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Disadvantage:
Procedure is lengthy & complicated
Does not give accurate acidophilic index
Results:
Epithelial cytoplasm:
o Pink–red to Orange (eosinophilic): Superficial
o Greenish Blue to Blue–Gray (basophilic): Intermediate
Routine Cervical/ Endocervical (Pap) Smear Vesicular nucleus Blue
Pyknotic nucleus: Dark blue to black
Bacteria (L. acidophilus): Dark blue
Fungal mycelia: Violet
Trichomonas vaginalis: Pale greenish blue blob of
cytoplasm
Vaginal Cytology
Cytohormonal assessment (CHMI)
The vagina epithelium is responsive to sex steroid, particularly
Ideally: Upper lateral third of the vaginal wall
E & P, & undergoes predictable changes through the cycle in
Where there is less contamination & hormone response to changes in blood concentrations of ovarian
influence is bet mirrored hormones. Rising levels of E cause the vaginal epithelium to
become “cornified” – the surface cells become large &
Very Important: flattened, with small (pyknotic) or absent nuclei.
FIX IMMEDIATELY
The moment the cells are removed from the bodily Effect of E: Promote the maturation of vaginal mucosa
surface, it immediately undergoes drying & autolytic Maturation: Changing the cell towards the superficial
changes. cell type becoming more orange in color in Pap’s smear.
Fixative will suspend the cells from autolytic
changes.
In essence, vaginal cytology is a type of endocrine assay. PYKNOTIC INDEX (P.I) – “karyo-pyknotic index”; percentage of
Tracking changes in the morphology of desquamated vaginal cells having shrunken, dark, small (less than 6 u) nuclei
epithelial cells provides a convenient means of assaying
changes in in E & P levels. CHMI
P I (P) S (E)
Vaginal smear may be taken regularly and often. 0 0 100 Shift to the Right
0 10 90 There is small amount of P that influences
Hormonal changes are best mirrored in the upper third of the intermediate differentiation
vagina. 0 80 20 Shift to the Midzone Effect
Interluteal phase of the menstrual cycle
They can also be taken from the lateral walls because their 0 100 0 Absolute Midzone Effect
more accessible and less likely to be contaminated by cellular P level are exaggerated
Perhaps seen in a pregnant state
debris or discharge.
100 0 0 Shift to the Left
Ovarian function is no longer there
Note: UPPER THIRD LATERAL WALL OF VAGINAL MUCOSA Atrophy in menopause (surgical included)
20 40 40 Not a good smear
Represents contamination, inflammation
Vaginal Cells
Superficial Cells
Large (30 – 60u)
Polyhedral flat cells
Cytoplasm: may be acidophilic or basophilic
Presence of small dark pyknotic nuclei (less than 6 u)
Parabasal Cells
Round to oval cells
Smaller than intermediate (15 – 25u)
Thick cytoplasmic edge
“Sunny side up” like cells
Have strong basophilic cytoplasm & vesicular nuclei (6 - 9
µ)
Quantitation in Vaginal Cytology Found from 2 weeks of age to puberty, after childbirth,
CYTOHORMONAL MATURATION INDEX (C.H.M.I) – percentage abortion, or miscarriages and after menopause
proportion of cells from the 3 layers of the vaginal epithelium Tall columnar epithelial ells with basal nuclei
Occurs in groups and strips of 3 or more cells (“picket
CHMI = Parabasal / Intermediate / Superficial fence configuration)
Cytoplasm: Basophilic with whispy mucin vacuole
ACIDOPHILIC INDEX (A.I) – percentage of cells that stain pink –
orange to red with Pap’s & red in Shorr method
Endocervical Cells Image: Adequacy
Tall columnar epithelial Cells with basal nuclei Satisfactory for evaluation
Occurs in groups and strips of 3 or more cells (“picket
fence configuration) Pap smear specimens are considered satisfactory for
Cytoplasm: Basophilic with whispy mucin vacuole interpretation if there are:
Important: since it tells you that you have sampled the Adequate numbers of well – visualized squamous cells
Transformation Zone. present
Adequate numbers of well – visualized endocervical cells
Endometrial cells or squamous metaplastic cells (from the transformation
Found during menstruation period (in groups) seen up to zone)
10 days from LMP Properly labeled specimens
Endometrial stromal cells: seen in tight clusters of small,
oval dark cells; Glandular cells: Slightly larger Image: Negative for Intraepithelial lesion or Malignant cell
Nucleus: small & moderately dark Formerly Class I
Cytoplasm: Basophilic & maybe vacuolated Intraepithelial Lesion: Dysplasia, HPV
Significant: Premenopausal or menopausal period
Image: Adequacy
Specimen Unsatisfactory
Normal Bacterial Flora
Pap smear specimens are considered unsatisfactory for
“Lactobacillus acidophilus” (Doderlein Bacilli)
interpretation if there are:
Gram + slender rod bacteria
Inadequate numbers of well- visualized squamous cells
Predominant organism of the vaginal normal flora:
present
establishes the low pH that inhibits the growth of
Inadequate numbers of well-visualized endocervical cells
pathogens
or squamous metaplastic cells (from the transformation
Stains pale blue to lavender
zone).
Energy is obtained by the fermentation of glycogen
> 75% of the cells obscured by blood or inflammation
derived from disintegrating epithelial cells
Improperly labeled specimens
Numerous in the luteal phase and during pregnancy
Change in the flora is indicative of change in the pH,
Usually, these smears are recommended for repeat sampling.
which makes the milieu vulnerable for infection. Smears
with infection such as Candidiasis or Trichomonas have
Specimens to which the following conditions apply will be
no lactobacillus in the background.
rejected:
1. Specimen is submitted without a requisition
Reporting
2. Specimen is not labeled with the patient name.
CLASS SYSTEM (up to 1988)
3. The patient name (or other identifying information) on
Class I Negative for Malignant Cells
the specimen and requisition do no correspond
Class II Atypical cells present, but Negative for Malignancy
4. The specimen is labeled appropriately but the requisition
Class III Suspicious for Malignant Cells
is not labeled.
Class IV Strongly Suggestive for Malignant Cells
5. The specimen slide(s) is (are) irreparably broken.
Class V Conclusive (Positive) for Malignant Cells
6. Specimen is submitted from an unauthorized source.
Confusing: Class I, III & IV were gray areas which where
EPITHELIAL CELL ABNORMALITIES
subjected to various interpretation depending on how
Squamous
the institution looks at the diagnosis.
Atypical squamous cell of Undetermined Significance
(ASC – US) favor mild dysplasia
The BETHESDA SYSTEM
Low Grade Squamous intraepithelial lesion
Specimen Adequacy:
encompassing HPV cytopathic effects
Satisfactory for Evaluation
Low Grade Squamous Intraepithelial lesion (LSIL)
Satisfactory but limited by ….
(encompassing: HPV/ mild dysplasia/ CIN 1)
Unsatisfactory
General Categorization High Grade Squamous Intraepithelial Lesion (HSIL)
Negative for Intraepithelial lesions or malignant cell (encompassing: moderate & severe dysplasia. CIS, CIN 2
Benign Cellular Changes & CIN 3)
Epithelial cell abnormalities o With features suspicious for invasion (if
Descriptive Diagnosis invasion is suspected)
Infections/ Radiation Effects o Biopsy is warranted
Atypical squamous/ glandular cells of unknown
Significance Image: Squamous Cell CA (Large Cell Keratinizing)
Low grade squamous intraepithelial lesion 95% of malignancy of uterine cervix as most common
High grade squamous intraepithelial lesion Note the nuclear & cytoplasmic changes of the cells
Squamous Cell Carcinoma
Adenocarcinoma
Others