SlideShare a Scribd company logo
1 of 114
Download to read offline
PAP SMEAR 
dr. monika nema
Definition:- 
The Babeș-Papanicolaou test (also called Pap 
smear, Pap test, cervical smear, or smear test) is 
a screening test used to detect potentially 
pre-cancerous and cancerous processes in the the 
endocervical canal (transformation zone) of the female 
reproductive system. 
Credit for its development goes to Dr George N. 
Papanicolaou. 
dr. monika nema
PPaattiieenntt pprreeppaarraattiioonn 
Women should be tested two weeks 
after the first day of their last menstrual 
period.(Day 14 of cycle is optimal). 
Women should not use any vaginal 
medication, contraceptive during the 48 
hrs prior to sample collection. 
Sexual relationship is not recommended 
the night before the test. 
dr. monika nema
SSppeecciimmeenn ccoolllleeccttiioonn 
Specimens should be obtained after a 
nonlubricated speculum (moistened only 
with warm water if needed) is inserted 
• Excess mucus or other discharge should 
be removed gently with ring forceps 
holding a folded gauze pad. 
• An optimal sample includes cells from the 
ectocervix and endocervix 
dr. monika nema
SSqquuaammoo--CCoolluummnnaarr JJuunnccttiioonn 
Junction of pink cervical 
skin and red 
endocervical canal 
Inherently unstable 
Key portion of the 
cervix to sample 
Most likely site of 
dysplasia
The location of the squamo-columnar 
junction ( 8 mm to 13 mm proximal to 
the external cervical OS) in most women 
varies with the age and fertility. 
dr. monika nema
CCOOLLLLEECCTTIIOONN OOFF SSAAMMPPLLEE 
dr. monika nema
AAyyeerrss SSppaattuullaa 
Concave end to fit the 
cervix 
Convex end for vaginal 
wall and vaginal pool 
scrapings. 
One end is longer so 
that spatula fits the 
external OS.
dr. monika nema
CCyyttoobbrruusshh 
Easier to introduce into 
narrow cervical canal 
because the hairs fold 
down along the shaft and 
is likely to retain cells. 
Insert ~ 2 cm (until 
brush is fully inside 
canal) 
Rotate only 180 degrees 
(otherwise will cause 
bleeding)
dr. monika nema
MMaakkee PPaapp SSmmeeaarr 
As thin as possible 
Properly labeled
FFiixxaattiioonn 
Fixative is an agent used to prepare 
cytologic specimen for the purpose of 
preserving and maintaining the existing 
form and structure of all constituent 
elements. 
dr. monika nema
95% Ethanol. 
95% Rectified Spirit. 
100% Methanol. 
80% Isopropanol or Propanol. 
Ether/95% Ethanol ( 1: 1). 
Spray fixatives contains isopropanol and 
propylene glycol. 
dr. monika nema
Immediate fixation (within seconds) is critical in order to prevent 
air-drying artifact 
dr. monika nema
PPAAPP ssttaaiinn 
 80% alcohol – 6 to 8 dips. 
 70% alcohol – 6 to 8 dips. 
 50% alcohol – 6 to 8 dips. 
 Distilled water - 6 to 8 dips. 
 Harris Haematoxylene – 6 minutes. 
 0.25% HCl- 6 to 8 dips. 
 Running tap water – 6 minutes. 
 50% alcohol – 6 to 8 dips. 
 70% alcohol – 6 to 8 dips. 
 80% alcohol – 6 to 8 dips. 
 95% alcohol – 6 to 8 dips. 
 O.G.G- 2 minutes. 
dr. monika nema
PPAAPP ssttaaiinn 
 95% alcohol – Rinse in two dishes. 
 E. A 50 - 2 minutes. 
 95% alcohol – Rinse in three dishes. 
 100% alcohol – 6 to 8 dips. 
 100% alcohol – 6 to 8 dips. 
 Equal parts of absolute alcohol and xylene– Rinse in two dishes. 
 Xylene– 6 to 8 dips 
 Xylene– 6 to 8 dips. 
 Xylene– 6 to 8 dips 
 DPX mount 
dr. monika nema
LLiiqquuiidd bbaasseedd ccyyttoollooggyy 
The liquid based cytology technique 
involves rinsing all the material collected 
on the sampling device into a fixative 
fluid, creating a cell suspension. 
Liquid sample is sent to the laboratory 
rather than glass slide preparation. 
dr. monika nema
LLiiqquuiidd--bbaasseedd mmoonnoollaayyeerr ccyyttoollooggyy 
Two of the types 
-Sure-Path (TriPath Imaging) 
-Thin-Prep (Cytyc Corp). 
The media are primarily ethanol-based for Sure- 
Path and methanol for ThinPrep. 
dr. monika nema
LIQUID BASED CYTOLOGY 
a Different types of brushes alllloowwiinngg ttoo ccoolllleecctt cceellllss 
ffrroomm tthhee eeccttoocceerrvviixx aanndd eennddoocceerrvviixx.. 
Ectocervix and 0.5 cm of 
endocervix are sampled 
The central bristles of the broom are 
inserted into the endocervical canal until 
the lateral bristles bend fully against the 
ectocervix. 
The sampling device is rotated 360 degree 
in the clockwise direction twice and then 
anticlockwise while maintaining gentle 
pressure. 
dr. monika nema
The brush is removed aanndd ddeeppoossiitteedd iinn tthhee mmeetthhaannooll 
bbaasseedd lliiqquuiidd mmeeddiiuumm..RRBBCC aarree llyysseedd bbyy ttrraannssppoorrtt 
mmeeddiiuumm.. 
dr. monika nema
TThhiinn PPrreepp mmeetthhoodd 
The entire procedure takes about 70 
seconds per slide and results in a thin 
deposit of cells in a circle 20 mm in 
diameter. 
dr. monika nema
SSuurree ppaatthh 
Samples are collected in ethanol based 
transport medium. 
The tip of the collection device is snipped 
off and included in the sample vial. 
The equipment to prepare slides includes 
a Hettich centrifuge and a PrepStain 
robotic sample processer with computer 
and monitor. 
dr. monika nema
• Red blood cells and some leukocytes are 
eliminated by density centrifugation. 
• In addition to preparing an evenly 
distributed deposit of cells in a circle 13 
mm in diameter, the method 
incorporates a final staining step that 
discretely stains each individual slide. 
dr. monika nema
LLIIQQUUIIDD BBAASSEEDD CCYYTTOOLLOOGGYY 
• Reduces number of inadequate smears and 
need for repeat smears 
• Thin-Prep appears to be superior to convention 
Pap test in detecting SIL. 
• Cellular preservation is enhanced. 
• Good fixation results in improved microscopic 
details. 
dr. monika nema
Conventional smear 
dr. monika nema
What we see under the microscope 
conventional smear 
dr. monika nema
The prepared slide with the new 
ThinPrep 
dr. monika nema
What we see under the 
microscope. Notice the clean back 
ground and how well the cells are 
dispersed rendering easier dr. monika to 
nema
Cervical cytology practice guidelines 
Test Requisition 
The minimal clinical data: 
 Age 
 Date of LMP or onset of menopause 
 Past or Current history of any abnormalities or treatment 
 Pregnancy status 
dr. monika nema
dr. monika nema
NNOORRMMAALL CCEERRVVIICCAALL CCEELLLLSS 
Superficial cells Intermediate cells 
Basal cells 
Parabasal cells Metaplastic cells 
dr. monika nema
PPaarraabbaassaall CCeellllss 
Small round cells with round nuclei and 
small amount of cytoplasm 
Uniform in size and shape 
dr. monika nema
IInntteerrmmeeddiiaattee CCeellllss 
May be small or large 
Round nuclei, nucleus 
similar in size as 
parabasal cells 
Entire cell 
approximately twice 
the size of parabasal 
cells 
Cytoplasm becomes 
angular, irregular and 
folded as cell enlarges dr. monika nema
SSuuppeerrffiicciiaall CCeellllss 
Largest epithelial cell 
As they age and degenerate, the nuclei 
becomes small, pyknotic and fades. 
Cytoplasm may contain vacuoles with age 
dr. monika nema
SSuuppeerrffiicciiaall CCeellllss CCoonnttiinnuueedd 
Cornification is the degeneration process 
Superficial cells are commonly called 
cornified cells 
Once nucleus is lost become Anuclear 
cells 
dr. monika nema
BBeetthheessddaa SSyysstteemm 22000011 
 Specimen type 
 Indicate conventional smear (Pap smear), 
 liquid based preparation or other preparation (describe) 
 (A) Statement of adequacy of the specimen. 
 Satisfactory 
 Satisfactory for evaluation but limited by 
 Unsatisfactory. 
 (B) General categorization of the diagnosis . 
 Within normal limits. 
 Benign cellular changes. 
 Epithelial cell abnormality. 
 (C) Descriptive diagnosis 
 Infections 
 Reactive changes 
 Epithelial cell abnormalities 
 Other malignant neoplasms 
 Hormonal evaluation. 
dr. monika nema
BBeetthheessddaa SSyysstteemm 22000011 
 Interpretation/result 
 Negative for Intraepithelial Lesion or Malignancy (NILM) 
 Organisms 
 • Trichomonas vaginalis 
 • Candida species 
 • Bacterial vaginosis 
 • Actinomyces species 
 • Herpes simplex virus 
Other non-neoplastic findings- 
Reactive cellular changes associated with 
 - inflammation (includes typical repair) 
 - irradiation 
 - Intrauterine contraceptive device (IUD) 
dr. monika nema
BBeetthheessddaa SSyysstteemm 22000011 
 Epithelial Cell Abnormalities 
 SQUAMOUS CELL 
 • Atypical squamous cells 
 - of undetermined significance (ASC-US) 
 - cannot exclude HSIL (ASC-H) 
 *Low grade squamous intraepithelial lesion (LSIL) 
 - encompassing HPV/mild dysplasia/CIN I 
 • High grade squamous intraepithelial lesion (HSIL) 
 - encompassing: moderate and severe dysplasia/CIN2/CIN3/CIS 
 - with features suspicious for invasion (if invasion suspected) 
 • Squamous cell carcinoma 
 GLANDULAR CELL 
• Atypical glandular cells of uncertain significance 
• Atypical glandular cells- endocervical, endometrial NOS 
• AGC, favor neoplastic 
 • Endocervical Adenocarcinoma in situ 
 • Adenocarcinoma 
 - endocervical 
 - endometrial 
 - extrauterine 
 - not otherwise specified (NOS) 
dr. monika nema
SSttaatteemmeenntt ooff SSppeecciimmeenn AAddeeqquuaaccyy 
dr. monika nema
AAddeeqquuaattee ssmmeeaarr 
An adequate pap smear is one that 
includes a sampling of both the exocervix 
and endocervix. 
An adequate cytologic sample contains 
more than 300 squamous cells, including 
at least two clusters of 5 cells each of 
endocervical and/ or metaplastic cells 
with mucus material. 
dr. monika nema
This image was composed to depict the appearance of a 4X field with 
approximately 1400 cells. It is to be used as a guide in assessing 
squamous cellularity of conventional specimens. An adequate 
conventional smear has an estimated minimum of approximately 
8,000-12,000 well visualized and preserved squamous cells. 
dr. monika nema
Cytomorphologic Criteria: 
Satisfactory squamous cellularity on a ThinPrep slide. Endocervical 
cells are also present. An adequate liquid based preparation 
should have an estimated minimum of 5,000 well-visualized/ 
preserved squamous cells 
dr. monika nema
Cytomorphologic Criteria: 
Distinct cytoplasmic borders are seen in the cluster of cells on the left, 
giving a ?honeycomb? appearance. The cell cluster on the right is seen 
from a side view, giving the ?picket fence? appearance. Interpretation is 
NILM. 
dr. monika nema
This specimen is unsatisfactory due to scant squamous cellularity seen at10X 
dr. monika nema
Cytomorphologic Criteria: 
Over 75% of cells are obscured by inflammation and blood. 
. 
dr. monika nema
Defination aanndd ccrriitteerriiaa ffoorr ssppeecciimmeenn 
aaddeeqquuaaccyy 
dr. monika nema
““SSaattiissffaaccoottrryy ffoorr eevvaalluuaattiioonn”” 
Approriate labelling and identifying 
information. 
Relevant clinical information. 
Adequate numbers of well preserved and 
well visualized squamous epithelial cells. 
An adequate endocervical transformation 
zone component. 
dr. monika nema
SSaattiissffaaccttoorryy ffoorr eevvaalluuaattiioonn bbuutt 
lliimmiitteedd bbyy…….. 
Lack of minimum clinical patient 
information. 
Partially obscuring 
blood,inflammation,thick areas,poor 
fixation etc that precludes interpretation 
of approximately 50% to 75% of the 
epithelial cells. 
Lack of endocervical / transformation 
zone component. 
dr. monika nema
UUnnssaattiissffaaccttoorryy ffoorr eevvaalluuaattiioonn…… 
Lack of patient identification on specimen. 
Slide that is broken and cannot be repaired, or 
cellular material that is inadequately preserved. 
Scant squamous epithelial component 
(well preserved and well visualized squamous 
epithelial cells covering less than 10% of the 
slide surface) 
Obscuring that precludes interpretation of 
approximately 75% or more of epithelial cells. 
dr. monika nema
Any epithelial abnormality is of 
paramount importance and must be 
reported regardless of compromised 
specimen adequacy. 
If abnormal cells are detected, the 
specimen is never categorised as “ 
UNSATISFACTORY” 
dr. monika nema
IInnffeeccttiioonnss 
dr. monika nema
LLAACCTTOOBBAACCIILLLLII 
Lactobacilli are observed in about 50% of normal healthy adult female 
population. 
These bacilli release enzymes causing extensive cytolysis of glycogen 
containing cells. 
Mainly affect intermediate and superficial cells. 
Parabasal cells are generally spared. dr. monika nema
BBaacctteerriiaall vvaaggiinnoossiiss 
Between puberty and the menopause the presence of 
lactobacilli maintains a pH of vagina between 3.8 and 
4.2. 
Changes in pH over 4.5 leads to non specific vaginitis. 
It is an infectious disease classically associated with gray 
or white,thin, homogenous discharge that tends to 
adhere to vaginal walls. 
Exudes a characteristic fishy odour when mixed with 
10% KOH. 
Gardnerella vaginalis – putative pathogen. 
dr. monika nema
BBaacctteerriiaall vvaaggiinnoossiiss 
Interpretation: 
NILM: Shift in Flora suggestive of bacterial vaginosis 
dr. monika nema
HHeerrppeess ssiimmpplleexx 
Cytomorphologic Criteria: 
Nuclei showing "ground-glass" appearance. Multinucleation, nuclear 
molding, and dense eosinophilic intranuclear inclusions surrounded by a 
halo are also seen. 
dr. monika nema
AAccttiinnoommyycceess 
 Cytomorphologic Criteria: 
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. 
Actinomyces is often associated with intrauterine device (IUD) 
usage. 
dr. monika nema
CCaannddiiddaa 
Cytomorphologic Criteria: 
Pseudohyphae and reactive changes in the squamous epithelial cells. 
dr. monika nema
TTrriicchhoommoonnaass vvaaggiinnaalliiss 
Cytomorphologic Criteria: 
Trichomonas is a pear-shaped, oval to round, cyanophilic organism that 
ranges in size from 15-30 microns. The nucleus is pale, vesicular and 
centrally located. Eosinophilic granules are often visible in the cytoplasm. 
dr. monika nema
AAccuuttee iinnffllaammmmaattiioonn 
Dirty background of the smear. 
Desquamation of cells in sheets and aggregates. 
Large number of degenerating polymorphs. 
Dark pyknotic nuclei in superficial and 
intermediate cells. 
Perinuclear halos. 
Increased number of parabasal cells. 
Enlarged endocervical cells with 
prominent chromocentres. 
dr. monika nema
IINNFFLLAAMMMMAATTOORRYY LLEESSIIOONNSS 
AACCUUTTEE IINNFFLLAAMMMMAATTIIOONN 
dr. monika nema
AACCUUTTEE CCEERRVVIICCIITTIISS 
nuclei with variable staining 
Polymorphs 
dr. monika nema
CCHHRROONNIICC CCEERRVVIICCIITTIISS 
Plasma cells 
Lymphocytes 
dr. monika nema
HHyyppeerrkkeerraattoossiiss 
Cytomorphologic Criteria: 
Anucleate mature polygonal squamous cells with ghost-like ?nuclear 
holes? 
dr. monika nema
LLyymmpphhooccyyttiicc cceerrvviicciittiiss 
Cytomorphologic Criteria: 
Polymorphous population of lymphoid cells and tingible body 
macrophages. 
dr. monika nema
RREEAACCTTIIVVEE CCHHAANNGGEESS IINN SSQQUUAAMMOOUUSS 
CCEELLLLSS IINN IINNFFLLAAMMMMAATTOORRYY LLEESSIIOONNSS 
Nuclear pallor & 
enlargement 
dr. monika nema
IINNFFLLAAMMMMAATTOORRYY CCHHAANNGGEESS IINN 
EENNDDOOCCEERRVVIICCAALL CCEELLLLSS 
Enlargement, 
Presence of 
prominent 
nucleoli 
dr. monika nema
IINNFFLLAAMMMMAATTOORRYY CCHHAANNGGEESS IINN 
EENNDDOOCCEERRVVIICCAALL CCEELLLLSS 
Cytoplasmic 
vacoulation of the 
endocervical cells 
dr. monika nema
IIUUDD EEFFFFEECCTT 
Calcified debris 
Small cluster of glandular cells with cytoplasmic vacuoles displacing 
nuclei.creating a signet-ring appearance 
dr. monika nema
RRAADDIIAATTIIOONN EEFFFFEECCTT 
Overall increase in 
cell size 
Cytoplasmic 
vacuolation. 
Uneven staining of 
cytoplasm. 
Nuclear enlargement 
with vacuolation. 
Multinucleation. 
Fragmentation of 
nuclei. 
dr. monika nema
EEnnddoommeettrriiaall cceellllss 
Squamous 
cells 
Endometrial cells 
dr. monika nema
EEppiitthheelliiaall cceellll aabbnnoorrmmaalliittyy 
The diagnosis of ASCUS ( Atypical 
squamous epithelial cells of undetermined 
significane) is offered only when the 
cytomorphological changes exceed the 
parameters related to benign,reactive 
processes but fall short of a definite 
diagnosis of a squamous intraepithelial 
lesion. 
dr. monika nema
AASSCC--UUSS 
Cells resemble superficial or 
intermediate cells. 
Nuclear size is increased 2-3 times. 
Nuclear boundraies are regularor with 
minimum irregularities. 
dr. monika nema
AASSCC--HH ((ccaannnnoott eexxcclluuddee hhiigghh ggrraaddee 
iinnttrraaeeppiitthheelliiaall lleessiioonn)) 
Cells resemble parabasal or basal in 
configuration and size. 
Nuclei are hyperchromatic with uneven 
chromatin pattern. 
Nuclear membrane is thick and uneven. 
dr. monika nema
AASSCCUUSS-- MMAATTUURREE 
Enlarged hyperchromatic nucleus 
dr. monika nema
AASSCC--HH ((ccaannnnoott eexxcclluuddee hhiigghh ggrraaddee 
iinnttrraaeeppiitthheelliiaall lleessiioonn)) 
Loosely cohesive metaplastic cells with 
increased N:C ratio. 
dr. monika nema
AASSCC--HH 
metaplastic cells and slightly enlarged nuclei with occasional 
nuclear contour irregularities. 
