The inset magnifies the cell indicated by the arrow, which shows abnormal features includ- ing a large hyperchromatic nucleus with irregular nuclear membranes and increased N/C ratio Fig. 5.29 HSIL (LBP, ThinPrep). A 32-year-old woman with a history of abnormal Pap tests and positive hrHPV testing. A syncytial cluster of cells with overlapping of hypochromatic nuclei are seen. The nuclei are often less hyperchromatic in liquid-based preparations. Follow-up cone biopsy revealed HSIL (CIN 3) Fig. 5.30 HSIL (CIN 3) (cervix, H&E stain). The histology of HSIL (CIN 3) reflects the findings seen in clusters of HSIL seen on cytology. The abnormal immature cells show minimal maturation from the base of the epithelium to the surface with nuclear size and shape variation Fig. 5.31 HSIL with extension into endocervical gland space (LBP, SurePath). Note flattening of cells at the edge of the cluster, a feature that favors HSIL over a glandular lesion Fig. 5.32 HSIL (CIN 3) with extension into endocervical glands (cervix, H&E stain). Squamous dysplasia, especially high-grade lesions, often extends into endocervical glands replacing the nor- mal endocervical glandular cells Fig. 5.33 HSIL (CP). A 30-year-old woman with atypical glandular cells on a prior Pap test. When HSIL lesions involve endocervical glands, they may show features that overlap with those of adeno- carcinoma in situ (AIS). Note normal columnar cells with residual mucin at the right upper edge of the cell cluster (arrow). Follow-up showed CIN with endocervical gland involvement Fig. 5.34 HSIL (LBP, SurePath). A 44-year-old woman. Syncytial cluster of HSIL cells with features of endocervical gland extension. Such "hyperchromatic crowded groups" may raise a wide differential diagnosis under low magnification; attention to architectural pattern and cellular detail are necessary for correct interpretation. Follow-up showed HSIL (CIN 3) with endocervical gland involvement Fig. 5.35 HSIL (a and b LBP, SurePath). This rare example of HSIL (a) shows a loosely aggre- gated group of dysplastic cells having a spindled appearance reminiscent of endometrial stromal cells. The cells at the margins of the group show tapered cytoplasmic ends. The nuclei show atypical chromatin and irregular nuclear contours that are more in keeping with the high-grade squa- mous lesion. Compare the cytologic features with shed endometrium (b) Fig. 5.36 HSIL (LBP, SurePath). HSIL can present in three-dimensional groups that closely mimic shed endometrial cells. In this example, the nuclei are smaller that might be expected for the typical HSIL; however, they do show atypical chromatin and irregular contours. Apoptotic debris is present within the groups, a feature that is commonly present in shed endometrium Fig. 5.37 HSIL (LBP, SurePath). In some cases of HSIL, more voluminous amounts of cytoplasm with cytoplasmic appendage formation reminiscent of repair can be present. Note also the presence of intermixed inflammatory cells within the group, another feature that overlaps with reparative changes. Such samples should be interpreted cautiously, with an attempt to find more typical HSIL cells Fig. 5.38 HSIL (LBP, ThinPrep). Abnormal, large stripped nuclei are seen that are considerably bigger than the intermediate cell nuclei. Such cells should elicit a search for classic, intact HSIL cells elsewhere on the same preparation. These stripped nuclei should be distinguished from endometrial cells or the stripped clusters of atrophic nuclei that are often seen in LBPS in the background of atrophy Fig. 5.39 HSIL-stripped nucleus pattern (CP). A 38-year-old woman with a history of LSIL. These abnormal stripped nuclei are often a useful diagnostic clue that other abnormal cells may be identi- fied on the same slide. They should be distinguished from the bare intermediate cell nuclei seen in cytolysis (Fig. 2.62) and from "small blue cells" (see Fig. 3.7) Fig. 5.40 HSIL (CP). At low magnification (right upper inset), the pattern of HSIL cells streaming within mucus can mimic histiocytes and endocervical/metaplastic cells. At high power, HSIL can be readily distinguished (see also Figs. 5.35, 4.33, and 4.34) Fig. 5.41 NILM; endocervical microglandular hyperplasia (a LBP, ThinPrep, b CP). A 34-year- old woman on day 19 of menstrual cycle. Degenerated endocervical cells, seen in a streaming pattern along with thick mucus, is a pattern that has been associated with microglandular hyperplasia (b). The appearance is more subtle in liquid-based preparations (a). When identified, it is typically during the second half of the menstrual cycle, often in women taking oral contraceptives, and may mimic HSIL at low magnification. Follow-up cytology showed NILM Fig. 5.42 HSIL (CP). Classification of atypical keratinized cells depends on the degree of nuclear abnormality, the N/C ratio, and to some extent on the pleomorphism of the abnormal cells. This image shows a range of cells from the LSIL cells seen in the center to the HSIL cells seen around the periphery. The high-grade cells have an increased N/C ratio as well as more marked variability in cytoplasmic shape (see also Figs. 5.8 and 5.26) Fig. 5.43 HSIL (LBP, ThinPrep). These cells demonstrate marked pleomorphism of the nuclei and keratinized cytoplasm. The marked variation in shape and the presence of cells with a high N/C ratio is consistent with an interpretation of HSIL Fig. 5.44 HSIL (LBP, ThinPrep). A 42-year-old woman. Keratinized dysplastic cells with nucleoli and