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Gynecologic cytopathology (view source)

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[[Image:Low grade squamous intraepithelial lesion.jpg|thumb|right|250px|A cytology specimen with LSIL. [[Pap stain]]. (WC/Nephron)]]
'''Gynecologic cytopathology''' is a subset of [[cytopathology]].  ''Gynecologic'' usually refers to Pap test specimens, i.e. uterine cervix, vaginal vault; other gynecologic specimens are considered ''non-gynecologic''.
'''Gynecologic cytopathology''' is a subset of [[cytopathology]].  ''Gynecologic'' usually refers to Pap test specimens, i.e. uterine cervix, vaginal vault; other gynecologic specimens are considered ''non-gynecologic''.


This article deals only with cervical cytopathology.  An introduction to cytopathology is in the ''[[cytopathology]]'' article.
This article deals only with cervical cytopathology.  An introduction to cytopathology is in the ''[[cytopathology]]'' article.


==Preparation==
'''Cervical cytology''' redirects to this article.
 
=Preparation=
The standard for Pap test is the Papanicolaou stain.  It is described in the ''[[staining]]'' article and discussed in the context of cytopathology in the ''[[cytopathology]]'' article.
The standard for Pap test is the Papanicolaou stain.  It is described in the ''[[staining]]'' article and discussed in the context of cytopathology in the ''[[cytopathology]]'' article.


==Slide marking conventions==
=Slide marking conventions=
Conventions are important for facilitating communication between various team members.  They are discussed in the ''[[cytopathology]]'' article.
Conventions are important for facilitating communication between various team members.  They are discussed in the ''[[cytopathology]]'' article.


==Normal cells==
=Normal cells=
Squamous cell types:<ref>Half-day. 10 November 2008.</ref>
Squamous cell types:<ref>Half-day. 10 November 2008.</ref>
#Intermediate cells:
#Intermediate cells:
Line 16: Line 19:
#*Associated with progesterone - (light) blue.
#*Associated with progesterone - (light) blue.
#*This '''is''' the cell of reference in Pap test, i.e. other cells are measured against this cell when assessing a Pap test.
#*This '''is''' the cell of reference in Pap test, i.e. other cells are measured against this cell when assessing a Pap test.
#**Nucleus ~ slightly smaller than a [[neutrophil]].
#**Nucleus ~ 7-8 micrometers.
#***Slightly smaller than a [[neutrophil]].
#Parabasal cells:
#Parabasal cells:
#*Blue-grey.  
#*Blue-grey.  
#*Assoc. with atrophy.
#*Associated with atrophy.
#Basal cells:
#Basal cells:
#*Small cells.
#*Small cells.
Line 34: Line 38:
*Nucleus approximately the size of an intermediate cell nucleus.
*Nucleus approximately the size of an intermediate cell nucleus.


===Mix of cells===
===Images===
<gallery>
Image: Benign endocervical epithelium -- high mag.jpg | Endocervical epithelium - high mag. (WC)
Image: Benign endocervical epithelium -- very high mag.jpg | Endocervical epithelium - very high mag. (WC)
Image: Benign endocervical epithelium - 2 -- high mag.jpg | Endocervical epithelium - high mag. (WC)
Image: Benign endocervical epithelium - 2 -- very high mag.jpg | Endocervical epithelium - very high mag. (WC)
Image: Benign endocervical epithelium - 3 -- high mag.jpg | Endocervical epithelium - high mag. (WC)
Image: Benign endocervical epithelium - 3 -- very high mag.jpg | Endocervical epithelium - very high mag. (WC)
</gallery>
<gallery>
Image:Low-grade_sil_and_endocx.jpg | Endocervical cells and LSIL. (WC)
</gallery>
 
==Mix of cells==
The mix of cells is dependent on age and hormones:<ref>GR. 4 February 2010.</ref>
The mix of cells is dependent on age and hormones:<ref>GR. 4 February 2010.</ref>
*Progesterone - makes the Pap test blue... more intermediate cells.
*Progesterone - makes the Pap test blue... more intermediate cells.
Line 41: Line 58:
*Older patients... more estrogen, glycogen.
*Older patients... more estrogen, glycogen.


===Abnormal non-malignant cells===
==Less common non-malignant cells==
#Clue cells:
*Clue cells.
#*Purple squamous cell; squamous cell covered with bacteria.
*Squamous metaplastic cells.
#*Associated with ''bacterial vaginosis'' - which is caused by ''Gardnerella vaginalis''.<ref name="pmid3493202">{{cite journal |author=Scott TG, Smyth CJ, Keane CT |title=In vitro adhesiveness and biotype of Gardnerella vaginalis strains in relation to the occurrence of clue cells in vaginal discharges |journal=Genitourinary medicine |volume=63 |issue=1 |pages=47–53 |year=1987 |month=February |pmid=3493202 |pmc=1194007 |doi= |url=}}</ref>
*Endometrial cells.
#**''Gardnerella vaginalis'' is a rod gram variable.<ref>{{cite journal |author=Taylor-Robinson D |title=The bacteriology of Gardnerella vaginalis |journal=Scand J Urol Nephrol Suppl |volume=86 |issue= |pages=41–55 |year=1984 |pmid=6399409 |doi= |url=}}</ref>
*Atrophic cells.
#Squamous metaplasia:
*Tingible body macrophages.
#*"Dense" cytoplasm.
*Navicular cells.
#*Nucleus ~2X the size of an intermediate cell nucleus.
 
#*Nucleoli.
===Clue cells===
#*Note:
Features:
#**Squamous metaplastic cells have a similar appearance to parabasal cells; they cannot be differentiated on morphologic grounds.
*Purple squamous cell covered with rod-shaped bacteria.
#**Squamous metaplastic cells have a high NC ratio - they are differentiated from HSIL via nuclear features (dark staining + irregular nuclear contour = HSIL).
 
#**Slight nuc. contour irregularies are accepted, may be darker staining.
Notes:
#Endometrial cells:<ref>SM. 14 January 2010.</ref>
*The cytologic finding of ''[[bacterial vaginosis]]''.
#*Sheet with well-defined border that is bilayered, i.e. clump of epithelioid cells surrounded by spindle cells.
 
#*Scant cytoplasm.
Image:
#*Chromatin clumping.
#*Raisin-like nuclei - approximately the size of an intermediate cell nucleus.
#**Nuclei can be considered normal if nucleus less than 2X the size of an intermediate cell nucleus.
#*Notes:
#**Endometrial cells may appear irregular in the context of an intrauterine device (IUD); abnormalities in the context of an IUD are often ignored.
#**The presence of endometrial cells on a Pap test on a woman >=40 years old (per Bethesda guidelines) should be noted in the pathology report<ref name=pmid15900572>{{cite journal |author=Thrall MJ, Kjeldahl KS, Savik K, Gulbahce HE, Pambuccian SE |title=Significance of benign endometrial cells in papanicolaou tests from women aged >=40 years |journal=Cancer |volume=105 |issue=4 |pages=207-16 |year=2005 |month=August |pmid=15900572 |doi=10.1002/cncr.21156 |url=}}</ref> - this prompts an endometrial biopsy.
#***In my humble opinion, reporting benign endometrial cells in premenopausal women is ''not'' evidence-based practise; the practise is driven by lawsuit-paranoia in the USA.
#Atrophy:<ref>DeMay, RM. The Art & Science of Cytopathology: Exfoliative Cytology. 1996. ISBN 0-89189-322-9. PP.116-7.</ref>
#*Cells smaller.
#*Cytoplasm grey/blue.
#*No "dancing"/"sparkling" chromatin.
#*+/-"Dirty" background - degenerated cells, inflammatory cells (neutrophils, histiocytes).
#**May mimic "dirty" background of tumour, i.e. 'tumour diathesis'.
#*Note:
#**Usually older women.
#**Main DDx is HSIL which has chromatin changes.
#Tingible body macrophages:
#*Abundant cytoplasm with vacuolization.
#*May be seen in the context of chlamydia.
Images:
*[http://www.atsu.edu/faculty/chamberlain/Website/lectures/lecture/image/clue2.jpg Clue cell (atsu.edu)].
*[http://www.atsu.edu/faculty/chamberlain/Website/lectures/lecture/image/clue2.jpg Clue cell (atsu.edu)].
*[http://commons.wikimedia.org/wiki/File:Low-grade_sil_and_endocx.jpg Endocervical cells and LSIL (WC)].
 