dr. monika nema
AAGGUUSS 
dr. monika nema
dr. monika nema
CCOOMMPPAARRIISSOONN OOFF CCLLAASSSSIIFFIICCAATTIIOONNSS 
CCIINN 
GGRRAADDEE 
WWHHOO BBSSCCCC BBEETTHHEESSDDAA 
bboorrddeerrlliinnee AASSCCUUSS 
II MMiilldd 
ddyyssppllaassiiaa 
MMiilldd 
ddyysskkaarryyoossiiss 
LLooww ggrraaddee 
SSIILL 
IIII MMooddeerraattee 
ddyyssppllaassiiaa 
MMooddeerraattee 
ddyysskkaarryyoossiiss 
HHiigghh ggrraaddee 
SSIILL 
IIIIII SSeevveerree 
ddyyssppllaassiiaa 
SSeevveerree 
ddyysskkaarryyoossiiss 
HHiigghh ggrraaddee 
SSIILL 
dr. monika nema
In CIN I and III , the characteristic 
nuclear changes are better observed in 
intermediate cells. 
As the grades of CIN increase, parabasal 
and basal cells start showing nuclear 
abnormalities. 
dr. monika nema
Cervical iinnttrraaeeppiitthheelliiaall nneeooppllaassiiaa --11 
Slight nuclear enlargement 
Hyperchromasia but finely granular chromatin. 
nuclear membrane is smooth and without indentation. 
dr. monika nema
CCeerrvviiccaall iinnttrraaeeppiitthheelliiaall 
nneeooppllaassiiaa --IIII 
Hyperchromasia is more marked. 
Chromatin can be seen in small clumps. 
Nuclear membrane is thickened slightly but indentation are 
ususlly absent. 
dr. monika nema
Cervical iinnttrraaeeppiitthheelliiaall nneeooppllaassiiaa 
--IIIIII 
Nuclear membrane is characteristically irregular and indented 
dr. monika nema
HHPPVV iinnffeeccttiioonn 
Seen in most of the cases of CIN. 
Lesions of CIN I and CIN II are usually 
positive for HPV 6,11,31,42. 
Lesions of CIN III and invasive cancer are 
usually positive for HPV 16,18,33. 
dr. monika nema
KKOOIILLOOCCYYTTEE ((HHPPVV)) 
Large squamous 
cell with 
enlarged 
hyperchromatic 
nucleus & large 
sharply 
demarcated 
perinuclear clear 
zone 
dr. monika nema
PPSSEEUUDDOOKKOOIILLOOCCYYTTEESS 
Glycogen in squamous 
cells can give the 
appearance of 
"pseudokoilocytosis". 
Nuclear abnormalities 
required for an 
interpretation of ASC-US/ 
LSIL are absent. 
dr. monika nema
SSqquuaammoouuss cceellll ccaarrcciinnoommaa-- nnoonn 
kkeerraattiinniizziinngg 
Irregular chromatin, 
prominent nucleolus 
Dysplastic squamous cells with anisocytosis and anisonucleosis 
including keratinization and tadpole cells are diagnostic of invasive 
squamous cell carcinoma. 
dr. monika nema
SSqquuaammoouuss cceellll ccaarrcciinnoomm-- 
kkeerraattiinniizziinngg 
Tadpole cell 
dr. monika nema
AAttyyppiiccaall eennddoocceerrvviiccaall cceellllss 
 enlarged round or oval nuclei with prominent 
nucleoli. 
Mitotic figures 
Sheet of cells with enlarged, variably-sized nuclei with some crowding 
and overlap of nuclei. 
dr. monika nema
EENNDDOOCCEERRVVIICCAALL AADDEENNOOCCAARRCCIINNOOMMAA 
IINN SSIITTUU ((AAIISS)) 
Atypical columnar endocervical cells, with enlarged, elongated and 
hyperchromatic nuclei. 
Typical feathering and palisading. 
Explanatory Notes: 
Pseudostratification, nuclear crowding and feathering are classic features of 
AIS dr. monika nema
AADDEENNOOCCAARRCCIINNOOMMAA 
Cytomorphologic Criteria: 
Cluster of cells with enlarged round or oval nuclei, irregular chromatin 
distribution and prominent nucleoli. 
Explanatory Notes: 
Irregular chromatin distribution and prominent or macronucleoli are a 
classic findings in invasive endocervical adenocarcinoma. 
dr. monika nema
Invasive adenocarcinoma 
Go back to the list 
IINNVVAASSIIVVEE AADDEENNOOCCAARRCCIINNOOMMAA:: 
Cells are round,crowded, 
hyperchromatic 
dr. monika nema
IINNVVAASSIIVVEE AADDEENNOOCCAARRCCIINNOOMMAA 
Crowding,large nucleoli 
dr. monika nema
EENNDDOOMMEETTRRIIAALL 
AADDEENNOOCCAARRCCIINNOOMMAA 
Large hyperchromatic nucleus, 
Vacuolated cytoplasm 
dr. monika nema
HHoorrmmoonnaall ccyyttoollooggyy 
Maturation of vaginal squamous cells 
form one cell to another is hormone 
dependent. 
The quantitative ratio between the 
different cell types can reflect the index 
of the hormonal status of the female. 
For hormonal assesment ideal site is 
lateral vaginal wall. 
dr. monika nema
Estrogens have proven action on 
maturation of squamous epithelium of 
vagina. 
Its excess causes enhancement of 
maturation and the smear contains more 
of superficial cells, on the other hand its 
lack causes lower degree of maturation 
or the atrophy of squamous epithelium, 
the same effect could be reflected due to 
antagonistic action of the excess of 
progesterone. 
dr. monika nema
CCeelllluullaarr iinnddiicceess ffoorr hhoorrmmoonnaall 
aasssseessssmmeenntt 
Karyopyknotic index 
Eosinophilic index 
Folded cell index 
Crowded cell index 
Maturation index 
dr. monika nema
KKaarryyooppyykknnoottiicc iinnddeexx 
Ratio between the superficial squamous 
cells with pyknotic nuclei to all mature 
squamous cells irrespective of staining 
character 
Peak of KPI usually coincides with the 
time of ovulation and may reach 50-85. 
dr. monika nema
EEoossiinnoopphhiilliicc iinnddeexx 
Ratio of mature squamous cells with 
eosinophilic cytoplasm to all mature 
squamous cells irrespective of size of 
nucleus. 
Peak value is 50-75 during ovulation. 
dr. monika nema
FFoollddeedd cceellll iinnddeexx 
Ratio of mature squamous cells with 
folded margins to all mature squamous 
cells irrespective of staining chararcter. 
Folding is usually observed in cells 
containing glycogen. 
dr. monika nema
CCrroowwddeedd cceellll iinnddeexx 
Represents the relationship of mature 
squamous cells lying in clusters of four or 
more cells, to all mature squamous cells. 
dr. monika nema
MMaattuurraattiioonn iinnddeexx 
It is count of the parabasal cells, 
intermediate and superficial cells . 
(P : I : S) 
In a normal menstruating woman during 
ovulation the menstruation index will be 
0/35/65. 
In postmenopausal it will be 85/15/0. 
dr. monika nema
MMaattuurraattiioonn vvaalluuee 
Meisels suggested that a value be given to 
each category of cells i.e, value of 1.0 to 
superficial cells, 0.5 to intermediate cells 
and 0.0 to parabasal cells. 
This system gives single value ranging 
from 0-100 to express hormonal status. 
dr. monika nema
Maturation value 
100 – purely superficial cells. 
0 – purely parabasal cells. 
50-95 – in normal menstruating woman. 
< 50 – atrophic squamous epithelium. 
dr. monika nema
DIFFRERENT PHASES OF MENSTRUAL 
CYCLE 
ESTROGEN PHASE 
eosinophilic superficial squamous 
cells, clean 
background 
. 
dr. monika nema
OVULATORY SMEAR 
fern-like crystalline structures 
eosinophilic superficial 
squamous cells 
dr. monika nema
. ( PROGESTERONE PHASE 
basophilic squamous cells with folded 
cytoplasm (boat cells) 
Glycogen 
deposits 
dr. monika nema
PROGESTERONE PHASE WITH 
ABUNDANT LACTOBACILLI AND 
CYTOLYSIS 
navicular cells 
Naked nuclei 
dr. monika nema
MMeennooppaauussee 
Maturation of cervical epithelium is 
estrogen dependent 
Due to its insufficiency, maturation is 
retarded. 
Number of mature squamous and 
intermediate cells is reduced. 
In early menopause intermediate cells 
increase in number. 
dr. monika nema
AAttrroopphhyy 
Cytomorphologic Criteria: 
Parabasal cells and blue blobs. 
Explanatory Notes: 
Overall cellularity of smear is reduced. Small and large parabasal cells are 
seen with almost absence of superficial cells. 
Blue blobs are globular collections of basophilic amorphous material 
reflecting either degenerated parabasal cells or inspissated mucus 
dr. monika nema
AAmmeerrcciiaann ccaanncceerr ssoocciieettyy 
rreeccoommmmeennddaattiioonnss 
 Screening should begin no later than age 21. 
 Screening should begin earlier than age 21 if the patient is sexually 
active. In this case, it should start 3 years after initiation of vaginal 
intercourse. 
 Once initiated, screening should be performed annually. 
 After age 30, for women who have had 3 consecutive normal pap 
smears, screening frequency may be reduced to every two to 
three years. 
 Women who are HIV positive, immunocompromised should 
continue annual screening. 
 Patient tested positive for HPV, should continue to be screened 
indefinitely. 
 May stop after age 70, if patient is low risk and has had three 
normal pap smears over the last 10 years. 
dr. monika nema
In developing countries where there are 
no organized screening programme for 
pap test due to financial constraints, poor 
infrastructure or inadequate human 
resources, the WHO recommends five 
yearly five pap tests during life span of 35 
to 55 years. 
dr. monika nema
TTHHAANNKK YYOOUU 
SPEAKER : Dr. MONIKA NEMA 
dr. monika nema