angulated or "carrot"-shaped nuclei that may raise suspicion for invasion and qualify for an interpreta- tion of HSIL cannot rule out invasion. Follow-up showed only HSIL (CIN 3) that was keratinizing Fig. 5.45 HSIL (LBP, SurePath). HSIL in atrophy may be difficult to distinguish from clusters of benign atrophic squamous cells. In HSIL, as seen here, the cells show a syncytial arrangement, and looking at these clusters by focusing in different planes allows one to better distinguish them from the parabasal cells in the background Fig. 5.46 HSIL (CP). Clusters of parabasal cells are commonly identified in the background of HSIL in atrophy. The HSIL illustrated here shows a sheet-like arrangement, a pattern commonly seen in HSIL, with significant nuclear size variation and a loss of polarity with overlapping of the nuclei. HSIL in the background of atrophy can be a diagnostic challenge Fig. 5.47 LSIL with some cells suggesting the possibility of a concurrent HSIL (CP). Routine screen from a 28-year-old woman. Most of these cells qualify as LSIL; however, there are three atypical metaplastic cells at the top center (arrow) that raise the possibility of a high-grade lesion. Cases such as this are may be interpreted as LSIL with a comment explaining the possibility of HSIL or as LSIL with an additional interpretation of ASC-H. The presence of a few diagnostic HSIL cells in the background of a predominant LSIL pattern should be interpreted as HSIL. Follow-up in this case showed HSIL (CIN 2) Fig. 5.48 HSIL (LBP, ThinPrep). In this case, diagnostic HSIL cells are present. Even if these cells are seen in the background of a majority of LSIL elsewhere on the slide, the final interpretation should be HSIL Fig. 5.49 Immature squamous metaplasia (LBP, ThinPrep). Immature metaplastic cells can mimic dysplastic cells. Degenerative and reactive changes in these small squamous cells can be confused with dysplasia or carcinoma. Cytologic features that support a benign interpretation include nuclear uniformity, smooth nuclear borders, and fine and evenly distributed chromatin Fig. 5.50 HSIL versus benign endocervical cells (LBP, ThinPrep). Single cells are randomly distributed in liquid-based preparations. Single benign endocervical cells are prone to cytoplasmic lysis and (b) may mimic single cells of HSIL. The common cellular features of HSIL (a), such as irregular nuclear membranes, absence of nucleoli, and hyperchromasia, help to make the correct interpretation Fig. 5.51 NILM, endometrial cells (LBP, ThinPrep). Single endometrial cells (a arrow) may be mistaken for HSIL. The small round nucleus with smooth nuclear membranes helps to classify this as benign. Comparison to more classic clusters of endometrial cells from the same slide (b) is also useful Fig.5.52 ASC-US (LBP, SurePath). Large bizarre cells may be seen in atrophic preparations. Because of the increased N/C ratio, these cells raise the possibility of HSIL, but the degenerative nuclear fea- tures and background atrophy make a benign process more likely. An interpretation of ASC-US may be more appropriate than ASC-H in this case. In this case, follow up hrHPV testing was negative and no abnormality was identified with colposcopic biopsy and subsequent repeat cytology Fig. 5.53 NILM (a, b LBP, ThinPrep, c cervix H&E stain). A young woman in the late second trimester of pregnancy. These single cells (a, b) with an increased N/C ratio and nuclear hyper- chromasia are worrisome for HSIL. Features suggesting the true stromal decidual nature of the cells include the smudgy chromatin and the presence of a nucleolus. Similar cells can be seen in a follow-up cervical biopsy (c) Fig. 5.54 NILM (a LBP, ThinPrep) versus HSIL (b CP). Both dysplastic and benign squamous cells can demonstrate longitudinal nuclear grooves. The benign cells seen in (a) are derived from transitional cell metaplasia and show distinct nuclear grooving without any of the other dysplastic features. In (b), the HSIL cells show other features of dysplasia including significant nuclear size variation and nuclear membrane notching, as well as grooves Fig. 5.55 HSIL with features suspicious for invasion (CP). A 71-year-old postmenopausal woman. HSIL filling endocervical glands may undergo focal necrosis that can mimic the tumor diathesis associated with invasive lesions. Follow-up showed HSIL (CIN 3) extending into glands with focal epithelial necrosis, but no invasion Fig. 5.56 Squamous cell carcinoma, keratinizing (LBP, SurePath). The malignant cells have variable shapes and sizes and show some keratinized "tadpole cells." Nuclei vary from vesicular with irregular nuclear contours and nucleoli to pyknotic in the keratinized cells. The cytoplasm is dense and may be deeply eosinophilic or cyanophilic. Cervical biopsy revealed an invasive squamous cell carcinoma Fig. 5.57 Squamous cell carcinoma, keratinizing (CP). There is marked pleomorphism of cell size and shape, cytoplasmic keratinization, and tumor diathesis in the background Fig. 5.58 Squamous cell carcinoma, keratinizing (LBP, ThinPrep). A 68-year-old woman. Diathesis may be more subtle in LBPs and often tends to collect at the periphery of cell groups, a pattern that has been referred to as "clinging diathesis." Follow-up showed squamous cell carcinoma Fig. 5.59 Squamous cell carcinoma, keratinizing (LBP, ThinPrep). A 57-year-old woman. Note the tumor diathesis, abnormal keratinized cells, and spindle cells. Follow-up biopsy revealed inva- sive squamous cell