Reactive cellular changes and organisms in papsmear

Dr. MohammadniaCytopathology Fellowship

Reactive cellular changes associated with:– Inflammation (includes typical repair)

Lymphocytic (follicular) cervicitis– Radiation– Intrauterine contraceptive device (IUD)

Glandular cells status post hysterectomy

Reactive Cellular Changes Associated with Inflammation

Involve:Mature squamous cellsSquamous metaplasticColumnar epithelium

Nuclear enlargement of a variable degree(Endocervical cells may show greater nuclear enlargement )

Nuclei: Nonoverlapping with smooth, round, and uniform outline

Other occasional nuclear features:Occasional binucleation or multinucleation Vesicular and hypochromatic NucleiMild hyperchromasia with uniformly finely granular chromatin Prominent single or multiple nucleoli

Cytoplasmic features:Well defined cytoplasmic border Polychromasia Vacuolization Perinuclear halos (without peripheral thickening) “school of fish” architecture

Reactive squamous epithelial cellsMild nuclear enlargement without any significant chromatin abnormalities

Reactive endocervical cellsVariation in nuclear size, prominent nucleoli, and rare intracytoplasmic PMN

Reactive squamous cells Mild nuclear enlargement, nuclear hypochromasiaperinuclear halos, cytoplasmic polychromasia“motheaten”appearanceTrichomonads in the background

Reactive squamous cellsnuclear enlargementsmooth nuclear contours and finely distributed chromatin

The streaming and interdigitation of cells (school of fish)intracytoplasmic polymorphonuclear leukocytes

DDx: ASC-US or ASC-H or AGC

Repair:Round nuclear contours Even chromatin distribution nucleoli Cellular cohesionoverall uniform cellular morphology Paucity of isolated cells

ASC-US or ASC-H or AGC:AnisonucleosisIrregularities in chromatin distribution,Nuclear contour irregularities variation in size and shape of nucleoli

Lymphocytic (Follicular) Cervicitis

• Polymorphous population of lymphocytes• Tingible body macrophages

lymphocytic (follicular) cervicitislymphoid cells with a tingible body macrophage

DDX: -HSIL-Lymphoma-Metastatic tumor cells

Reactive Cellular Changes Associated with Radiation• Cell size is markedly increased (Cytomegaly)• Normal nuclear to cytoplasmic ratio

• Bizarre cell shapes

• Variation in nuclear size (some cell groups having both enlarged and normal-sized nuclei)• Binucleation or multinucleation

• Mild nuclear hyperchromasia

• Degenerative changes in nuclei (smudging or hypochromatic chromatin)• Cytoplasmic vacuolization, cytoplasmic polychromatic (two-color, amphophilic) staining

• Intracytoplasmic polymorphonuclear leukocytes

Acute radiation-induced changes:

• Bizarre cell forms• Cellular debris

Generally resolve within 6 months following therapy

Certain chemotherapeutic agents may produce changes similar to radiation effects.

Chemotherapy effect are usually temporary.

Chronic radiationinduced cellular changes may persist for years.

Reactive cellular changes associated with radiationenlarged nuclei, abundant vacuolated polychromatic cytoplasm, mild nuclear hyperchromasia without coarse chromatin, and prominent nucleoli

DDx:Invasive carcinoma

Reactive Cellular Changes Associated with IUDBoth glandular and squamous changes may occur. High nuclear to cytoplasmic ratio Prominent nucleoli Nuclear hyperchromasia large vacuoles may displace the nucleus (Signet-ring appearance) Calcifications resembling psammoma bodies are sometimes present. Actinomyces-like organisms may be present in up to 25 % of cases.

Reactive cellular changes associated with IUD. Small cluster of glandular cells with cytoplasmic vacuoles displacing nuclei

Reactive-reparative cellular changes associated with IUDEpithelial cells with a high nuclear to cytoplasmic ratioPresence of nucleoli in isolated cells with a high N/C ratio

Reactive Cellular Changes Associated with IUD may persist for several months after removal of the device.

DDX: Adenocarcinoma HSIL

Glandular Cells Status Post Hysterectomy

Benign-appearing glandular cells in cervical cytology from women with prior hysterectomy.

Probable explanations: The existence of glandular rests adjacent to vaginal mucosa Development of adenosis after trauma Mucinous or goblet cell metaplasia in response to atrophy Prolapse of the remaining fallopian tube after simple hysterectomy

DDx: Adenocarcinoma

If benign: No clinical significance Reporting is optional

Glandular cells status post hysterectomy

OrganismsTrichomonas vaginalis• Fungal organisms morphologically consistent with

Candida spp.• Shift in flora suggestive of bacterial vaginosis• Bacteria morphologically consistent with

Actinomyces spp.• Cellular changes consistent with herpes simplex virus• Cellular changes consistent with cytomegalovirus

Trichomonas vaginalis• Pear-shaped, oval, or round cyanophilic organism • Ranging in area from 15 to 30 μm2

• Nucleus is pale, vesicular, and eccentrically located

• Eosinophilic cytoplasmic granules are often evident

Associated changes: a. Mature squamous cells with small perinuclear halos (“trich change”) b. 3-dimensional clusters of neutrophils (“polyballs”)

c. Presence of Leptothrix

Many neutrophilic infiltrate is common. Exception: Women with total hysterectomy

Trichomonas vaginalis

Trichomonas vaginalis and Leptothrix. Leptothrix

Trichomonas vaginalis with polyballs

DDX:Degenerated fragments of cytoplasm (especially in cytolysis) Degenerated inflammatory cells

Trichomonad organisms are usually plentiful. A rare fragment of cyanophilic debris is not likely to be a true trichomonad.

Fungal Organisms Morphologically Consistent with Candida Species

Budding yeast (3–7 μm) and/or pseudohyphae Eosinophilic to gray brown on the Papanicolaou stain

Candida species

Candida species“spearing” or a “shish kebab” appearance

Shift in Flora Suggestive of Bacterial Vaginosis

Clue cells: Individual squamous cells covered by a layer of coccobacilli that obscure the cell membrane Conspicuous absence of lactobacilli Few inflammatory cells

Shift in flora suggestive of bacterial vaginosis

• Bacteria Morphologically Consistent with Actinomyces

Cotton ball (Tangled clumps of filamentous organisms, often with acute angle branching)

An acute inflammatory response

LBC:

The strands are finer and more delicate

Fewer neutrophils

Actinomyces has an association with the presence of IUD

Bacteria morphologically consistent with Actinomycescotton ball” appearance with acute infalammatory cells

Bacteria morphologically consistent with Actinomyces

• DDX:Aggregation of lactobacilli in LBC

Cellular Changes Consistent with Herpes Simplex Virus

Ground-glass appearance in nuclei

Dense eosinophilic intranuclear (Cowdry) inclusions surrounded by a halo or clear zone

Large multinucleated epithelial cells with molded nuclei

Cellular changes consistent with herpes simplex virus

DDX: Multinucleated endocervical cells Multinucleated histiocytes Syncytiotrophoblast cells LSIL and HSIL

Cellular Changes Consistent with Cytomegalovirus

Mostly in immunocompromised individuals

Mostly involve the endocervical glandular cells

Dx:

Cellular and nuclear enlargement

Large eosinophilic intranuclear viral inclusions with a prominent halo Small cytoplasmic, basophilic inclusions

Cytomegalovirus

Chlamydia

• Squamous metaplastic cells and endocervical columnar cells are involved.• Morphology:-Acute inflammation

-Target forms-Motheaten appearance

• DDX: Cellular degeneration

Cytomorphologic recognition in genital smears is not recommended.

Thank you