Cytopathology(Gyn)

Front 1

The portion of the menstrual cycle that is constant is:
A. follicular phase
B. secretory
C. ovulation
D. proliferative

Back 1

B secretory
The secretory or luteal phase lasts 14 days due to a programmed life/death span of 14 days for the corpus luteum/corpus albicans.

Front 2

Which of the following is considered a pituitary gonadotropin?
A. luteinizing hormone
B. estrogen
C. androgen
D. glucocorticoid

Back 2

A luteinizing hormone
Luteinizing hormone (LH) and follicle stimulating hormone (FSH) are pituitary gonadotropins associated with the menstrual cycle. Estrogen and progesterone are
produced within the ovary as a result of these pituitary gonadotropins.
DeMay RM, The Art & Science of Cytopathology.
Intermediate predominant maturation index, p. 69.

Front 3

Cells normally found in the endocervical canal that resemble histiocytes, possess uniform nuclei with fine, regular chromatin distribution, and have discretely vacuolated
but poorly defined cytoplasm are:
A. reserve cells
B. cells from microglandular hyperplasia
C. metaplastic cells
D. oxyphilic cells

Back 3

A reserve cells
Reserve cells usually occur high in the endocervical canal. The presence of these cells occurs normally in response to squamous differentiation, but they may also serve
as the stem cell for initiation of pre-neoplastic conditions. Histiocytic in appearance, they may be linked to endocervical mucosal cells, be associated with squamous
metaplastic cells, or lie singularly.
DeMay RM, The Art & Science of Cytopathology.
Reserve cell hyperplasia, p. 71.

Front 4

LH peaks at which day of the menstrual cycle?
A. 28
B. 5
C. 14
D. 1

Back 4

C 14
The surge of luteinizing hormone (LH) occurs at ovulation.
DeMay RM, The Art & Science of Cytopathology.
Superficial predominant maturation index, p. 69.

Front 5

The presence of mitotic figures indicates:
A. the possibility of neoplasia
B. reparative/regenerative processes
C. a current HPV infection
D. no pathologic information

Back 5

D no pathologic information
Mitotic figures are normal findings in benign, reactive/reparative, premalignant, or malignant processes. Their presence merely infers metabolic activity, protein
synthesis, and cell viability. Abnormal mitotic figures, however, may be occasionally found in association with premalignant or malignant processes.
DeMay RM, The Art & Science of Cytopathology.
The nucleus, p. 43.

Front 6

A 41-year-old patient suffering from oligomenorrhea presents for a Papanicolaou smear. Clinically, an ectocervical lesion is identified.
A. nonkeratinizing squamous cell carcinoma
B. keratinizing squamous cell carcinoma
C. endocervical adenocarcinoma
D. LSIL, consistent with mild dysplasia

Back 6

C endocervical adenocarcinoma
The cellular morphology suggests an endocervical adenocarcinoma. Cells with palisading features, overlapping nuclei, irregular chromatin, and columnar morphology demonstrate invasive endocervical morphology.

Front 7

These cells are from a vaginal smear from a 61-year-old post-menopausal woman with a history of ovarian disease.
A. adenocarcinoma, ovarian
B. poorly differentiated endocervical carcinoma
C. poorly differentiated squamous cell carcinoma
D. endometrial polyp

Back 7

A adenocarcinoma, ovarian
Mucinous adenocarcinomas of the ovary present with signet ring morphology and may recapitulate signet ring endometrial adenocarcinomas. Clinical history is paramount in establishing an ovarian primary tumor. A tumor diathesis is usually absent in cases of metastatic carcinoma unless the lesion has seeded at the secondary site. A vaginal smear, rather than a directed cervical smear and endocervical brushing, also helps rule out the other processes.

