Tadrous P.J. Diagnostic criteria handbook in histopathology: a surgical pathology vade mecum

Подождите немного. Документ загружается.

PIC

JWBK208-23 December 8, 2007 21:30 Char Count= 0

Infection and Immunity 349

d/dg Toxoplasma, Histoplasma: these lack a kinetoplast (also, EM is diagnostic)

d/dg TB: apart from ZN, PCR on ﬁxed/fresh tissue can be done for Leishmania and TB

d/dg Trypanosoma cruzi amastigotes form similar double-dots when they multiply within smooth

muscle, cardiac muscle, M or ganglion cells during Chagas’ disease (best seen in early stages)

Metazoa

Enterobius vermicularis (Pinworm/Threadworm/Oxyuriasis)

Adult worms have two longitudinal lateral pointy alae (wings)

The eggs are ovoid, have a bilayered shell and are slightly ﬂatter on one side

Usually intralumenal (in the GIT) and not a cause of appendicitis or other GI inﬂammation

May cause intra-abdominal granulomas in women (via the genital tract) or genital tract inﬂam

Other sites rare and via an intra-lumenal route (e.g. to prostate) – never pathological tissue invasion

Schistosoma spp.

Clin.: rash, diarrhoea, weight loss, portal HT et seq., haematuria, obstructive uropathy, renal failure

Eggs hatch in fresh water →ciliated miracidia →multiply in snail →fork-tailed cercariae →penetrate

human skin (and loose tail = schistosomulae) → lung/liver (mature into adult trematodes) → settle in

veins (thinner, darker-staining female within gynaecophoral groove of male) → eggs

Symmers clay pipestem ﬁbrosis of liver (PT ﬁbrosis, dilated PT arterial branches, collapse of PT veins

but no nodular cirrhosis), cirrhosis, varices, mass lesions (e.g. colonic pseudopolyps, bladder polyps,

cystitis cystica calcinosa, ﬁbrous plaques), immune complex mediated (e.g. mesangioproliferative GN)

and cancers (e.g. SCC bladder)

150 × 80 eggs are seen in the gut/bladder/liver/lung/genitals ± ‘ectopic’ sites e.g. LN/CNS

ZN +ve shell and spine (lateral in S. mansoni, lateral but small/invisible in S. japonicum)

ZN +ve spine only (terminal in S. haematobium)[NB: ‘Bilharzia’ = urinary haematobium infection]

The egg shell is often buckled after ﬁxation and an internal ‘horseshoe’/‘ring’ of nuclei is characteristic

(but only seen if cut in the right plane – otherwise there will just be a central mass of nuclei)

Viable eggs have well-preserved nuclei and lie in cellular granulomas ± eos./ Splendore-Hoeppli

Dead eggs show variable involution ± fragmentation of the shell/Ca

and the granulomas become

less cellular to form ﬁbrous foci (but live eggs may be present elsewhere .

. use CPC, smears, etc.)

Granulomas without eggs may have (Perls −ve) schistosome pigment ± eos. → do levels

d/dg eggs of Enterobius or ﬂukes are much smaller and lack schistosomal horseshoe string of nuclei

Sarcoptes scabii (Scabies)

May see eosinophil-containing chronic inﬂam

in the dermis but must see ≥1 of the following for

diagnosis

Egg-shells or eggs (containing larvae) or faecal fragments } all are present in the stratum corneum

Adult mite (female) – seen at the end of the burrow in the stratum Malpighii (has an ≈ round body)

Larva Migrans (Toxocara canis, Toxocara cati, etc.)

Baylisascaris (70

 ×1600 long) has large

(8) alae, triangular excretory columns &

ovoid intestine (central, laterally compressed

& multicellular with prominent granules)

Toxocara (18

 ×400 long) has small (1)

alae, ovoid excretory columns & triangular

intestine (dorsal/laterally displaced & unicel-

lular with nucleus at anterior, pointy, end of

worm)

intestine

lateral

ala

excretory

column

canaliculus

BAYLISASCARIS

TOXOCARA

nucleus

FIGURE 23.1 Larva migrans.