===Squamous metaplastic cells===
Features:
*"Dense" cytoplasm.
*Nucleus ~2X the size of an intermediate cell nucleus.
**Nucleolus (small) - '''important'''.
**Regular/smooth nuclear membrane.
 
Note:
*Squamous metaplastic cells have a similar appearance to parabasal cells; they cannot be differentiated on morphologic grounds.
*Squamous metaplastic cells have a high NC ratio - they are differentiated from HSIL via nuclear features (dark staining + irregular nuclear contour = HSIL).
**Slight nuc. contour irregularies are accepted, may be darker staining.
 
====Images====
<gallery>
Image: Squamous metaplasia - Pap test -- high mag.jpg | SM - high mag. (WC)
Image: Squamous metaplasia - Pap test -- very high mag.jpg | SM - very high mag. (WC)
Image: Squamous metaplasia - Pap test - alt -- very high mag.jpg | SM - very high mag. (WC)
</gallery>
 
===Endometrial cells===
Features:<ref>SM. 14 January 2010.</ref>
*Cluster of cells with a well-defined border that is bilayered, i.e. a clump of (epithelioid) stromal cells surrounded by (flatted) glandular cells. Classically described as a cluster with a ''double contour''; known as ''exodus pattern''.<ref>URL: [http://nih.techriver.net/view.php?patientId=78 http://nih.techriver.net/view.php?patientId=78]. Accessed on: 31 March 2012.</ref>
*Scant cytoplasm.
*Chromatin clumping.
*Raisin-like nuclei - approximately the size of an intermediate cell nucleus.
**Nuclei can be considered normal if nucleus less than 2X the size of an intermediate cell nucleus.
 
Notes:
*Endometrial cells may appear irregular in the context of an [[intrauterine device]] (IUD); abnormalities in the context of an IUD are often ignored.
**Cytology: cytoplasmic vacuolization, +/-multinucleation.
***May be [[signet ring cell carcinoma|signet ring cell]]-like.
*The presence of endometrial cells on a Pap test on a woman >=40 years old (per Bethesda guidelines) should be noted in the pathology report<ref name=pmid15900572>{{cite journal |author=Thrall MJ, Kjeldahl KS, Savik K, Gulbahce HE, Pambuccian SE |title=Significance of benign endometrial cells in papanicolaou tests from women aged >=40 years |journal=Cancer |volume=105 |issue=4 |pages=207-16 |year=2005 |month=August |pmid=15900572 |doi=10.1002/cncr.21156 |url=}}</ref> - this prompts an endometrial biopsy.
**The practise of reporting ''benign'' endometrial cells in premenopausal women is ''not'' backed by evidence that demonstrates a significant benefit.
 
====Images====
<gallery>
Image: Endometrial cells on Pap - 2 -- very high mag.jpg | Endometrial cells - very high mag.
Image: Endometrial cells on Pap - 2 -- very high mag.gif | Endometrial cells - very high mag.
Image: Endometrial cells on Pap - 2a -- very high mag.jpg | Endometrial cells - very high mag.
Image: Endometrial cells on Pap - 2a -- very high mag.gif | Endometrial cells - very high mag.
</gallery>
<gallery>
Image: Endometrial cells on Pap -- high mag.jpg | Endometrial cells - high mag.
Image: Endometrial cells on Pap -- very high mag.jpg | Endometrial cells - very high mag.
Image: Endometrial cells on Pap - alt -- very high mag.jpg | Endometrial cells - very high mag.
</gallery>
www:
*[http://rapids001.techriver.net/nih/patientImages/1826.jpg Endometrial cells - double contour (techriver.net)].
*[http://rapids001.techriver.net/nih/patientImages/1826.jpg Endometrial cells - double contour (techriver.net)].
*[http://nih.techriver.net/view.php?patientId=221 Endometrial cells with "exodus" pattern (techriver.net)].
*[http://nih.techriver.net/view.php?patientId=221 Endometrial cells with "exodus" pattern (techriver.net)].
===Atrophic cells===
Features:<ref>DeMay, RM. The Art & Science of Cytopathology: Exfoliative Cytology. 1996. ISBN 0-89189-322-9. PP.116-7.</ref>
*Cells smaller.
*Cytoplasm grey/blue.
*No "dancing"/"sparkling" chromatin.
*+/-"Dirty" background - degenerated cells, inflammatory cells (neutrophils, histiocytes).
**May mimic "dirty" background of tumour, i.e. 'tumour diathesis'.
Notes:
*Usually older women.
*May be a cellular cluster.
DDx:
*[[HSIL]] - chromatin pattern irregular.
===Tingible body macrophages===
Features:
*Abundant cytoplasm with vacuolization.
*May be seen in the context of chlamydia.
===Navicular cells===
{{Main|Navicular cell}}
Features:
*Intermediate cells with:
*#Folded edges.
*#Abundant cytoplasmic glycogen - central yellow.
====Images====
<gallery>
Image: Navicular cell -- very high mag.jpg | NC - very high mag.
Image: Navicular cell - alt -- very high mag.jpg | NC - very high mag.
Image: Navicular cell -- extremely high mag.jpg | NC - extremely high mag.
Image: Navicular cells -- extremely high mag.jpg | NCs - extremely high mag.
</gallery>


==Glycogen halos versus HPV effect==
==Glycogen halos versus HPV effect==
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|}
|}


==Gynecologic pathology in tables==
=Gynecologic pathology in tables=
===Normal cells===
==Normal cells==
{| class="wikitable"
{| class="wikitable sortable"
! Cell
! Cell
! Architecture
! Architecture
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| Irregular
| Irregular
| '''Blue, abundant'''
| '''Blue, abundant'''
| Small nucleus (~ size of PMN), no [[nucleolus]]
| Small nucleus (~ size of [[PMN]]), no [[nucleolus]]
| -
| -
|-  
|-  
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| Dense, dark blue
| Dense, dark blue
| 2X IC nucleus, '''nucleolus''', no membrane irreg., no chromatin changes
| 2X IC nucleus, '''nucleolus''', no membrane irreg., no chromatin changes
| DDx: HSIL, basal cell
| DDx: [[HSIL]], basal cell
|-
|-
| Endometrial cell
| Endometrial cell
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| DDx: HSIL
| DDx: HSIL
|-
|-
| Radiation change
| [[Radiation changes in cervical cytology|Radiation changes]]
| Single cells/groups
| Single cells/groups
| Well-circumscribed
| Well-circumscribed
| vacuolated, usu. abundant
| vacuolated, usu. abundant
| '''Normal NC ratio''', enlarged nucleus, no nuclear membrane irregularies
| '''Normal NC ratio''', enlarged nucleus, no nuclear membrane irregularies, +/-multinucleation
| DDx: LSIL, vitamin B12 def.
| DDx: [[LSIL]], vitamin B12 def.
|}
|}
Note:
Note:
*If ''only'' normal cells are present the diagnosis is ''negative for intraepithelial lesion and malignancy'' (NILM).
*If ''only'' normal cells are present the diagnosis is ''negative for intraepithelial lesion and malignancy'' (NILM).