carcinoma Fig. 5.60 Squamous cell carcinoma, nonkeratinizing (CP). These dysplastic cells demonstrate nuclear features of HSIL. Pleomorphic cell shapes should raise concern for invasion even though prominent nucleoli and tumor diathesis are absent in this field. Follow-up cervical biopsy revealed an invasive squamous cell carcinoma Fig. 5.61 Squamous cell carcinoma, nonkeratinizing (LBP, SurePath). A 59-year-old woman with postmenopausal bleeding. Abnormal nuclei are present with prominent nucleoli and irregular chromatin distribution. Single abnormal cells are also seen. There is a tumor diathesis present in the background. Follow-up revealed a nonkeratinizing squamous cell carcinoma of the cervix Fig. 5.62 Squamous cell carcinoma (LBP, SurePath). Malignant cell clusters tend to show more rounding on LBPs, and distinction between a squamous and glandular lesion may be difficult. Attention should be given to looking for isolated neoplastic cells in the background Fig. 5.63 Squamous cell carcinoma, nonkeratinizing (LBP, ThinPrep). A 63-year-old woman with postmenopausal bleeding. Clusters of cells and single abnormal cells are identified with a background of inflammatory cells. Follow-up revealed a nonkeratinizing squamous cell carcinoma of the uterine cervix Fig. 5.64 Squamous cell carcinoma (CP). There is tumor diathesis in the background and prominent nucleoli in the malignant cells (left). On the right, from a different case, tumor diathesis is prominent, and only a naked nucleus is seen in this field (right) Fig. 5.65 Squamous cell carcinoma (LBP, ThinPrep). Bloody samples are often seen in the pres- ence of squamous carcinoma. Because the blood may clog the filter of the ThinPrep, these samples may be very scantly cellular and technically unsatisfactory. Bloody unsatisfactory specimens should still be screened closely to look for rare abnormal cells buried in the blood as seen here (arrow). Re-prepping these samples with glacial acetic acid may yield a more cellular preparation Fig. 5.66 Atypical repair (CP). A 48-year-old woman with a normal screening history. Prominent nucleoli are identified in virtually every nucleus. The cells are cohesive and lack irregular chroma- tin distribution. Atypical repair is a differential in the diagnosis of carcinoma of the cervix Fig. 5.67 Diathesis look-alike (LBP, ThinPrep). (a) Left, a 66-year-old postmenopausal woman. Routine cervical cytology. (b) Right, a 39-year-old woman on day 12 of menstrual cycle. The background of atrophy (left) and inflammatory debris (right) can mimic tumor diathesis. Lack of hyperchromatic crowded groups and atypical pleomorphic keratinized cells should aid in the correct interpretation Fig. 5.68 Diathesis look-alike (LBP, ThinPrep). A 63-year-old postmenopausal woman. Lubricant may be used in Pap test collection and presents as granular debris that may mimic tumor diathesis Fig. 5.69 Squamous cell carcinoma, cell block (cell block, H&E stain). A 57-year-old postmeno- pausal woman with irregular bleeding. A cell block preparation was made from the residual ThinPrep vial. An abnormal cluster of cells with dense pink cytoplasm and abnormal nuclei is seen. Follow-up cervical biopsy revealed an invasive squamous cell carcinoma ■■■【6】Endocervical/Endometrial abnormality Fig. 6.1 Atypical endocervical cells, most likely from a reparative process (CP). Routine screen from a 39-year-old woman. Sheet of cells that demonstrate nuclear enlargement, increased nuclear to cytoplasmic (N/C) ratios, prominent, sometimes multiple nucleoli, and mitotic activity. Three- year follow-up showed NILM cytology Fig. 6.2 Atypical endocervical cells, not otherwise specified (NOS) (LBP, ThinPrep). Cluster of slightly crowded endocervical cells with some nuclear crowding and round to oval nuclei showing washed-out chromatin. Follow-up showed tubal metaplasia. The terminal bars and cilia were difficult to visualize in this case. The fine granularity of the chromatin pattern is an important feature of cases that are derived from tubal metaplasia Fig. 6.3 Atypical endocervical cells, most likely related to ionizing radiation therapy (CP). A 54-year-old woman, 4 months status post radiation therapy for cervical carcinoma. Sheet of glandular cells showing nuclear enlargement, marked variation in nuclear size, prominent nucleoli, and distinct cell borders. Follow-up showed NILM Fig. 6.4 Atypical endocervical cells, NOS (LBP, ThinPrep). Cluster of crowded endocervical cells with nuclear enlargement, overlap and some nuclear irregularity. An ill-defined rosette is present at 11 o'clock. Follow-up showed AIS and HSIL. The cells in this image represent the three to four clusters of atypical endocervical cells present on the slide that correlate with AIS in the tissue biopsy. The rest of the slide showed cells diagnostic of HSIL which are not shown in this image Fig. 6.5 Reactive glandular cells associated with IUD (LBP, SurePath). A 45-year-old woman with an intrauterine device (IUD). The presumed endocervical cells demonstrate nuclear enlargement, nucle- oli, and cytoplasmic vacuolization, consistent with changes associated with presence of an IUD. In the absence of a clinical history of IUD, such changes may be reported as atypical glandular cells, NOS Fig. 6.6 Atypical endocervical cells, NOS (CP). Cluster of cells with crowding and overlapping of nuclei, nuclear enlargement, chromocenters, and small nucleoli. Follow-up biopsies showed high-grade squamous intraepithelial lesion (HSIL) with