1. Cytopathology: Technique and Interpretation

2. Definition of cytopathology
Cytopathology is the study of normal and abnormal exfoliated cells in tissue fluid.
The individual cells reflect the normal and abnormal morphology of the tissue from which they are derived.

3. Types of exfoliated cyto-pathology
Natural spontaneous exfoliation
Natural covering epithelium: skin, urinary tract, vagina, and cervix.
Glandular epithelial secretion: Breast (Nipple secretion).
Sputum
Urine
Exudates and transudate:
Pleural fluid Peritoneal fluid
Pericardial fluid Joint fluid CSF

4. Artificial enhanced exfoliation:
Scrapings from cervix, vagina, oral cavity, and skin
Brushing and lavage: bronchi, GIT, and urinary tract
Fine needle aspiration (FNA) for:
Body cavity fluid: pleural, pericardial & peritoneal fluids
Cysts: neck, breast & ovary
Solid tissue: body organs, tumors & other swell

5. Role of cytopathology
Early detection of unsuspected diseases (malignant or pre-malignant lesions).
Confirmation of suspected diseases without surgical trauma.
Diagnosis of hormonal imbalance.
Useful in flow up the course of disease or monitoring therapy.

6. Advantage of Cytopathology
Rapid diagnosis Inexpensive Simple
It is better in evaluating the infectious diseases.
Supplement or replace frozen section or biopsy
No injury to tissue allowing repeated sampling
It is better for hormonal assay
Cytopathological smear cover a wider surface than that involved in surgical biopsy.

7. Disadvantage of Cytopathology
Interpretation of the morphological cellular changes is based only on individual cell observation.
Not always finally diagnosis, so it is confirmed by histopathology in some cases.
Not determine the size and type of lesion of some cases.

8. Factors that determine the appearance of cells
Type of the technique used.
Level of cell maturation at the time of cell collection.
Nature of the parents tissue: soft tissue, cyst, or solid organ.
Medium of the exfoliated cells.
Interval between the stain of the exfoliated cells and collection of samples.
Type of fixative, stain, and processing of the technique used.

9. PAP smear: named after Dr. George Papanicolaou (1883-1962)
Vaginal smears from guinea pigs (1917)
Women (1920)
Hormonal cycles
Pathological conditions (1928)

10. Normal Cervix

11. Taking the Sample

13. Liquid Based Cytology – lab processing

14. The Pap Smear

15. 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

16. 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

17. Requires adequate patient and physician follow-up
10% of women with cervical cancer had inappropriate follow-up.
Requires access to care
50% of women with cervical cancer were never screened and 10% had not been screened within 5 years of diagnosis.

18. Who to screen
Any woman with a cervix who has ever had sexual activity.

19. When to screen
Start within 3 years of onset of sexual activity or by age of 21, whichever is first.
Risk factors for cervical dysplasia
Early onset of sexual activity
Multiple sexual partners
Tobacco
Oral contraceptives

20. 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.

21. 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 for benign disease
Hysterectomy for invasive cervical cancer

22. Cervical histology

23. Original Squamous Epithelium
Vagina and outer ectocervix
4 cell layers
Well-glycogenated (pink) unless atrophic

24. Columnar Epithelium Upper and middle endo-cervical canal
Single layer of columnar cells arranged in folds
Mucin producing (not true glands)

25. 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

26. Transformation Zone
Zone between original squamo-columnar junction and the “new” squamo-columnar junction
Nabothian cysts visually identify the transformation zone if present

27. Original Squamo-columnar Junction
Placement determined between weeks gestation
Most often found on ectocervix
Can be found in vagina or vaginal fornices
Less apparent over time with maturation of epithelium

28. “New” Squamo-columnar Junction
Border between squamous epithelium and columnar epithelium
Found on ecto-cervix or in endo-cervical canal
Majority of cervical cancers and precursor lesions arise in immature squamous metaplasia, i.e. the leading edge of the squamo-columnar junction

29. Squamous Epithelium

30. Parabasal Cells

31. Intermediate Cells

32. Superficial Cells

33. Endocervix

34. Endocervical Cells

35. Endometrial Cells

36. Non-Epithelial Cells
Lymphocytes
Polymorphs
sperms

37. Normal smear

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

39. Wide Ectropion

40.   Metaplasia
The endocervical cells are transformed into squamous cells through the process of squamous metaplasia

41. Metaplastic Cells