===Abnormal cells===
==Abnormal cells==
{| class="wikitable"
{| class="wikitable"
! Cell
! Cell
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! DNA
! DNA
! Other
! Other
! Image
|-
|-
| Low-grade squamous intraepithelial lesion (LSIL)
| [[Low-grade squamous intraepithelial lesion]] (LSIL)
| Single cells/groups
| Single cells/groups
| Irregular or moderately-circumscribed
| Irregular or moderately-circumscribed
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| Large nucleus (3-4X IC nuc. - see ''Note 1''), perinuclear clearing, nuc. membrane irregularities, chromatin clumping  
| Large nucleus (3-4X IC nuc. - see ''Note 1''), perinuclear clearing, nuc. membrane irregularities, chromatin clumping  
| DDx: HSIL, reactive changes
| DDx: HSIL, reactive changes
| [[Image:Low-grade squamous intraepithelial lesion - 3 -- very high mag.jpg| thumb|center|150px|LSIL (WC)]]
|-
|-
| High-grade squamous intraepithelial lesion (HSIL)
| [[High-grade squamous intraepithelial lesion]] (HSIL)
| Often single cells, may be groups
| Often single cells, may be groups
| Well-circumscribed
| Well-circumscribed
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| Large nucleus (3-4X IC nuc. - see ''Note 1''), '''nuc. membrane irregularities, clumping of coarse chromatin, dark nuc. staining''', +/- small nucleoli
| Large nucleus (3-4X IC nuc. - see ''Note 1''), '''nuc. membrane irregularities, clumping of coarse chromatin, dark nuc. staining''', +/- small nucleoli
| DDx: squamous metaplasia, atrophy with atypia, superficial endometrial cells
| DDx: squamous metaplasia, atrophy with atypia, superficial endometrial cells
| [[Image:High-grade squamous intraepithelial lesion - 2 -- very high mag.jpg |thumb|center|150px|HSIL (WC)]]
|-
|-
| Atypical squamous cells of unknown significance (ASCUS)
| [[Atypical squamous cells of undetermined significance]] (ASC-US)
| Single cells/groups
| Single cells/groups
| Irregular or moderately-circumscribed
| Irregular or moderately-circumscribed
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| '''Moderately enlarged nucleus''' (~2.5-3.0X IC nuc.), minimal changes in nuclear membrane and chromatin
| '''Moderately enlarged nucleus''' (~2.5-3.0X IC nuc.), minimal changes in nuclear membrane and chromatin
| DDx: LSIL, reactive changes
| DDx: LSIL, reactive changes
|
|-
|-
| Atypical squamous cells cannot exclude HSIL (ASC-H)
| [[Atypical squamous cells, cannot exclude HSIL]] (ASC-H)
| Often single cells, may be groups
| Often single cells, may be groups
| Irregular or moderately-circumscribed
| Irregular or moderately-circumscribed
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| '''Moderately enlarged nucleus''' (~1.5-2.0X IC nuc.), minimal changes in nuclear membrane and chromatin
| '''Moderately enlarged nucleus''' (~1.5-2.0X IC nuc.), minimal changes in nuclear membrane and chromatin
| DDx: HSIL, AIS
| DDx: HSIL, AIS
|
|-
|-
| Atypical glandular cell (AGC)
| [[Atypical glandular cells]] (AGC)
| Usu. groups of cells
| Usu. groups of cells
| Usually well-circumscribed (?)
| Usually well-circumscribed (?)
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| Moderately enlarged nucleus (~2X IC nuc.), '''nuc. membrane irregularities, chromatin clumping, dark nuc. staining''', nucleoli
| Moderately enlarged nucleus (~2X IC nuc.), '''nuc. membrane irregularities, chromatin clumping, dark nuc. staining''', nucleoli
| DDx: AIS, HSIL
| DDx: AIS, HSIL
|
|-
|-
| Adenocarinoma in situ (AIS)
| [[Adenocarcinoma in situ]] (AIS)
| groups; '''rosette formation'''
| groups; '''rosette formation'''
| Usually well-circumscribed
| Usually well-circumscribed
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| Large nucleus (>=2X IC nuc.), '''nuc. membrane irregularities, chromatin clumping, dark nuc. staining''', nucleoli (very common), pseudostratification (as in endocervical AIS)
| Large nucleus (>=2X IC nuc.), '''nuc. membrane irregularities, chromatin clumping, dark nuc. staining''', nucleoli (very common), pseudostratification (as in endocervical AIS)
| DDx: AGC, HSIL
| DDx: AGC, HSIL
| [[Image:Endocervical adenocarcinoma in situ - cyto -- very high mag.jpg|thumb|center|150px|Endocervical AIS (WC)]]
|-
|-
| Features of SCC (see ''Note 2'')
| Features of SCC (see ''Note 2'')
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| Large NC ratio, '''nucleolus''', nuc. membrane irregularities, chromatin clumping
| Large NC ratio, '''nucleolus''', nuc. membrane irregularities, chromatin clumping
| DDx: HSIL
| DDx: HSIL
|
|}
|}


Line 233: Line 321:
*By definition, it is not possible to diagnose [[squamous cell carcinoma]] (SCC) on a pap test as one cannot demonstrate stromal invasion.
*By definition, it is not possible to diagnose [[squamous cell carcinoma]] (SCC) on a pap test as one cannot demonstrate stromal invasion.


====HSIL versus LSIL====
===HSIL versus LSIL===
{| class="wikitable"
{| class="wikitable"
!
!
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| Hypermature (orangeophilic cell present)
| Hypermature (orangeophilic cell present)
|-
|-
| Image (example)
| Images (example)
| [http://commons.wikimedia.org/w/index.php?title=File:High-grade_squamous_intraepithelial_lesion.jpg HSIL (WC)]
| [[Image:High-grade_squamous_intraepithelial_lesion.jpg |thumb|center|150px| HSIL (WC)]] [[Image:High-grade squamous intraepithelial lesion - 4 -- very high mag.jpg| thumb|center|150px| HSIL (WC)]]
| [http://commons.wikimedia.org/w/index.php?title=File:Low-grade_squamous_intraepithelial_lesion.jpg LSIL (WC)], [http://commons.wikimedia.org/wiki/File:Low-grade_sil_and_endocx.jpg LSIL & endoCx (WC)]
| [[Image:Low-grade_squamous_intraepithelial_lesion.jpg |thumb|center|150px| LSIL (WC)]] [[Image:Low-grade_sil_and_endocx.jpg |thumb|center|150px| LSIL & endoCx (WC)]]
|}
|}


Line 278: Line 366:
**LSIL cells: classically the size of IC.
**LSIL cells: classically the size of IC.