Front 8

These cells are observed in a cervical/endocervical smear from a 58-year-old patient.
A. nonkeratinizing squamous cell carcinoma
B. ovarian adenocarcinoma
C. endocervical adenocarcinoma
D. mixed müllerian tumor

Back 8

C endocervical adenocarcinoma
The presence of columnar morphology in the presence of obvious malignant criteria may help one to distinguish endocervical adenocarcinomas from those of endometrial origin. Other criteria that help discriminate the cells of endocervical adenocarcinoma (EA) from endometrial adenocarcinoma (EM) include the presence of rosettes versus cell balls and elongated, hyperchromatic, multinucleated cells with prominent multiple nucleoli vs. rounded, finely granular chromatin and conspicuous nucleoli. EA possesses a granular cytoplasmic texture whereas EM lesions have lacy, frothy, vacuolated cytoplasm. Last, EA tends to stain eosinophilic while EM shows generally basophilic cytoplasm.

Front 9

A 44-year-old woman presents with a decrease in weight, abdominal distention, ascites, and malaise.
A. normal endometrial cells
B. tubal metaplasia
C. papillary serous cystadenocarcinoma, ovarian
D. nonkeratinizing squamous cell carcinoma

Back 9

C papillary serous cystadenocarcinoma, ovarian
The diagnosis of papillary serous adenocarcinoma of the ovary in a Pap smear is centered around the finding of three-dimensional aggregates with hyperchromatic nuclei and finely granular, irregularly distributed chromatin. Cervical/endocervical/endometrial biopsies and colposcopy findings are negative. The presence of papillary groups of malignant cells and psammoma bodies may help in identifying these lesions as ovarian, but are not specific findings. A history of ascites is helpful.

Front 10

Culdocentesis and laparoscopic findings reveal the following structures in the presence of a malignant ovarian tumor.
A. papillary serous cystadenocarcinoma
B. mucinous cystadenocarcinoma
C. endometrioid-type adenocarcinoma
D. Brenner tumor

Back 10

A papillary serous cystadenocarcinoma
The diagnosis of papillary serous adenocarcinoma of the ovary in a Pap smear is centered on the finding of three-dimensional aggregates with hyperchromatic nuclei and finely granular, irregularly distributed chromatin. Cervical/endocervical/endometrial biopsies and colposcopy findings are negative. The presence of papillary groups of malignant cells and psammoma bodies may help in identifying these lesions as ovarian, but are not specific findings. A history of ascites is helpful.

Front 11

The presence of these structures in a Papanicolaou smear indicates
A. a malignant ovarian process
B. a benign ovarian process
C. a malignant metastatic process
D. nonspecific findings

Back 11

D nonspecific findings
Psammoma bodies are three-dimensional structures with concentric ringing containing calcified secretions of mucus. These structures are often found associated with papillary lesions of the ovary, including papillary serous adenocarcinoma. However, these are nonspecific findings and are not pathognomonic of malignancy.

Front 12

Clinical History:
Routine Pap Test, 28 year old female

Back 12

Adequacy Description:
NILM: Squamous metaplasia

Cytomorphologic Criteria:
Normal polygonal squamous metaplastic cells with round to oval nuclei and bland chromatin pattern. On liquid based preparations cells may appear more rounded, and nuclei may appear smaller. This would be interpreted as "NILM".

Explanatory Notes:
The presence of squamous metaplastic cells indicates that the transformation zone has been sampled (a minimum of 10 well-preserved endocervical or metaplastic cells is required for this quality indictor).

Front 13

Back 13

Adequacy Description:
NILM Endocervical cells

Cytomorphologic Criteria:
Satisfactory squamous cellularity. Endocervical cells are seen in a honeycomb arrangement.

Explanatory Notes:
An adequate liquid based preparation should have an estimated minimum of 5,000 well-visualized/preserved squamous cells. This image depicts the approximate cellular density of an adequate(>5000 cells) SurePath specimen. It is to be used as a guide in assessing squamous cellularity of SurePath specimens. Endocervical cells are present, indicating that the transformation zone has been sampled (a minimum of 10 well-preserved endocervical or metaplastic cells is required; they do not have to be in groups).

Front 14

Clinical History:
34 year old woman on oral contraceptives, Day 19

Back 14

Interpretation:
NILM: Microglandular hyperplasia

Cytomorphologic Criteria:
These are degenerating endocervical cells in a streaming pattern that has been associated with microglandular hyperplasia. It is typically seen in second half of the menstrual cycle in women taking oral contraceptives and may mimic HSIL at low magnification.