More Related Content

What's hot

Fine Needle Aspiration Cytology (FNAC)
Fine Needle Aspiration Cytology (FNAC)Fine Needle Aspiration Cytology (FNAC)
Fine Needle Aspiration Cytology (FNAC)Alisha Karmali
 
Cell block and liquid based cytology
Cell block and liquid based cytologyCell block and liquid based cytology
Cell block and liquid based cytologyDr Neha Mahajan
 
cytology of urinary tract
cytology of urinary tractcytology of urinary tract
cytology of urinary tractSHRUTHI VASAN
 
FNAC FINE NEEDLE ASPIRATION CYTOLOGY
FNAC FINE NEEDLE ASPIRATION CYTOLOGYFNAC FINE NEEDLE ASPIRATION CYTOLOGY
FNAC FINE NEEDLE ASPIRATION CYTOLOGYSURAMYA BABU
 
Utility of cell block in cytology.
Utility of cell block in cytology.Utility of cell block in cytology.
Utility of cell block in cytology.Manan Shah
 
Cell block in cytology
Cell block in cytologyCell block in cytology
Cell block in cytologyAnam Khurshid
 
Special stains in cytology
Special stains in cytologySpecial stains in cytology
Special stains in cytologySuma Venugopal
 
Fluid cytology in CSF
Fluid cytology in CSFFluid cytology in CSF
Fluid cytology in CSFtashagarwal
 
Liquid based cytology ( l b c)
Liquid  based  cytology ( l b c)Liquid  based  cytology ( l b c)
Liquid based cytology ( l b c)vikramsaraswat
 
Fine needle aspiration cytology
Fine needle aspiration cytologyFine needle aspiration cytology
Fine needle aspiration cytologyAayra
 
Semen analysis by Dr.Renukadevi
Semen analysis by Dr.RenukadeviSemen analysis by Dr.Renukadevi
Semen analysis by Dr.RenukadeviMorris Jawahar
 
Atlas on bethesda system for reporting cervical cytology
Atlas on bethesda system for reporting cervical cytologyAtlas on bethesda system for reporting cervical cytology
Atlas on bethesda system for reporting cervical cytologyAshish Jawarkar
 
Automation in cytology.
Automation in cytology.Automation in cytology.
Automation in cytology.Manan Shah
 
CYTOLOGY OF BREAST LESIONS??!
CYTOLOGY OF BREAST LESIONS??! CYTOLOGY OF BREAST LESIONS??!
CYTOLOGY OF BREAST LESIONS??! Ashish Jawarkar
 
CYTOLOGY OF CSF
CYTOLOGY OF CSFCYTOLOGY OF CSF
CYTOLOGY OF CSFMusa Khan
 
Liquid based cytology | Abdul Quddus
Liquid based cytology | Abdul QuddusLiquid based cytology | Abdul Quddus
Liquid based cytology | Abdul QuddusAbdul Quddus
 

What's hot (20)

Fine Needle Aspiration Cytology (FNAC)
Fine Needle Aspiration Cytology (FNAC)Fine Needle Aspiration Cytology (FNAC)
Fine Needle Aspiration Cytology (FNAC)
 
Cell block and liquid based cytology
Cell block and liquid based cytologyCell block and liquid based cytology
Cell block and liquid based cytology
 
cytology of urinary tract
cytology of urinary tractcytology of urinary tract
cytology of urinary tract
 
Semen analysis
Semen analysis Semen analysis
Semen analysis
 
FNAC FINE NEEDLE ASPIRATION CYTOLOGY
FNAC FINE NEEDLE ASPIRATION CYTOLOGYFNAC FINE NEEDLE ASPIRATION CYTOLOGY
FNAC FINE NEEDLE ASPIRATION CYTOLOGY
 
Utility of cell block in cytology.
Utility of cell block in cytology.Utility of cell block in cytology.
Utility of cell block in cytology.
 
Cell block in cytology
Cell block in cytologyCell block in cytology
Cell block in cytology
 
Cervix cyto
Cervix cytoCervix cyto
Cervix cyto
 
Special stains in cytology
Special stains in cytologySpecial stains in cytology
Special stains in cytology
 
Fluid cytology in CSF
Fluid cytology in CSFFluid cytology in CSF
Fluid cytology in CSF
 
Liquid based cytology ( l b c)
Liquid  based  cytology ( l b c)Liquid  based  cytology ( l b c)
Liquid based cytology ( l b c)
 
Fine needle aspiration cytology
Fine needle aspiration cytologyFine needle aspiration cytology
Fine needle aspiration cytology
 
Semen analysis by Dr.Renukadevi
Semen analysis by Dr.RenukadeviSemen analysis by Dr.Renukadevi
Semen analysis by Dr.Renukadevi
 
Atlas on bethesda system for reporting cervical cytology
Atlas on bethesda system for reporting cervical cytologyAtlas on bethesda system for reporting cervical cytology
Atlas on bethesda system for reporting cervical cytology
 
Automation in cytology.
Automation in cytology.Automation in cytology.
Automation in cytology.
 
introduction of cytopathology
introduction of cytopathologyintroduction of cytopathology
introduction of cytopathology
 
CYTOLOGY OF BREAST LESIONS??!
CYTOLOGY OF BREAST LESIONS??! CYTOLOGY OF BREAST LESIONS??!
CYTOLOGY OF BREAST LESIONS??!
 
CYTOLOGY OF CSF
CYTOLOGY OF CSFCYTOLOGY OF CSF
CYTOLOGY OF CSF
 
Liquid based cytology | Abdul Quddus
Liquid based cytology | Abdul QuddusLiquid based cytology | Abdul Quddus
Liquid based cytology | Abdul Quddus
 
Imprint cytology
Imprint cytology Imprint cytology
Imprint cytology
 

Similar to Cervical cytopathology

Cytotechniques
Cytotechniques  Cytotechniques
Cytotechniques drtousif
 
Exfoliative cytology
Exfoliative cytology Exfoliative cytology
Exfoliative cytology Atifa Ambreen
 
basic cytology techniques.pptx
basic cytology techniques.pptxbasic cytology techniques.pptx
basic cytology techniques.pptxssuser75fd45
 
Exfoliative cytology
Exfoliative cytologyExfoliative cytology
Exfoliative cytologysandeep singh
 
Histological and cytological specimens
Histological and cytological specimensHistological and cytological specimens
Histological and cytological specimensJoseph Kitukulu
 
Pap Smear: A Bird's Eye View from a Cytopathologist
Pap Smear: A Bird's Eye View from a CytopathologistPap Smear: A Bird's Eye View from a Cytopathologist
Pap Smear: A Bird's Eye View from a CytopathologistDr. Shubhi Saxena
 
Dr Ayman Ewies - Basic principles of colposcopy 2009
Dr Ayman Ewies - Basic principles of colposcopy 2009Dr Ayman Ewies - Basic principles of colposcopy 2009
Dr Ayman Ewies - Basic principles of colposcopy 2009AymanEwies
 
urinarytract-180126143744.pptx
urinarytract-180126143744.pptxurinarytract-180126143744.pptx
urinarytract-180126143744.pptxAnees Puthawala
 
Management of hydatid cyst and osteoid osteoma
Management of hydatid cyst and osteoid osteomaManagement of hydatid cyst and osteoid osteoma
Management of hydatid cyst and osteoid osteomaSangeeta Jha
 
A.B.C. of Paps Smear Update (2016) ,DR. SUDHIR JAIN Consultant Pathologist
A.B.C. of Paps Smear Update (2016) ,DR. SUDHIR JAIN  Consultant Pathologist A.B.C. of Paps Smear Update (2016) ,DR. SUDHIR JAIN  Consultant Pathologist
A.B.C. of Paps Smear Update (2016) ,DR. SUDHIR JAIN Consultant Pathologist Lifecare Centre
 
preinvasive lesion of cervix and management ,quick revise tool
preinvasive lesion of cervix and management ,quick revise toolpreinvasive lesion of cervix and management ,quick revise tool
preinvasive lesion of cervix and management ,quick revise toolmahadevbpatil
 
Taking A Pap Smear
Taking A Pap SmearTaking A Pap Smear
Taking A Pap Smeardrsubir
 
Laser scanning cytometry and liquid based cytology
Laser scanning cytometry and liquid based cytologyLaser scanning cytometry and liquid based cytology
Laser scanning cytometry and liquid based cytologyanaonline
 
