1. Glandular lesion and Iatrogenic lesion
연세대학교 원주의과대학
병리학교실 최준정

2. 2nd edition of the Bethesda System – Glandular cells
Atypical
endocervical cells (NOS or specify in comments)
endometrial cells (NOS or specify in comments)
glandular cells (NOS or specify in comments)
endocervical cells, favor neoplastic
glandular cells, favor neoplastic
Endocervical carcinoma in situ
Adenocarcinoma
endocervical, endometrial, extrauterine, NOS

3. Glandular Lesions of the Female Genital Tract
Sampling techniques;
Routine smears: The vaginal pool may contain exfoliated cells from the endocervix, endometrium, and endosalpinx, and even from the ovaries
2. Endometrial aspiration
3. Endometrial lavage

5. Normal endocervical cells
Columnar cells with basal nuclei, in flat variable sized sheets or loosely associated
Cyanophilic translucent cytoplasm or vacuolated
Sheets have a honeycomb appearance
Cells in ‘picket-fence’ palisades with basal nuclei and columnar cytoplasm
Nuclei rounded, from the side the nuclei are oval
Fine chromatin pattern, one or more small nucleoli often near the nuclear membrane
Bare nuclei may accompany groups of degenerate endocervical cells

7. Normal endocervical cells

11. Endocervical Adenocarcinoma
Risk Factors;
Estrogen
High socio-economic status
HPV 16,18 (18 more common in adenoCa.)
No relation with smoking
Relation with squamous lesion;
Endocervical adenoCa. → squamous lesion (>50%)
Squamous lesion → adenocarcinoma (4%)

12. Endocervical Adenocarcinoma
Glandular epithelial dysplasia (atypical glandular cells)
Adenocarcinoma in situ (AIS)
Invasive adenocarcinoma
Well differentiated adenocarcinoma without mucin formation
Well differentiated mucus-secretory adenocarcinoma
Poorly differentiated adenocarcinoma

13. Adenocarcinoma in Situ (AIS)
10~25% of adenocarcinoma of the cervix
Age: usually 10~20 yrs younger than invasive Ca.
Symptom;
Usually asymptomatic
Vaginal bleeding
Coexists with SIL or SqCC in 2/3 of cases

15. Cytologic Findings of AIS -Architectural Features-
Cohesive sheets and tissue fragments of varying size in clean background
Loss of honeycomb pattern: crowding and overlap of nuclei
Specific architectural features;
Pseudo-stratified strips of columnar epithelium
Feathering (nuclear protrusion at group margins)
Epithelial rosettes
Crypt opening within an epithelial sheet

16. Cytologic Findings of AIS -Architectural Features-
Exfoliation pattern;
Cohesive sheets and tissue
fragments of varying size
in clean background

17. Cytologic Findings of AIS -Architectural Features-
Exfoliation pattern ;
Loss of honeycomb pattern; crowding and overlap of nuclei

19. Cytologic Findings of AIS -Architectural Features-
Exfoliation pattern;
Crypt opening may be seen within a sheet

20. Cytologic Findings of AIS -Architectural Features-
Feathering;
Stratification
Cytoplasm is usually totally or
partially lost
Nuclei are somewhat attenuated

23. Cytologic Findings of AIS -Architectural Features-
Rosettes;

25. Cytologic Findings of AIS -Nuclear Features-
Higher than normal N/C ratio
Nuclear enlargement with pleomorphism:
elongation of nuclei common
Distinctive coarsely granular, evenly distributed chromatin pattern
Nucleoli are not typically prominent
Mitoses and apoptotic bodies may be often present

27. Invasive Adenocarcinoma
8~25% of primary carcinoma of the cervix
Age: usually 45~53 yrs
Symptom;
Watery discharge or vaginal bleeding
Coexists with SIL or SqCC in 2/3 of cases

28. Invasive Adenocarcinoma
Well differentiated adenocarcinoma without mucin formation
Well differentiated mucus-secretory adenocarcinoma
Poorly differentiated adenocarcinoma

29. Well differentiated adenocarcinoma without mucin formation
Pattern:
- Flat cell groups with nuclear crowding forming rosette pattern
- Nuclear palisading arrangement, common
Mitosis in 1/3 of the cases
Cells: columnar with basal nuclei
Nuclei: oval and hyperchromatic with coarse chromatin
Nucleoli: may be present with halo
Well-defined group borders (scalloped edges)