Explanatory Notes:
Degenerating endocervical cells can appear to be "pseudoparakeratotic" and this cytoplasmic feature should not be misinterpreted as favoring squamous origin.

Front 15

Back 15

Interpretation:
NILM: Glandular cells post-hysterectomy (Colonic Neuralgia)

Cytomorphologic Criteria:
Orderly cohesive groups of glandular cells with goblet cells.

Explanatory Notes:
Orderly arrangement and bland nuclear features distinguish from adenocarcinoma. Goblet cells are classic for colonic origin.

Front 16

Clinical History:
49 year old female status post hysterectomy for squamous cell cancer of cervix

Back 16

Interpretation:
NILM: Glandular cells status post-hysterectomy

Cytomorphologic Criteria:
Goblet cell metaplasia and bland cellular features.

Explanatory Notes:
On occasion benign appearing glandular cells may be seen post-hysterectomy. Adenosis may occur after traumatic stimulation of mesenchymal cells. This can be mentioned in the cytology report. The most important point is to exclude malignancy.

Front 17

Clinical History:
32 year old, routine cervical screening

Back 17

Interpretation:
ASC-US (Low end)

Cytomorphologic Criteria:
Multinucleated cells with small perinuclear halo.

Explanatory Notes:
Features are insufficient for an interpretation of LSIL.

Follow-up:
HPV typing not done

Front 18

Clinical History:
27 year old, Day 8. History of "abnormal Pap"

Back 18

Interpretation:
NILM vs ASC-H

Cytomorphologic Criteria:
Less mature squamous cells/metaplastic cells with polygonal shape, and slightly enlarged nuclei with occasional nuclear contour irregularities.

Explanatory Notes:
Boundary of ASC-US and ASC-H; differential includes CIN 2.

Front 19

Back 19

Interpretation:
ASC-H

Cytomorphologic Criteria:
Thick aggregate of loosely cohesive, overlapping cells containing enlarged nuclei with even chromatin, variation in size and shape and obscured cell boundaries. The cluster demonstrates poor preservation/ staining.

Explanatory Notes:
Possible interpretations include reactive endocervical and / or metaplastic squamous cells, HSIL, and AIS.

Front 20

Clinical History:
69 year old postmenopausal female. S/P TAH/BSO for Stage 2 endometrial adenocarcinoma. H/O VAIN 10 years ago. Vaginal ThinPrep

Back 20

Interpretation:
ASC-H

Cytomorphologic Criteria:
Atypical multinucleated cell.

Explanatory Notes:
Atypical cells may be seen in atrophy, but the differential includes a high grade lesion. Repeat sampling following a course of estrogen may clarify the findings.

Follow-up:
Vaginal cuff biopsies and repeat Pap test 2 months later showed severe dysplasia/CIS (CIN 3)

Front 21

Clinical History:
32 year old with prior abnormal Pap test

Back 21

Interpretation:
ASC-US vs LSIL

Cytomorphologic Criteria:
Clusters of abnormal squamous cells may be seen in ?spike-like? aggregates. These clusters should be classified as NILM, ASC, or SIL based on the degree of nuclear abnormalities. This patient had an LSIL interpretation on a conventional smear, two months prior to this LBP, that was interpreted as ASC-US (atypical PK).

Explanatory Notes:
Limited personal experiences suggest that this pattern is more frequent in liquid based preparations. It has been hypothesized that it may represent the Pap Test equivalent of a histologic "condylomatous spike". Limited correlation with HPV testing suggests that cases showing this pattern (and without obvious SIL elsewhere in the Pap test) can be positive for high-risk HPV.

Front 22

Clinical History:
18 year old

Back 22

Interpretation:
ASC-US vs LSIL (Borderline)

Cytomorphologic Criteria:
Several cells in this group exhibit changes suggestive of koilocytes. Nuclei are only slightly enlarged and do not meet the criteria for LSIL (3 times larger than an intermediate nucleus). Nuclear features are borderline between those required for ASC-US and LSIL.