Laser scanning cytometry and liquid based cytology
Laser scanning cytometry and liquid based cytologyLaser scanning cytometry and liquid based cytology
Laser scanning cytometry and liquid based cytologyanaonline
 
SEMEN ANALYSIS PPT.pptx
SEMEN ANALYSIS PPT.pptxSEMEN ANALYSIS PPT.pptx
SEMEN ANALYSIS PPT.pptxsherin783017
 
Cytopathology Lab manual for MLT Students
Cytopathology Lab manual for MLT Students Cytopathology Lab manual for MLT Students
Cytopathology Lab manual for MLT Students Vamsi kumar
 
Exfoliative cytology
Exfoliative cytologyExfoliative cytology
Exfoliative cytologyAkhil s
 

Similar to Cervical cytopathology (20)

Cytotechniques
Cytotechniques  Cytotechniques
Cytotechniques
 
Exfoliative cytology
Exfoliative cytology Exfoliative cytology
Exfoliative cytology
 
basic cytology techniques.pptx
basic cytology techniques.pptxbasic cytology techniques.pptx
basic cytology techniques.pptx
 
Exfoliative cytology
Exfoliative cytologyExfoliative cytology
Exfoliative cytology
 
Histological and cytological specimens
Histological and cytological specimensHistological and cytological specimens
Histological and cytological specimens
 
Pap Smear: A Bird's Eye View from a Cytopathologist
Pap Smear: A Bird's Eye View from a CytopathologistPap Smear: A Bird's Eye View from a Cytopathologist
Pap Smear: A Bird's Eye View from a Cytopathologist
 
Dr Ayman Ewies - Basic principles of colposcopy 2009
Dr Ayman Ewies - Basic principles of colposcopy 2009Dr Ayman Ewies - Basic principles of colposcopy 2009
Dr Ayman Ewies - Basic principles of colposcopy 2009
 
urinarytract-180126143744.pptx
urinarytract-180126143744.pptxurinarytract-180126143744.pptx
urinarytract-180126143744.pptx
 
Management of hydatid cyst and osteoid osteoma
Management of hydatid cyst and osteoid osteomaManagement of hydatid cyst and osteoid osteoma
Management of hydatid cyst and osteoid osteoma
 
A.B.C. of Paps Smear Update (2016) ,DR. SUDHIR JAIN Consultant Pathologist
A.B.C. of Paps Smear Update (2016) ,DR. SUDHIR JAIN  Consultant Pathologist A.B.C. of Paps Smear Update (2016) ,DR. SUDHIR JAIN  Consultant Pathologist
A.B.C. of Paps Smear Update (2016) ,DR. SUDHIR JAIN Consultant Pathologist
 
preinvasive lesion of cervix and management ,quick revise tool
preinvasive lesion of cervix and management ,quick revise toolpreinvasive lesion of cervix and management ,quick revise tool
preinvasive lesion of cervix and management ,quick revise tool
 
Taking A Pap Smear
Taking A Pap SmearTaking A Pap Smear
Taking A Pap Smear
 
Laser scanning cytometry and liquid based cytology
Laser scanning cytometry and liquid based cytologyLaser scanning cytometry and liquid based cytology
Laser scanning cytometry and liquid based cytology
 
GYNAECOLOGY SKILLS.pptx
GYNAECOLOGY SKILLS.pptxGYNAECOLOGY SKILLS.pptx
GYNAECOLOGY SKILLS.pptx
 
Colposcopy2 1
Colposcopy2 1Colposcopy2 1
Colposcopy2 1
 
Laser scanning cytometry and liquid based cytology
Laser scanning cytometry and liquid based cytologyLaser scanning cytometry and liquid based cytology
Laser scanning cytometry and liquid based cytology
 
SEMEN ANALYSIS PPT.pptx
SEMEN ANALYSIS PPT.pptxSEMEN ANALYSIS PPT.pptx
SEMEN ANALYSIS PPT.pptx
 
Hydatid diseases
Hydatid diseasesHydatid diseases
Hydatid diseases
 
Cytopathology Lab manual for MLT Students
Cytopathology Lab manual for MLT Students Cytopathology Lab manual for MLT Students
Cytopathology Lab manual for MLT Students
 
Exfoliative cytology
Exfoliative cytologyExfoliative cytology
Exfoliative cytology
 

More from Monika Nema

Microcytic anemia
Microcytic anemiaMicrocytic anemia
Microcytic anemiaMonika Nema
 
Laboratory diagnosis of Diabetes mellitus
Laboratory diagnosis of Diabetes mellitus Laboratory diagnosis of Diabetes mellitus
Laboratory diagnosis of Diabetes mellitus Monika Nema
 
Grossing procedure for ovary
Grossing procedure for ovaryGrossing procedure for ovary
Grossing procedure for ovaryMonika Nema
 
Reporting thyroid fine needle aspiration by the bethesda system
Reporting thyroid fine needle aspiration by the bethesda systemReporting thyroid fine needle aspiration by the bethesda system
Reporting thyroid fine needle aspiration by the bethesda systemMonika Nema
 
Gross of thyroid gland
Gross of thyroid glandGross of thyroid gland
Gross of thyroid glandMonika Nema
 
Gross of esophagus
Gross of esophagusGross of esophagus
Gross of esophagusMonika Nema
 
Eosinophils in lymph node
Eosinophils in lymph nodeEosinophils in lymph node
Eosinophils in lymph nodeMonika Nema
 
Acute myeloid leukemia
Acute myeloid leukemiaAcute myeloid leukemia
Acute myeloid leukemiaMonika Nema
 

More from Monika Nema (9)

Microcytic anemia
Microcytic anemiaMicrocytic anemia
Microcytic anemia
 
Laboratory diagnosis of Diabetes mellitus
Laboratory diagnosis of Diabetes mellitus Laboratory diagnosis of Diabetes mellitus
Laboratory diagnosis of Diabetes mellitus
 
Grossing procedure for ovary
Grossing procedure for ovaryGrossing procedure for ovary
Grossing procedure for ovary
 
Reporting thyroid fine needle aspiration by the bethesda system
Reporting thyroid fine needle aspiration by the bethesda systemReporting thyroid fine needle aspiration by the bethesda system
Reporting thyroid fine needle aspiration by the bethesda system
 
Gross of thyroid gland
Gross of thyroid glandGross of thyroid gland
Gross of thyroid gland
 
Gross of esophagus
Gross of esophagusGross of esophagus
Gross of esophagus
 
stem cells
stem cellsstem cells
stem cells
 
Eosinophils in lymph node
Eosinophils in lymph nodeEosinophils in lymph node
Eosinophils in lymph node
 
Acute myeloid leukemia
Acute myeloid leukemiaAcute myeloid leukemia
Acute myeloid leukemia
 

Recently uploaded

Male Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaMale Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaSujoy Dasgupta
 
Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Vaikunthan Rajaratnam
 
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfCONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfDolisha Warbi
 
Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.kishan singh tomar
 
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.pptRamDBawankar1
 
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.aarjukhadka22
 
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationPhysiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationMedicoseAcademics
 
Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Peter Embi
 
How to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyHow to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyZurück zum Ursprung
 
Using Data Visualization in Public Health Communications
Using Data Visualization in Public Health CommunicationsUsing Data Visualization in Public Health Communications
Using Data Visualization in Public Health Communicationskatiequigley33
 
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfHongBiThi1
 
Mental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil ThirusanguMental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil Thirusangu Medical University
 
Unit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptUnit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptPradnya Wadekar
 
Male Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondMale Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondSujoy Dasgupta
 
High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)kishan singh tomar
 
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptxDNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptxMAsifAhmad
 
blood bank management system project report
blood bank management system project reportblood bank management system project report
blood bank management system project reportNARMADAPETROLEUMGAS
 
Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024EwoutSteyerberg1
 
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdfSGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdfHongBiThi1
 
power point presentation of Clinical evaluation of strabismus
power point presentation of Clinical evaluation  of strabismuspower point presentation of Clinical evaluation  of strabismus
power point presentation of Clinical evaluation of strabismusChandrasekar Reddy
 

Recently uploaded (20)

Male Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaMale Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
 
Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.
 
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfCONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
 
Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.
 
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
 
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
 
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationPhysiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
 
Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024
 
How to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyHow to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturally
 
Using Data Visualization in Public Health Communications
Using Data Visualization in Public Health CommunicationsUsing Data Visualization in Public Health Communications
Using Data Visualization in Public Health Communications
 
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
 
Mental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil ThirusanguMental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil Thirusangu
 
Unit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptUnit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.ppt
 
Male Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondMale Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and Beyond
 
High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)
 
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptxDNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
 
blood bank management system project report
blood bank management system project reportblood bank management system project report
blood bank management system project report
 
Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024
 
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdfSGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
 
power point presentation of Clinical evaluation of strabismus
power point presentation of Clinical evaluation  of strabismuspower point presentation of Clinical evaluation  of strabismus
power point presentation of Clinical evaluation of strabismus
 