34. MIMICERS Repair Non-keratinizing squamous cell carcinoma
Predominantly syncytia
Scattered single cells
Vacuolated cyonoph

39. Well differentiated mucus-secretory adenocarcinoma
Pattern:
papillary groups / disorganized honeycomb pattern with unequal vacuoles
Nuclei:
- hyperchromatic, anisokaryotic
- flattened by large mucous vacuoles

40. Poorly differentiated adenoCa.
Pattern: Three-dimensional
Cells: rounded
Nuclei: round, hyperchromatic, several nucleoli,
abnormal-shaped
Cytoplasm: absent vacuoles
Tumor diathesis: always present

41. Endocervical AIS vs. Invasive adenocarcinoma
In situ Adenocarcinoma
Invasive Adenocarcinoma
Architecture
Crowded gland/sheet, strips, rosettes
Irregular and crowded glands
Pseudostratification
Stratification with supercrowding
Polarity preserved
Loss of polarity
Peripheral feathering
Peripheral feathering may be present
Cells: normal or small in size
Cells: large
N/C: high
Single malignant cells: uncommon
Single malignant cells: common
Nucleus
Large
Large, pleomorphic
Hyperchromasia with evenly distributed chromatin
Hyperchromasia, clearing and irregularly distributed chromatin
Inconspicuous nucleoli
Prominent nucleoli
Cytoplsam
Focal mucin loss
Secretion varies
Background: Clear or bloody with intact RBCs
Necroinflammatory of bloody, with broken-down RBCs

42. Distinguishing Points Between SqCC and Adenocarcinoma
Cell shape
Polygonal
Cuboidal, columnar
Nuclei
Central
Eccentric
Chromatin
Coarse, compact
Vesicular
Nucleoli
Not prominent
Prominent
Cytoplasm
Thick , eosinophlic
Thin, vacuoles
Cell group
Irregular
Round, oval
Lumen No
Gland, acini, rosettes
Row
Yes

44. Atypical Endocervical Cells: NOS
Cells occurs in sheets and strips with some cell crowding and nuclear overlap
Nuclear enlargement, up to 3-5 times the area of normal endocervical nuclei, may be seen.
Some variation in nuclear size and shape is present.
Mild hyperchromasia is frequently evident.
Nucleoli may be present.
Mitotic figures are rare.
Cytoplasm may be fairly abundant but the N/C ratio is increased.
Distinct cell borders often are discernible.

47. Atypical Endocervical Cells, favor Neoplastic
Cell morphology, either quantitatively or qualitatively, falls just short of an interpretation of endocervical adenocarcinoma in situ or invasive adenocarcinoma.
Criteria
Abrnomal cells occur in sheets and strips with nuclear crowding and overlap.
Rare cell groups may show rosetting or feathering
Nuclei are enlarged with some hyperchromasia.
Occasional mitoses may be seen.
N/C ratios are increased, quantity of cytoplasm is diminished, and cell borders may be ill defined.

50. Normal endometrial cells
Epithelial cell aggregates in tubular or sheet-like arrangements
Small cells with scanty cytoplasm
 Uniform small round nuclei
Fine granular chromatin with chromocentres
Single or overlapping stromal cell groups or single spindle-shaped cells
Epithelial and stromal cells are influenced by hormonal changes.

51. Endometrial cells may be seen normally in cervical samples up to 12 days from the onset of menstruation.
Factors influencing their presence beyond this may reflect underlying endometrial pathology in a woman over 40 years of age or could be due to exogenous hormonal manipulation such as hormone replacement therapy or oral contraceptive use.
Tamoxifen use, intrauterine device carriage and dysfunctional bleeding

52. During and shortly after menstruation they are grouped in well-formed tight three-dimensional clusters with a peripheral rim of epithelial cells and a central core of stromal cells

53. Degenerative changes quickly supervene, with crumpling of the nuclei and disorganisation of the cells.
These then stand out as small clusters of densely hyperchromatic crowded cells Neutrophil polymorphs are often seen within endometrial clusters.

