1. Cytology Training Program: Gyn Cytology Revision Exercise by Tony Chan
Reference:
THE BETHESDA SYSTEM WEBSITE ATLAS
American Society of Cytopathology

2. Select Your Interpretation from below:
NILM: Negative for Intraepithelial Lesion or Malignancy
Endometrial cells in a woman >= 40
ASC-US
ASC-H
LSIL
HSIL
Invasive Squamous Cell Carcinoma
Atypical Endocervical Cells
Atypical Endometrial Cells
Adenocarcinoma in situ (AIS), Endocervical
Adenocarcinoma, Endocervical
Adenocarcinoma, Endometrial

3. 27 year old woman, colposcopy visit
NILM: Fungal organisms consistent with Candida spp
Pseudohyphae and reactive changes in the squamous epithelial cells.

4. 31 year old
HSIL
Important features of high grade squamous intraepithelial lesions are enlarged and/or high N/C ratio, centrally placed nuclei, hyperchromasia, and irregular nuclear membranes.

5. 40 year old woman, history of squamous cell carcinoma of the cervix.
NILM: Reactive cellular changes associated with Radiation
Enlarged nuclei with abundant polychromatic cytoplasm with vacuolization. Mild nuclear hyperchromasia without coarse chromatin, prominent nucleoli (coexisting repair). Note multinucleation (upper right corner insert).

6. What is your interpretation?
NILM
Pseudokoilocytosis: cytoplasmic vacuolization without nuclear change of HPV effect.

7. 67 year old woman with postmenopausal bleeding
Adenocarcinoma, endometrial
Three-dimensional papillary cluster of abnormal cells with irregular nuclear membranes and nucleoli. No evidence of feathering
Follow-up: adenocarcinoma of the endometrium, FIGO Grades I-II

8. Just this cell seen. What’s your interpretation?
ASC-US
Enlarged nuclei with small perinuclear halo
Features are insufficient for an interpretation of LSIL.

9. 27 year old woman. LMP two weeks ago
ASC-H
Metaplastic cells with increased N:C ratios and nuclear contour irregularities.
HSIL on repeat Pap; CIN3 on LEEP

10. 26 year old woman, LMP 2 weeks, mild vaginal discharge
NILM: Reactive squamous cellular changes associated with Trichomonas vaginalis
Trichomonas also seen. Where?

11. What is your interpretation?
LSIL
Binucleation and koilocytes in mildly dysplastic mature cells is consistent with HPV effect.

12. What is your interpretation?
HSIL
"Keratinizing dysplasia". The dysplastic cells in this field display enlarged nuclei with coarsely granular chromatin and keratinized cytoplasm. Occasional cells have pyknotic or opaque nuclei with sharp, angled edges and abnormal cell shapes are seen.

13. What is your interpretation?
NILM: Shift in Flora suggestive of bacterial vaginosis
Filmy background of small coccobacilli. Individual squamous cells covered by a layer of bacteria. Conspicuous absence of lactobacilli.

14. 58 year old woman, LMP 8 years, postmenopausal bleeding
Adenocarcinoma, Endometrial
Large aggregate of small cells with irregular chromatin distribution, small nucleoli, poorly defined finely vacuolated cytoplasm in a watery background.
In conventional smears, endometrial adenocarcinoma tends to be associated with a thin watery diathesis in contrast to the bloody, necrotic background often seen with endocervical adenocarcinoma.
Follow-up: Adenocarcinoma of the endometrium

15. What is your interpretation?
NILM: Cellular changes consistent with Herpes simplex virus
Note the intranuclear inclusions Vs nucleoli
The ground-glass appearance of the nuclei is due to accumulation of viral particles leading to peripheral margination of chromatin.

16. 45 year old Squamous cell carcinoma
Dysplastic squamous cells with anisocytosis and anisonucleosis including keratinization and tadpole cells are diagnostic of invasive squamous cell carcinoma.

17. 41 yrs old, routine exam NILM: Endometrial cells in a woman >= 40
Three-dimensional cluster with slightly larger nuclei and nucleoli.

18. 39 year old woman, routine Pap smear, no LMP date given
Atypical endocervical cells, NOS
Sheet of cells with enlarged round or oval nuclei with prominent nucleoli. Chromatin is finely granular and evenly distributed but occasional chromocenters are seen. Cell borders are well-defined. Mitotic figures are noted.

19. 63 year old woman with postmenopausal bleeding
Atypical endometrial cells
Aggregate of small cells with slightly enlarged round or oval nuclei, small nucleoli and finely vacuolated cytoplasm.
Follow-up: Adenocarcinoma of the endometrium, grade I

20. 32 years old, mother of 3 children
NILM: Reactive cellular changes associated with IUD
Note small cluster of glandular cells with cytoplasmic vacuoles displacing nuclei. The cytoplasmic vacuoles may displace the nucleus, creating a signet-ring appearance.

21. What is your interpretation?
Squamous Cell Carcinoma-clinging diathesis
Tumor diathesis, variation in cell size and shape, evidence of keratinization, and nuclear abnormalities are all demonstrated in this image from a squamous cell carcinoma.

22. 41 year old. No history provided
NILM: Bacteria morphologically consistent with Actinomyces spp.
Tangled clumps of filamentous organisms, often with acute angle branching, sometimes showing irregular wooly appearance. Swollen filaments may be seen with clubs at periphery. A cotton ball like acute inflammatory response is common.

23. What is your interpretation?
NILM: Tubal metaplasia
Cell group demonstrating crowding, pseudostratification and oval or elongated nuclei. Note the presence of cilia in some cells.

24. What is your interpretation?
Endocervical adenocarcinoma in situ (AIS)
Cluster of cells with crowded overlapping oval nuclei that show hyperchromasia and evenly distributed by coarsely granular chromatin. Smear background is clean.
Nuclear crowding and overlapping, hyperchromasia and evenly distributed granular chromatin are classic features of AIS.

25. 39 year old female, Day 12 of cycle
Adenocarcinoma, Endocervical
Cluster of cells enlarged nuclei, macronucleoli and some nuclear membrane irregularities; poorly defined, finely vacuolated cytoplasm; ghost of RBC's and cell debris noted at the edge of the cluster ("clinging diathesis").
Follow-up: Endocervical adenocarcinoma

26. What is your interpretation?
HSIL
HSIL with extension into gland space. Note that in addition to the abnormal cells themselves, there is flattening of cells at the edge of the cluster, lack of columnar shape and loss of polarity.

27. 32 year old, LMP now, abnormal cervix on exam
Adenocarcinoma, endocervical
Large group of abnormal cells with round to elongated hyperchromatic nuclei and granular chromatin. Note pseudostratified strips with feathering at the edges. Nuclear crowding and overlap are prominent. Smear background is bloody.
The cytologic features of endocervical adenocarcinoma may overlap with those of endocervical adenocarcinoma in situ, but features of invasion, such as tumor diathesis, are seen.
Follow up: Endocervical adenocarcinoma

28. 79 year old postmenopausal woman, being evaluated for possible Squamous cell carcinoma of vulva
NILM: Atrophy
Sheets of uniform orderly parabasal cells are observed representing deep parabasal cells. Some nuclei show grooves, but chromatin pattern is fine. Atrophic cells may have nucleoli (lower right insert).

29. End of Exercise More cases: http://nih.techriver.net/atlas.php
Self-test: