Cytology

Notes from Review Guide

Chapter 1 Basic Science:
Cells are most sensitive to radiation in S phase (synthesis).
Initiation is the primary step in neoplasia: permanent & irreversible. Promotion (second step) is dose-dependent: depends on the # of initiated cells.
Three junctional complexes: occludens (tight junctions: fuse cell membranes), adherens (desmosomes: allow material to pass between cells), gap junctions.
Benign tumors with cytogenetic abnormalities: meningiomas, pleomorphic adenomas (t 8, 12, or 3), lipoma, leiomyoma, villous adenoma.

Chapter 2 Female Reproductive Tract
Vagina, uterus and ovaries formed from mesoderm.
Pleomorphism is the single most important criterion in establishing a diagnosis of a keratinizing prcess/lesion.
Endometrial cells: Spontaneously exfoliated endometrial cells are normally present only in the first half of the menstrual cycle (ie, up to day 14), but can be inadvertently obtained at any time using an endocervical brush. Classic "double contour" arrangement (stroma in center surrounded by epithelium) is associated with "exodus" (days 6 to 10).

Bethesda System: Specimen Adequacy
(1) patient and specimen identification: Unsatisfactory if there is lack of patient identification or no requisition form.
(2) pertinent clinical information:
(3) technical interpretability (eg, adequate fixation without air drying): The slide is technically unacceptable (eg, irreparably broken, inadequate preservation). Unsatisfactory if >75% of cells obscured by air drying.
(4) cellular composition and sampling of the T zone (eg, presence of squamous and endocervical cells in the Pap smear): squamous cells should be spread over more than 10% of the slide surface: 5,000 cells be present for an adequate Pap smear, less than 1,000 is unsatisfactory, and between 1,000 - 5,000 is "limited."
At least two clusters of well-preserved endocervical or metaplastic cells, with each cluster composed of at least five cells. Otherwise "limited."
Caveat: if abnormal cells are present, the specimen should not be categorized as unsatisfactory.

CLIA '88
· 5 year retrospective review for HGSIL or worse
· LGSIL or worse mandates patient follow up
· Daily records of time spent & #s of slides/each cytopathologist
· Board certified pathologists or cytopathologists can't review >100 slides/24 hrs (>12.5 slides/hr); pathologist can review unlimited rescreens.
· Technical supervisor of lab must be a board-certified pathologist.
· Cytotech supervisor must have 3 years experience: provide intralab QC and 10% rescreen.
· Final reports must be kept 10 years; original requisitions kept 2 years; glass slides 5 years
· 10% review of focused or high risk cases as well as random review.

2/3 of serous tumors of the ovary are bilateral; compared to <5% mucinous, rare sex-cord stromal tumors;
Trichomonas vaginalis presents as "strawberry cervix": petechial hemorrhages on mucosa.
Cockleburs: degenerate radiate crystals, seen in pregnancy, IUD & OCP

Pregnancy Changes:
· Glycogenated intermediate cells (navicular cells, boat cells)
· Histiocytes (early and late)
· Endocervical cells (ectropion)
· Decidual cells
· Arias-Stella reaction
· Trophoblast

Threatened abortion: syncytiotrophoblasts, increased superficial cell maturation.
Progesterone decreases maturation of estrogen-primed epithelium to intermediate cell level.
Vaginal adenosis: ectopic glandular or squamous metaplastic cells in a vaginal smear. Associated with DES exposure in utero.
Increased vascularization of basal lamina in a post-menopausal woman thought to cause deep atrophy.

Menstrual Cycle:
LH and Estrogen peak: day 14
Exodus: days 6-10 (endometrial cell tophats)
estrogen: FSH ratio is inverse due to feedback inhibition.
secretory/luteal phase is constant at 14 days.
Late in cycle: progesterone effects stronger associated w/increased #s intermediate cells, cytolysis & Lactobacillus.

Parabasal predominance: hypothyroid, androgen Rx, intrauterine fetal demise, hypopituitary, starvation, cervicovaginal ulceration.
Microglandular hyperplasia (AKA: pseudoparakeratosis) assoc with: OCP, pregnancy; degenerated endocervical cells w/cytoplasmic orangeophilia, nuclear pyknosis, in classic linear array.
Spider cells are immature squamous metaplastic cells forcibly scraped from the mucosal surface.
Virilization: bilateral ovarian enlargement, hirsuitism, deepening of voice, acne, enlarged clitoris.
Arrhenoblastoma: androgen-producing
Hypothalamic lesions can ® pituitary to produce FSH ® precocious puberty.
Long term, low dose estrogen ® intermediate cell predominance vs. short-term ® superficial cells.
Reserve cells ® small cell squamous carcinoma.
Diathesis: tissue necrosis associated with invasive malignancy.
Viral genomic segment responsible for host cellular transformation in vivo: early region 6,7 (regulate viral growth). Bind anti-oncogenes or tumor-suppressor genes p53 and Rb.
Trichomonas infection can cause perinuclear, inflammatory halos that can be mistaken for koilocytes. They are caused by alcohol fixation of an inflamed nuclei, wheras true koilocytes have cave-like halos at least the width of an intermediate cell nucleus.
Post-irradiation carcinoma: presence of malignant cells after 8 weeks is considered residual (irradiation changes present) or recurrent (absent irradiation changes).
Signs of a post-irradiation carcinoma include round to oval, stripped nuclei & cells are usually smaller than the original carcinoma cells.
Atrophy: degenerated parabasal cells of atrophy, "blue blobs" degenerating karyolytic cells, "mummified cells" pyknotc parabasal cells with eosinophilic cytoplasm.
Homologous MMMT: most common sarcomatous element is leiomyosarcoma. Heterologeous: rhabdomyosarcoma
Poorly differentiated adenocarcinoma has an increase in sheets over glands, syncytia.
Adenoacanthoma: adenocarcinoma with squamous diffrentiation.