Clin.: visceral and ocular larva migrans rarely overlap (cutaneous and neural forms also occur)

Ocular form may infect retina, choroid +/ vitreous, may form a mass and shows variable amounts of

eosinophils (even abscesses), granulomatous inﬂam

and ﬁbrosis ± Splendore-Hoeppli reaction

For morphology see Figure 23.1 (Baylisascaris occurs mainly in North America)

d/dg ﬁlariform larvae of Strongyloides (difﬁcult unless good transverse sections are present)

d/dg clinically, retinal lesions may be misdiagnosed as retinoblastoma → unnecessary enucleation

PIC

JWBK208-23 December 8, 2007 21:30 Char Count= 0

Infection and Immunity 350

Cysticercosis (Pork Tapeworm, Taenia soleum, Cysticercus cellulosae)

Poorly cooked pork with cysticerca is eaten →cysticerca evert and attach to jejunum → grow to adult

tapeworm and release proglottid segments bearing eggs into faeces → faecoral egg ingestion → eggs

release oncospheres that burrow into tissues to form cysticerca (muscle, eye, brain, soft tissues)

Cysticercal cyst: a couple of cm in  with one scolex (with hooklets and four suckers)

Cyst wall has a loose stroma (± small calcispherules) and cellular serrated lining with microvilli

NB: Beef tapeworm (taenia saginata) is rare nowadays and rarely causes cysticercal disease in man

Hydatid Disease (Echinococcus spp., e.g. E. granulosus)

Tape worm in dog → eggs in dog faeces → contaminated vegetation is eaten by man/sheep → eggs

hatch in GIT → resulting oncospheres lodge in tissues → cysts

Cysts may form in many tissues (liver, lung, brain, soft tissues, etc.) with an outer ﬁbrous reaction

Cyst wall is 1 mm thick, acellular and lamellated with a simple inner lining of cells (= germinal layer)

Scolices may be seen in the cysts (they have suckers and rows of ZN +ve hooklets)

Strongyloides stercoralis

Filariform larvae penetrate skin → lungs via lymphatics → mature, migrate up and swallowed →

females anchor in proximal SI (males shed into lumen after mating) → eggs containing rhabdatidiform

larvae in mucosa → hatch into lumen → passed PR → moult in soil to become ﬁlariform larvae

Autoinfection: a few rhabdatidiform larvae moult in the gut → ﬁlariform larvae penetrate gut wall

Immunosuppression (e.g. steroids, AIDS, HTLV-1): many larvae become ﬁlariform →penetrate the gut

(and carry bacteria with them) → hyperinfection/superinfection (= larva migrans, multiorgan disease,

systemic Sx ± septicaemia)

Range of GI inﬂam

: none; submucosal PMN and ↑ surface mucin (catarrhal enteritis); submucosal

oedema with variable ﬁbrosis (oedematous enteritis); severe inﬂam

with much oedema and ﬁbrosis

(ulcerative enteritis) and may affect the colon to mimic UC (clinically and endoscopically)

Adult female: 30–90 , contains a GI tract and paired ovaries (± eggs)

Rhabdatidiform larva: 25 , one end blunt and one pointy, bulbous oesophagus, thin intestine

Filariform larva: 15 , speckled body, thin intestine, 4 lateral alae (a useful feature for diagnosis but

may be hard to see on routine histology preparations)

Some Immunological Disorders

Hypersensitivity (Types I–V)

I Immediate/Anaphylactic/Atopic: mast cells/basophils coated with Ab generated in 1

◦

response have

their receptors cross-liked on exposure to Ag → degranulation → histamine, etc.

II Cytotoxic Ab Mediated: Ag binds to Ab on surface of cells but instead of cross-linkage of receptors and

degranulation as occurs in type I, it causes destruction of the cells coated with Ag by antibody-directed

cell cytotoxicity, binding and activation of complement or opsonic phagocytosis. Examples incl. Rhesus

D isoimmune haemolytic anaemia and homograft Tx rejection (hyperacute and acute)

III Immune Complex Mediated: persistent Ag (chronic infection, autoimmunity, environmental Ag) com-

bines with Ab either circulating (serum sickness) or in situ (e.g. Arthus reaction in skin or GN in kidney)

resulting in complement activation and inﬂammation.

IV Cell Mediated Delayed Hypersensitivity: due to cell mediated immunity e.g. chronic Tx rejection,

reaction to TB

V Stimulatory/Inhibitory Ab Mediated: e.g. Graves’ disease, Myasthenia gravis

Cryoglobulins and Cryoglobulinaemia

Clin.: ischaemia, Raynaud’s phenomenon, vasculitis, GN, ± HCV

Type I (monoclonal IgM) e.g. Waldenstr¨om/myeloma

Type II ‘Mixed’ (monoclonal IgM rheumatoid factor) e.g. Waldenstr¨om/myeloma/CLL

Type III ‘Mixed’ (polyclonal IgM rheumatoid factor) e.g. RhA, SLE, PAN

‘Mixed’ indicates that there are two types of immunoglobulin involved (viz. IgM and IgG)