54. Endometrial Glandular Lesions
Endometrial hyperplasia
Endometrial atypical hyperplasia and
in situ adenocarcinoma
Endometrial adenocarcinoma

55. “TBS” – Glandular cells
Atypical
endocervical cells (NOS or specify in comments)
endometrial cells (NOS or specify in comments)
glandular cells (NOS or specify in comments)
endocervical cells, favor neoplastic
glandular cells, favor neoplastic
Endocervical carcinoma in situ
Adenocarcinoma
endocervical, endometrial, extrauterine, NOS

57. Endometrial cells, day 4
Exodus, day 7

58. Endometrial hyperplasia
Should be suspected when benign endometrial cells are found 10 days after the end of the last menstrual period
Abundance of thick clusters of reactive endometrial cells
In postmenopausal women, any crowded clusters of reactive endometrial cells

60. Cystic hyperplasia, day22
Adenomatous hyperplasia, day22

62. Endometrial atypical hyperplasia and in situ adenocarcinoma (AIS)
Variable numbers of polymorphic endometrial cells
Cytoplasm: abundant and eosinophilic
Nuclei: enlarged with granular chromatin, irregularly distributed
Nucleoli: often prominent

64. Normal
Atypical hyperplasia
Atypical hyperplasia, day 25

65. Malignant glandular lesions
Endometrial adenocarcinoma
Detection rate;
Cervical scraping only: 15%
Vaginal pool smear and cervical scraping: 45%
Endocervical aspiration & vaginal pool smears: 65%
Intrauterine & endocervical aspiration and lavage: 90%

66. Endometrial adenocarcinoma
Risk factors;
Estrogen (granulosa cell tumor)
Obesity
Hypertension
Diabetes mellitus
High socio-economic status

67. Helpful hints for diagnosis of endometrial adenocarcinoma (1)
Presence of degenerate or well-preserved normal endometrial cells in a post-menopausal woman
In an asymptomatic premenopausal woman, the presence of normal-appearing endometrial cells at mid-cycle or post-ovulatory time
Presence of an increased number of small or large histiocytes, often with phagocytized necrotic cellular debris, in the non-atrophic smear of any post-menopausal woman (small: 4%, large: 17%)

68. Helpful hints for diagnosis of endometrial adenocarcinoma (2)
Increased number of foreign body giant cells in the non-atrophic smear of any post-menopausal woman
Presence of unexplained fresh and old blood or an increase in necrotic debris or fibrin (tumor diathesis) in the smear of a post-menopausal woman
A history of DM, obesity, hypertension, breast cancer, family history of breast and ovarian cancer, late menopause, or post-menopausal bleeding

69. General diagnostic cellular criteria in endometrial adenocarcinoma
Number of diagnostic cells: very scanty or abundant
Imitate the appearance of the benign columnar cells (arranged in row)
Shed in tight clumps, in loose clusters, or singly
Background: usually dirty (watery diathesis)

70. Architectural
Loss of polarity
Papillary cell clusters
Discohesive cells
Cellular
High nucleo/cytoplasmatic ratio
Anisonucleosis and poikilonucleosis
Coarse and/or marginated chromatin
Nucleolar prominence
Nuclear membrane indentations
Cell cannibalism
Background
Scarcity of stromal cells
Necrosis.

73. Differentiation
Well
Moderate
Poor

76. DDx. between endometrial and endocervical adenocarcinoma
Number of cells
Less abundant
Abundant
Degeneration
Marked
Mild
Size
160±40 u2
190±60 u2
Ingestion of leukocytes
Rare
Nuclear size
60±10 u2
80±20 u2
Chromatin
Moderately coarse
Finely granular
Nucleoli
Multiple 20%, Macronucleoli 20%
Multiple 60%, Macronucleoli 40%
Background
Very dirty
Relatively clean
Squamous dyskaryosis
Very rare
Occasional

77. Atypical endometrial cells
Cells occur in small groups, usually 5-10 cells/group
Nuclei are slightly enlarged compared to normal endometrial cells.
Mil hyperchromasia may be seen.
Small nucleoli may be present.
Scant cytoplasm is occasionally vacuolated.
Cell borders are ill defined.