===Infectious organisms===
==Infectious organisms==
{| class="wikitable"
{| class="wikitable sortable"
! Disease
! Disease
! Organism
! Organism
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! Image
! Image
|-
|-
| Trichomoniasis
| [[Trichomoniasis]]
| Trichomonas vaginalis
| Trichomonas vaginalis
| Protozoan
| Protozoan
| '''Pale-grey fluffy cytoplasm with well-defined nucleus''', approx. 30 micrometres.
| Pear-shaped '''pale-grey fluffy cytoplasm with well-defined nucleus''', approx. 30 μm.
| Acute inflammation (PMNs)
| Acute inflammation (PMNs), may be seen with Leptothrix (hair-like appearance ~0.5 x 20 μm)
| Sexually transmitted
| Sexually transmitted
| <ref name=Ref_WMSP446>{{Ref WMSP|446}}</ref>
| <ref name=Ref_WMSP446>{{Ref WMSP|446}}</ref>
| [http://commons.wikimedia.org/wiki/File:Trichomonas_pap_test.jpg T. vaginalis - Pap stain (WC)], [http://commons.wikimedia.org/wiki/File:Pap_test_trichomonas.JPG Trichomonas - Pap stain (WC)]
| [[Image:Trichomonas_pap_test.jpg |thumb|150px|center|T. vaginalis - Pap stain (WC)]] [[Image:Trichomonas - Pap - 3 -- very high mag.jpg |thumb|150px|center|Trichomonas - Pap stain (WC)]]
|-
|-
| Candidiasis
| [[Gynecologic_cytopathology#Candida|Candidiasis]]
| Candida albicans
| Candida albicans
| [[Fungi]]
| [[Fungi]]
Line 305: Line 393:
| ?
| ?
| ?
| ?
| [http://commons.wikimedia.org/w/index.php?title=File:Candida_pap_1.jpg Candida on Pap test (WC)]
| [[Image:Candida_pap_1.jpg|thumb|150px|center| Candida on Pap test (WC)]]
|-
|-
| Herpes
| [[Gynecologic_cytopathology#Herpes simplex virus|Herpes]]
| [[Herpes simplex virus]] (HSV 1 - less commonly, HSV 2 - more commonly)
| [[Herpes simplex virus]] (HSV 1 - less commonly, HSV 2 - more commonly)
| [[Virus]]
| [[Virus]]
Line 314: Line 402:
| Sexually transmitted
| Sexually transmitted
| ?
| ?
| [http://commons.wikimedia.org/wiki/File:Herpes_simplex_virus_pap_test.jpg HSV (WC)],[http://commons.wikimedia.org/wiki/File:Herpes_simplex_virus_pap_test_2.jpg HSV (WC)], [http://www.virology.org/sbpgphoto2.html Herpes simplex virus - surgical (virology.org)]
| [[Image:Herpes_simplex_virus_pap_test.jpg |thumb|center|150px| HSV (WC)]] [[Image:Herpes_simplex_virus_pap_test_2.jpg |thumb|center|150px| HSV (WC)]]
|-
|-
| Actinomycetes
| [[Gynecologic_cytopathology#Actinomycetes|Actinomycetes]]
| Actinomycetes
| Actinomycetes
| Gram-positive bacteria  
| Gram-positive bacteria  
| '''Clusters of cocci in chains - hyphae-like appearance'''
| '''Clusters of cocci in chains - hyphae-like appearance'''
| ?
| low power: pom-pom ''or'' fuzzy ball-like appearance
| Should prompt removal of IUD, if present.
| Should prompt removal of [[IUD]], if present.
| <ref name=Ref_WMSP446>{{Ref WMSP|446}}</ref>
| <ref name=Ref_WMSP446>{{Ref WMSP|446}}</ref>
| [http://www.sas.upenn.edu/~jbryson/webpics/Actinomycetes3.jpg Actinomycetes (upenn.edu)]
| [http://www.gfmer.ch/selected_images_v2/detail_list.php?cat1=4&cat2=23&cat3=552&cat4=6&stype=n Actinomycetes (gfmer.ch)], [http://o.quizlet.com/Swjzk-aC7Ah8aYQmYzQ8Kg_m.jpg Actinomycetes (quizlet.com)]
|-
|-
| Bacterial vaginosis (see ''Note 1'')
| [[Bacterial vaginosis]] (see ''Note 1'')
| Gardnerella vaginalis
| Gardnerella vaginalis
| Gram-variable rod
| Gram-variable rod
Line 332: Line 420:
| Fishy smell
| Fishy smell
| ?
| ?
| [http://commons.wikimedia.org/wiki/File:Vaginose-G15.jpg Bacterial vaginosis (WC)], [http://www.atsu.edu/faculty/chamberlain/Website/lectures/lecture/image/clue2.jpg Clue cell (atsu.edu)]
| [[File:Vaginose-G15.jpg|thumb|center|150px|Bacterial vaginosis (WC)]] [http://www.atsu.edu/faculty/chamberlain/Website/lectures/lecture/image/clue2.jpg Clue cell (atsu.edu)]
|}
|}


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*Usually not reported.
*Usually not reported.


==Adequacy of specimens==
=Adequacy of specimens=
There is a generally accepted standard for cervical (liquid-based) cytology specimens:<ref>UHN PCY50001.08 P.10.</ref>
There is a generally accepted standard for cervical (liquid-based) cytology specimens:<ref>UHN PCY50001.08 P.10.</ref>
*>5000 squamous cells/slide, if no abnormality is present.
*>5000 squamous cells/slide, if no abnormality is present.
Line 347: Line 435:


Note:
Note:
*The standard for conventional pap smears is: 8000-12000 squamous cells/slide.<ref>GR. 4 February 2010.</ref>
*The standard for conventional pap smears is: 8000-12000 (well-visualized) squamous cells.<ref name=pmid12645338>{{Cite journal  | last1 = Sheffield | first1 = MV. | last2 = Simsir | first2 = A. | last3 = Talley | first3 = L. | last4 = Roberson | first4 = AJ. | last5 = Elgert | first5 = PA. | last6 = Chhieng | first6 = DC. | title = Interobserver variability in assessing adequacy of the squamous component in conventional cervicovaginal smears. | journal = Am J Clin Pathol | volume = 119 | issue = 3 | pages = 367-73 | month = Mar | year = 2003 | doi =  | PMID = 12645338 }}</ref>
 
===Transformation zone (TZ)===
===Transformation zone (TZ)===
The presence of the TZ should be commented on:<ref>GR. 4 February 2010.</ref>
The presence of the TZ should be commented on:<ref>GR. 4 February 2010.</ref>
Line 357: Line 446:
*Young nulliparous.
*Young nulliparous.


=Specific entities - infectious=
==Candida==
==Candida==
{{Main|Candidiasis}}
===General===
*Common.
*May be asymptomatic.
*Usually ''Candida albicans''.
===Cytology===
Features:
Features:
*Typically in clusters - lead to darkened clusters of squamous cells (at low power).
*Typically in clusters - lead to darkened clusters of squamous cells (at low power).
Line 366: Line 463:
*Presence should be noted in the pathology report.
*Presence should be noted in the pathology report.


Images:
====Images====
<gallery>
Image:Candida_pap_1.jpg | Candida on Pap test - example 1. (WC)
Image:Candida_pap_2.jpg | Candida on Pap test - example 2. (WC)
</gallery>
<gallery>
Image: Candida - Pap test -- high mag.jpg | Candida - high mag. (WC)
Image: Candida - Pap test -- very high mag.jpg | Candida - very high mag. (WC)
</gallery>
=====www=====
*[http://www.flickr.com/photos/moorepix4u2c/1425271033/in/set-72157602113534479/ Candida on Pap test (flickr.com)].
*[http://www.flickr.com/photos/moorepix4u2c/1425271033/in/set-72157602113534479/ Candida on Pap test (flickr.com)].
*[http://commons.wikimedia.org/w/index.php?title=File:Candida_pap_1.jpg Candida on Pap test - example 1 (WC)].
*[http://commons.wikimedia.org/w/index.php?title=File:Candida_pap_2.jpg Candida on Pap test - example 2 (WC)].


==Trichomonas==
==Trichomoniasis==
===General===
*Caused by ''Trichomonas vaginalis'' - a protozoa.
*Sexually transmitted.
*Sexually transmitted.
*Common.
*Occasionally found in [[urine cytology]] specimens.<ref>{{cite journal |authors=Doxtader EE, Elsheikh TM |title=Diagnosis of trichomoniasis in men by urine cytology |journal=Cancer Cytopathol |volume=125 |issue=1 |pages=55–59 |date=January 2017 |pmid=27636204 |doi=10.1002/cncy.21778 |url=}}</ref>


===Cytopathology===
===Cytopathology===
Features:
Features:
*Low power: grey blob with a nucleus.
*Low power: grey blob with a nucleus, may be pear-shaped:
**Size: approximately 30 micrometres.<ref name=Ref_WMSP446>{{Ref WMSP|446}}</ref>
**Size: approximately 30 micrometres.<ref name=Ref_WMSP446>{{Ref WMSP|446}}</ref>
**Shape: usually oval, may have teardrop-shaped.
**Shape: usually oval, may have teardrop-shaped.
Line 390: Line 498:
Notes:
Notes:
*Trichomonas is tricky - it is easy to miss if one is not suspicious, in the context of inflammation.
*Trichomonas is tricky - it is easy to miss if one is not suspicious, in the context of inflammation.
*May vaguely resemble a neutrophil:
*May vaguely resemble a [[neutrophil]]:
**Flagellum useful to differentiate.
**Flagellum useful to differentiate.
**Neutrophil has multiple lobulations of the nucleus.
**Neutrophil has multiple lobulations of the nucleus.
*May be seen in association of Leptothrix.
**Appearance: long, hair-like.
**Size: ~0.5 x 20 micrometres.