extension into endocervical glands Fig. 6.7 Atypical endocervical cells, NOS (LBP, ThinPrep). ThinPrep imager stained cluster of endocervical cells with dark nuclei and some focal feathering with minimal nuclear overlap which was initially interpreted as atypical endocervical cells, NOS. Follow-up was normal. In retrospect dark imager staining, mimicking hyperchromasia, resulted in the overinterpretation Fig. 6.8 Normal endocervical cell "brush effect" (LBP, SurePath). Pictured is one of many such groups present on this slide, resulting from vigorous sampling with an endocervical "broom" device. The endocervical cells show uniform, evenly distributed, finely granular chromatin, and well-defined cytoplasmic boundaries consistent with a benign etiology Fig. 6.9 Atypical endocervical cells, favor neoplastic (CP). Routine screen from a 29-year-old woman. Sheet of crowded cells with increased N/C ratios and mitotic activity. Note feathering at the edges of the sheet. Follow-up showed endocervical AIS Fig. 6.10 Atypical endocervical cells, favor neoplastic (CP). Pseudostratified strip of endocervical cells with enlarged, elongated nuclei and evenly distributed chromatin granularity Fig. 6.11 Atypical endocervical cells, favor neoplastic (LBP, ThinPrep). Atypical endocervical cells characterized by round or oval nuclei with nuclear enlargement, crowding, disordered arrangement, and occasional nucleoli. A rosette-like cellular arrangement is present. Follow-up showed endocervical AIS Fig. 6.12 Atypical endocervical cells, most likely associated with tubal metaplasia (CP). Routine screen from a 38-year-old woman. Sheet of cells having enlarged, variably sized nuclei with some nuclear crowding and overlap. Note cilia at upper edge of sheet. Follow-up biopsy showed only tubal metaplasia Fig. 6.13 Tubal metaplasia. (a) Tubal metaplasia showing pseudostratified nuclei in a cellular strip (LBP, ThinPrep). Note the prominent terminal bars and cilia on the cells. (b) p16 immunostaining of tubal metaplasia (biopsy H&E) can show some positivity of the cells; however, not all cells in the epithelium are stained, in contrast to the diffuse staining typically noted in AIS (see Fig. 6.20) Fig. 6.14 Atypical endocervical cells, probably derived from tubal metaplasia (CP). Cell groups from tubal metaplasia may raise the differential diagnosis of endocervical adenocarcinoma in situ (AIS). It is useful to note that due to the presence of mucin in goblet cells overlying some nuclei, and the variety of cell types (goblet, ciliated, and peg) in tubal metaplasia, scattered nuclei demon- strate relative hypochromasia or a "washed-out" appearance and lack the monotony of changes characteristic of AIS (contrast with Fig. 6.21) Fig. 6.15 Atypical endometrial cells (CP). An 82-year-old woman with postmenopausal bleeding. Three-dimensional groups of small cells with mildly hyperchromatic nuclei, small nucleoli, and occasionally vacuolated cytoplasm. (a) shows a very tight cluster, while (b) shows a more loosely aggregated group. Follow-up showed endometrial hyperplasia Fig. 6.16 Atypical endometrial cells (LBP, ThinPrep). Small groups of cells with slightly enlarged nuclei, small nucleoli, and vacuolated cytoplasm. (a) A 63-year-old woman. Follow-up showed endometrial adenocarcinoma grade 1. (b) A 55-year-old woman. Follow-up showed endometrial hyperplasia Fig. 6.17 Atypical endometrial cells (LBP, ThinPrep). A 63-year-old woman with postmeno- pausal bleeding. Aggregate of small cells with slightly enlarged round or oval nuclei, small nucleoli, and finely vacuolated cytoplasm. Follow-up showed endometrial adenocarcinoma grade 1 Fig. 6.18 Atypical endometrial cells (LBP, ThinPrep). A 52-year-old woman on hormone replacement therapy. Three-dimensional grouping of small cells with crowded round or oval nuclei. Follow-up showed endometrial hyperplasia Fig. 6.19 Directly sampled tubular endometrial glands with adjacent stromal elements seen post trachelectomy (LBP, SurePath). The geometric/tubular shapes of the endometrial glands should clue one in to the possibility of directly sampled endometrium. The stromal fragments consist of spindled cells but may be separated from the glands in liquid-based preparations Fig. 6.20 Comparison between benign endometrial tissue and endocervical AIS stained with the p16 immunostain. (a) Shed endometrium (cell block H&E), (b) shed endometrium (cell block p16), (c) AIS (biopsy H&E), and (d) AIS (biopsy p16). p16 is diffusely positive in AIS and essentially negative in shed endometrium. Cell blocks of residual material from cytologic specimens can be useful for the application of biomarkers (Compare to Fig. 6.13 for p16 staining pattern in benign tubal metaplasia) Fig. 6.21 Endocervical adenocarcinoma in situ (CP). Sheet of crowded cells with enlarged, hyperchromatic nuclei, increased nuclear to cytoplasmic ratios, and feathering at the periphery of the sheet. Note the monotony of the hyperchromatic nuclei as contrasted with the more variable nuclear changes in tubal metaplasia (see Figs. 6.12 and 6.14 for comparison) Fig. 6.22 Endocervical adenocarcinoma in situ (histology, H&E) Fig. 6.23 Endocervical adenocarcinoma in situ (CP). The typically oval nuclei are crowded with nuclear overlapping and show hyperchromasia with evenly distributed but coarsely granular chromatin. Note the prominent gland-like configuration (rosette) Fig. 6.24 Endocervical adenocarcinoma in situ (CP). Pseudostratified strip of cells demonstrating