>90% of mixed cryoglobulinaemia cases have HCV (50% of HCV cases have cryoglobulinaemia)

PIC

JWBK208-23 December 8, 2007 21:30 Char Count= 0

Infection and Immunity 351

Common Variable Immunodeﬁciency (CVID)

Usu. sporadic (late onset), some are familial (early onset)

B-cells can’t mature to plasma cells (and there is also T-cell dysfunction which may result in the

granulomatous form of CVID)

↓Serum IgG, IgA, ± IgM; ±↓CD4 count (! d/dg AIDS)

General features

Lack of plasma cells in tissues (esp. noticeable in the GIT MALT)

Lymphoid follicular hyperplasia

± Granulomas in many organs (d/dg Sarcoidosis, etc.)

↑ risk of NHL (incl. MALToma)

↑ risk of all types of infection e.g. Giardia, Cryptosporidia, viruses, Haemophilus inﬂuenzae, fungi

↑ risk of autoimmune disorders (e.g. AIH)

Speciﬁc organs

LN: follicular hyperplasia ± granulomas, ± NHL

Lung: LIP ± MALToma

Liver: viral hepatitis/AIH/granulomas

Kidney: mesangial and paramesangial immune complexes ± interstitial granulomas

GIT: nodular lymphoid hyperplasia, villous atrophy, Giardia, Cryptosporidia, CMV, Candida, granu-

lomas, etc., absence of plasma cells (see also pp. 142 and 148)

Antiphospholipid Antibody Syndrome (Anticardiolipin Antibody or Hughes’ Syndrome)

Def

: persistent antiphospholipid Abs + TMA/thrombocytopenia ± recurrent IUD

Due to a prothrombotic (in vivo) antiphospholipid Ab (e.g. anticardiolipin) that occur in SLE and other

conditions. These inhibit coagulation tests in vitro (so also called ‘lupus inhibitor’/‘lupus anticoagulant’)

and requires immunosuppression +/ anticoagulant cover (or may be self limited)

Non-thrombogenic antiphospholipid Abs (which .

. do not cause the syndrome) occur with many infec-

tions (incl. HCV, HIV, bacterial, etc.), drugs (incl. antibiotics and cocaine) and some normals

Pathology is that of a TMA (see pp. 61–62, p. 71 and p. 207)

d/dg the vasculitis of CTD/lupus (see p. 71)

d/dg clinically it may be misdiagnosed as MS

The Concept of Granuloma

Deﬁnition of granuloma: ‘chronic inﬂammation in the form of a mass’ was the original deﬁnition.

Some modern student texts prefer ‘a collection of epithelioid histiocytes’.

However, the following terminologies only make sense in the light of the original deﬁnition (although

some are now known to be neoplastic): pyogenic granuloma, foreign body granuloma, xanthogranu-

loma (juvenile), eosinophil granuloma (HX), nodular paragranuloma, plasma cell granuloma, D¨urck’s

granuloma, etc.

Furthermore, diffuse epithelioid granulomatous inﬂammation (= swathes of epithelioid histiocytes), not

being a tight collection, may be underdiagnosed by those adhering to the simplistic student-deﬁnition

of ‘granuloma’

Bibliography

Allason-Jones, E. (1987) The Gay Bowel Syndrome. British Journal of Hospital Medicine, 38 (5), 397.

Chandler, F. and Watts, C. (1987) Pathologic Diagnosis of Fungal Infections,1

edn, American Society of Clinical Pathologists Press, Chicago.

Chapel, H. and Haeney, M. (1988) Essentials of Clinical Immunology,2

edn, Blackwell Scientific Publications, Oxford.

Connor, D.H., Chandler, F.W., Schwartz, D.A. et al. (eds) (1997) Pathology of Infectious Diseases,1

edn, Appleton & Lange, Stamford, Connecticut.

Cotran, R.S., Kumar, V. and Collins, T. (eds) (1999) Robbins Pathologic Basis of Disease,6

edn, W.B. Saunders Co., Philadelphia.

Duerden, B.I., Reid, T.M.S., Jewsbury, J.M. et al. (1987) A New Short Textbook of Medical Microbiology,1

edn, Edward Arnold (Hodder &

Stoughton), London.

Eapen, M., Mathew, C.F. and Aravindan, K.P. (2005) Evidence based criteria for the histopathological diagnosis of toxoplasmic lymphadenopathy.

Journal of Clinical Pathology, 58 (11), 1143–1146.

Goedert, J.J., Cot´e, T.R., Virgo, P. et al. (1998) Spectrum of AIDS-associated malignant disorders. The Lancet, 351 (9119), 1833–1839.

