Cytopathology Feb. 21. 2016

Forcible removed cytopathology: Gynecological Cytology Pap smear, used as screening tool, to detect precancerous cervical lesions. Vaginal smear Bronchial wash & Bronchial brush.

The Pap Smear

PAP smear: named after Dr. George Papanicolaou (1883-1962) Women (1920) Hormonal cycles Pathological conditions (1928)

Cervical histology Squamous Epithelium Vagina and outer ectocervix 4 cell layers Well-glycogenated Columnar Epithelium Endo-cervical Single layer arranged in folds Mucin producing (not true glands)

Vaginal Speculum

Squamo-columnar Junction Transformation Zone Majority of cervical cancers and precursor lesions arise in immature squamous metaplasia, i.e. the leading edge of the squamo-columnar junction

Gynecological Cytology – Pap Smear

Pap Smear

Gynecological cytopathology: For reporting of cervico- vaginal cytology, Bethesda system (1991) is used.

FNA: Ovary and Female Genital Tract The Bethesda classification system for cervical cytopathology (Pap Smear). Normal and inflammatory cellular changes Squamous cell abnormalities Atypical Squamous Cells of Uncertain Significance (ASC, ASCUS) Squamous Intraepithelial Lesions (SIL) and Squamous Carcinoma (SCCa), HPV lesion Glandular abnormalities (AGC, AGUS, Ca) Atypical Glands of Uncertain Significance (AGUS) and Adenocarcinoma FNA: Ovary and Female Genital Tract

Cytologic screening for cervical cancer Cervical cancer screening has decreased morbidity and mortality Deaths from cervical cancer decreased from 26,000 to less than 5,000 between 1941 and 1997

Pap smears are not perfect For a high grade lesion, the sensitivity of a single pap smear is only 60-80% Estimated false negative rate is 30-50% Requires adequate specimen collection Requires adequate cytological review Requires adequate patient and physician follow-up

Who to screen? When to screen HPV Risk factors for cervical dysplasia Early onset of sexual activity Multiple sexual partners Tobacco Oral contraceptives

Screening frequency Yearly until three consecutive normal pap smears, then may decrease frequency to every three years Annual screening for high-risk women is highly recommend.

When to stop routine screening Age 65 and “adequate recent screening” Three consecutive normal pap smears No abnormal pap smears in last 10 years No history of cervical or uterine cancer Hysterectomy

Normal Cervix

Squamous Epithelium

Endocervix

Normal smear

Non-Epithelial Cells Lymphocytes Polymorphs sperms

Endometrial Cells

Squamous Metaplasia Central ectocervix and proximal endocervical canal Replacement of columnar cells by squamous epithelium Progressive and stimulated by Acidic environment with onset of puberty Estrogen causing eversion of endocervix Normal Squamous metaplasia

Ectropion / Erosion At puberty & pregnancy the endocervical cells are pushed out to lie on the ectocervix Normal Ectropion

Normal Cervix Wide Ectropion

Metaplastic Cells

Normal squamous cells

Squamous metaplastic cells

Squamous cell carcinoma

Koilocytes - HPV