crowding, nuclear enlargement, and peripheral feathering Fig. 6.25 Endocervical adenocarcinoma in situ (CP). Cell group in a rosette-like arrangement. Nuclei are oval or elongated, are hyperchromatic, and have granular, evenly distributed chromatin Fig. 6.26 Endocervical adenocarcinoma in situ (LBP, ThinPrep). A 64-year-old woman with prior abnormal cytology. Cell groups in LBPs may be more three-dimensional with sharper, smoother margins, and feathering may have a more subtle presentation. Follow-up showed AIS with a small focus of invasion Fig. 6.27 Endocervical adenocarcinoma in situ (LBP, SurePath). Routine screen from a 25-year- old woman. Pseudostratified strips of cells often present as short "bird tail-like” arrangements in SP as seen on the right side of this image (b). Feathering, although less prominent than in conventional smears, is demonstrated on the left (a). Follow-up showed AIS Fig. 6.28 Endocervical adenocarcinoma in situ (LBP, ThinPrep). AIS may occasionally demon- strate nucleoli, raising the differential of invasive endocervical carcinoma (see Fig. 6.40) Fig. 6.29 Endocervical AIS on low magnification (LBP, ThinPrep). Hyperchromatic crowded groups of cells characterized by sheets with nuclear crowding with peripheral feathering as seen in the center of image. A strip of cell with nuclear crowding, overlapping, and hyperchromasia is seen near the upper edge of the image. Dense cellular groups present on low-magnification scans may be the first clue to the presence of a glandular lesion Fig. 6.30 Benign and neoplastic endocervical cells (LBP, ThinPrep). The group on the right side of the image shows a strip of normal endocervical cells with low nuclear to cytoplasmic ratios and lack of overlapping contrasted with the groups on the left side of the image which show strips and rosettes of AIS with high nuclear to cytoplasmic ratios, nuclear hyperchromasia, crowding, feathering and overlapping Fig. 6.31 Endocervical adenocarcinoma in situ, intestinal type (CP). Cells show nuclear crowding and overlap and have elongated nuclei. Note numerous goblet-type cells Fig. 6.32 Endocervical adenocarcinoma in situ, endometrioid variant (CP). Endometrioid AIS has similar features to the usual type of AIS but shows much smaller average nuclear area (compare to intermediate cell nucleus in the image). Because of this size difference, endometrioid AIS can be mistaken for directly sampled benign endometrium. Attention to overall architecture and lack of stromal cells can be helpful in differentiation Fig. 6.33 AIS and HSIL (histology, H&E). Glandular and squamous lesions may coexist. HSIL is present on the squamous epithelial surface on the left side of this image, and endocervical adenocarcinoma in situ is present in gland spaces on the right (© 2001 American Society for Clinical Pathology Reprinted with permission) Fig. 6.34 AIS and HSIL (LBP, ThinPrep). The preparation showing HSIL (11-12 o'clock), LSIL (3 o'clock), and AIS (endometrioid type, 7-8 o'clock) all in one medium-magnification field. Note the smaller size of the cells in the cluster of AIS characterized by some peripheral feathering. Follow-up showed HSIL as well as AIS Fig. 6.35 Adenocarcinoma, endocervical (CP). A 32-year-old woman with abnormal cervix on pelvic exam. Cytologic features may overlap with those of endocervical adenocarcinoma in situ. Follow-up showed invasive endocervical adenocarcinoma Fig. 6.36 Adenocarcinoma, endocervical (CP). Nuclei are enlarged and pleomorphic with irregular chromatin distribution and prominent or macronucleoli. Cytoplasm is finely vacuolated. Note the prominent blood-filled background Fig. 6.37 Adenocarcinoma, endocervical (LBP, SurePath). Large cell groups may be thick and three-dimensional, making architecture more difficult to interpret and visualization of cell nuclei more problematic Fig. 6.38 Adenocarcinoma, endocervical (LBP, SurePath). Cell group demonstrates glandular architecture and large nuclei, irregular chromatin distribution, and prominent macronucleoli. This group shows well-defined cytoplasmic boundaries mimicking reparative change, which can often be a problematic differential diagnosis Fig. 6.39 Adenocarcinoma, endocervical (LBP, ThinPrep). A 46-year-old woman. Cell nuclei may have more vesicular chromatin with irregular distribution and chromatin clearing as well as macronucleoli. Follow-up showed invasive endocervical adenocarcinoma Fig. 6.40 Adenocarcinoma, endocervical (LBP, ThinPrep). A 39-year-old woman on day 12 of menstrual cycle. Tumor diathesis may be less prominent and seen as debris clinging to the periphery of the abnormal cell clusters in LBPs. Follow-up showed invasive endocervical adenocarcinoma Fig. 6.41 Adenocarcinoma, endocervical (LBP, ThinPrep). Note the prominent wispy or frothy diathesis surrounding the malignant cells and present as a coagulum in the background. This type of diathesis is common in liquid-based preparations due to the immediate fixation of material Fig. 6.42 Adenocarcinoma, endocervical villoglandular (LBP, ThinPrep). A rare neoplasia of the cervix, villoglandular carcinoma may demonstrate large cohesive groups of endocervical cells with nuclear crowding and loss of normal honeycomb pattern, with true papillary clusters being characteristic. (a) Cytologic atypia is often minimal, emphasizing the importance of appreciating the low-power architectural abnormalities of this neoplasm (b) Fig. 6.43 Mucinous carcinoma, gastric type (adenoma malignum) (H&E biopsy). Note the