Gotuzzo, E., Terashima, A., Alvarez, H. et al. (1999) Strongyloides stercoralis hyperinfection associated with human T cell lymphotrophic virus type

1 infection in Peru. American Journal of Tropical Medicine and Hygeine, 60 (1), 146–149.

Hale, M.J. (2000) Mycobacterial infection: a histopathological chameleon. Current Diagnostic Pathology, 6 (2), 93–102.

Harada, M., Fujisawa, Y., Sakisaka, S. et al. (2000) High prevalence of anticardiolipin antibodies in hepatitis C virus infection: lack of effects on

thrombocytopaenia and thrombotic complications. Journal of Gastroenterology, 35 (4), 272–277.

PIC

JWBK208-23 December 8, 2007 21:30 Char Count= 0

Infection and Immunity 352

Jannotta, F.S. and Sideway, M.K. (1989) The recognition of mycobacterial infections by intraoperative cytology in patients with acquired immunod-

eficiency syndrome. Archives of Pathological Laboratory Medicine, 113 (10), 1120–1123.

Lucas, S. (2000) Update on the pathology of AIDS. Current Diagnostic Pathology, 6 (2), 103–112.

Mount, S.L. and Cooper, K. (2001) Beware of biotin: a source of false positive immunohistochemistry. Current Diagnostic Pathology, 7 (3), 161–167.

Niedobitek, G. and Young, L.S. (1995) Epstein-Barr virus and lymphomas: an overview, in Progress in Pathology, Vol. 2 (eds N. Kirkham and N.R.

Lemoine), Churchill Livingstone, Edinburgh, pp. 247–264.

Peters, W. and Gilles, H.M. (1989) A Colour Atlas of Tropical Medicine & Parasitology, 3

edn, Wolfe Medical publications, Ltd., London.

Pritt, B., Mount, S.L., Cooper, K. et al. (2006) Pseudoactinomycotic radiate granules of the gynaecological tract: a review of a diagnostic pitfall.

Journal of Clinical Pathology, 59 (1), 17–20.

Roitt, I. (1988) Essential Immunology,6

edn, Blackwell Scientific Publications, Oxford.

Spencer, H. et al. (1973) Tropical Pathology,1

edn, Springer−verlag, Berlin.

Youngberg, G.A., Wallen, E.D.B. and Giorgadze, T.A. (2003) Narrow-Spectrum Histochemical Staining of Fungi. Archives of Pathology and

Laboratory Medicine, 127 (11), 1529–1530.

Winn Jr., W.C. (2000) Demonstration of infectious agents in tissues. Current Diagnostic Pathology, 6 (2), 84–92.

JWBK208-24 December 8, 2007 15:53 Char Count= 0

Cytopathology 353

24. Cytopathology

Cervix Uteri

Sampling

◦

cervical scrape with Ayre spatula (best single method) combined, these detect 98%

◦

endocervical scrape with brush/pointed spatula of all neoplasia



◦

upper

vaginal wall scrape (to assess hormonal response – it is more sensitive cf. cervix)

◦

vaginal vault smear (for follow up of patients who have had the cervix removed)

Staining

Papanicolaou: Harris haematoxylin, Orange G6, EA50 ( = eosin solution with light green)

Allows you to see through mucin (which stains a pale peach/apricot/grey colour)

Immature cytoplasmic keratin stains delicate pink but depends on pH and ﬁxation .

. nuclear morphology

is more reliable for diagnosis

Mature keratin stains orange yellow due to the formation of eosin dimers and has a coarse refractile

quality in SCC

Assessing a Cervical Smear

Adequacy

A smear is always adequate if abnormal cells are seen. If sparse dyskaryotic cells are present then call

it ‘dyskaryosis difﬁcult to grade’. If no abnormal cells are present then consider the following:

Report as inadequate if you are told that the cervix was not completely visualised or if an inappropriate

method was used (‘ﬁnger smear’, etc.)