Cervical cytopathology

  • 1. PAP SMEAR dr. monika nema
  • 2. Definition:- The Babeș-Papanicolaou test (also called Pap smear, Pap test, cervical smear, or smear test) is a screening test used to detect potentially pre-cancerous and cancerous processes in the the endocervical canal (transformation zone) of the female reproductive system. Credit for its development goes to Dr George N. Papanicolaou. dr. monika nema
  • 3. PPaattiieenntt pprreeppaarraattiioonn Women should be tested two weeks after the first day of their last menstrual period.(Day 14 of cycle is optimal). Women should not use any vaginal medication, contraceptive during the 48 hrs prior to sample collection. Sexual relationship is not recommended the night before the test. dr. monika nema
  • 4. SSppeecciimmeenn ccoolllleeccttiioonn Specimens should be obtained after a nonlubricated speculum (moistened only with warm water if needed) is inserted • Excess mucus or other discharge should be removed gently with ring forceps holding a folded gauze pad. • An optimal sample includes cells from the ectocervix and endocervix dr. monika nema
  • 5. SSqquuaammoo--CCoolluummnnaarr JJuunnccttiioonn Junction of pink cervical skin and red endocervical canal Inherently unstable Key portion of the cervix to sample Most likely site of dysplasia
  • 6. The location of the squamo-columnar junction ( 8 mm to 13 mm proximal to the external cervical OS) in most women varies with the age and fertility. dr. monika nema
  • 8. AAyyeerrss SSppaattuullaa Concave end to fit the cervix Convex end for vaginal wall and vaginal pool scrapings. One end is longer so that spatula fits the external OS.
  • 10. CCyyttoobbrruusshh Easier to introduce into narrow cervical canal because the hairs fold down along the shaft and is likely to retain cells. Insert ~ 2 cm (until brush is fully inside canal) Rotate only 180 degrees (otherwise will cause bleeding)
  • 12. MMaakkee PPaapp SSmmeeaarr As thin as possible Properly labeled
  • 13. FFiixxaattiioonn Fixative is an agent used to prepare cytologic specimen for the purpose of preserving and maintaining the existing form and structure of all constituent elements. dr. monika nema
  • 14. 95% Ethanol. 95% Rectified Spirit. 100% Methanol. 80% Isopropanol or Propanol. Ether/95% Ethanol ( 1: 1). Spray fixatives contains isopropanol and propylene glycol. dr. monika nema
  • 15. Immediate fixation (within seconds) is critical in order to prevent air-drying artifact dr. monika nema
  • 16. PPAAPP ssttaaiinn  80% alcohol – 6 to 8 dips.  70% alcohol – 6 to 8 dips.  50% alcohol – 6 to 8 dips.  Distilled water - 6 to 8 dips.  Harris Haematoxylene – 6 minutes.  0.25% HCl- 6 to 8 dips.  Running tap water – 6 minutes.  50% alcohol – 6 to 8 dips.  70% alcohol – 6 to 8 dips.  80% alcohol – 6 to 8 dips.  95% alcohol – 6 to 8 dips.  O.G.G- 2 minutes. dr. monika nema
  • 17. PPAAPP ssttaaiinn  95% alcohol – Rinse in two dishes.  E. A 50 - 2 minutes.  95% alcohol – Rinse in three dishes.  100% alcohol – 6 to 8 dips.  100% alcohol – 6 to 8 dips.  Equal parts of absolute alcohol and xylene– Rinse in two dishes.  Xylene– 6 to 8 dips  Xylene– 6 to 8 dips.  Xylene– 6 to 8 dips  DPX mount dr. monika nema
  • 18. LLiiqquuiidd bbaasseedd ccyyttoollooggyy The liquid based cytology technique involves rinsing all the material collected on the sampling device into a fixative fluid, creating a cell suspension. Liquid sample is sent to the laboratory rather than glass slide preparation. dr. monika nema
  • 19. LLiiqquuiidd--bbaasseedd mmoonnoollaayyeerr ccyyttoollooggyy Two of the types -Sure-Path (TriPath Imaging) -Thin-Prep (Cytyc Corp). The media are primarily ethanol-based for Sure- Path and methanol for ThinPrep. dr. monika nema
  • 20. LIQUID BASED CYTOLOGY a Different types of brushes alllloowwiinngg ttoo ccoolllleecctt cceellllss ffrroomm tthhee eeccttoocceerrvviixx aanndd eennddoocceerrvviixx.. Ectocervix and 0.5 cm of endocervix are sampled The central bristles of the broom are inserted into the endocervical canal until the lateral bristles bend fully against the ectocervix. The sampling device is rotated 360 degree in the clockwise direction twice and then anticlockwise while maintaining gentle pressure. dr. monika nema
  • 21. The brush is removed aanndd ddeeppoossiitteedd iinn tthhee mmeetthhaannooll bbaasseedd lliiqquuiidd mmeeddiiuumm..RRBBCC aarree llyysseedd bbyy ttrraannssppoorrtt mmeeddiiuumm.. dr. monika nema
  • 22. TThhiinn PPrreepp mmeetthhoodd The entire procedure takes about 70 seconds per slide and results in a thin deposit of cells in a circle 20 mm in diameter. dr. monika nema
  • 23. SSuurree ppaatthh Samples are collected in ethanol based transport medium. The tip of the collection device is snipped off and included in the sample vial. The equipment to prepare slides includes a Hettich centrifuge and a PrepStain robotic sample processer with computer and monitor. dr. monika nema
  • 24. • Red blood cells and some leukocytes are eliminated by density centrifugation. • In addition to preparing an evenly distributed deposit of cells in a circle 13 mm in diameter, the method incorporates a final staining step that discretely stains each individual slide. dr. monika nema
  • 25. LLIIQQUUIIDD BBAASSEEDD CCYYTTOOLLOOGGYY • Reduces number of inadequate smears and need for repeat smears • Thin-Prep appears to be superior to convention Pap test in detecting SIL. • Cellular preservation is enhanced. • Good fixation results in improved microscopic details. dr. monika nema
  • 26. Conventional smear dr. monika nema
  • 27. What we see under the microscope conventional smear dr. monika nema
  • 28. The prepared slide with the new ThinPrep dr. monika nema
  • 29. What we see under the microscope. Notice the clean back ground and how well the cells are dispersed rendering easier dr. monika to nema
  • 30. Cervical cytology practice guidelines Test Requisition The minimal clinical data:  Age  Date of LMP or onset of menopause  Past or Current history of any abnormalities or treatment  Pregnancy status dr. monika nema
  • 32. NNOORRMMAALL CCEERRVVIICCAALL CCEELLLLSS Superficial cells Intermediate cells Basal cells Parabasal cells Metaplastic cells dr. monika nema
  • 33. PPaarraabbaassaall CCeellllss Small round cells with round nuclei and small amount of cytoplasm Uniform in size and shape dr. monika nema
  • 34. IInntteerrmmeeddiiaattee CCeellllss May be small or large Round nuclei, nucleus similar in size as parabasal cells Entire cell approximately twice the size of parabasal cells Cytoplasm becomes angular, irregular and folded as cell enlarges dr. monika nema
  • 35. SSuuppeerrffiicciiaall CCeellllss Largest epithelial cell As they age and degenerate, the nuclei becomes small, pyknotic and fades. Cytoplasm may contain vacuoles with age dr. monika nema
  • 36. SSuuppeerrffiicciiaall CCeellllss CCoonnttiinnuueedd Cornification is the degeneration process Superficial cells are commonly called cornified cells Once nucleus is lost become Anuclear cells dr. monika nema
  • 37. BBeetthheessddaa SSyysstteemm 22000011  Specimen type  Indicate conventional smear (Pap smear),  liquid based preparation or other preparation (describe)  (A) Statement of adequacy of the specimen.  Satisfactory  Satisfactory for evaluation but limited by  Unsatisfactory.  (B) General categorization of the diagnosis .  Within normal limits.  Benign cellular changes.  Epithelial cell abnormality.  (C) Descriptive diagnosis  Infections  Reactive changes  Epithelial cell abnormalities  Other malignant neoplasms  Hormonal evaluation. dr. monika nema
  • 38. BBeetthheessddaa SSyysstteemm 22000011  Interpretation/result  Negative for Intraepithelial Lesion or Malignancy (NILM)  Organisms  • Trichomonas vaginalis  • Candida species  • Bacterial vaginosis  • Actinomyces species  • Herpes simplex virus Other non-neoplastic findings- Reactive cellular changes associated with  - inflammation (includes typical repair)  - irradiation  - Intrauterine contraceptive device (IUD) dr. monika nema
  • 39. BBeetthheessddaa SSyysstteemm 22000011  Epithelial Cell Abnormalities  SQUAMOUS CELL  • Atypical squamous cells  - of undetermined significance (ASC-US)  - cannot exclude HSIL (ASC-H)  *Low grade squamous intraepithelial lesion (LSIL)  - encompassing HPV/mild dysplasia/CIN I  • High grade squamous intraepithelial lesion (HSIL)  - encompassing: moderate and severe dysplasia/CIN2/CIN3/CIS  - with features suspicious for invasion (if invasion suspected)  • Squamous cell carcinoma  GLANDULAR CELL • Atypical glandular cells of uncertain significance • Atypical glandular cells- endocervical, endometrial NOS • AGC, favor neoplastic  • Endocervical Adenocarcinoma in situ  • Adenocarcinoma  - endocervical  - endometrial  - extrauterine  - not otherwise specified (NOS) dr. monika nema
  • 40. SSttaatteemmeenntt ooff SSppeecciimmeenn AAddeeqquuaaccyy dr. monika nema
  • 41. AAddeeqquuaattee ssmmeeaarr An adequate pap smear is one that includes a sampling of both the exocervix and endocervix. An adequate cytologic sample contains more than 300 squamous cells, including at least two clusters of 5 cells each of endocervical and/ or metaplastic cells with mucus material. dr. monika nema
  • 42. This image was composed to depict the appearance of a 4X field with approximately 1400 cells. It is to be used as a guide in assessing squamous cellularity of conventional specimens. An adequate conventional smear has an estimated minimum of approximately 8,000-12,000 well visualized and preserved squamous cells. dr. monika nema
  • 43. Cytomorphologic Criteria: Satisfactory squamous cellularity on a ThinPrep slide. Endocervical cells are also present. An adequate liquid based preparation should have an estimated minimum of 5,000 well-visualized/ preserved squamous cells dr. monika nema
  • 44. Cytomorphologic Criteria: Distinct cytoplasmic borders are seen in the cluster of cells on the left, giving a ?honeycomb? appearance. The cell cluster on the right is seen from a side view, giving the ?picket fence? appearance. Interpretation is NILM. dr. monika nema
  • 45. This specimen is unsatisfactory due to scant squamous cellularity seen at10X dr. monika nema
  • 46. Cytomorphologic Criteria: Over 75% of cells are obscured by inflammation and blood. . dr. monika nema
  • 47. Defination aanndd ccrriitteerriiaa ffoorr ssppeecciimmeenn aaddeeqquuaaccyy dr. monika nema
  • 48. ““SSaattiissffaaccoottrryy ffoorr eevvaalluuaattiioonn”” Approriate labelling and identifying information. Relevant clinical information. Adequate numbers of well preserved and well visualized squamous epithelial cells. An adequate endocervical transformation zone component. dr. monika nema
  • 49. SSaattiissffaaccttoorryy ffoorr eevvaalluuaattiioonn bbuutt lliimmiitteedd bbyy…….. Lack of minimum clinical patient information. Partially obscuring blood,inflammation,thick areas,poor fixation etc that precludes interpretation of approximately 50% to 75% of the epithelial cells. Lack of endocervical / transformation zone component. dr. monika nema
  • 50. UUnnssaattiissffaaccttoorryy ffoorr eevvaalluuaattiioonn…… Lack of patient identification on specimen. Slide that is broken and cannot be repaired, or cellular material that is inadequately preserved. Scant squamous epithelial component (well preserved and well visualized squamous epithelial cells covering less than 10% of the slide surface) Obscuring that precludes interpretation of approximately 75% or more of epithelial cells. dr. monika nema
  • 51. Any epithelial abnormality is of paramount importance and must be reported regardless of compromised specimen adequacy. If abnormal cells are detected, the specimen is never categorised as “ UNSATISFACTORY” dr. monika nema
  • 53. LLAACCTTOOBBAACCIILLLLII Lactobacilli are observed in about 50% of normal healthy adult female population. These bacilli release enzymes causing extensive cytolysis of glycogen containing cells. Mainly affect intermediate and superficial cells. Parabasal cells are generally spared. dr. monika nema
  • 54. BBaacctteerriiaall vvaaggiinnoossiiss Between puberty and the menopause the presence of lactobacilli maintains a pH of vagina between 3.8 and 4.2. Changes in pH over 4.5 leads to non specific vaginitis. It is an infectious disease classically associated with gray or white,thin, homogenous discharge that tends to adhere to vaginal walls. Exudes a characteristic fishy odour when mixed with 10% KOH. Gardnerella vaginalis – putative pathogen. dr. monika nema