bland nuclear morphology and the similarity to normal mucinous endocervical epithelium Fig. 6.44 Mucinous carcinoma, gastric type (adenoma malignum) (LBP, SurePath). Abundant mucinous cytoplasm and occasional goblet cells are present. Note bland nuclear morphology simi- lar to what is noted in the histology (see Fig. 6.43) Fig. 6.45 Mucinous carcinoma, gastric type (adenoma malignum) (LBP, SurePath). Note the centrally located goblet cells with typical brown/yellow hue to the mucin, consistent with pyloric differentiation Fig. 6.46 Adenocarcinoma, endometrial, low grade (CP) Fig. 6.47 Endometrial adenocarcinoma, high grade. (a) A 61-year-old woman with postmeno- pausal bleeding (CP). (b) A 57-year-old woman with PM bleeding (LBP, ThinPrep). High-grade endometrial adenocarcinoma is characterized by tight clusters of glandular endometrial type cells with enlarged hyperchromatic nuclei and a clinging granular diathesis as well as a precipitate of acellular diathesis material in the background. Nucleoli are prominent, and chromatin is coarse and irregularly distributed. As grade increases, larger numbers of cells are shed and present in the cervical cytologic specimen. Both cases seen here had histologic follow-up of endometrial adeno- carcinoma FIGO grade 3 Fig. 6.48 Adenocarcinoma, endometrial, high grade (CP). A 58-year-old woman with postmeno- pausal bleeding. Nuclei in higher-grade tumors are larger and display moderate hyperchromasia with irregular chromatin distribution. Note finely granular diathesis in background. Follow-up showed high-grade endometrial adenocarcinoma Fig. 6.49 Endometrial adenocarcinoma on (LBP, SurePath). Large tight cluster of hyperchromatic and enlarged endometrial cells with some maturation of background normal cells. Endometrial biopsy showed a FIGO grade 2 endometrioid adenocarcinoma Fig. 6.50 Adenocarcinoma, endometrial. A 67-year-old woman with postmenopausal bleeding. (a) Three-dimensional cell group with papillary configuration (LBP, SurePath). (b) Follow-up histology (biopsy H&E) showed endometrial adenocarcinoma grade 1-2 Fig. 6.51 Adenocarcinoma, endometrial (LBP, ThinPrep). A 64-year-old woman. Papillary serous carcinomas may resemble their ovarian counterparts and present with papillary groups, large cell size, and prominent nucleoli. Follow-up showed papillary serous adenocarcinoma of the endometrium Fig. 6.52 Adenocarcinoma, endometrial, high grade (CP). Tumor diathesis, if present, is watery and may be difficult to appreciate (Reprinted with permission from Kurman [40]) Fig. 6.53 Adenocarcinoma, endometrial (LBP, ThinPrep). Amorphous, finely granular (“wrinkled tissue paperlike") diathesis. The malignant and inflammatory cells may be trapped in the diathesis. There is usually a clear space surrounding this type of diathesis as there is shrinkage once fixed in alcohol after the ThinPrep is prepared Fig. 6.54 Endometrial adenocarcinoma (LBP, SurePath). Endometrial adenocarcinoma often shows cells with prominent cytoplasmic vacuoles full of neutrophils ("bag of polys cells") (inset— high magnification) Fig. 6.55 Adenocarcinoma, extrauterine (CP). A 70-year-old woman with large pelvic mass and ascites. Ovarian/tubal/peritoneal carcinoma may be characterized by papillary configurations and psammomatous calcifications (psammoma bodies). Follow-up showed an ovarian primary Fig. 6.56 Adenocarcinoma, extrauterine (CP). Clusters of cells from ovarian carcinoma have enlarged, variably sized round or oval nuclei with prominent macronucleoli. The background is typically clean Fig. 6.57 Adenocarcinoma, extrauterine (LBP, ThinPrep). A 66-year-old woman with pelvic mass and ascites. Papillary clusters from ovarian carcinoma may be three-dimensional, making evaluation of the component cells difficult. Follow-up showed intra-abdominal dissemination of ovarian carcinoma Fig. 6.58 Colonic adenocarcinoma (LBP, SurePath). Adenocarcinoma of the colon typically involves cervical specimens by direct invasion. (a) A columnar architecture can closely mimic endocervical adenocarcinoma. (b) The presence of background vegetable material (fecal material) is a clue to the diagnosis Fig. 6.59 (a-d) These are images of lobular breast carcinoma (LBP, SurePath). Lobular breast cancers presenting in an atrophic background can be challenging. (a) Small clusters of cells and (b) individual cells with mucin vacuoles contrast with a background of parabasal cells. Confirmation with immunostains can be helpful, including (c) gross cystic disease fluid protein 15 and (d) estrogen receptor immunocytochemistry ■■■【7】Other malignant neoplasms Fig. 7.1 Spindle cell carcinoma (CP). Spindle-shaped nonkeratinizing cells displaying variability in nuclear size, nuclear membrane irregularity, coarse granular chromatin, and conspicuous nucle- oli are arranged in a loosely cohesive cluster. The cytologic features are not specific and could be compatible with sarcoma, spindle cell carcinoma, or malignant melanoma Fig. 7.2 (a, b) Squamous cell carcinoma with small cells (CP). Clusters of small cells with scant cytoplasm and small cell morphology with crowded nuclei and attempt at nuclear molding. The inset shows single cells with characteristic squamous cell features and dense cytoplasm Fig. 7.3 (a, b) Small cell undifferentiated carcinoma. (a) The malignant cells are dispersed in loosely cohesive clusters. They show nuclear pleomorphism and more conspicuous nucleoli. Nuclear molding although present is less prominent and crush artifact