reactive cellular changes and organisms in papsmear
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Reactive cellular changes and organisms in papsmear
Dr. MohammadniaCytopathology Fellowship
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Reactive cellular changes associated with:– Inflammation (includes typical repair)
Lymphocytic (follicular) cervicitis– Radiation– Intrauterine contraceptive device (IUD)
Glandular cells status post hysterectomy
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Reactive Cellular Changes Associated with Inflammation
Involve:Mature squamous cellsSquamous metaplasticColumnar epithelium
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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
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Cytoplasmic features:Well defined cytoplasmic border Polychromasia Vacuolization Perinuclear halos (without peripheral thickening) “school of fish” architecture
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Reactive squamous epithelial cellsMild nuclear enlargement without any significant chromatin abnormalities
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Reactive endocervical cellsVariation in nuclear size, prominent nucleoli, and rare intracytoplasmic PMN
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Reactive squamous cells Mild nuclear enlargement, nuclear hypochromasiaperinuclear halos, cytoplasmic polychromasia“motheaten”appearanceTrichomonads in the background
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Reactive squamous cellsnuclear enlargementsmooth nuclear contours and finely distributed chromatin
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The streaming and interdigitation of cells (school of fish)intracytoplasmic polymorphonuclear leukocytes
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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
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Lymphocytic (Follicular) Cervicitis
• Polymorphous population of lymphocytes• Tingible body macrophages
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lymphocytic (follicular) cervicitislymphoid cells with a tingible body macrophage
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DDX: -HSIL-Lymphoma-Metastatic tumor cells
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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
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Acute radiation-induced changes:
• Bizarre cell forms• Cellular debris
Generally resolve within 6 months following therapy
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Certain chemotherapeutic agents may produce changes similar to radiation effects.
Chemotherapy effect are usually temporary.
Chronic radiationinduced cellular changes may persist for years.
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Reactive cellular changes associated with radiationenlarged nuclei, abundant vacuolated polychromatic cytoplasm, mild nuclear hyperchromasia without coarse chromatin, and prominent nucleoli
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DDx:Invasive carcinoma
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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.
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Reactive cellular changes associated with IUD. Small cluster of glandular cells with cytoplasmic vacuoles displacing nuclei
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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
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Reactive Cellular Changes Associated with IUD may persist for several months after removal of the device.
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DDX: Adenocarcinoma HSIL
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Glandular Cells Status Post Hysterectomy
Benign-appearing glandular cells in cervical cytology from women with prior hysterectomy.
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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
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DDx: Adenocarcinoma
If benign: No clinical significance Reporting is optional
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Glandular cells status post hysterectomy
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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
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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
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Trichomonas vaginalis
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Trichomonas vaginalis and Leptothrix. Leptothrix
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Trichomonas vaginalis with polyballs
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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.
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Fungal Organisms Morphologically Consistent with Candida Species
Budding yeast (3–7 μm) and/or pseudohyphae Eosinophilic to gray brown on the Papanicolaou stain
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Candida species
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Candida species“spearing” or a “shish kebab” appearance
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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
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Shift in flora suggestive of bacterial vaginosis
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• 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
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Bacteria morphologically consistent with Actinomycescotton ball” appearance with acute infalammatory cells
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Bacteria morphologically consistent with Actinomyces
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• DDX:Aggregation of lactobacilli in LBC
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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
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Cellular changes consistent with herpes simplex virus
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DDX: Multinucleated endocervical cells Multinucleated histiocytes Syncytiotrophoblast cells LSIL and HSIL
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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
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Cytomegalovirus
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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.
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Thank you