Pap smear

The first workshop was held in 1988, to reduce widespread confusion among
laboratories and clinicians created by the use of multiple classification
systems and inconsistently defined numerical grading conventions.
Earlier versions of bethesda include 3 categories of adequacy:
 Satisfactory
 Unsatisfactory
 Borderline.
The 2001 bethesda system eliminates the borderline category. To provide a
clearer indication of adequacy specimens are now designated as
“satisfactory” or “unsatisfactory”.

Area of metaplastic epithelium proximal to the original squamocolumnar junction is referred to as
transformation zone since it is an area of epithelial instability.

 Endometrial cells
 Neutrophils,basophils,eosinophils,lymphoc
ytes
 Macrophages
 Spermatozoa
 Contaminants.

 Conventional pap smear  Liquid based preparations

Minimum squamous cellularity criteria
 Conventional smear-8000 to 12000 well preserved, well visualised squamous
cells.
 Liquid based prep-min 5000.

Endocervical zone component
 Atleast 10 well preserved endocervical or squamous metaplastic cells ,singly
or in clusters.
 If high grade cancer is present,it is not necessary to report presence or
absence of transformation zone component.

SATISFACTORY:
1. Describes presence or absence of endocervical/transformation zone component and
any other quality indicators.
2. Any specimen with abnormal cells (ASC-US,AGC or worse)is by definition satisfactory
for evaluation.

UNSATISFACTORY:
1. Rejected specimen-not processed because(specimen not labelled,slide
broken, patient particulars not mentioned etc.)
2. Fully evaluated, unsatisfactory specimen-specimen processed and
examined, but unsatisfactory for evaluation of epithelial abnormality
because of-obscuring blood, inflammatory cells,etc.
3. Specimens with more than 75% of squamous cells obscured should be
termed unsatisfactory.
4. When 50-75% cells are obscured,a statement describing the specimen as
partially obscured should be made.

DIAGNOSTIC CATEGORIES
Non neoplastic neoplastic
Epithelial cell abnormality

Organisms: Other: Glandular cell
•Trichomonas
•Candida
•Reactive- Squamous cell: abnormalities:
*inflammation •Atypical squamous •Atypical
•Chlamydia
•HSV *radiation cells(ASC) *endocervical
•HPV *IUD *ASCUS *endometrial
•Glandular cells post *glandular
•CMV *ASC-H
hysterectomy •Atypical
•Squamous *endocervical cells
•Atrophy. intraepithelial favour neoplastic.
lesion *glandular cells favor
*LSIL neoplastic
*HSIL •Endocervical ca in situ
•Squamous cell ca •Adenooca
*keratinising *endocervical
*non-keratinising *endometrial
*extrauterine

Interpretation af ASC requires that cells demonstrate 3 features-
 Squamous differentiation
 Increased N/C ratio
 Minimal nuclear hyperchromasia,chromatin clumping,irregularity,smudging or multinucleation

 Nuclei approx 2 and 2.5 times area of nucleus of intermediate cells
 Slightly increased N/C ratio.
 Minimal hyperchromasia,irregilarity in chromatin distribution or nuclear shape.

Include 2 categories
 Small cells with high N/C ratio-atypical metaplasia
*cells occur singly or in small fragments of less than 10 cells.
*cells size of metaplastic cells,nuclei about 1.5 to 2.5 times larger than normal.
 Crowded sheet pattern-
*crowded cells,nuclei show loss of polarity or difficult to visualize.
*dense cytoplasm, polygonal cells and fragments with sharp linear edges generally favor
squamous over glandular differentiation.

 Mature type cytoplasm
 Large cell size,increased N/C ratio.
 Nuclear enlargement more than 3 times the area of normal intermediate nuclei
 Bi and multinucleation
 Chromatin uniformly distributed.
 Nucleoli generally absent
 Nuclear membrane slightly irreguilar
 distinct cytoplasmic borders.
 Koilocytosis.

LSIL ASCUS

INFLAMMATION

 Less mature than cells in LSIL.
 Nuclear hyperchromasia accompanied by variations in nuclear size and shape.
 Degree of nuclear enlargement more variable
 Nuclear membrane quite irregular with indentations and grooves
 Nucleoli absent,occassionally present
 cytoplasm immature,lacy,delicate or densely metaplastic

 KERATINISING
1. relatively few cells present.
2. Marked variation in cell size and shape,wiith caudate , spindle cells and tadpole cells
3. Marked variation in nuclear size, irregular nuclear membrane, numerous dense opaque nuclei.
4. Coarsely granular chromatin with parachromatin clearing .
5. Tumor diathesis may be present, less than non keratinizing.

