Problem Based Learning in Cytology
Diagnosis and Management of Glandular Lesions on Pap Test
Learning Objectives:
1.
2.
3.
4.
List the types of cells normally seen on a Pap Test
Recognize how and when endometrial cells are reported
Identify a variety of glandular cell abnormalities detected on Pap Test
Analyze the criteria for distinguishing normal and abnormal glandular cell
findings that may be seen on Pap Test
5. Summarize the management guidelines for glandular cell abnormalities detected
by Pap Test
Select Resources:
1. The Bethesda System for Reporting Cervical Cytology. Definitions, Criteria, and
Explanatory Notes. By Soloman D. and Nayar R. Springer Press 2004, pp57-66,
pp123-156.
2. Simsir A, Elgert P, Carter W, Cangiarella J. Reporting endometrial cells in
women 40 years and older: assessing the clinical usefulness of Bethesda 2001.Am
J Clin Pathol. 123(4):571-5, 2005.
3. Simsir A, Hwang S, Cangiarella J, Elgert P, Levine P, Sheffield MV, Roberson J,
Talley L, Chhieng DC. Glandular cell atypia on Papanicolaou smears:
Interobserver variability in the diagnosis and prediction of cell of origin. Cancer.
99(6):323-30, 2003.
4. Aslan D, Crapanzano JP, Harshan M, Erroll M, Vakil B, Pirog EC. The Bethesda
System 2001 Recommendation for Reporting of Benign Appearing Endometrial
Cells in Pap Test of Women Age 40 Years and Older Leads to Unwarranted
Surveillance When Followed Without Clinical Qualifiers. Gynecol Oncol.
107:86-93, 2007.
5. Guidelines for Management of Cytologic Abnormalities at
http://www.asccp.org/ConsensusGuidelines/tabid/7436/Default.aspx
6. Clinical Management Guidelines for Obstetricians-Gynecologists. ACOG
Practice Bulletin. No99, December 2008.
7. Dunton CJ. Management of atypical glandular cells and adenocarcinoma in situ.
Obstet Gynecol Clin North Am. 2008 Dec;35(4):623-32.
Diagnosis and Management of Glandular Lesions on Pap Test
Session 1
Case Presentation:
You are the Cytopathology fellow in a very busy City Hospital affiliate of a large
Medical School. You have 45 Pap Test slides waiting for your review. Your attending
tells you that you have to review all of these slides with the rotating pathology resident.
You see that you have four cases with similarities and you are wondering if you are
beginning to overcall some of these cases. To top it all, the rotating resident is beginning
to get very confused and slow you down with questions. He states that all four cases you
are pointing out to him as abnormal look very similar. He wants to know how you can
differentiate one from the other and if it really makes a difference in management since
the Pap Test is just a screening test. He says “why don’t we call them all “atypical” and
reflex them for human papilloma virus (HPV) testing?” You go back to look into these
cases in more depth and explain to him the importance of accurate cytologic
classification.
Case 1: A 45-year-old woman with screening Pap test; no prior abnormals noted. The
date of her last menstrual period is not indicated on the requisition form.
Figure 1. A. Surepath Pap stain, 60 x. B. Surepath Pap stain, 60X. C. Surepath Pap stain, 60x.
Case 2: A 49-year-old woman presented with vaginal spotting. She states she had
several prior abnormal Pap tests with positive high risk HPV test but she did not follow
up with her gynecologist.
Figure 2. A. SurePath Pap stain, 20x. B. SurePath Pap stain, 40x C. SurePath Pap stain, 60x. D. SurePath
Pap stain, 60x.
Case 3: A 66-year-old woman with postmenopausal bleeding for 3 months. No other
relevant history provided.
Figure 3. A. SurePath Pap stain, 40x. B/C. SurePath Pap stain, 60x.
Case 4: A 66-year-old woman presenting for routine Pap test screening. She has had
chemotherapy and radiation therapy for locally advanced lung cancer. She has been
disease free for 13 months.