Cellularity: inadequate if squamous cells cover <

of the slide when evenly spread (except in atrophic

hormonal states when other factors should be used to judge adequacy)

Vaginal smears are inadequate (entirely composed of separated superﬁcial cells)

Endocervical smear: inadequate if entirely composed of endocervical cells unless the object of the test

was to sample the endocervical mucosa

Visual obfuscation: poor ﬁxation/air-drying, thickly spread, cornﬂakes ++, blood, debris, PMN

(→ infective cause should be sought [e.g. Trichomonas, HSV, Candida] and advise repeat after Rx)

Quality

Transparent well-stained cytoplasm (not pale)

Good nuclear morphology

Evenly spread, well ﬁxed and lack of air-drying

Cell content

Squamous/glandular/blood/inﬂammatory/sperm/seminiferous tubule epithelium

Microbes/artefacts/unusual tumour cells

Atrophic cells (? postpartum/postmenopause)

Normal Smear Cytology

‘Superﬁcial cells’

Cytoplasm: 45–50 , polygonal (angular), transparent

Nuclear: small, pyknotic ± karyorrhectic

Other: dissociated cells but nests (squamous pearls) may also be seen

‘Intermediate cells’

Cytoplasm: 35–40 , less angular, denser cyanophil, folds

Nuclear: 8, clearly deﬁned chromatin network (chromocentres, Barr body)

Other: tend to clump

‘Parabasal cells’

Cytoplasm: 15–30 , rounded/ragged/disintegrated, dense cyanophil (unless air-dried)

Nuclear:

of cytoplasmic , granular and occ. chromocentres. Some are pyknotic ± karyorrhectic

Other: seen postpartum, postmenopause and during regeneration

Diagnostic Criteria Handbook in Histopathology: A Surgical Pathology Vade Mecum. Paul J. Tadrous



2007 by John Wiley & Sons, Ltd. ISBN: 978-0-470-51903-5

JWBK208-24 December 8, 2007 15:53 Char Count= 0

Cytopathology 354

Metaplastic cells

May be confused with parabasal cells but can be distinguished by:

a) the company they keep = superﬁcial and intermediate cells

b) cytoplasmic vacuolation

c) angular/pointy processes

Hyperplastic reserve cells

Bare nuclei forms are common

Resemble glandular cells in shape but have more solid cytoplasm

Form supercrowded groups (lack architectural features of glandular neoplasia)

Endocervical columnar cells

Prone to degenerative changes

Honeycomb/palisaded sheets or single cells or ciliated tufts

Tall delicate cytoplasm ± vacuoles and basal nuclei

Reserve cell bare nuclei may be present

Endocervical mucus ± mid-cycle ferning

Endometrial cells

Normal for the ﬁrst 10–12 days of the cycle and seen with: IUCD, COC, HRT

Cytoplasm: 5–20 , cyanophil, delicate

Nuclear: round, chromatin coarse but not clearly visible (because they are partly degenerate)

Other: berry-like clusters ± stromal core ( = ‘top hat’ formation)

Histiocytes

Found during the exodus or with IUCD

Cytoplasm: 15 , delicate, foamy/vacuolated

Nuclear: round/oval/bean-shaped

Other: multinucleate forms are non-speciﬁc esp. postmenopause

Flora

D¨oderlein bacilli (lactobacilli)

Candida albicans

Gardnerella vaginalis (overgrowth covers cell → ‘clue cell’ of bacterial vaginosis)

Contaminants

Spermatozoa and male epithelial cells, RBC, PMN

Pregnancy

Intermediate cells: navicular (boat-shaped, thick borders, eccentric nucleus, brown glycogen)

Cytolysis

D¨oderlein bacilli ++

Endocervical cells ++ (due to ectropion), nuclei may have nipple-like projections

Postpartum

Glycogen-laden parabasal cells and intermediate cells

Postmenopausal

Parabasal cells ± karyorrhexis

Blue blobs (dense basophil mucus plugs which vary in size and lack structure)

Air-drying and paucicellularity, fragile cytoplasm and PMN

Multinucleated cells

HPV Changes

Koilocytes: vacuole is large (cf. post inﬂam

halo), empty and hard-edged (cf. glycogen vacuole)

Nuclear abnormalities: should be present – borderline at least

Multinucleation (also seen in inﬂam

and HSV but the latter has ground glass nuclei)

Dyskeratosis: single and in groups (cones/rafts/whorls)

Borderline Nuclear Changes in Cervical Smears (National Cancer Network, BSCC and RCPath, 1994)

Borderline = ‘genuine doubt as to whether neoplastic or not’ and usu. occurs in three settings:

◦

In HPV changes

i) less than overt dyskaryosis in koilocytes (NB: this criterion will be superseded if the 2002 BSCC Ter-

minology is accepted and all HPV-type koilocytic changes are lumped together with mild dyskaryosis

as ‘Low grade squamous dyskaryosis’)

ii)

Variable nuclear enlargement

↑ NCR in dyskeratotic clusters forming cones, rafts or whorls

Condensed chromatin



JWBK208-24 December 8, 2007 15:53 Char Count= 0

Cytopathology 355

If dyskaryosis is present, report grade of dyskaryosis regardless of HPV cytoplasmic changes.