80. Effects of Irradiation and Other Techniques
Cellular changes from radiotherapy;
Inhibit the formation of DNA or RNA or cause cross-links and breaks in the DNA double strands of benign & malignant cells (G2-M)
Cytoplasm: more abundant, may have peri-nuclear halo
Nuclei:
- often enlarged and hyperchromatic with prominent Nu.
- differ from dysplasia or cancer cells by
(1) finely granular or amorphous chromatin
(2) smooth regularity of the nuclear membrane

81. Cellular changes from radiation (radiation response)
Mechanism of action;
1. Prevent the synthesis of DNA proteins → rapid death of cells
2. Inhibit cellular mitosis
3. Change the chromosomal or genetic information of cells
Radiation responses (RR)
= cellular changes resulting from irradiation
appear first in the nuclei, then in the cytoplasm

82. Cellular changes from radiation (radiation response)
Some irradiation cellular changes may persist for the whole life of patients
Acute reaction:
- appear about 1 day after the start of irradiation and continue for 6 weeks after the end of the treatment
- cellular necrosis and increase in the exfoliation of degenerated, nonviable, benign or malignant cells
Healing stage: mixed with repair & inflammatory cells

84. Cellular changes from radiation (radiation response)
Cytoplasmic changes;
Similar changes in chemotherapy, UV irradiation, or cautery
1) Edema and hypertrophy (3~4 times)
2) Biphasic stain and loss of normal fine granularity
→ amorphous, homogeneous, amphophilic, or eosinophilic
3) Cytoplasmic fibrils, often seen in concentric or irregular
4) Vacuolization
5) Pseudo-cannibalism
6) Cytoplasmic fragments and naked nuclei:
-mainly in the late stage of irradiation
-indicate the death of cells

87. Cellular changes from radiation (radiation response)
Changes in the nuclei;
1) Nuclear hypertrophy (2-10 times):
- most consistent and common changes
- may be extremely irregular, with nuclear wrinkling
2) N/C ratio remains within the normal limits
3) Peri-nuclear halo, sometimes with pyknotic nuclei
4) Vacuolization: indicates death of the cell
5) Chromatin (the amount of DNA):
-increases but finely granular & uniformly distributed
-decreases: pale and empty-appearing nuclei
6) Multi-nucleation

88. Other irradiation changes;
7) Nucleoli: enlarged, remain round and regular in shape
8) Changes indicating the death of the cells
(benign or malignant)
(1) Peripheral condensation of the chromatin
(2) Vacuolization (3) Fragmentation (4) Nuclear pyknosis
(5) Karyorrhexis
Other irradiation changes;
1) Soon after irradiation: large No. of inflammatory cells
2) In the healing stage: an increase in repair cells
3) Increase in mucus secretion during radiation

91. Cytology of irradiated malignant lesions
During RTx. & in the 2 wks following it;
(1) Cancer cells are shed in large numbers
(2) Absence of cancer cells may indicate a poor prognosis
(3) Most of malignant cells show irradiation changes
similar to those described for benign cells
(4) The diagnosis of persistent carcinoma should not be
made at this time, because the exfoliated cells with
these changes are dead or are still alive
(5) The death of a malignant cell should be suspected
when the nucleus show pyknosis, karyorrhexis, and
karyolysis or vacuolization.

92. Cytology of irradiated malignant lesions
B. 4 wks after irradiation;
(1) The presence of malignant cells showing minimal irradiation changes suggest the possibility of persisting cancer
(2) These cells usually have the same features as the original non-irradiated malignant cells

93. Cytology of irradiated malignant lesions
C. Recurrence of carcinoma; (1) Should be suspected when malignant cells appear after an interval of smears free of tumor cells (2) Recurrent cancer cells tend to be smaller and less differentiated D. All patients after radiotherapy; Need to be closely followed by periodic repeated smears, taken every 3 ~ 6 months

95. SqCC, radiotherapy 2 wks

96. Endometrial adenoCa, radiotherapy 3 wks

97. Cellular changes from chemotheraphy
Similar to cellular changes of irradiation
Systemic effect
Cyclophosphamide (urinary bladder) & busulfan (lung, pancreas, spleen, urinary tract, uterine cervix)
More prominent in nuclei
Atrophic smear
Need close long-term follow-up: 3 ~ 6 months