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Case 2

View the images and select the correct diagnosis from the list of differentials.

Tall, dark & mysterious

Pap smear taken from a 78-year old woman:

 

Image2 

Image3 

Image4 

Select the correct diagnosis:

You answered: CIN III       

That is CORRECT!!


CYTOPATHOLOGY:

  • The smear contains numerous syncytial aggregates of small cells that have a high N/C ratio and loss of nuclear polarity. The nuclei are hyperchromatic with slight nuclear membrane irregularity. (Images 1, 2)
  • Other syncytial groups contain larger cells with more abundant cytoplasm. The nuclei show variation in size and have irregular nuclear outlines. (Images 3, 4)
  • The background contains intermediate and superficial cells. Some stripped nuclei are present but significant numbers of parabasal cells are not noted.
  • These cytologic features are suggestive of squamous carcinoma in situ.

DISCUSSION:

  • The cervical biopsy revealed squamous carcinoma in-situ (CIN III). There was no evidence of invasion. Koilocytotic change was also noted (not in image).
  • Interpretation of postmenopausal smears is often very challenging. In this case, despite the patient's age, the smear suggests hormonal effect (exogenous or endogenous) with intermediate and occasional superficial squamous cells present. This suggests the squamous atypia is more likely squamous dysplasia and less likely benign degenerate change in atrophy. A recommendation for colposcopy based on this smear is reasonable. In cases with more atrophic change, supplemental estrogen to enhance the degree of squamous maturation is often helpful.
  • The differential diagnosis of fragments of hyperchromatic syncytial cell groups includes atrophic squamous, metaplastic or endocervical epithelium and high grade squamous dysplasia. The diagnosis can at times be impossible, especially with advanced atrophy, inflammation and thick poorly preserved smears. A high index of suspicion is essential. It is necessary to focus through the cell clusters, looking for nuclear hyperchromasia, irregular nuclear membranes, nuclear crowding and mitotic figures. Cells at the margins of the fragments may be the most revealing. If in doubt, report as atypical squamous cells with a recommendation for a repeat smear after estrogen or colposcopy.

BACK TO IMAGES 


HISTOLOGY


REFERENCES:

Kurman RJ, Norris HJ, Wilkinson E. Tumors of the Cervix, Vagina, and Vulva, Atlas of Tumor Pathology. 3rd series 1992: 104

Bonfiglio TA, Erozan YS. Gynecologic Cytopathology. Philadelphia: Lipincott-Raven 1997:145

 

 

You answered: Atrophic endocervical epithelium
Sorry, that is INCORRECT


The correct diagnosis is: CIN III


CYTOPATHOLOGY:

  • The smear contains numerous syncytial aggregates of small cells that have a high N/C ratio and loss of nuclear polarity. The nuclei are hyperchromatic with slight nuclear membrane irregularity. (Images 1, 2)
  • Other syncytial groups contain larger cells with more abundant cytoplasm. The nuclei show variation in size and have irregular nuclear outlines. (Images 3, 4)
  • The background contains intermediate and superficial cells. Some stripped nuclei are present but significant numbers of parabasal cells are not noted.
  • These cytologic features are suggestive of squamous carcinoma in situ.

DISCUSSION:

  • The cervical biopsy revealed squamous carcinoma in-situ (CIN III). There was no evidence of invasion. Koilocytotic change was also noted (not in image).
  • Interpretation of postmenopausal smears is often very challenging. In this case, despite the patient's age, the smear suggests hormonal effect (exogenous or endogenous) with intermediate and occasional superficial squamous cells present. This suggests the squamous atypia is more likely squamous dysplasia and less likely benign degenerate change in atrophy. A recommendation for colposcopy based on this smear is reasonable. In cases with more atrophic change, supplemental estrogen to enhance the degree of squamous maturation is often helpful.
  • The differential diagnosis of fragments of hyperchromatic syncytial cell groups includes atrophic squamous, metaplastic or endocervical epithelium and high grade squamous dysplasia. The diagnosis can at times be impossible, especially with advanced atrophy, inflammation and thick poorly preserved smears. A high index of suspicion is essential. It is necessary to focus through the cell clusters, looking for nuclear hyperchromasia, irregular nuclear membranes, nuclear crowding and mitotic figures. Cells at the margins of the fragments may be the most revealing. If in doubt, report as atypical squamous cells with a recommendation for a repeat smear after estrogen or colposcopy.