◦

In inﬂammatory changes

These must include epithelial changes (not just PMN) and must be called ‘negative’ unless there is

heavy Trichomonas infection on F/U for dyskaryosis

i) Squamous metaplastic cells:

Nuclear enlargement with normal NCR

Minor variations in size and shape

Smooth, well-deﬁned nuclear membrane

Pyknosis/karyorrhexis

Bi/multinucleation

⎫

⎪

⎬

⎪

⎭

inﬂammatory changes

Speckled, evenly-distributed chromatin and small round nucleoli

± Engulfed PMN (also seen in dyskaryosis)

Cytoplasmic rufﬂing/strands (‘spider cells’)

(Perinuclear halo in superﬁcial/intermediate cells)

↑ NCR, mild hyperchromasia, mild coarsening of chromatin



borderline

± Minimally irregular nuclear membrane changes

ii) Glandular metaplasias (Tuboendometrioid):

Small cells with ↑ NCR (very little cytoplasm) in crowded or supercrowded groups

Well-deﬁned nuclear membrane

Dispersed, ﬁnely-granular chromatin

No rosettes, feathering or pseudostratiﬁcation

iii) Endocervical cells:

Atypical changes occur in inﬂammation, IUCD, polyps, MGH

Dyskaryosis:  the features are described in ‘Glandular Dyskaryosis’, pp. 356–357

 repeated observation of >1 of those features is required else = borderline

Inﬂammatory:  anisonucleosis with normal NCR and normal, well-deﬁned, contour (i.e. vari-

ation in sizes of whole cells – not just nuclei [= anisocytosis])

 ﬁnely granular chromatin

 prominent, multiple, regular nucleoli (vary in size from cell-to-cell)

 normal mitoses

 crisp, unilocular cytoplasmic vacuoles indenting nuclei (esp. seen with IUCD

– but ill-deﬁned, scalloped vacuoles overlying nuclei with irregular macronu-

cleoli suggests adenocarcinoma, esp. ovarian)

Borderline:  3D groups with disorderly arrangement

 irregular ‘grainy’ chromatin

⎫

⎪

⎬

⎪

⎭

in the absence of

 variable hyperchromasia [= anisochromasia] overt dyskaryosis

 irregularity of the nuclear membrane

◦

In the atrophic smear

For general features and causes see section on ‘Atrophy’, p. 358

In pregnancy previous dyskaryotic changes diminish/vanish and sampling error ↑(due to big ectropion)

. borderline changes are not taken as evidence of improvement if the F/U smear was taken during

pregnancy

Folate ↓ /Inﬂam

changes:  ↑nuclear size, normal NCR, anisocytosis, ﬁne chromatin, well-deﬁned

nuclear membrane

Dyskaryosis:  individual nuclear enlargement and ↑ NCR

 ill-deﬁned nuclear membrane

 crowded groups with nuclear overlapping/moulding/mitoses

Borderline:  orangeophil pattern, ↑ NCR, irregular but degenerate nuclei – unsure of dyskaryosis

Nucleoli

Are not a feature of squamous dyskaryosis

Prominent nucleoli are seen in invasive carcinoma

Irregular/pleomorphic/macro nucleoli are seen in glandular neoplasms

Identical monotonous nucleoli present in all cells in a group (i.e. a ‘clonal’ pattern) are also suspicious

of glandular neoplasia

JWBK208-24 December 8, 2007 15:53 Char Count= 0

Cytopathology 356

Small nucleoli are typical of normal glandular/metaplastic cells

Larger nucleoli with some size variation are typical of reactive glandular lesions

Dyskaryosis in Squamous Cells

↑ NCR (nuclear diameter of <

the cell diameter in mild, >

the cell diameter in severe)

Coarse, unevenly distributed chromatin

Irregularity of the nuclear membrane

Hyperchromasia (except pale cell dyskaryosis)

Dyskaryosis Difﬁcult to Grade

Scant cells/poor preservation (esp. in recurrent CIN after Rx) → Mx as for moderate dyskaryosis

In invasive SCC cells may be sparse/obscured by exudate

Differential Diagnosis/Pitfalls for Severe Dyskaryosis

Histiocytes (degenerate ones have dark granular chromatin and denser cytoplasm)

Follicular cervicitis (chromatin coarse but evenly clumped ± tingible body M)

Endometrial cells

Keratinised HPV

IUCD-irritated endometrial cells (rounded with dense cytoplasm and eosinophilic nucleolus ± multi-

nucleated with PMN and karyorrhectic debris in streaks of cervical mucus)