  • 55. BBaacctteerriiaall vvaaggiinnoossiiss Interpretation: NILM: Shift in Flora suggestive of bacterial vaginosis dr. monika nema
  • 56. HHeerrppeess ssiimmpplleexx Cytomorphologic Criteria: Nuclei showing "ground-glass" appearance. Multinucleation, nuclear molding, and dense eosinophilic intranuclear inclusions surrounded by a halo are also seen. dr. monika nema
  • 57. AAccttiinnoommyycceess  Cytomorphologic Criteria: 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. Actinomyces is often associated with intrauterine device (IUD) usage. dr. monika nema
  • 58. CCaannddiiddaa Cytomorphologic Criteria: Pseudohyphae and reactive changes in the squamous epithelial cells. dr. monika nema
  • 59. TTrriicchhoommoonnaass vvaaggiinnaalliiss Cytomorphologic Criteria: Trichomonas is a pear-shaped, oval to round, cyanophilic organism that ranges in size from 15-30 microns. The nucleus is pale, vesicular and centrally located. Eosinophilic granules are often visible in the cytoplasm. dr. monika nema
  • 60. AAccuuttee iinnffllaammmmaattiioonn Dirty background of the smear. Desquamation of cells in sheets and aggregates. Large number of degenerating polymorphs. Dark pyknotic nuclei in superficial and intermediate cells. Perinuclear halos. Increased number of parabasal cells. Enlarged endocervical cells with prominent chromocentres. dr. monika nema
  • 61. IINNFFLLAAMMMMAATTOORRYY LLEESSIIOONNSS AACCUUTTEE IINNFFLLAAMMMMAATTIIOONN dr. monika nema
  • 62. AACCUUTTEE CCEERRVVIICCIITTIISS nuclei with variable staining Polymorphs dr. monika nema
  • 63. CCHHRROONNIICC CCEERRVVIICCIITTIISS Plasma cells Lymphocytes dr. monika nema
  • 64. HHyyppeerrkkeerraattoossiiss Cytomorphologic Criteria: Anucleate mature polygonal squamous cells with ghost-like ?nuclear holes? dr. monika nema
  • 65. LLyymmpphhooccyyttiicc cceerrvviicciittiiss Cytomorphologic Criteria: Polymorphous population of lymphoid cells and tingible body macrophages. dr. monika nema
  • 66. RREEAACCTTIIVVEE CCHHAANNGGEESS IINN SSQQUUAAMMOOUUSS CCEELLLLSS IINN IINNFFLLAAMMMMAATTOORRYY LLEESSIIOONNSS Nuclear pallor & enlargement dr. monika nema
  • 67. IINNFFLLAAMMMMAATTOORRYY CCHHAANNGGEESS IINN EENNDDOOCCEERRVVIICCAALL CCEELLLLSS Enlargement, Presence of prominent nucleoli dr. monika nema
  • 68. IINNFFLLAAMMMMAATTOORRYY CCHHAANNGGEESS IINN EENNDDOOCCEERRVVIICCAALL CCEELLLLSS Cytoplasmic vacoulation of the endocervical cells dr. monika nema
  • 69. IIUUDD EEFFFFEECCTT Calcified debris Small cluster of glandular cells with cytoplasmic vacuoles displacing nuclei.creating a signet-ring appearance dr. monika nema
  • 70. RRAADDIIAATTIIOONN EEFFFFEECCTT Overall increase in cell size Cytoplasmic vacuolation. Uneven staining of cytoplasm. Nuclear enlargement with vacuolation. Multinucleation. Fragmentation of nuclei. dr. monika nema
  • 71. EEnnddoommeettrriiaall cceellllss Squamous cells Endometrial cells dr. monika nema
  • 72. EEppiitthheelliiaall cceellll aabbnnoorrmmaalliittyy The diagnosis of ASCUS ( Atypical squamous epithelial cells of undetermined significane) is offered only when the cytomorphological changes exceed the parameters related to benign,reactive processes but fall short of a definite diagnosis of a squamous intraepithelial lesion. dr. monika nema
  • 73. AASSCC--UUSS Cells resemble superficial or intermediate cells. Nuclear size is increased 2-3 times. Nuclear boundraies are regularor with minimum irregularities. dr. monika nema
  • 74. AASSCC--HH ((ccaannnnoott eexxcclluuddee hhiigghh ggrraaddee iinnttrraaeeppiitthheelliiaall lleessiioonn)) Cells resemble parabasal or basal in configuration and size. Nuclei are hyperchromatic with uneven chromatin pattern. Nuclear membrane is thick and uneven. dr. monika nema
  • 75. AASSCCUUSS-- MMAATTUURREE Enlarged hyperchromatic nucleus dr. monika nema
  • 76. AASSCC--HH ((ccaannnnoott eexxcclluuddee hhiigghh ggrraaddee iinnttrraaeeppiitthheelliiaall lleessiioonn)) Loosely cohesive metaplastic cells with increased N:C ratio. dr. monika nema
  • 77. AASSCC--HH metaplastic cells and slightly enlarged nuclei with occasional nuclear contour irregularities. dr. monika nema
  • 80. CCOOMMPPAARRIISSOONN OOFF CCLLAASSSSIIFFIICCAATTIIOONNSS CCIINN GGRRAADDEE WWHHOO BBSSCCCC BBEETTHHEESSDDAA bboorrddeerrlliinnee AASSCCUUSS II MMiilldd ddyyssppllaassiiaa MMiilldd ddyysskkaarryyoossiiss LLooww ggrraaddee SSIILL IIII MMooddeerraattee ddyyssppllaassiiaa MMooddeerraattee ddyysskkaarryyoossiiss HHiigghh ggrraaddee SSIILL IIIIII SSeevveerree ddyyssppllaassiiaa SSeevveerree ddyysskkaarryyoossiiss HHiigghh ggrraaddee SSIILL dr. monika nema
  • 81. In CIN I and III , the characteristic nuclear changes are better observed in intermediate cells. As the grades of CIN increase, parabasal and basal cells start showing nuclear abnormalities. dr. monika nema
  • 82. Cervical iinnttrraaeeppiitthheelliiaall nneeooppllaassiiaa --11 Slight nuclear enlargement Hyperchromasia but finely granular chromatin. nuclear membrane is smooth and without indentation. dr. monika nema
  • 83. CCeerrvviiccaall iinnttrraaeeppiitthheelliiaall nneeooppllaassiiaa --IIII Hyperchromasia is more marked. Chromatin can be seen in small clumps. Nuclear membrane is thickened slightly but indentation are ususlly absent. dr. monika nema
  • 84. Cervical iinnttrraaeeppiitthheelliiaall nneeooppllaassiiaa --IIIIII Nuclear membrane is characteristically irregular and indented dr. monika nema
  • 85. HHPPVV iinnffeeccttiioonn Seen in most of the cases of CIN. Lesions of CIN I and CIN II are usually positive for HPV 6,11,31,42. Lesions of CIN III and invasive cancer are usually positive for HPV 16,18,33. dr. monika nema
  • 86. KKOOIILLOOCCYYTTEE ((HHPPVV)) Large squamous cell with enlarged hyperchromatic nucleus & large sharply demarcated perinuclear clear zone dr. monika nema
  • 87. PPSSEEUUDDOOKKOOIILLOOCCYYTTEESS Glycogen in squamous cells can give the appearance of "pseudokoilocytosis". Nuclear abnormalities required for an interpretation of ASC-US/ LSIL are absent. dr. monika nema
  • 88. SSqquuaammoouuss cceellll ccaarrcciinnoommaa-- nnoonn kkeerraattiinniizziinngg Irregular chromatin, prominent nucleolus Dysplastic squamous cells with anisocytosis and anisonucleosis including keratinization and tadpole cells are diagnostic of invasive squamous cell carcinoma. dr. monika nema
  • 89. SSqquuaammoouuss cceellll ccaarrcciinnoomm-- kkeerraattiinniizziinngg Tadpole cell dr. monika nema
  • 90. AAttyyppiiccaall eennddoocceerrvviiccaall cceellllss  enlarged round or oval nuclei with prominent nucleoli. Mitotic figures Sheet of cells with enlarged, variably-sized nuclei with some crowding and overlap of nuclei. dr. monika nema
  • 91. EENNDDOOCCEERRVVIICCAALL AADDEENNOOCCAARRCCIINNOOMMAA IINN SSIITTUU ((AAIISS)) Atypical columnar endocervical cells, with enlarged, elongated and hyperchromatic nuclei. Typical feathering and palisading. Explanatory Notes: Pseudostratification, nuclear crowding and feathering are classic features of AIS dr. monika nema
  • 92. AADDEENNOOCCAARRCCIINNOOMMAA Cytomorphologic Criteria: Cluster of cells with enlarged round or oval nuclei, irregular chromatin distribution and prominent nucleoli. Explanatory Notes: Irregular chromatin distribution and prominent or macronucleoli are a classic findings in invasive endocervical adenocarcinoma. dr. monika nema
  • 93. Invasive adenocarcinoma Go back to the list IINNVVAASSIIVVEE AADDEENNOOCCAARRCCIINNOOMMAA:: Cells are round,crowded, hyperchromatic dr. monika nema
  • 95. EENNDDOOMMEETTRRIIAALL AADDEENNOOCCAARRCCIINNOOMMAA Large hyperchromatic nucleus, Vacuolated cytoplasm dr. monika nema
  • 96. HHoorrmmoonnaall ccyyttoollooggyy Maturation of vaginal squamous cells form one cell to another is hormone dependent. The quantitative ratio between the different cell types can reflect the index of the hormonal status of the female. For hormonal assesment ideal site is lateral vaginal wall. dr. monika nema
  • 97. Estrogens have proven action on maturation of squamous epithelium of vagina. Its excess causes enhancement of maturation and the smear contains more of superficial cells, on the other hand its lack causes lower degree of maturation or the atrophy of squamous epithelium, the same effect could be reflected due to antagonistic action of the excess of progesterone. dr. monika nema
  • 98. CCeelllluullaarr iinnddiicceess ffoorr hhoorrmmoonnaall aasssseessssmmeenntt Karyopyknotic index Eosinophilic index Folded cell index Crowded cell index Maturation index dr. monika nema
  • 99. KKaarryyooppyykknnoottiicc iinnddeexx Ratio between the superficial squamous cells with pyknotic nuclei to all mature squamous cells irrespective of staining character Peak of KPI usually coincides with the time of ovulation and may reach 50-85. dr. monika nema
  • 100. EEoossiinnoopphhiilliicc iinnddeexx Ratio of mature squamous cells with eosinophilic cytoplasm to all mature squamous cells irrespective of size of nucleus. Peak value is 50-75 during ovulation. dr. monika nema
  • 101. FFoollddeedd cceellll iinnddeexx Ratio of mature squamous cells with folded margins to all mature squamous cells irrespective of staining chararcter. Folding is usually observed in cells containing glycogen. dr. monika nema
  • 102. CCrroowwddeedd cceellll iinnddeexx Represents the relationship of mature squamous cells lying in clusters of four or more cells, to all mature squamous cells. dr. monika nema
  • 103. MMaattuurraattiioonn iinnddeexx It is count of the parabasal cells, intermediate and superficial cells . (P : I : S) In a normal menstruating woman during ovulation the menstruation index will be 0/35/65. In postmenopausal it will be 85/15/0. dr. monika nema
  • 104. MMaattuurraattiioonn vvaalluuee Meisels suggested that a value be given to each category of cells i.e, value of 1.0 to superficial cells, 0.5 to intermediate cells and 0.0 to parabasal cells. This system gives single value ranging from 0-100 to express hormonal status. dr. monika nema
  • 105. Maturation value 100 – purely superficial cells. 0 – purely parabasal cells. 50-95 – in normal menstruating woman. < 50 – atrophic squamous epithelium. dr. monika nema
  • 106. DIFFRERENT PHASES OF MENSTRUAL CYCLE ESTROGEN PHASE eosinophilic superficial squamous cells, clean background . dr. monika nema
  • 107. OVULATORY SMEAR fern-like crystalline structures eosinophilic superficial squamous cells dr. monika nema
  • 108. . ( PROGESTERONE PHASE basophilic squamous cells with folded cytoplasm (boat cells) Glycogen deposits dr. monika nema
  • 109. PROGESTERONE PHASE WITH ABUNDANT LACTOBACILLI AND CYTOLYSIS navicular cells Naked nuclei dr. monika nema
  • 110. MMeennooppaauussee Maturation of cervical epithelium is estrogen dependent Due to its insufficiency, maturation is retarded. Number of mature squamous and intermediate cells is reduced. In early menopause intermediate cells increase in number. dr. monika nema
  • 111. AAttrroopphhyy Cytomorphologic Criteria: Parabasal cells and blue blobs. Explanatory Notes: Overall cellularity of smear is reduced. Small and large parabasal cells are seen with almost absence of superficial cells. Blue blobs are globular collections of basophilic amorphous material reflecting either degenerated parabasal cells or inspissated mucus dr. monika nema
  • 112. AAmmeerrcciiaann ccaanncceerr ssoocciieettyy rreeccoommmmeennddaattiioonnss  Screening should begin no later than age 21.  Screening should begin earlier than age 21 if the patient is sexually active. In this case, it should start 3 years after initiation of vaginal intercourse.  Once initiated, screening should be performed annually.  After age 30, for women who have had 3 consecutive normal pap smears, screening frequency may be reduced to every two to three years.  Women who are HIV positive, immunocompromised should continue annual screening.  Patient tested positive for HPV, should continue to be screened indefinitely.  May stop after age 70, if patient is low risk and has had three normal pap smears over the last 10 years. dr. monika nema
  • 113. In developing countries where there are no organized screening programme for pap test due to financial constraints, poor infrastructure or inadequate human resources, the WHO recommends five yearly five pap tests during life span of 35 to 55 years. dr. monika nema
  • 114. TTHHAANNKK YYOOUU SPEAKER : Dr. MONIKA NEMA dr. monika nema