Images:
====Images====
*[http://commons.wikimedia.org/wiki/File:Trichomonas_pap_test.jpg T. vaginalis - Pap stain (WC)].
<gallery>
*[http://commons.wikimedia.org/wiki/File:Pap_test_trichomonas.JPG T. Vaginalis - Pap stain (WC)].
Image:Trichomonas_pap_test.jpg | T. vaginalis - Pap stain. (WC)
*[http://commons.wikimedia.org/wiki/File:Trichomonas_vaginalis_01.jpg Trichomonas vaginalis - Giemsa stain (WC)].
Image:Pap_test_trichomonas.JPG | T. vaginalis - Pap stain. (WC)
*[http://www.bioweb.uncc.edu/1110lab/notes/notes1/labpics/Trichomonas%20100x.jpg T. vaginalis - Giemsa stain, high magnification (bioweb.uncc.edu)].
Image:Trichomonas_vaginalis_01.jpg | Trichomonas vaginalis - Giemsa stain. (WC)
</gallery>
<gallery>
Image: Trichomonas - Pap - 2 -- high mag.jpg | Trichomonas - high mag.
Image: Trichomonas - Pap - 2 -- very high mag.jpg | Trichomonas - very high mag.
</gallery>
<gallery>
Image: Trichomonas - Pap - 3 -- high mag.jpg | Trichomonas - high mag.
Image: Trichomonas - Pap - 3 -- very high mag.jpg | Trichomonas - very high mag.
</gallery>
=====www=====
*[http://nih.techriver.net/view.php?patientId=305 Trichomonas and Leptothrix (nih.techriver.net)].
*[http://nih.techriver.net/view.php?patientId=325 Trichomonas and Leptothrix (nih.techriver.net)].


==Herpes simplex virus==
==Herpes simplex virus==
{{Main|Herpes simplex virus}}
===General===
*May be ''HSV1'' or ''HSV2''.
**Classically HSV2 based on epidemiology and location.
===Cytology===
Features:<ref name=Ref_WMSP446>{{Ref WMSP|446}}</ref>
Features:<ref name=Ref_WMSP446>{{Ref WMSP|446}}</ref>
#Early: Large "ground-glass" nuclei - nuclei with hazy & uniformly dull appearance.
#Early: Large "ground-glass" nuclei - nuclei with hazy & uniformly dull appearance.
#Late: multi-nucleation with moulding of nuclei and nuclear inclusions surrounded by a clear halo.
#Late: multi-nucleation with moulding of nuclei and nuclear inclusions surrounded by a clear halo.
DDx:
*[[Reactive endocervical cells]] - may be multinucleated.
====Image====
<gallery>
Image:Herpes simplex virus pap test.jpg | HSV on pap test. (WC)
</gallery>


==Actinomycetes==
==Actinomycetes==
Line 420: Line 557:
*''Mycete'' = fungus.<ref>URL: [http://en.wiktionary.org/wiki/-mycete#English http://en.wiktionary.org/wiki/-mycete#English]. Accessed on: 14 September 2011.</ref>
*''Mycete'' = fungus.<ref>URL: [http://en.wiktionary.org/wiki/-mycete#English http://en.wiktionary.org/wiki/-mycete#English]. Accessed on: 14 September 2011.</ref>


==Squamous intraepithelial lesion (SIL)==
DDx - sulfur granule:<ref name=asc_cockle>URL: [http://www.cytology-asc.com/cec/normal/index.htm#cockle http://www.cytology-asc.com/cec/normal/index.htm#cockle]. Accessed on: 10 April 2012.</ref>
*Hematoidin (cockleburr) crystal - radiating crystal, refractile, classically golden-brown.
 
==Bacterial vaginosis==
===General===
*Benign.
*Very common.
*Classically associated with ''Gardnerella vaginalis''.<ref name=pmid3493202>{{cite journal |author=Scott TG, Smyth CJ, Keane CT |title=In vitro adhesiveness and biotype of Gardnerella vaginalis strains in relation to the occurrence of clue cells in vaginal discharges |journal=Genitourinary medicine |volume=63 |issue=1 |pages=47–53 |year=1987 |month=February |pmid=3493202 |pmc=1194007 |doi= |url=}}</ref><ref name=pmid22082330>{{Cite journal  | last1 = Polatti | first1 = F. | title = Bacterial vaginosis, Atopobium vaginae and nifuratel. | journal = Curr Clin Pharmacol | volume = 7 | issue = 1 | pages = 36-40 | month = Feb | year = 2012 | doi =  | PMID = 22082330 }}</ref>
 
Clinical:
*Fishy odor.
 
Treatment:
*Antibiotics (metronidazole or clindamycin).<ref name=pmid22082330/>
 
===Cytopathology===
Features:
*Purple squamous cell covered with rod-shaped micro-organisms.
 
Image:
*[http://www.atsu.edu/faculty/chamberlain/Website/lectures/lecture/image/clue2.jpg Clue cell (atsu.edu)].
 
===Stains===
*Gram stain +ve/-ve.
**''Gardnerella vaginalis'' is a gram variable rod.<ref name=pmid6399409>{{cite journal |author=Taylor-Robinson D |title=The bacteriology of Gardnerella vaginalis |journal=Scand J Urol Nephrol Suppl |volume=86 |issue= |pages=41–55 |year=1984 |pmid=6399409 |doi= |url=}}</ref>
 
===Sign out===
*Usually not reported.
 
=Squamous intraepithelial lesions=
*Abbreviated ''SIL''.
 
General:
General:
*The nucleus makes it SIL.
*The nucleus makes it SIL.
Line 427: Line 595:
Management (in short):
Management (in short):
*LSIL = repeat Pap test in 6 months.
*LSIL = repeat Pap test in 6 months.
*HSIL = referal for coloposcopy.
*HSIL = referral for coloposcopy.


==Low-grade squamous intraepithelial lesion==
==Low-grade squamous intraepithelial lesion==
*Abbreviated '''LSIL'''.
*Abbreviated '''LSIL'''.
{{Main|Low-grade squamous intraepithelial lesion}}
===General===
===General===
*Usually regress, i.e. will disappear on their own.
*Usually regress, i.e. will disappear on their own.
*Low inter-rater concordance.<ref name=pmid22007754>{{Cite journal  | last1 = Bigras | first1 = G. | last2 = Wilson | first2 = J. | last3 = Russell | first3 = L. | last4 = Johnson | first4 = G. | last5 = Morel | first5 = D. | last6 = Saddik | first6 = M. | title = Interobserver concordance in the assessment of features used for the diagnosis of cervical atypical squamous cells and squamous intraepithelial lesions (ASC-US, ASC-H, LSIL and HSIL). | journal = Cytopathology | volume = 24 | issue = 1 | pages = 44-51 | month = Feb | year = 2013 | doi = 10.1111/j.1365-2303.2011.00930.x | PMID = 22007754 }}</ref>


===Cytopathology===
===Cytopathology===
Features:
Features:
*Nuclei 3x size of intermediate cell.
#Nuclei 3x size of intermediate cell - '''key feature'''. †
*Irreg. nuclear border.
#Irregular nuclear border.
*Perinuclear 'cavity' (clearing).
#+/-Perinuclear 'cavity' (clearing).
**The best perinuclear halos have a sharp punched-out edge.
#*The best perinuclear halos have a sharp punched-out edge.
#Chromatin clumping/irregular & granular.
 
Note:
* † Nucleus diameter ~21-24 μm.
* In the context of exams: 2 of criteria 1-3 is enough to call LSIL.<ref>Chan, S. 26 April 2012.</ref>
 
====Images====
<gallery>
Image:Low-Grade_SIL_with_HPV_Effect.jpg | LSIL with HPV effect. (WC)
Image:Low_grade_squamous_intraepithelial_lesion.jpg | LSIL. (WC)
Image:ThinPrep_Pap_smear_HPV.jpeg | LSIL. (WC)
</gallery>
www:
*[http://www.flickr.com/photos/moorepix4u2c/1440144102/in/set-72157602113534479/ Possible LSIL (flickr.com)].


Images:
===Sign out===
*[http://www.flickr.com/photos/moorepix4u2c/1440144102/in/set-72157602113534479/ LSIL ? (flickr.com)].
<pre>
*[http://commons.wikimedia.org/wiki/File:Low-Grade_SIL_with_HPV_Effect.jpg LSIL with HPV effect (WC)].
Low grade squamous intraepithelial lesion (LSIL).  
</pre>
 
====Cannot exclude HSIL====
<pre>
At least low grade squamous intraepithelial lesion; CANNOT EXCLUDE high-grade squamous intraepithelial lesion.
</pre>


==High-grade intraepithelial lesion==
==High-grade squamous intraepithelial lesion==
*Abbreviated '''HSIL'''.
*Abbreviated '''HSIL'''.
{{Main|Squamous intraepithelial lesion of the uterine cervix}}
===General===
===General===
*Often progress to cervical cancer.
*Often progress to [[cervical cancer]].