Adenocarcinoma/ASC (extracervical tumours usu. yield scant cells with a clean background)

False negatives: small/pale cell dyskaryosis, sparse keratinised dyskaryotic cells in atrophic smears,

solid microbiopsies of CIN 3, gland crypt involvement, moderately dyskaryotic groups confused for

endocervical cells

False positives: endometriosis/TEM, lower uterine segment endometrium

Small Cell Severe Dyskaryosis

Irregularly clumped chromatin (nuclear membrane may be smooth and nucleoli inconspicuous)

Some may show keratinisation

Presence of unequivocal lesser grades of dyskaryosis help to make the diagnosis

d/dg histiocytes, immature metaplastic or parabasal squames

Pale Dyskaryosis (any grade)

Irregularly clumped chromatin but no nuclear hyperchromasia (paler than PMN nuclei)

Solid Microbiopsies of CIN 3

Loss of polarity/chaotic architecture

Mitoses

Coarse chromatin and ↑NCR

Presence of scattered dyskaryotic cells elsewhere

If unsure, call it ‘borderline’ with immediate referral (i.e. ‘borderline, possibly high grade’)

CIN 2/3 Involving Gland Crypts

Groups of mod/severe dyskaryotic cells intimately assoc

with endocervical cells

Groups may have a regular border lined by endocervical cells

Groups do not have architectural features of glandular neoplasia

Moderate Dyskaryotic Groups confused for Endocervical cells

Squamous cells have central nuclei and more densely staining cytoplasm

Glandular Dyskaryosis (Result Code 6)

Crowded/supercrowded 3D groups

Feathering at the border (loss of cohesion with tapering cytoplasm)/rosettes/pseudostratiﬁcation

Elongated nuclei with ‘grainy’ chromatin, poorly-deﬁned nuclear membrane and anisonucleosis

Dyskaryosis may vary from cell to cell with some looking normal

Clonal pattern: regular arrangement with prominent red nucleoli, all the same size (reactive glandular

cells may have prominent nucleoli but these vary in size from cell to cell)

JWBK208-24 December 8, 2007 15:53 Char Count= 0

Cytopathology 357

Features suggesting invasion (i.e. ‘adenocarcinoma’ cf. ‘?glandular neoplasia’): malignant diathesis,

macronucleoli, chromatin ‘windowing’

Features suggesting extracervical origin: clean background, few groups, alternative architectures (e.g.

3D balls of vacuolated cells)

Atypical endometrial cells: larger than PMN and with clearly visible chromatin

Endometrial Carcinoma (Result Code 6)

Small cells in rounded/oval/papillary 3D clusters

Coarse cytoplasmic vacuoles, PMN engulfment, ‘signet-ring’ cells

Degenerate, necrotic cell debris

Epithelial ‘Repair’ (Post-surgery, HSV Blistering, etc.)

Metaplastic cells disorganised with indistinct cell borders and anisokaryosis with an irregular nuclear

membrane, coarse chromatin and prominent nucleoli (normal NCR on average)

Appear within 4 weeks and resolve by 8 weeks

Advisable to suggest early repeat

Tuboendometrioid Metaplasia (TEM)

Only an occasional or a few groups

Pattern 1: supercrowded groups of very small cells with very little cytoplasm

Pattern 2: columnar cells with denser cytoplasm ± terminal bars (± cilia – but this is not reliable

because they are prone to degeneration)

± Stratiﬁcation and ‘reversed’

rosettes but:

 blunt cytoplasmic ends (not tapering feathers as in glandular dyskaryosis)

 visible lateral cell borders (cf. indistinct in glandular dyskaryosis)

 denser cytoplasm (cf. fragile in glandular dyskaryosis)

Well-deﬁned and enhanced nuclear membrane, hyperchromatic but evenly granular chromatin

Lack architectural features of glandular neoplasia and mitoses

± Large casts of endometrial glands

Pure tubal metaplasia tends to form ‘dirty’-looking ragged groups

Lower Uterine Segment Endometrium / Isthmic Endometrium

Combined epithelial-stromal fragments are extremely unlikely to be neoplastic

Stroma: tangles of spindle cells and non-polarised thick sheets (!d/dg feathering in glandular

dyskaryosis)

Epithelium: tubular fragments/branching/gland openings/supercrowded cuboidal groups

Mitoses may be present in glands and stroma

Esp. seen in high scrape (e.g. after cone Bx or use of a cytobrush)

Microglandular Endocervical Hyperplasia (MGH)

Denser cytoplasm (cf. glandular dyskaryosis)