Explanatory Notes:
Some of these cellular alterations can be seen in a reactive process; however, due to the slight nuclear enlargement, hyperchromasia, and cytoplasmic changes, an interpretation ASC-US may be more appropriate.

Follow-up:
Follow-up was CIN 1 (mild dysplasia)

Front 23

Clinical History:
49 year old woman, follow-up Pap smear after treatment for SIL

Back 23

Interpretation:
NILM: Keratotic cellular changes?"typical parakeratosis"

Cytomorphologic Criteria:
Note keratin pearl. Nuclei within it are small and bland.

Explanatory Notes:
"Typical parakeratosis" by itself is a benign cellular change. In this case it is likely an example of post-treatment effect in the Pap smear.

Follow-up:
No recurrence of SIL has been identified

Front 24

Back 24

nterpretation:
NILM: Keratotic cellular changes- Hyperkeratosis

Cytomorphologic Criteria:
Anucleate but otherwise unremarkable mature polygonal squamous cells.

Explanatory Notes:
They usually represent a benign process or result from inadvertent contamination of the specimen with vulvar material.

Front 25

Clinical History:
30 year old female, routine cervical cytology

Back 25

nterpretation:
NILM: Keratotic cellular changes-Hyperkeratosis

Cytomorphologic Criteria:
Anucleate mature polygonal squamous cells with ghost-like ?nuclear holes?.

Explanatory Notes:
By itself, hyperkeratosis is a benign cellular change. Extensive hyperkeratosis may correlate with colposcopic findings.

Front 26

Back 26

Interpretation:
NILM: Reactive endocervical cells

Cytomorphologic Criteria:
Reactive endocervical cells with enlarged nuclei and easily visible nucleoli. Note however that there are no nuclear membrane irregularities, the chromatin is fine and evenly distributed. There is no nuclear hyperchromasia, crowding, pseudostratification or feathering- criteria that would raise the differential diagnosis of glandular neoplasia

Front 27

Back 27

Interpretation:
Endocervical adenocarcinoma in situ (AIS)

Cytomorphologic Criteria:
Rosette arrangement of cells with enlarged oval or elongated nuclei and evenly distributed, coarsely granular chromatin.

Explanatory Notes:
Rosette arrangements, oval or elongated nuclei and evenly distributed granular chromatin are classic features of AIS.

Follow-up:
Endocervical adenocarcinoma in situ

Back 28

Interpretation:
HSIL

Cytomorphologic Criteria:
High nuclear to cytoplasmic ratio, enlarged nuclei (3 times normal intermediate cell nucleus), and hyperchromasia are consistent with HSIL.

Explanatory Notes:
Cytoplasm of abnormal cells is dense and slightly vacuolated suggesting the possibility that they are histiocytes. Nuclei of histiocytes are often bean-shaped with vesicular and finely granular chromatin and contain discrete nucleoli.

Front 29

Back 29

Interpretation:
Endocervical adenocarcinoma in situ (AIS)

Cytomorphologic Criteria:
Rosette arrangement of cells with enlarged oval or elongated nuclei and evenly distributed, coarsely granular chromatin.

Explanatory Notes:
Rosette arrangements, oval or elongated nuclei and evenly distributed granular chromatin are classic features of AIS.

Follow-up:
Endocervical adenocarcinoma in situ

Front 30

Clinical History:
45 year old with LMP reported 15 days prior to obtaining the Pap smear

Back 30

nterpretation:
NILM

Cytomorphologic Criteria:
Large tissue fragments with a biphasic pattern of glands and spindle cells. Densely packed spindle cells with glands embedded. Glands are simple, nonbranching, with indistinct cytoplasm and round uniform nuclei.

Explanatory Notes:
The lower uterine segment (LUS) can easily be sampled if the endocervical sampling device is pushed into the endocervical canal far enough to reach LUS. In isolation, the epithelial fragments may be mistaken for endocervical adenocarcinoma, endocervical adenocarcinoma in situ, tubal metaplasia or reactive endocervical cells. Abraded LUS does not carry the same significance as exfoliated endometrial cells and should not be reported.

Follow-up:
5 year follow up consisted of negative Pap tests