Specimen adequacy (mandatory) : Satisfactory Adequate number of well visualized or preserved squamous or squamous metaplastic cells Conventional smear: minimum of 8,000 to 12,000 cells Liquid based preparation: minimum of 5,000 cells Woman's postchemotherapy, radiotherapy, postmenopausal, atrophic changes or posthysterectomy may have < 5,000 cells and be deemed adequate at laboratory's discretion (if > 2,000 cells) Exception: adequate if any abnormal cells are present : Unsatisfactory > 75% of cells obscured by inflammation, bacteria or interfering substances (lubricants and blood) . Glacial acetic acid treatment may be applied to liquid based collections that are inadequate based on the Bethesda system to facilitate the removal of mucus, erythrocytes, inflammatory cells and debris . If 50 - 75% of cells are obscured, include a disclaimer describing how they are obscured and the percentage of cells obscured Normal cells :Superficial cells Cytoplasm is polygonal, transparent, eosinophilic Nucleus is pyknotic, round/oval =========================== :Intermediate cells Cytoplasm is polygonal, transparent, basophil Nucleus is about the size of a red blood cell and vesicul round/oval Nuclear texture and size is reference for dysplasia to compare ================================ :Parabasal cells Cytoplasm is round, dense, basophilic Nucleus is vesicular, central, round and relatively large May see naked nuclei Higher N/C ratio and smaller size than intermediate cells ============================== : Navicular cells have folded edges, with a thickened outer rim of cytoplasm and an eccentric nucleus. They contain abundant glycogen in the cytoplasm, giving it a central yellow halo ============================ : Endocervical cells Columnar cells with granular cytoplasm.Prominent cell borders Basal nuclei with fine chromatin.Honeycomb appearance ========================== : Endometrial cells 3dimensional appearance(compare endocervical cells), highN/C ratio, chromatin coarse but evenly distributed Infections : Lactobacillus Lactobacilli are blue thick rods usually found on the top of the intermediate squamous cells.They can lyse glycogen rich intermediate cells which may cause cytolysis Cytolysis is characterized by bare normal size intermediate cell nuclei, fragments of squamous cytoplasm and abundant bacterial rods .Abundant cytolysis (> 50%) may be mentioned as quality indicator in Bethesda system but the specimen should not be regarded as unsatisfactory ======================== : Bacterial vaginosis Clue cells are squamous cells covered by coccobacilli with extension to the cell edges (velvety coat or shaggy appearance) .The entire cell does not need to be covered Lactobacilli and inflammatory cells are absent, unless there is another infectious process.The small coccobacilli form a granular blue background (sandy background) on conventional smears In liquid based cytology, the background is cleaner than with conventional smears =========================== : Candida Candida albicans: pseudohyphae and yeasts; reactive squamous epithelial cells in the form of "shish kebab" Geotrichum: arthroconidia Candida glabarata: only yeast forms, no pseudohyphae ========================= : Leptothrix Long, thin, segmented, filamentous structures with occasional branching .May form loops more frequently in conventional smears • Tend to form clumps in liquid based cytology preparations, as opposed to conventional smears.Frequently noticed with coexistent Trichomonas vaginalis infections .Rarely observed with Döderlein bacillus infection.Trichomonas and Leptothrix together have been referred to as spaghetti and meatballs appearance =============================== : Trichomonas Organism is a 15-30 μm, pear shaped protozoan Nucleus is small, very pale, eccentrically placed.Cytoplasm often contains tiny red granules. Clusters of the organisms are colloquially called trich parties Sometimes accompanied by Leptothrix, nonpathogenic, longe filamentous bacterium ================== : Acttinomyces Aggregates of pseudofilamentous material, often with acute angle branching .May have wooly appearance; periphery may contain swollen filaments with clubs ============================= : HSV Multinucleated giant cells with ground glass nuclei due to intranuclear virus ========================== : CMV Involvement of glandular and squamous cells • Cellular enlargement, nuclear enlargement and large nuclear inclusion surrounded by a halo "owl's eye" Occasionally smaller nuclear or cytoplasmic inclusions ======================= : Chlamydia Involvement of endocervical cells or metaplastic cells but not mature squamous cells.Granular cytoplasm with multiple intracytoplasmic inclusions with central small coccoid bodies.Targetoid inclusion within large intracytoplasmic vacuole."Nebular bodies" are more specific, but are difficult to differentiate from intracytoplasmic mucin vacuoles .Marked acute inflammatiin and lymphocytic cervicitis is seen Reactive cellular changes : Inflammation PMNs in acute cervicitis .Lymphocytes of varying stages of maturation with tingible body macrophages in chronic (follicular) cervicitis ====================== : Repair Flat monolayer sheets of squamous cells with distinct cytoplasmic outlines, enlarged uniformly rounded nuclei, streaming nuclear polarity,prominent nucleoli in almost every cell ====================== : Atrophy Sheets of uniform orderly parabasal cells. Some nuclei may show grooves, but chromatin pattern is fine. Atrophic cells may have nucleoli Blue blobs appear in atrophic smear in postmenopausal women due to the lack of mucus and stagnation of exfoliated cells, which are then further degenerated. Disintegration of chromatin results in the characteristic dense cyanophilic appearance of blue blobs (reminiscent of trichomonas) and they eventually become granular background ========================== : Metaplasia Squamous metaplasia small squamous cells with cytoplasmic projections. regular nuclear outlines with fine chromatin pattern.dens refractile cyanophilic cytoplasm Tubal metaplasia columnar cells with ciliated cytoplasmic border and round basal nuclei and acidophilic cytoplasm ========================= : IUD changes Small clusters of hypersecretory endocervical cells with abundant cytoplasm, large cytoplasmic vacuoles (bubblegum cytoplasm), and distinct cell borders. Actinomycotic colonies and calcified debris may be observed ============================== : Pregnancy changes -decidual: abundant eosiophilic cytoplasm with occasional vacuolizaion and enlarged round nuclei with prominent nucleoli arias stella: like decidual cells with enlarged pleomorphic nuclei and irregular nuclear contour trophoblasric: like decidual cells with enlarged multinucleated nuclei ========================== : Post hysterectomy changes Vaginal adenosis (usually causes adenosis in vagina, not cervix) has been identified in vaginal smears of post- hysterectomy patients also associated with intrauterine DES exposure.Single or syncytial glandular cells with delicate cytoplasm, and intracytoplasmic mucin (goblet cell metaplasia) =============================== : Keratotic changes Hyperkeratosis single or sheets of anucleated squamous superficial cells Parakeratosis single or sheets of small squamous superficial cells with dens orangophilic cytoplasm and small piknotic nuclei Similar to hyperkeratosis, parakeratosis represents a reactive surface process due to chronic irritation, but may be seen with cervical dysplasia Persistence of parakeratosis without a known etiology may warrant further investigation to exclude an associated LSIL =================================== : Radiation effect Marked concomitant nuclear and cytoplasmic enlargement, with normal N/C ratio. Degenerative changes, such as nuclear and cytoplasmic vacuoles, prominent nucleoli, multinucleation, bizarre shapes and cloudy polychromatic cytoplasm are also encountered Dysplastic cellular changes : ASCUS Cells that classified as ASCUS typically have the size and shape of superficial or intermediate squamous cells also repair changes keratotic changes and metaplastic changes :Diagnostic criteria :Incomplete koilocytosis Nuclear changes : Size of nuclei approximately 2.5-3.0x the area of the nucleus of a normal intermediate squamous cell . or 2.0x the size of a metaplastic squamous cell nucleus Low N/C ratio.minimal hyperchrimasia Cytoplasmic changes : suggestive of HPV cytopathic effect , such as ill defined cytoplasmic halos or cytoplasmic vacuoles resembling koilocytes but without or with minimal nuclear changes :Other patterns Atypical parakeratosis: cells with dense orangeophilic cytoplasm with some degree of nuclear atypia or arranged in 3 dimensional clusters Atypical repair: reparative changes with some degree of cytology atypia, including cellular overlap, dyscohesion, anisonucleosis Atypical metaplasia: squamous metaplasia with some nuclear enlargement and hyperchromasia ============================= LSIL :Diagnostic criteria Complete koilocytosis Nuclear changes (LSIL) :Nuclear enlargement > 3x the area of normal intermediate nuclei low N/C ratio, generally hyperchromasia other nuclear changes: raising like, binucleation Cytoplasmic changes (HPV charactetstic effects) Broad, sharply demarkerd clear perinuclear zone and a peripheral rim of densely stained cytoplasm Other cytoplasmic changes : finely granules and kerathyalin globules :Other patterns Keratotic changes: hyperkeratosis , parakeratosis and atypical parakeratosis(dyskeratosis) ============================ ASC-H Nuclear enlargement 2-3 times with high N/C ratio, hyperchromasia and pleomorphism (small HSILs) usually seen in single cells or small groups(<10cells) =========================== HSIL Nuclear enlargement more than 3 times with high N/C ratio, hyperchromasia and pleomorphism =========================== : AGC Cells occur in crowded sheets with some irregularity pattern and disorganized oriented cells. Nuclear hyperchromasia ,enlargement increased N:C ratio and anisonucleosis ============================== : AIS Smaller sheets of cells ,Peripheral feathering ,peripheral palisading ,Rosette-likes tructure , Strips,Torn glands structures,buldging out of group Nuclear pleolorphism and elongation .