is absent (left, LBP, ThinPrep). (b) Small to medium-sized cells with minimal cytoplasm, high nuclear/cytoplasmic ratio, hyper- chromatic nuclei, inconspicuous nucleoli, and prominent nuclear molding. The upper right inset shows a characteristic finely granular, stippled "neuroendocrine" chromatin pattern (right, CP) Fig. 7.4 Large cell neuroendocrine carcinoma (LBP, ThinPrep). The malignant cells are larger than those of small cell carcinoma with more cytoplasm and are arranged in loosely cohesive clusters. The nuclei are only mildly pleomorphic with one or more prominent nucleoli and coarser chromatin. No crush artifact or nuclear molding is observed Fig. 7.5 (a, b) Glassy cell carcinoma (LBP, ThinPrep). The tumor cells are arranged in sheets with abundant granular, ground glass-like cytoplasm. Large pleomorphic nuclei, coarse irregular chromatin, and prominent (inclusion-like) nucleoli are characteristic. An inflammatory cell infiltrate is present Fig. 7.6 Minimal deviation adenocarcinoma/adenoma malignum (LBP, SurePath). Large numbers of glandular clusters with overall bland cytologic features, resembling benign endocervical cells show subtle nuclear pleomorphism, crowding, and loss of polarity. Cells have abundant, occasionally yellow/golden vacuolated cytoplasm. The nuclei are enlarged and may have visible nucleoli Fig. 7.7 Malignant Müllerian mixed tumor (MMMT) (CP). Three-dimensional cluster of large epithelioid cells with round but pleomorphic nuclei, coarse granular chromatin, macronucleoli, and a moderate amount of cytoplasm Fig. 7.8 Malignant mixed mesodermal tumor (MMMT) (CP). Spindle cells with pleomorphic nuclei, coarse granular chromatin, macronucleoli, and a moderate amount of cytoplasm constitute the "sarcomatous" component of the same tumor depicted in Fig. 7.7 Fig. 7.9 Clear cell adenocarcinoma (CP). Tumor cells with delicate finely granular cytoplasm and large pleomorphic nuclei are arranged in sheets and papillae (a, b). A “tigroid” background and stripped nuclei are also seen (a, left) Fig. 7.10 Sarcoma not otherwise specified (NOS) (CP). A loosely cohesive group of haphazardly arranged malignant cells with enlarged irregular nuclei and prominent nucleoli. Distinctive epithelial or mesenchymal differentiating features are not seen Fig. 7.11 Leiomyosarcoma (CP). Spindle cells with delicate ill-defined cytoplasm and elongated pleomorphic nuclei are arranged in groups and as single cells. Usually, the scant number of exfoliated cells from this tumor is reflected by scattered single cells. Nuclear membrane irregularity, coarse irreg- ular chromatin, and prominent nucleoli separate the spindle-shaped cells of leiomyosarcoma from those of reactive reparative changes characterized by round nuclei and smooth nuclear membranes Fig. 7.12 Rhabdomyosarcoma (CP). Spindle/strap cells with cytoplasmic cross striations are an indication of skeletal muscle differentiation. Some bizarre-shaped cells are present in the back- ground. Nuclei may vary from oval to elongated and display membrane irregularity and coarsely granular chromatin Fig. 7.13 Metastatic gastric carcinoma (CP). A small cluster of cells with malignant nuclear features displays the "cell in cell" arrangement often seen in gastric carcinoma. A cytoplasmic vacuole is present in one of the single cells. The background is free of tumor diathesis, a feature that favors metastatic rather than a primary origin of the tumor Fig. 7.14 Metastatic colon carcinoma (CP). A group of tall columnar glandular cells demonstrates nuclear pleomorphism, hyperchromasia, cellular overlap, and loss of polarity within the cell group. These morpho- logic features would lead to an interpretation of malignancy. The columnar cell shape, palisading cigar- shaped nuclei, and scattered goblet cells containing distended mucin-filled vacuoles seen in this image are distinctive morphologic features of colonic adenocarcinoma, as is "dirty necrosis" (not shown here) Fig. 7.15 Metastatic colon cancer (LBP, ThinPrep). A cluster of malignant cells from metastatic colon carcinoma shows tall columnar cells with elongated nuclei at the upper edge and a glandular lumen in the center. Goblet cells are not identified in this group, and a mild degree of degeneration is noted. A fragment of normal colonic epithelium is shown in the lower right inset for comparison with the tumor cells in this figure and Fig. 7.14 Fig. 7.16 (a, b) Metastatic breast carcinoma. Clusters of small cells with scant to moderate amounts of vacuolated cytoplasm, including an intracytoplasmic lumen, show a cell within cell arrangement similar to gastric carcinoma. Nuclei are round with minimal variation in size (a left, LBP, SurePath). A single file of small monotonous cells with scant cytoplasm, round nuclei, and prominent nucleoli is a feature that is highly suggestive of breast carcinoma (b right, CP) Fig. 7.17 Ovarian carcinoma. Papillary clusters with scalloped border consisting of large over- lapping cells with round nuclei, prominent nucleoli, and moderate amounts of cytoplasm showing eccentrically placed vacuoles (a left, CP). Similar papillary clusters comprise cells with enlarged nuclei with finely granular chromatin and prominent nucleoli. Occasional psammoma bodies are seen in ovarian carcinoma (b right, LBP, Thin Prep) Fig. 7.18 Urothelial carcinoma (LBP, ThinPrep). Small clusters and single cells with markedly atypical nuclei showing hyperchromasia, nuclear irregularity and prominent nucleoli, and dense cytoplasm