3rd kamc kamc cytopathologycytopathology …€¦ · irregular nucleolar shapes nuclear euchromasia...
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January 23, 2011January 23, 2011
33rdrd KAMC KAMC CytopathologyCytopathology SymposiumSymposium
Lecture G1: Cervical Benign EntitiesLecture G1: Cervical Benign Entities
NikolaosNikolaos ChantziantoniouChantziantoniou, , BScBSc, ART(CSMLS), CMIAC, ART(CSMLS), CMIAC
CytopathologyCytopathology SectionSection
Department of Pathology and Laboratory MedicineDepartment of Pathology and Laboratory Medicine
King Abdulaziz Medical City King Abdulaziz Medical City –– RiyadhRiyadh
Kingdom of Saudi ArabiaKingdom of Saudi Arabia
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ObjectivesObjectives
Diagnostic certaintyDiagnostic certaintyPap TestPap Test
Sampling devicesSampling devices
Normal Uterine CervixNormal Uterine CervixPhysiologically normal histology, cellPhysiologically normal histology, cell--typestypes
CytomorphologicCytomorphologic range of benign cellular changesrange of benign cellular changesEpithelial integrity, TEpithelial integrity, T--zone activityzone activity
•• EctropionEctropion ((EctopyEctopy), erosion / ulceration), erosion / ulcerationCytomorphologicCytomorphologic template overlaptemplate overlapCytomorphologyCytomorphology::
•• Infection, inflammationInfection, inflammation•• Tissue repair / regenerationTissue repair / regeneration•• Reserve cell hyperplasiaReserve cell hyperplasia•• Atrophic Atrophic vaginitisvaginitis
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Reporting Schemes Reporting Schemes –– IntentIntent
CarcinomaCarcinomaCarcinomaCarcinoma
inin--situsituSevereSevere
DysplasiaDysplasiaModerateModerate
DysplasiaDysplasiaSlightSlight
DysplasiaDysplasiaNormalNormal
CarcinomaCarcinomaCIN IIICIN IIICIN IICIN IICIN ICIN INormalNormal
CarcinomaCarcinomaHSILHSILLSILLSILNormalNormal
High risk HPVLow risk HPV
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Negative for intraNegative for intra--epithelial lesion, NILMepithelial lesion, NILM
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? Abnormal? Abnormal
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? LSIL? LSIL
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? LSIL? LSIL
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? LSIL? LSIL
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? HSIL, CIS? HSIL, CIS
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? HSIL, CIS? HSIL, CIS
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? HSIL, CIS? HSIL, CIS
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? Keratinizing ? Keratinizing SquamousSquamous CarcinomaCarcinoma
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? Non? Non--Keratinizing Keratinizing SquamousSquamousCarcinomaCarcinoma
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? ? EndocervicalEndocervical AdenocarcinomaAdenocarcinoma
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? Endometrial ? Endometrial AdenocarcinomaAdenocarcinoma
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CytomorphologicCytomorphologic Templates: CertaintyTemplates: CertaintyCarcinomaCarcinomaHSILHSILLSILLSILNormalNormal
90% Agreement: Precursor, Malignant Lesions?? %
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? Normal? Normal
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? NILM? NILM
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? NILM? NILM
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? NILM? NILM
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? NILM? NILM
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? NILM? NILM
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? NILM? NILM
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? NILM? NILM
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? NILM? NILM
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Interpretive Uncertainty (?% Agreement)Interpretive Uncertainty (?% Agreement)
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Pap TestPap Test
Dr. George N. Dr. George N. PapanicoalouPapanicoaloudeveloped a method whereby developed a method whereby cellular material removed cellular material removed directly from the directly from the ectocervixectocervix may may be processed, stained and be processed, stained and examined microscopically to examined microscopically to indirectly classify and infer indirectly classify and infer likely cervical neoplasialikely cervical neoplasia
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Sampling DevicesSampling Devices
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Normal Uterine CervixNormal Uterine Cervix
The PapThe Pap--Test consisted of Test consisted of removal of epithelial cells removal of epithelial cells from the from the ectocervixectocervix
The uterine cervix physical The uterine cervix physical anatomy depends on anatomy depends on patient clinical history, patient clinical history, previous interventionprevious intervention
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Transformation ZoneTransformation Zone