===Cytopathology===
===Cytopathology===
Features:
Features:
*Often single cells.
*Often single cells, may be in clusters.
*Blue cells - nucleus and cytoplasm.
*Blue cells - nucleus and cytoplasm.
*Increased NC ratio - '''key feature'''.
*Increased NC ratio - '''key feature'''.
*Irregular nuclear border.
**Irregular nuclear border.
*Chromatin clumping.
**Chromatin clumping.
 
Note:
*Nucleoli uncommon - should prompt consideration of [[squamous carcinoma]].
 
DDx:
*[[LSIL]].
*[[ASC-H]].
*[[Squamous carcinoma]].


Image:
====Images====
*[http://commons.wikimedia.org/wiki/File:High-Grade_SIL.jpg HSIL (WC)].
<gallery>
*[http://commons.wikimedia.org/wiki/File:ThinPrep_Pap_smear_HPV.jpeg HSIL (WC)].
Image:High-Grade_SIL.jpg | HSIL. (WC)
Image:High-grade_squamous_intraepithelial_lesion.jpg | HSIL. (WC/Nephron)
</gallery>


===Squamous cell carcinoma===
===Squamous cell carcinoma===
Line 469: Line 670:


Features suggestive of invasion:
Features suggestive of invasion:
*Nucleoli.
*Loose clumps of ovoid-to-spindled cells with:
*Blood.
**+/-Orange/red cytoplasm (orangeophilic cytoplasm).
*Necrotic debris.
**Nucleoli - '''key feature'''.
*Clumps of large cells.
**Coarse chromatin.
**Nuclear hyperchromasia.
*Necrotic debris - often obscures cell borders:
**Anucleate, fragmented cells - cytoplasm-like material.
**Neutrophils.
 
Note:
*Nucleoli DDx:
**[[Reactive squamous epithelium of the uterine cervix|Reactive changes]].
**Glandular lesions ([[adenocarcinoma in situ]], atypical glandular cells).


Image:
Image:
*[http://commons.wikimedia.org/wiki/File:Squamous_cell_carcinoma_in_the_cervix,_pap_stain.jpg HSIL with features suggestive of invasion (WC)]
*[http://commons.wikimedia.org/wiki/File:Squamous_cell_carcinoma_in_the_cervix,_pap_stain.jpg HSIL with features suggestive of invasion (WC)]


==Atypical squamous cells of unknown significance==
=Glandular lesions=
*Abbreviated ''ASCUS''.
==Adenocarcinoma in situ==
===General===
*Abbreviated ''AIS''.
*This is a [[waffle diagnosis|waffle category]] that should be used very rarely.
**Residents should not use it.
 
===Cytology===
Features:
*Nuclear size >2.5X IC nucleus, but <3X IC nucleus.


==Adenocarcinoma==
''Adenocarcinoma in situ'' on Pap test is classically divided into:
Adenocarcinoma on Pap test is classically divided into:
*Endocervical.
*Endocervical.
*Uterine.
*Uterine.
*Extra-uterine.
*Extra-uterine.


===Adenocarcinoma vs. squamous carcinoma===
Adenocarcinoma vs. squamous carcinoma:
*"Feathering" - seen in adenocarcinoma<ref>URL: [http://www.cytology-asc.com/cec/endocx/ http://www.cytology-asc.com/cec/endocx/]. Accessed on: 13 September 2011.</ref> more commonly on smears.<ref name=pmid18335553>{{Cite journal  | last1 = Belsley | first1 = NA. | last2 = Tambouret | first2 = RH. | last3 = Misdraji | first3 = J. | last4 = Muzikansky | first4 = A. | last5 = Russell | first5 = DK. | last6 = Wilbur | first6 = DC. | title = Cytologic features of endocervical glandular lesions: comparison of SurePath, ThinPrep, and conventional smear specimen preparations. | journal = Diagn Cytopathol | volume = 36 | issue = 4 | pages = 232-7 | month = Apr | year = 2008 | doi = 10.1002/dc.20782 | PMID = 18335553 | URL=http://onlinelibrary.wiley.com/doi/10.1002/dc.20782/pdf }}</ref>
*Adenocarcinoma:
*"Birdtails" - seen on liquid preparations.
**Mucin vacuole.
**Eccentric nucleus.
*Endocervical adenocarcinoma in situ:
**"Feathering" - seen in adenocarcinoma<ref>URL: [http://www.cytology-asc.com/cec/endocx/ http://www.cytology-asc.com/cec/endocx/]. Accessed on: 13 September 2011.</ref> more commonly on smears.<ref name=pmid18335553>{{Cite journal  | last1 = Belsley | first1 = NA. | last2 = Tambouret | first2 = RH. | last3 = Misdraji | first3 = J. | last4 = Muzikansky | first4 = A. | last5 = Russell | first5 = DK. | last6 = Wilbur | first6 = DC. | title = Cytologic features of endocervical glandular lesions: comparison of SurePath, ThinPrep, and conventional smear specimen preparations. | journal = Diagn Cytopathol | volume = 36 | issue = 4 | pages = 232-7 | month = Apr | year = 2008 | doi = 10.1002/dc.20782 | PMID = 18335553 | URL=http://onlinelibrary.wiley.com/doi/10.1002/dc.20782/pdf }}</ref>
**"Birdtails" - seen on liquid preparations.
*Squamous carcinoma:
**Orangeophilic cytoplasm.
**Central nucleus.


Images:
===Images===
www:
*[http://www.cytology-asc.com/cec/endocx/endo4.html Feathering in adenocarcinoma (cytology-asc.com)].
*[http://www.cytology-asc.com/cec/endocx/endo4.html Feathering in adenocarcinoma (cytology-asc.com)].
*[http://www.edupathonline.com/apps/blog/show/3692069-endocervical-ais AIS (edupathonline.com)].
*[http://www.edupathonline.com/apps/blog/show/3692069-endocervical-ais AIS (edupathonline.com)].


==Adenocarcinoma of the endocervix==
==Endocervical adenocarcinoma in situ==
{{Main|Endocervical adenocarcinoma in situ}}
*[[AKA]] ''adenocarcinoma in situ of the endocervix''.
===General===
*Associated with [[HPV]].
*Associated with [[HPV]].
**May be seen in conjunction with a SIL.
*Management - like AGC and other types of AIS: coloscopy +/- endometrial biopsy.


===Cytopathology===
===Cytopathology===
Features:
Features:
*Cluster of small cells.
*Cluster of small cells with:
**Cells approximately the size of a lymphocyte ~ 10 micrometres.
**Moderate nuclear enlargement.
*Nucleoli - '''key feature''' (may be subtle).
**Coarse chromatin.
**Nucleoli - prominent - '''key feature'''.
**+/-Mitoses.
*"Feathering" - picket fence-like arrangement of the cells at the edge of the cell cluster.
*Apoptotic/necrotic cells.


Negatives:
Negatives:
Line 514: Line 734:
**Cilia on cells is a feature of benignancy and should sway the pathologist away from adenocarcinoma.
**Cilia on cells is a feature of benignancy and should sway the pathologist away from adenocarcinoma.


Image:  
DDx:
*[http://commons.wikimedia.org/wiki/File:Cervical_AIS,_ThinPrep.jpg AIS endocervix (wikimedia.org)].
*[[AGC]] - no prominent nucleoli, not 3-dimensional.
*[[Endometrial adenocarcinoma in situ]].
*Metastatic [[colorectal adenocarcinoma]].
*Lower uterine segment epithelium<ref name=Ref_GP167>{{Ref GP|167}}</ref> - esp. [[proliferative phase endometrium]] - mitoses rare, NC ratio normal.
 