have cytologic features overlapping with squamous metaplastic cells and high-grade squamous intraepithelial lesion. Identification of racket-shaped or cercariform cells in the presence of a history of an urothelial primary can contribute to making the correct interpretation Fig. 7.19 Malignant melanoma. Dispersed and loosely cohesive large cells have a moderate amount of cytoplasm, round nuclei, irregular nuclear membranes, coarsely clumped, irregularly distributed chromatin, and prominent nucleoli (a left, CP). Cytoplasmic pigment consistent with melanin is a helpful finding but is not always present (b, c left lower inset panels) Mostly single cells, some binucleated, with scant to moderate amounts of dense, well-defined cytoplasm. Nuclei are round with prominent nucleoli (d right, SurePath) Fig. 7.20 Malignant spindle cell melanoma (LBP, ThinPrep). Clusters of spindle-shaped cells with elongated atypical pleomorphic nuclei and irregular chromatin that can mimic a sarcoma, such as stromal sarcoma, or a spindle cell carcinoma. The presence of an intranuclear pseudoinclusion in the inset provides a clue to the correct interpretation which can be confirmed by immunocytochemistry Fig. 7.21 Malignant non-Hodgkin lymphoma. A monotonous population of lymphoid cells with scant cytoplasm forms loose groups. The absence of tingible body macrophages and lack of a range of maturation of the lymphocytes, which are seen in chronic follicular cervicitis, should raise the possibility of a malignant lymphoma (a right, CP; b left, LBP, SurePath) ■■■【8】Anal cytology Fig. 8.1 Satisfactory specimen, negative for intraepithelial lesion (NILM) (LBP, SurePath). Benign intermediate type squamous cells, squamous metaplasia, and rectal columnar cells are present Fig. 8.2 Negative for intraepithelial lesion (LBP, ThinPrep). Several round squamous metaplastic cells with dense cytoplasm are present Fig. 8.3 Negative for intraepithelial lesion (LBP, ThinPrep). Benign squamous cells and anucleated squames. Nuclear karyorrhexis is present Fig. 8.4 Unsatisfactory specimen (conventional preparation). Particularly on conventional anal smears, bacteria and fecal material can predominate and obscure cellular detail Fig. 8.5 Unsatisfactory specimen (LBP, ThinPrep). Anucleated squames only. On ThinPrep anal cytology, an average of 1-2 nucleated squamous cells per high-power field are needed for adequacy Fig. 8.6 Squamous cells with reactive nuclear changes including nuclear enlargement, hypochromasia, and nucleoli. Other cells have narrow perinuclear halos Fig. 8.7 Candida (LBP, ThinPrep). Fungal pseudohyphae are squamous cells threading through the cluster of Fig. 8.8 HSV (LBP, SurePath). Molded nuclei with "ground-glass" appearance are present Fig. 8.9 (a) Numerous amebic cysts are present (LBP, ThinPrep). Internal structure and refractile cyst wall help differentiate ameba from HSIL. (b) Macrophages (LBP, ThinPrep) may be seen on anal cytology, particularly after ablative treatment and need to be distinguished from ameba. Note the cytoplasmic cellular debris Fig. 8.10 Pinworm eggs (LBP, ThinPrep) Fig. 8.11 ASC-US (LBP, ThinPrep). Atypical squamous cells with enlarged but smooth nuclear contours with smudgy chromatin and narrow perinuclear clearing. One cell is binucleated Fig. 8.12 ASC-H (LBP, ThinPrep). Small immature squamous metaplastic cells with dark but smudgy nuclear chromatin Fig. 8.13 LSIL (LBP, ThinPrep). Criteria for interpretation of SIL are similar to cervical specimens Fig. 8.14 LSIL with karyorrhectic nuclei (LBP, SurePath) Fig. 8.15 HSIL (LBP, ThinPrep). Hyperchromatic group with altered chromatin pattern and irregular nuclear contours Fig. 8.16 HSIL (LBP, SurePath). Dysplastic cells with metaplastic cytoplasm and irregular nuclear contours Fig. 8.17 HSIL (LBP, ThinPrep). High-grade keratinizing dysplasia Fig. 8.18 Both HSIL and LSIL are present in this figure (LBP, ThinPrep). Note the cytoplasmic keratinization, a feature that is often more prominent in squamous lesions of the anal canal than in cervical lesions Fig. 8.19 HSIL (LBP, ThinPrep). Loose cluster of cells with dysplastic nuclei. Several nuclei have distinct nucleoli raising the possibility of an invasive process Fig. 8.20 SCC, keratinizing (LBP, ThinPrep). Marked pleomorphism of cell size and shape. Two tumor cells show cytoplasmic keratinization Fig. 8.21 Squamous cell carcinoma, nonkeratinizing. Pleomorphic cell cluster (LBP, ThinPrep). Some tumor cells have prominent nucleoli. A tumor diathesis is not prominent in this field Fig. 8.22 SCC with "clinging" diathesis (LBP, ThinPrep) Fig. 8.23 Rectal adenocarcinoma (LBP, ThinPrep). Malignant cells have vesicular nuclei with prominent nucleoli and finely vacuolated cytoplasm. This is a recurrence of a rectal adenocarcinoma ■■■【9】Adjunctive testing Fig. 9.1 An example of cells from a high-grade squamous intraepithelial lesion from the same specimen: (a) Papanicolaou stain; (b) p16 immunocytochemical stain showing both nuclear and cytoplasmic staining. The presence of p16-positive cells is predictive of a precancerous lesion and may be useful in the screening and triage of cytologic specimens. (LBP, SurePath) Fig. 9.2 An immunocytochemical stain for p16 and Ki67 performed together on the same slide (dual stain): p16 stains both the cytoplasm and nucleus (brown), and Ki67 stains the nucleus (red). Cells that show combined staining are a strong predictor of the presence of a high-grade squamous intraepithelial lesion. (LBP, ThinPrep)