Editor's Notes

  1. In obtaining the Pap smear, it is important to sample the &amp;quot;Squamo-columnar Junction.&amp;quot; This is the circular area right at the opening of the cervix where the pink, smooth skin of the cervix meets the fiery-red, fragile, mucous-producing lining of the cervical canal. If there is going to be a problem with cancer or precancerous changes, it is this area that is most likely to be effected. This area is also known as the SQJ, or transition zone.
  2. The Ayers spatula is specially designed for obtaining Pap smears. The concave end (curving inward) fits against the cervix, while the convex end (curving outward) is used for scraping vaginal lesions or sampling the &amp;quot;vaginal pool,&amp;quot; the collection of vaginal secretions just below the cervix. The spatula is made of either wood or plastic. Both give very satisfactory results.
  3. Push the cytobrush into the canal, no deeper than the length of the brush (1.5 cm - 2.0 cm). Rotate the brush 180 degrees (half a circle) and pull the cytobrush straight out. Don&amp;apos;t keep spinning the brush round and round or you will cause bleeding. Even the 180 degree rotation may cause a little bleeding but usually it doesn&amp;apos;t.
  4. Label the slide with pencil on the frosted end. Two slides may be made, one for the spatula and one for the brush (“two-slide” technique). Alternatively, a single slide may be used (the “one-slide” technique) in which the brush is spread on one half the slide and the spatula is used on the other half. Both techniques give good results.
  5. Conventional Pap Smear (Macroscopic) •The manual smearing method is readily noted macroscopically. Conventional slide experience is transferable to the ThinPrep process. Cytology does not have to be relearned, base knowledge is merely refined.
  6. CP •Microscopically, the uneven distribution of cellular material associated with the CP smear pattern is evident.
  7. TP (Macroscopic) •The key difference in presentation is no longer seeing the smear pattern. ThinPrep takes the same material which is concentrated onto the center of the slide in a thin, uniform layer. Specimen preparation is standardized, eliminating the inconsistency associated with manual preparations.
  8. TP Same Patient •Tissue architecture is maintained. TP rearranges the relationship of cell groups on the glass slide. A group/sheet of endocervical cells present represents this.