===Image===
<gallery>
Image: Endocervical adenocarcinoma in situ - cyto -- high mag.jpg | ECAIS - high mag. (WC)
Image: Endocervical adenocarcinoma in situ - cyto -- very high mag.jpg | ECAIS - very high mag. (WC)
Image: Endocervical adenocarcinoma in situ - cyto -- very high mag.gif | ECAIS - very high mag. (WC)
Image: Endocervical adenocarcinoma in situ - cyto - alt -- high mag.jpg | ECAIS - high mag. (WC)
Image: Endocervical adenocarcinoma in situ - cyto - alt -- very high mag.jpg | ECAIS - very high mag. (WC)
</gallery>
<gallery>
Image:Cervical_AIS,_ThinPrep.jpg | Endocervical AIS. (WC/euthman)
</gallery>
 
==Endometrial adenocarcinoma in situ==
*[[AKA]] ''adenocarcinoma in situ of the endometrium''.
===General===
*Management - like AGC and other types of AIS: coloscopy + endometrial biopsy.
 
===Cytopathology===
Features:
*Single cells or cluster of small cells with:
**Moderate nuclear enlargement ~2x intermediate cell nucleus.
**Nuclear hyperchromasia.
**Coarse chromatin.
**Nucleoli - prominent - '''key feature'''.
**+/-Mitoses.
**+/-Intracytoplasmic neutrophils.
*Apoptotic/necrotic cells.
*+/-[[Psammoma bodies]].
**Suggestive of [[serous carcinoma of the endometrium]].
 
DDx:
*[[AGC]] - no prominent nucleoli, not 3-dimensional.
*[[Endocervical adenocarcinoma in situ]].
 
=Waffle categories=
*Like all [[waffle diagnosis|waffle diagnoses]], these should be used sparingly.
 
==Atypical squamous cells of undetermined significance==
*Abbreviated ''ASC-US'' or ''ASCUS''.
===General===
*This is a [[waffle diagnosis|waffle category]] that should be used sparingly.
**The ASCUS/LSIL rate is used as a [[quality]] measure<ref name=pmid10757336>{{Cite journal  | last1 = Duggan | first1 = MA. | title = Cytologic and histologic diagnosis and significance of controversial squamous lesions of the uterine cervix. | journal = Mod Pathol | volume = 13 | issue = 3 | pages = 252-60 | month = Mar | year = 2000 | doi = 10.1038/modpathol.3880046 | PMID = 10757336 | URL = http://www.nature.com/modpathol/journal/v13/n3/full/3880046a.html }}</ref> - the specific ratios are dependent on how they specimens are processed.<ref>URL: [http://www.cap.org/apps/docs/proficiency_testing/CYP07600.pdf http://www.cap.org/apps/docs/proficiency_testing/CYP07600.pdf]. Accessed on: 2 May 2012.</ref>
*Diagnosis may be an indication for HPV testing.
 
===Cytology===
Features:
*Squamous differentiation:
**Central nucleus.
**Dense/solid-appearing cytoplasm.
*Nuclear size >2.5X IC nucleus, but <3X IC nucleus.
*+/-Orange/red cytoplasmic (orangeophilic cytoplasm).<ref name=pmid16299739>{{Cite journal  | last1 = Owens | first1 = CL. | last2 = Ali | first2 = SZ. | title = Atypical squamous cells in exfoliative urinary cytology: clinicopathologic correlates. | journal = Diagn Cytopathol | volume = 33 | issue = 6 | pages = 394-8 | month = Dec | year = 2005 | doi = 10.1002/dc.20344 | PMID = 16299739 }}</ref>
 
Note:
*One should '''not''' see [[nucleoli]].
**Nucleoli are seen in [[reactive changes]] and [[squamous cell carcinoma of the uterine cervix]].
*The IC nucleus is ~ 8 μm.<ref>URL: [http://www.curran.pwp.blueyonder.co.uk/cytology.htm http://www.curran.pwp.blueyonder.co.uk/cytology.htm]. Accessed on: 5 November 2012.</ref>
 
DDx:
*[[NILM]].
*[[LSIL]].
 
===Images===
<gallery>
Image: Atypical squamous cell of undetermined significance - 1 -- high mag.jpg | ASCUS - high mag. (WC)
Image: Atypical squamous cell of undetermined significance - 1 -- very high mag.jpg | ASCUS - very high mag. (WC)
 
Image: Atypical squamous cell of undetermined significance - 1a -- high mag.jpg | ASCUS - high mag. (WC)
Image: Atypical squamous cell of undetermined significance - 1a -- very high mag.jpg | ASCUS - very high mag. (WC)
Image: Atypical squamous cell of undetermined significance - 1b -- very high mag.jpg | ASCUS - very high mag. (WC)
</gallery>
 
===Sign out===
<pre>
Atypical squamous cells of undetermined significance (ASC-US).
</pre>
 
==Atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion==
*Abbreviated ''ASC-H''.
===General===
*This is a [[waffle diagnosis|waffle category]] that should be used very rarely.
*Higher HPV positivity vs. ASC-US.<ref name=pmid16136595>{{Cite journal  | last1 = Srodon | first1 = M. | last2 = Parry Dilworth | first2 = H. | last3 = Ronnett | first3 = BM. | title = Atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion: diagnostic performance, human papillomavirus testing, and follow-up results. | journal = Cancer | volume = 108 | issue = 1 | pages = 32-8 | month = Feb | year = 2006 | doi = 10.1002/cncr.21388 | PMID = 16136595 }}</ref>
*Management - like HSIL: colposcopy.
 
===Cytology===
Features:
*Atypia that falls short of diagnosing [[HSIL]]:
**Increased NC ratio.
*Architecture: cell clusters or rare single cells.
 
DDx:<ref name=pmid16686950>{{Cite journal  | last1 = Chivukula | first1 = M. | last2 = Shidham | first2 = VB. | title = ASC-H in Pap test--definitive categorization of cytomorphological spectrum. | journal = Cytojournal | volume = 3 | issue =  | pages = 14 | month =  | year = 2006 | doi = 10.1186/1742-6413-3-14 | PMID = 16686950 | PMC = 1524979 | URL = http://www.ncbi.nlm.nih.gov/pmc/articles/pmid/16686950/?tool=pubmed }}</ref>
*[[HSIL]].
*[[NILM]] - atrophy, parabasal cells.
*[[LSIL]].
 
==Atypical glandular cells==
*Abbreviated ''AGC''.
*Previously ''atypical glandular cells of undetermined significance'', abbreviated ''AGUS''.
===General===
*[[Waffle diagnosis]].
*Clinical management, like AIS: coloscopy +/- endometrial biopsy.
 
May represent either:
*Endocervical cells, i.e. atypical endocervical cells (AEC).
*Endometrial cells, i.e. atypical endometrial cell (AEM).
 
===Microscopic===
Features:
*Atypical glandular cells:
**Cell cluster with cells with a diameter <= 2x intermediate cell nucleus.
**Some features of nuclear atypia, e.g. irregular nuclear membrane, granular chromatin, nuclear hyperchromasia, nuclear enlargement.
 
DDx:
*Adenocarcinoma in situ.
 
=Uncommon stuff=
==Follicular cervicitis==
===General===
*Uncommon. (???)
*Finding may be associated with ''[[Chlamydia trachomatis]]''.<ref name=pmid6893939>{{Cite journal  | last1 = Hare | first1 = MJ. | last2 = Toone | first2 = E. | last3 = Taylor-Robinson | first3 = D. | last4 = Evans | first4 = RT. | last5 = Furr | first5 = PM. | last6 = Cooper | first6 = P. | last7 = Oates | first7 = JK. | title = Follicular cervicitis--colposcopic appearances and association with Chlamydia trachomatis. | journal = Br J Obstet Gynaecol | volume = 88 | issue = 2 | pages = 174-80 | month = Feb | year = 1981 | doi =  | PMID = 6893939 }}</ref>
 
===Cytology===
Features:<ref name=pmid12485172>{{Cite journal  | last1 = Halford | first1 = JA. | title = Cytological features of chronic follicular cervicitis in liquid-based specimens: a potential diagnostic pitfall. | journal = Cytopathology | volume = 13 | issue = 6 | pages = 364-70 | month = Dec | year = 2002 | doi =  | PMID = 12485172 }}</ref>
*Discohesive clusters of small (lymphoid) cells with interspersed:
**Tingible-body macrophages.
**[[Plasma cells]].
 
DDx:
*[[AGC]] - nuclei larger, more cohesive
 
Image:
*[http://nih.techriver.net/view.php?patientId=146 Follicular cervicitis (nih.techriver.net)].
 