 NON KERATINISING-
1. Cells occur singly or in syncitial aggregate with poorly defined cell borders.
2. Smaller than HSIL.
3. Marked irregular distribution of coarsely clumped chromatin.
4. A tumour diathesis consisting of necrotic debris and old blood.

 Cells in sheets and strips, cell crowding, nuclear overlap.
 Nuclear enlargement upto 3 to 5 times area of normal endocervical nuclei.
 Some variation in nuclear size and shape.
 Mild hyperchromasia
 Nucleoli may be present
 Mitosis rare
 Cytoplasm fairly abundant, N/C ratio increased
 Distinct cell border

 Cells occur in small groups ,usually 5-10 cells/group.
 Nuclei slightly enlarged
 Mild hyperchromasia
 Small nucleoli
 Scant cytoplasm,ocassionaly vacuolated
 Ill defined cell borders.

 Cells occur in sheets,clusters,strips and rosettes with nuclear crowding and overlap, loss of honeycomb
pattern.
 palisading nuclear arrangement with feathering
 Enlarged. Stratified nuclei.
 Hyperchromasia
 Nucleoli small, inconspicuous
 Mitosis and apoptosis seen
 N/C ratio increased,cytoplasm and mucin diminished
 Abnormal squamous cells may be present

 Abundant abnormal cells,typically with columnar configuration
 Single cells,2dimensional sheets or 3 dimensional clusters and syncitial aggregates commonly
seen
 Enlarged pleomorphic nuclei,parachromatin clearing,nuclear membrane irregularities.
 Macronucleoli present
 Cytoplasm finely vacuolated
 Necrotic tumour diathesis may be seen

 Pear shaped,oval,cyanophilic organisms,15-30μ
 Pale vesicular eccentrically located nucleus.
 Eosinophilic cytoplasm granules centrally.
 Inflammatory changes.

 Clue cells
 Mixed bacteria,mainly coccoid
 Neutrophilic satellitosis.

 Double contoured pale pink hyphae and pseudohyphae
 Pseudohyphae appear septate
 Spores are eosinophilic
 Inflammatory changes variable

 Swollen nuclei with multinucleation.
 Ground glass chromatin with prominent nuclear membrane and nuclear
inclusions(tombstones).
 Nuclear moulding.

 Koilocytosis-superficial and intermediate cells
 Multinucleation
 Nuclear swelling and degeneration
 Keratotic spikes,pearls and rafts
 Single dyskeratotic cells.

CHANGES IN SQUAMOUS EPITHELIAL CELLS-
 Cytoplasmic abnormalities
*vacuolation
*perinuclear halo
*altered staining
*abnormal keratinisation
 Changes in nucleaus-
*wrinkling of nuclear membrane
*multinucleation
*chromatin degeneration
CHANGES IN ENDOCERVICAL CELLS-
 Cytoplasmic degeneration
 Nuclear variation

 Cell size markedly increased without increase in N/C ratio.
 Nuclei show degenerative changes
 Bi or multinucleation
 Prominent single or multiple nucleoli
 Cytoplasmic vacuolation

 Endometrial shedding at any stage.
 Single and clustered enlarged vacuolated glandular cells.
 Neutrophilic exudate
 Actinomycotic colony

 Flat monolayer sheets of parabasal cells with preserved nuclear polarity
 Parabasal cells may have hyprechromaisa
 Chromatin uniformly distributed
 Autolysis result in naked nuclei.
 Abundant inflammatory exudate.

 ASC-US + ASC-H:
*no immediate cancer risk.
*most cases don’t progress to cancer.
*perform HPV testing +ve----colposcopy

-ve---repeat PAP smear in
12m
•LSIL:
*12-16% cases progress to cancer in 10years
*50% cases regress in 2years.
*HPV testing +ve-colposcopy LOOP
-ve—repeat PAP smear at 6 and 12m

•HSIL:
*20% progress to cancer in 10years. colposcopy

 Specimen type-conventional smear
 Specimen adequacy
*satisfactory
*unsatisfactory
 General categorisation
*NILM
*epithelial cell abnormality
*other
 Interpretation

Pap smear

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