CLINICAL DETAILS CERVICOVAGINAL SMEARS OF A 40 YEAR

CLINICALLY RELEVANT ANATOMY 123 ULNAR NERVE ENTRAPMENT
LONG ISLAND BHM CONCURRENT CLINICAL PLEASE COMPLETE
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An atrophic smear usually shows few intermediate and many parabasal cells

Clinical Details

Cervico-vaginal smears of a 40 year old asymptomatic female.


Images

Image 1 (Pap, 200x)


Image 2 (Pap, 200x)


Image 3 (Pap, 200x)


Image 4 (Pap, 400x)


Choose the correct alternative

1. AGC/AIS

2. Reparative change, NILM

3. HSIL

4. HSV

The correct answer is Reparative changes, NILM


Clinical Details

Cervico-vaginal smears of a 40 year old asymptomatic female.


Description

Images show columnar and metaplastic cells in a background of inflammation and hemorrhage. Few sheets of cells showing enlarged hypochromatic nuclei, thickened but smooth nuclear membrane, finely granular chromatin and prominent nucleoli. Occasional cells show altered N:C.


Discussion

In High grade squamous intraepithelial lesions (HSIL) the nuclear abnormality is seen in small squamous and metaplastic cells. The cells show nuclear enlargement 4-5 times that of its normal counterpart with coarsely granular chromatin, jagged nuclear border and markedly increased N:C ratio. Pale dyskaryosis is also a feature often associated with HSIL. Nucleoli are absent is in HSIL. However the N:C ratio and nuclear membrane irregularity is evident. The case image shows nuclear enlargement only 2-3 times when compared to its normal counterpart. Although the nuclear membrane is thick it does not show a jagged appearance. The chromatin is pale, at times finely granular and the most important differentiating feature is presence of nucleoli. Hence these cells are not diagnostic of HSIL.


Atypical glandular cells (AGC) are those showing either endometrial or endocervical differentiation displaying nuclear atypia that exceeds obvious reactive or reparative changes but lack unequivocal features of invasive adenocarcinoma. They show sheets or strips of glandular cells with minimal overlapping, mild variation in shape and size, hyperchromatic enlarged nuclei and inconspicuous or absence of nucleoli.

Adenocarcinoma in situ (AIS) shows hyperchromatic crowded groups with pseudostratified strips, rosette formation, enlarged nuclei and variable nucleoli. Feathering is commonly seen.

The case images do not show overlapping, pseudostratification or feathering. Also hyperchromatic nuclei with subtle nuclear membrane irregularity are not seen and prominent nucleoli are present. Hence they cannot be classified as AGC or AIS


HSV infection shows nuclear moulding, ground glass appearance of the nuclei and viral intranuclear inclusions are noted. The case image does show hypochromatic nuclei with a prominent nucleoli, which do mimic HSV infection but the round nuclei, are giving a glassy appearance and nucleoli is resembling intranuclear inclusions. So the features are neither that of a true ground glass appearance nor of a viral inclusion.


In reparative changes flat sheets of cells with enlarged nuclei, anisonucleosis, smooth nuclear membrane, finely granular evenly dispersed chromatin and prominent nucleoli are seen. The case images show a similar picture. Hence a diagnosis of reparative changes with no evidence of SIL or malignancy was rendered.

Follow Up

The colposcopy of this patient showed no abnormality. The patient had an endocervical polyp that was resected and showed no histopathological abnormality.

Polyps may produce very alarming cellular changes in columnar and metaplastic cells which should not be mistaken as SIL/AGC/AIS.


References

1. Koss LG: Diagnostic Cytopathology and its Histopathologic Bases, 4th Ed.,J B Lippincott Company Philadelphia 1992

2. Bibbo M: comprehensive cytopathology, 2nd ed, by Bibbo M., 1997


Case provided by : Mrs. Sonali Gavas


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Tags: details, clinical, smears, cervicovaginal