==Hematoidin crystal==
*[[AKA]] ''hematoidin cockleburr''.
*[[AKA]] ''cockleburr''.
 
===General===
*Rare.
*Benign.
*Associated with hemorrhage in pregnancy.<ref name=pmid8465632>{{Cite journal  | last1 = Minassian | first1 = H. | last2 = Schinella | first2 = R. | last3 = Reilly | first3 = JC. | title = Crystalline bodies in cervical smears. Clinicocytologic correlation. | journal = Acta Cytol | volume = 37 | issue = 2 | pages = 149-52 | month =  | year =  | doi =  | PMID = 8465632 }}</ref>
 
Note:
*Overlap with ''crystalline bodies''. (???)
**''Crystalline bodies'' associated with pregnancy, and OCP use.<ref name=pmid8465632/>
 
===Cytology===
Features:<ref name=asc_cockle>URL: [http://www.cytology-asc.com/cec/normal/index.htm#cockle http://www.cytology-asc.com/cec/normal/index.htm#cockle]. Accessed on: 10 April 2012.</ref><ref name=pmid3866455>{{Cite journal  | last1 = Zaharopoulos | first1 = P. | last2 = Wong | first2 = JY. | last3 = Keagy | first3 = N. | title = Hematoidin crystals in cervicovaginal smears. Report of two cases. | journal = Acta Cytol | volume = 29 | issue = 6 | pages = 1029-34 | month =  | year =  | doi =  | PMID = 3866455 }}</ref>
*Radiating crystal.
*Refractile.
*Classically golden-brown.
*+/-Surrounded by macrophages.
 
DDx:
*Sulfur granule of ''[[Actinomycetes]]''.
 
Images:
*[http://www.cytology-asc.com/cec/normal/images/cockleburrs%20%281%29.jpg Cockleburr crystal (cytology-asc.com)].<ref name=asc_cockle>URL: [http://www.cytology-asc.com/cec/normal/index.htm#cockle http://www.cytology-asc.com/cec/normal/index.htm#cockle]. Accessed on: 10 April 2012.</ref>
*[http://www.cytology-asc.com/cec/normal/images/cockleburrs%20%282%29.jpg Cockleburr crystal (cytology-asc.com)].
*[http://www.cytology-asc.com/cec/normal/images/cockleburrs%20%283%29.jpg Cockleburr crystal (cytology-asc.com)].
 
==Carpet beetle larval parts==
===General===
*Uncommon distinctive contaminant.<ref name=pmid3859134>{{Cite journal  | last1 = Bechtold | first1 = E. | last2 = Staunton | first2 = CE. | last3 = Katz | first3 = SS. | title = Carpet beetle larval parts in cervical cytology specimens. | journal = Acta Cytol | volume = 29 | issue = 3 | pages = 345-52 | month =  | year =  | doi =  | PMID = 3859134 }}</ref>
*Fragment of a beetle.
*Benign.
 
===Cytology===
Features:
*Slender long structure - fern-like.
 
Note:
*One may have a complete insect.<ref>URL: [http://www.cytology-asc.com/cec/normal/index.htm#dustmite http://www.cytology-asc.com/cec/normal/index.htm#dustmite]. Accessed on: 10 April 2012.</ref>
 
Image:
*[http://www.archivesofpathology.org/na101/home/literatum/publisher/pinnacle/journals/content/arpa/2005/15432165-129.6/1543-2165%282005%29129%5B809%3Aufics%5D2.0.co%3B2/production/images/large/i1543-2165-129-6-809-f01.jpeg Carpet beetle (archivesofpathology.org)].
 
==Radiation changes in cervical cytology==
{{Main|Radiation changes}}
===General===
*Radiation is used to treat cervical cancer.
 
===Cytology===
Features:<ref name=pmid2887465>{{Cite journal  | last1 = Gupta | first1 = S. | last2 = Mukherjee | first2 = K. | last3 = Gupta | first3 = YN. | last4 = Kumar | first4 = M. | title = Sequential radiation changes in cytology of vaginal smears in carcinoma of cervix uteri during radiotherapy. | journal = Int J Gynaecol Obstet | volume = 25 | issue = 4 | pages = 303-8 | month = Aug | year = 1987 | doi =  | PMID = 2887465 }}</ref>
*Architecture: single cells/groups.
*Cell borders: well-circumscribed.
*Cytoplasm: vacuolated, usually abundant.
*Nucleus:
**Enlarged nucleus - but '''normal NC ratio'''.
**No nuclear membrane irregularies.
**Chromatin: "smudgy".
**+/-Multinucleation.
 
DDx:
*[[LSIL]].
*Vitamin B12 deficiency.
 
Images:
*[http://screening.iarc.fr/atlascyto_detail.php?flag=0&lang=1&Id=cyt17095&cat=E2f1 Radiation changes (iarc.fr)].
*[http://screening.iarc.fr/atlascyto_detail.php?flag=0&lang=1&Id=cyt17099&cat=E2f1 Radiation changes (iarc.fr)].
 
==Cornflaking artifact==
===General===
*Processing artifact - due to air under the cover slip.<ref name=asc_cornflake>URL: [http://www.cytology-asc.com/cec/normal/index.htm#cornflake http://www.cytology-asc.com/cec/normal/index.htm#cornflake]. Accessed on: 10 April 2012.</ref>
 
===Cytology===
Features:<ref name=asc_cornflake>URL: [http://www.cytology-asc.com/cec/normal/index.htm#cornflake http://www.cytology-asc.com/cec/normal/index.htm#cornflake]. Accessed on: 10 April 2012.</ref>
*Central brown discolourization in squamous cells.
 
Images:
*[http://www.cytology-asc.com/cec/normal/index_cornflakes.jpg Corn-flaking artifact (cytology-asc.com)].<ref name=asc_cornflake>URL: [http://www.cytology-asc.com/cec/normal/index.htm#cornflake http://www.cytology-asc.com/cec/normal/index.htm#cornflake]. Accessed on: 10 April 2012.</ref>
*[http://www.cytology-asc.com/cec/normal/index_Cornflaking%20x20.jpg Corn-flaking artifact (cytology-asc.com)].
 
==Endocervical repair==
===General===
*Benign.
 
===Cytology===
Features:
*Cluster of (2-dimensional) glandular cells with:
**Streaming (school of fish-appearance).
**Prominent nucleoli.
**[[Neutrophil]]s.
 
Image:
*[http://nih.techriver.net/view.php?patientId=316 Reactive endocervical cells (nih.techriver.net)].
 
=Historical=
==Maturation index==
*Abbreviated ''MI''.
===General===
*Based on vaginal wall scrape.
 
===Definition===
<math>MI = P : I : S </math>.
 
Where:
*P = number of parabasal cells / 300 squamous cells * 100 %.
*I = number of intermediate cells / 300 squamous cells * 100 %.
*S = number of superficial cells / 300 squamous cells * 100 %.
 
===Interpretation===
Common patterns:
*Superficial predominant, no parabasal = high estrogen effect.
*Parabasal predominant, no superficial = atrophy.
 
Examples:
* ''70 : 30 : 0'' is an atrophic pattern.
* ''0 : 30 : 70'' is a high estrogen pattern.
Note:
*Significant inflammation distorts the result.


==See also==
=See also=
*[[Cytopathology]].
*[[Cytopathology]].
*[[Basics]].
*[[Basics]].
*[[Cervix]].
*[[Cervix]].
*[[Uterus]].
*[[Uterus]].
*[[Gynecologic pathology]].


==References==
=References=
{{reflist|2}}
{{reflist|2}}


==External links==
=External links=
*[http://www.cytology-asc.com/cec/normal/index.htm Collection of usual benign findings on pap tests (cytology-asc.com)].
*[http://www.cytology-asc.com/cec/normal/index.htm Collection of usual benign findings on pap tests (cytology-asc.com)].
*[http://nih.techriver.net/ Bethesda system atlas (techriver.net)].
*[http://nih.techriver.net/ Bethesda system atlas (techriver.net)].
*[http://www.i2k.com/~suzanne/normalpap.htm Normal pap test - drawing (i2k.com)].


[[Category:Cytopathology]]
[[Category:Cytopathology]]
Michael
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