SquamousSquamous epithelium epithelium --stratifiedstratifiedEndocervicalEndocervical epithelium epithelium ––simple, columnar cellssimple, columnar cells
Every individual columnar Every individual columnar cell is attached to the cell is attached to the basement membranebasement membrane
Ciliated or goblet typeCiliated or goblet type
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Physiologically Normal CellPhysiologically Normal Cell--typestypes
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Epithelium IntegrityEpithelium Integrity
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SquamousSquamous Epithelium InjuryEpithelium Injury
A reparative A reparative process is initiated process is initiated to restore the to restore the epitheliumepithelium
Active mitotic Active mitotic activityactivity
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EndocervicalEndocervical Epithelium InjuryEpithelium Injury
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Overall TOverall T--zone Activityzone Activity
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TT--zone Schematiczone Schematic
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Cervical Cervical EctropionEctropion ((EctopyEctopy))
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Cervical Erosion / UlcerationCervical Erosion / Ulceration
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CytomorphologicCytomorphologic OverlapOverlap
Nuclear enlargementProminent nucleoliSingle or multiple nucleoliVariable nucleolar sizesIrregular nucleolar shapesNuclear hyperchromasiaIrregular chromatin distributionCells single or in groupsEvidence of cellular debris, necrosis
Nuclear enlargementProminent nucleoli
Single or multiple nucleoliVariable nucleolar sizes
Irregular nucleolar shapesNuclear euchromasia
Mainly regular chromatin distributionCells mainly in sheets, syncytial arrangements
No necrosis
SQUAMOUS CARCINOMA, Non-KeratinizingTISSUE REPAIR / REGENERATION
TemplateB
TemplateA
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CytomorphologicCytomorphologic OverlapOverlap
Nuclear enlargementProminent nucleoliSingle or multiple nucleoliVariable nucleolar sizesIrregular nucleolar shapesNuclear hyperchromasiaIrregular chromatin distributionCells single or in groupsEvidence of cellular debris, necrosis
Nuclear enlargementProminent nucleoli
Single or multiple nucleoliVariable nucleolar sizes
Irregular nucleolar shapesNuclear euchromasia
Mainly regular chromatin distributionCells mainly in sheets, syncytial arrangements
No necrosis
SQUAMOUS CARCINOMA, Non-KeratinizingTISSUE REPAIR / REGENERATION
TemplateB
TemplateA
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CytomorphologicCytomorphologic Template PhenomenonTemplate Phenomenon
╓ ╩ ╫ ╬◙ ▓ □ ▌▼ ◄ ● ◘■ ▬ ▲ ►Cytomorphologic Spectrum
Category IVCategory IIICategory IICategory IInterpretive Spectrum
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Infection / InflammationInfection / Inflammation
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Factors Predisposing Inflammation, Factors Predisposing Inflammation, MetaplasiaMetaplasia
Chemical Chemical –– decrease in vaginal acidity during menses when the ph becomes decrease in vaginal acidity during menses when the ph becomes alkaline, use of douches, gels and foamsalkaline, use of douches, gels and foams
Traumatic injury Traumatic injury –– child birth, biopsy, polyp, prolapsed uteruschild birth, biopsy, polyp, prolapsed uterus
Foreign bodies Foreign bodies –– IUD, diaphragm, IUD, diaphragm, pessarypessary, etc, etc
ImmunosuppressionImmunosuppression –– HIV positive status, pregnancy, organ transplant HIV positive status, pregnancy, organ transplant recipient, patients on chemotherapyrecipient, patients on chemotherapy
Infectious processes Infectious processes -- microbiologic, viral, bacterial or protozoanmicrobiologic, viral, bacterial or protozoan
NeoplasiaNeoplasia –– secondary infection of necrotic tissuesecondary infection of necrotic tissue
Irradiation, chemotherapy, (nonIrradiation, chemotherapy, (non--specific specific –– idiopathic factors)idiopathic factors)
Epithelial atrophy Epithelial atrophy –– thinning of the squamous epithelium in postthinning of the squamous epithelium in post--menopausal menopausal women, women on birth control pills (rarely) and who are lactatiwomen, women on birth control pills (rarely) and who are lactatingng
Extent of cervical Extent of cervical ectopyectopy ((ectropionectropion))
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Tissue Repair / RegenerationTissue Repair / Regeneration
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Reserve Cell HyperplasiaReserve Cell Hyperplasia
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SubSub--epithelial epithelial ‘‘RestingResting’’ Reserve cellsReserve cells
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Reserve Cell HyperplasiaReserve Cell Hyperplasia
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Immature Immature SquamousSquamous MetaplasiaMetaplasia
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Atrophic Atrophic VaginitisVaginitis
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Thank YouThank You