Fenestrated (‘moth-eaten’) sheets

Well-deﬁned and enhanced nuclear membrane, bland chromatin

Multinucleation

No architectural features of glandular dyskaryosis

Acetic Acid Artefact (topical application at time of smear)

Elongated, mis-shapen endocervical cells (pseudo-ﬁbre cells)

Intra-Uterine Contraceptive Device (IUCD) Changes

Endometrial cells and histiocytes ± actinomyces

Irritated endometrial cells (rounded with dense cytoplasm and eosinophilic nucleolus ±multinucleated

in a background of PMN and karyorrhectic debris in streaks of cervical mucus)

Bubblegum cells (crisp, unilocular cytoplasmic vacuole indenting nuclei)

Brown cells (mis-stained endometrial cells)

Cockleburrs (small aggregates of M surrounding gunk/haematoidin)

i.e. nuclei nearer the centre of the rosette (cf. nearer periphery in glandular dyskaryosis)

JWBK208-24 December 8, 2007 15:53 Char Count= 0

Cytopathology 358

Atrophy

Occurs in: pregnancy, postpartum, lactation, postmenopausal, progestational Rx (e.g. POP users) and

post ovarian radioRx

Epithelial ‘crazy paving’, orangeophilia (inversely proportional to cell size)

Parabasal NCR but cells have ﬁne chromatin, small nucleoli and well-deﬁned nuclear membranes

Parabasal predominance, blue blobs, air-drying, inﬂammation and blood complicate the picture

Orangeophil pattern: may get many small keratinised cells (similar to but not due to, HPV changes)

Tamoxifen

↑Maturation

↑Glycogen-laden navicular-like cells

If endometrial cells are present advise further Ix for

ﬁbrous polyps with metaplasias

—–

endometrioid adeno

oestrogen-independent cancers

CCC

—–

pap. serous

MMMT

Radiotherapy Changes

Iridescent two-tone staining (high colour saturation)

Inﬂammatory debris

Cytomegaly, bizarre shapes, cytoplasmic vacuolation (may be ﬁne and non-coalescent)

Wrinkled hyperchromatic nuclei, prom. nucleoli, multinucleation, karyorrhexis, nuclear vacuolation

Radiation-induced ‘dysplasia’ (greater risk of progression than sporadic CIN, esp. if <3 years post Rx)

Malignancy: ↑NCR, mitoses, (± hyperchromasia) and similar appearances to pre-Rx cancer cells

If cytology is used to check for recurrent carcinoma post local radioRx, the smear should be done >8

weeks after Rx because cells from the original tumour take this long to disappear with successful Rx

Chemotherapy Changes

Hard to distinguish from dyskaryosis. Advise F/U

NHSCSP Guidelines 2001

Mild dyskaryosis is an indication for referral on its second occurrence unless

a) the woman is unlikely to comply with the repeat (→ refer on ﬁrst occurrence)

b) mild follows Rx for CIN (→ manage at discretion of pathologist/gynaecologist)

?Glandular neoplasia (Result Code 6)

 do NOT use for equivocal changes (use ‘borderline, repeat in 6 months with brush as well as

smear’)

 should expect repeated observations of >1 of the features in the smear to make the diagnosis

Normal endometrial cells shed at inappropriate times

 age <40 years, ignore

 age >40 years, call ‘negative, routine recall’ – but note their presence and possible signiﬁcance

Borderline nuclear abnormalities

 a pathologistmayrecommend gynaecological referral at its ﬁrst occurrence if there is suspicion

of an underlying high grade abnormality (e.g. ? solid microbiopsies of CIN 3)

Management guidelines

 there should be no more than three abnormal smears over any 10 year period without a referral

 after mild dyskaryosis/BNA: at least three negative smears (at least 3 months apart) should be

obtained before returning to routine recall or screening is ceased for reasons of age

 after Rx for CIN 1: 5 year follow-up with at least three smears

 after Rx for CIN 2/3: 5 year follow-up (two smears in the ﬁrst year then annually)

 gynaecological referral: when changes suggest extracervical disease

 urgent referral: if ? invasive carcinoma or ? glandular dyskaryosis

Recent Advances in Gynae Cytology (2003–2007)

Uniform approach to screening across the UK

First call at age 25, then three-yearly till 49, then ﬁve-yearly till 64

Introduction of liquid-based cytology (LBC)

 ThinPrep



and SurePath



give less inadequates because the screener puts the spatula directly into

ﬂuid (no smear = no air-drying) and lack of clumping, blood, mucus and inﬂammation

 LBC preps are more amenable to automated image analysis