BACK TO IMAGES


HISTOLOGY


REFERENCES:

Kurman RJ, Norris HJ, Wilkinson E. Tumors of the Cervix, Vagina, and Vulva, Atlas of Tumor Pathology. 3rd series 1992: 104

Bonfiglio TA, Erozan YS. Gynecologic Cytopathology. Philadelphia: Lipincott-Raven 1997:145 

 


 

 

You answered: Atypical squamous cells, recommend stilbestrol
Sorry, that is INCORRECT


The correct diagnosis is:CIN III


CYTOPATHOLOGY:

  • The smear contains numerous syncytial aggregates of small cells that have a high N/C ratio and loss of nuclear polarity. The nuclei are hyperchromatic with slight nuclear membrane irregularity. (Images 1, 2)
  • Other syncytial groups contain larger cells with more abundant cytoplasm. The nuclei show variation in size and have irregular nuclear outlines. (Images 3, 4)
  • The background contains intermediate and superficial cells. Some stripped nuclei are present but significant numbers of parabasal cells are not noted.
  • These cytologic features are suggestive of squamous carcinoma in situ. 

DISCUSSION:

  • The cervical biopsy revealed squamous carcinoma in-situ (CIN III). There was no evidence of invasion. Koilocytotic change was also noted (not in image).
  • Interpretation of postmenopausal smears is often very challenging. In this case, despite the patient's age, the smear suggests hormonal effect (exogenous or endogenous) with intermediate and occasional superficial squamous cells present. This suggests the squamous atypia is more likely squamous dysplasia and less likely benign degenerate change in atrophy. A recommendation for colposcopy based on this smear is reasonable.
  • In cases with more atrophic change, supplemental estrogen to enhance the degree of squamous maturation is often helpful.
  • The differential diagnosis of fragments of hyperchromatic syncytial cell groups includes atrophic squamous, metaplastic or endocervical epithelium and high grade squamous dysplasia. The diagnosis can at times be impossible, especially with advanced atrophy, inflammation and thick poorly preserved smears. A high index of suspicion is essential. It is necessary to focus through the cell clusters, looking for nuclear hyperchromasia, irregular nuclear membranes, nuclear crowding and mitotic figures. Cells at the margins of the fragments may be the most revealing. If in doubt, report as atypical squamous cells with a recommendation for a repeat smear after estrogen or colposcopy.

BACK TO IMAGES


HISTOLOGY


REFERENCES:

Kurman RJ, Norris HJ, Wilkinson E. Tumors of the Cervix, Vagina, and Vulva, Atlas of Tumor Pathology. 3rd series 1992: 104

Bonfiglio TA, Erozan YS. Gynecologic Cytopathology. Philadelphia: Lipincott-Raven 1997:145



You answered: Benign changes in atrophic squamous epithelium
Sorry, that is INCORRECT


The correct diagnosis is: CIN III


CYTOPATHOLOGY:

  • The smear contains numerous syncytial aggregates of small cells that have a high N/C ratio and loss of nuclear polarity. The nuclei are hyperchromatic with slight nuclear membrane irregularity. (Images 1, 2)
  • Other syncytial groups contain larger cells with more abundant cytoplasm. The nuclei show variation in size and have irregular nuclear outlines. (Images 3, 4)
  • The background contains intermediate and superficial cells. Some stripped nuclei are present but significant numbers of parabasal cells are not noted.
  • These cytologic features are suggestive of squamous carcinoma in situ.

DISCUSSION:

  • The cervical biopsy revealed squamous carcinoma in-situ (CIN III). There was no evidence of invasion. Koilocytotic change was also noted (not in image).
  • Interpretation of postmenopausal smears is often very challenging. In this case, despite the patient's age, the smear suggests hormonal effect (exogenous or endogenous) with intermediate and occasional superficial squamous cells present. This suggests the squamous atypia is more likely squamous dysplasia and less likely benign degenerate change in atrophy. A recommendation for colposcopy based on this smear is reasonable.
  • In cases with more atrophic change, supplemental estrogen to enhance the degree of squamous maturation is often helpful.
  • The differential diagnosis of fragments of hyperchromatic syncytial cell groups includes atrophic squamous, metaplastic or endocervical epithelium and high grade squamous dysplasia. The diagnosis can at times be impossible, especially with advanced atrophy, inflammation and thick poorly preserved smears. A high index of suspicion is essential. It is necessary to focus through the cell clusters, looking for nuclear hyperchromasia, irregular nuclear membranes, nuclear crowding and mitotic figures. Cells at the margins of the fragments may be the most revealing. If in doubt, report as atypical squamous cells with a recommendation for a repeat smear after estrogen or colposcopy.

BACK TO IMAGES


HISTOLOGY


REFERENCES:

Kurman RJ, Norris HJ, Wilkinson E. Tumors of the Cervix, Vagina, and Vulva, Atlas of Tumor Pathology. 3rd series 1992: 104

Bonfiglio TA, Erozan YS. Gynecologic Cytopathology. Philadelphia: Lipincott-Raven 1997:145

 

From the Cytopathology files of the BC Cancer Agency
Submitted by: Brenda Smith, BSc and Tom Thomson, MD

SOURCE: Case 2 ( )
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