Cytology Training Program:
Gyn Cytology Revision Exercise
by Tony Chan
Reference:
THE BETHESDA SYSTEM WEBSITE
ATLAS
American Society of Cytopathology
Select Your Interpretation
from below:
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NILM: Negative for Intraepithelial Lesion or Malignancy
Endometrial cells in a woman >= 40
ASC-US
ASC-H
LSIL
HSIL
Invasive Squamous Cell Carcinoma
Atypical Endocervical Cells
Atypical Endometrial Cells
Adenocarcinoma in situ (AIS), Endocervical
Adenocarcinoma, Endocervical
Adenocarcinoma, Endometrial
27 year old woman, colposcopy
visit
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NILM: Fungal
organisms consistent
with Candida spp
Pseudohyphae and
reactive changes in
the squamous
epithelial cells.
31 year old
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HSIL
Important features of
high grade squamous
intraepithelial lesions are
enlarged and/or high N/C
ratio, centrally placed
nuclei, hyperchromasia,
and irregular nuclear
membranes.
40 year old woman, history of
squamous cell carcinoma of the
cervix.
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NILM: Reactive cellular
changes associated with
Radiation
Enlarged nuclei with abundant
polychromatic cytoplasm with
vacuolization. Mild nuclear
hyperchromasia without coarse
chromatin, prominent nucleoli
(coexisting repair). Note
multinucleation (upper right
corner insert).
What is your interpretation?
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NILM
Pseudokoilocytosis:
cytoplasmic
vacuolization without
nuclear change of
HPV effect.
67 year old woman with
postmenopausal bleeding
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Adenocarcinoma, endometrial
Three-dimensional papillary
cluster of abnormal cells with
irregular nuclear membranes
and nucleoli. No evidence of
feathering
Follow-up:
adenocarcinoma of the
endometrium, FIGO Grades III
Just this cell seen. What’s your
interpretation?
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ASC-US
Enlarged nuclei with
small perinuclear halo
Features are
insufficient for an
interpretation of LSIL.
27 year old woman. LMP two
weeks ago
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ASC-H
Metaplastic cells with
increased N:C ratios
and nuclear contour
irregularities.
HSIL on repeat Pap;
CIN3 on LEEP
26 year old woman, LMP 2 weeks, mild vaginal
discharge
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NILM: Reactive
squamous cellular
changes associated
with Trichomonas
vaginalis
Trichomonas also
seen. Where?
What is your interpretation?
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LSIL
Binucleation and
koilocytes in mildly
dysplastic mature
cells is consistent with
HPV effect.
What is your interpretation?
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HSIL
"Keratinizing dysplasia".
The dysplastic cells in this
field display enlarged
nuclei with coarsely
granular chromatin and
keratinized cytoplasm.
Occasional cells have
pyknotic or opaque nuclei
with sharp, angled edges
and abnormal cell shapes
are seen.
What is your interpretation?
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NILM: Shift in Flora
suggestive of bacterial
vaginosis
Filmy background of
small coccobacilli.
Individual squamous cells
covered by a layer of
bacteria. Conspicuous
absence of lactobacilli.
58 year old woman, LMP 8 years,
postmenopausal bleeding
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Adenocarcinoma, Endometrial
Large aggregate of small cells
with irregular chromatin
distribution, small nucleoli,
poorly defined finely
vacuolated cytoplasm in a
watery background.
In conventional smears,
endometrial adenocarcinoma
tends to be associated with a
thin watery diathesis in
contrast to the bloody,
necrotic background often
seen with endocervical
adenocarcinoma.
Follow-up: Adenocarcinoma of
the endometrium
What is your interpretation?
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NILM: Cellular changes
consistent with Herpes simplex
virus
Note the intranuclear
inclusions Vs nucleoli
The ground-glass appearance
of the nuclei is due to
accumulation of viral particles
leading to peripheral
margination of chromatin.
45 year old
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Squamous cell carcinoma
Dysplastic squamous cells
with anisocytosis and
anisonucleosis including
keratinization and tadpole
cells are diagnostic of
invasive squamous cell
carcinoma.
41 yrs old, routine exam
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NILM: Endometrial
cells in a woman >=
40
Three-dimensional
cluster with slightly
larger nuclei and
nucleoli.
39 year old woman, routine Pap
smear, no LMP date given
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Atypical endocervical cells,
NOS
Sheet of cells with enlarged
round or oval nuclei with
prominent nucleoli. Chromatin
is finely granular and evenly
distributed but occasional
chromocenters are seen. Cell
borders are well-defined.
Mitotic figures are noted.
63 year old woman with
postmenopausal bleeding
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Atypical endometrial cells
Aggregate of small cells
with slightly enlarged
round or oval nuclei,
small nucleoli and finely
vacuolated cytoplasm.
Follow-up:
Adenocarcinoma of the
endometrium, grade I
32 years old, mother of 3 children
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NILM: Reactive cellular
changes associated with IUD
Note small cluster of glandular
cells with cytoplasmic vacuoles
displacing nuclei. The
cytoplasmic vacuoles may
displace the nucleus, creating
a signet-ring appearance.
What is your interpretation?
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Squamous Cell
Carcinoma-clinging
diathesis
Tumor diathesis, variation
in cell size and shape,
evidence of keratinization,
and nuclear abnormalities
are all demonstrated in
this image from a
squamous cell carcinoma.
41 year old. No history provided
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NILM: Bacteria morphologically
consistent with Actinomyces
spp.
Tangled clumps of filamentous
organisms, often with acute
angle branching, sometimes
showing irregular wooly
appearance. Swollen filaments
may be seen with clubs at
periphery. A cotton ball like
acute inflammatory response is
common.
What is your interpretation?
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NILM: Tubal metaplasia
Cell group demonstrating
crowding,
pseudostratification and
oval or elongated nuclei.
Note the presence of cilia
in some cells.
What is your interpretation?
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Endocervical adenocarcinoma
in situ (AIS)
Cluster of cells with crowded
overlapping oval nuclei that
show hyperchromasia and
evenly distributed by coarsely
granular chromatin. Smear
background is clean.
Nuclear crowding and
overlapping, hyperchromasia
and evenly distributed granular
chromatin are classic features
of AIS.
39 year old female, Day 12 of cycle
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Adenocarcinoma,
Endocervical
Cluster of cells
enlarged nuclei,
macronucleoli and
some nuclear
membrane
irregularities; poorly
defined, finely
vacuolated cytoplasm;
What is your interpretation?
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HSIL
HSIL with extension into
gland space. Note that in
addition to the abnormal
cells themselves, there is
flattening of cells at the
edge of the cluster, lack
of columnar shape and
loss of polarity.
32 year old, LMP now, abnormal
cervix on exam
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Adenocarcinoma, endocervical
Large group of abnormal cells
with round to elongated
hyperchromatic nuclei and
granular chromatin. Note
pseudostratified strips with
feathering at the edges.
Nuclear crowding and overlap
are prominent. Smear
background is bloody.
The cytologic features of
endocervical adenocarcinoma
may overlap with those of
endocervical adenocarcinoma
in situ, but features of
invasion, such as tumor
diathesis, are seen.
Follow up: Endocervical
79 year old postmenopausal woman, being
evaluated for possible Squamous cell
carcinoma of vulva
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NILM: Atrophy
Sheets of uniform orderly
parabasal cells are
observed representing
deep parabasal cells.
Some nuclei show
grooves, but chromatin
pattern is fine. Atrophic
cells may have nucleoli
(lower right insert).
End of Exercise
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More cases:
http://nih.techriver.net/atlas.php
Self-test:
http://nih.techriver.net/diagnosis.php