Figure 4: A. SurePath Pap stain, 40x. B. SurePath Pap stain, 60x. C. SurePath Pap stain, 60x
Problem Statement:
1. How should the Pap test from Case 1 be reported? Is this an abnormal finding?
How should the clinician manage her?
2. Which patient would benefit from reflex HPV testing?
3. Based on the Bethesda /ASCCP management guidelines, which case needs
colposcopy with tissue sampling for definitive diagnosis/treatment?
4. Which case would benefit from additional testing for a more definitive diagnosis?
What kind of testing would you ask for?
Identify at least 4 learning objectives related to the topic and case presentation that you
think will be required to solve this problem.
1.
2.
3.
4.
Identify possible resources to obtain information related to these learning objectives.
1.
2.
3.
Once you’ve completed these tasks, assign each person in the group a concept to review,
and break for independent study.
Diagnosis and Management of Glandular Lesions on Pap Test
Session 2
Case Presentation:
You are the Cytopathology fellow in a very busy City Hospital affiliate of a large
Medical School. You have 45 Pap Test slides waiting for your review. Your attending
tells you that you have to review all of these slides with the rotating pathology resident.
You see that you have four cases with similarities and you are wondering if you are
beginning to overcall some of these cases. To top it all, the rotating resident is beginning
to get very confused and slow you down with questions. He states that all four cases you
are pointing out to him as abnormal look very similar. He wants to know how you can
differentiate one from the other and if it really makes a difference in management since
the Pap Test is just a screening test. He says “why don’t we call them all “atypical” and
reflex them for human papilloma virus (HPV) testing?” You go back to look into these
cases in more depth and explain to him the importance of accurate cytologic
classification.
Case 1: A 45-year-old woman with screening Pap test; no prior abnormals noted. The
date of her last menstrual period is not indicated on the requisition form.
Figure 1. A. Surepath Pap stain, 60 x. B. Surepath Pap stain, 60X. C. Surepath Pap stain, 60x.
Case 2: A 49-year-old woman presented with vaginal spotting. She states she had
several prior abnormal Pap tests with positive high risk HPV test but she did not follow
up with her gynecologist.
Figure 2. A. SurePath Pap stain, 20x. B. SurePath Pap stain, 40x C. SurePath Pap stain, 60x. D. SurePath
Pap stain, 60x.
Case 3: A 66-year-old woman with postmenopausal bleeding for 3 months. No other
relevant history provided.
Figure 3. A. SurePath Pap stain, 40x. B/C. SurePath Pap stain, 60x.
Case 4: A 66-year-old woman presenting for routine Pap test screening. She has had
chemotherapy and radiation therapy for locally advanced lung cancer. She has been
disease free for 13 months.
Figure 4: A. SurePath Pap stain, 40x. B. SurePath Pap stain, 60x. C. SurePath Pap stain, 60x
Review the learning objectives you created last session. Each person in the group should
present the summary of their assignment. Provide copies of relevant articles as needed.
Readiness Questions:
These questions are designed to make sure you have reviewed the material fully, and
covered all aspects of the topic. Review the questions in a group, and attempt to fully
answer them.
1. How do we determine the presence of endometrial cells on a Pap test as being a
normal or an abnormal finding? Explain based on age, menstrual and menopausal
status of a woman.
2. How are atypical glandular cells reported? Is it necessary to subclassify based on
cell type? Is it always possible to subclassify?
3. What is the current management guidelines for atypical glandular cells?
4. Is Pap test used for screening for adenocarcinoma? What different types of
adenocarcinomas can be detected on Pap test screening? How do they differ in
appearance?
Return to the Problem:
1. How should the Pap test from Case 1 be reported? Is this an abnormal finding?
How should the clinician manage her?
2. Which patient would benefit from reflex HPV testing?
3. Based on the Bethesda /ASCCP management guidelines, which case needs
colposcopy with tissue sampling for definitive diagnosis/treatment?
4. Which case would benefit from additional testing for a more definitive diagnosis?
What kind of testing would you ask for?
Is there any additional information would you like to know regarding these cases that
would help your interpretation?