Associated Findings:
Basophilic watery diathesis - well differentiated endometrial adenocarcinoma
Coarsely granular necrotic diathesis - squamous carcinoma
Sheets of neoplastic cells - poorly differentiated adenocarcinoma
Paipllary groups with psammoma bodies - papillary serous carcinoma

As the differentiation of an adenocarcinoma decreases (more poorly differentiated) you see:
· diminished gland formation
· sheets, syncytia or single cells
· increase in size & number of nucleoli
· coarse chromatin
· anisonucleosis

IUD changes:
· proliferatve or secretory changes (vacuolated endocervical cells)
· Enatmeoba gingivalis
· IUD cells "litigation cells" single, round condensed nucleus, look HG but are really reactive endocervical cells
· psammoma bodies
· Actinomyces (sulfur granules)

Ghonorrhea vuvlvitis occurs in children - fragile vulvovaginal mucosa.
Donovan bodies: safety pins, gram negative bacilli Calymmatobacterium granulomatis.
Bartholin's gland adenocarcinoma presents as a \vulvar submucosal lesion with malignant mucous cells & signet-ring cells.
Clear cell adenocarcinoma: 20's, "hobnail cells", arises from vaginal adenosis from DES exposure in utero (8th week of gestation).
Arias-Stella: large cells, multinucleation but orderly. You shouldn't see single cells or overlapping.
Vinegar eel: Tubatrix aceti assoc with douching.

PAP Radiation changes:
· Multinucleated giant cells
· 2-toned cytoplasm
· Enlarged cells with maintained N/C ratio
· Vacuolization
· Fibroblasts

Secretory adenocarcinoma: uniform nuclear features, PAS+
Intestinal or mucinous endometrial carcinoma usually presents as grade I with pale, sticky diathesis. DDx: ovarian mucinous adenocarcinoma (no diathesis).
Cofactors in cervical carcinogenesis: HPV, Vitamin A, B, C deficiency, smoking, cervical trauma, CMV, Chlamydia, steroids, pregnancy, decreased cellular immunity.

Karyorrhexis: chromatinic, broken or interrupted nuclear membranes.
Karyolysis: dissolution of nuclear membranes.
Karyopyknosis: condensed nuclear membranes.

Lactobacillus associated with acid pH.
Cowdry type A inclusions - Herpesevirus: Eosinophilic intranuclear inclusions surrounded by a pale halo, multiple nuclei, molding, ground glass nucleus.
Torulopsis glabrata: spore form predominates; no pseudohyphae.
Geotrichum candidum: yeast branch at 90° angles. True hyphae & arthospores.
Cornflakes: too long between application of mounting medium & coverslipping.
Coccoid bacteria accompany Trichomonas vaginalis.
Administration of estrogen has no effect on progesterone-primed epithelium (as in a normal pregnancy).
Hyperkeratosis on PAP = Leukoplakia on biopsy
Parakeratosis may overlie HPV, dysplsia or invasive carcinoma. Considered ASCUS by Bethesda terminology.
Pemphigus vulgaris: reactive/reparitive cells with bullet-shaped nucleoli.
Reparative/Regenerative processes: sheets with well-defined cell borders, cell streaming and maintenance of polarity.
Follicular cytosis: ovarian follicle persistence, hyper-estrogenic hormonal status.
Serum analysis is gold standard of hormonal evaluation.
Immature metaplasia ® keratinizing squamous dysplasia VS. Mature metaplasia ® nonkeratinizing squamous dysplasia.
Mature metaplastic dysplasia is the most common type of dysplasia but, it is seldom advanced VS. Immature metaplastic dysplasia is more likely to be advanced
Keratinizing SCCa usually exophytic while nonkeratinizing is usually flat. For ker SCCa: anterior cx lip, spindle or tadpole cells.
Tumor diathesis in squamous lesions; rare in small cell lesions. Ker and non-ker SCCa have a low mitotic rate compared to small cell lesions.

Chapter 9: Cytoprep Techniques/Lab Operations
100% methanol produces less cell shrinkage.
Slides should be fixed for 15-30 minutes.
Lysing agent for excess blood: 1:14 glacial acetic acid in 95% ethanol.
EA-36 Pap's original stain.
Coverslip 1.0 mm ideal for cytology
70% ethanol better for sputum.
Nile blue sulfate stains only sebaceous gland cells = fetal maturity.
International Academy of Cytology (IAC) and American Society of Cytopathology accredit and evaluate education and practice of cytopathology.


Sathema's Notes:
Carcinoma by Age:
30's cervical
40's endocervical
50's endometrial
60's ovarian

Associations:
Trichomonas - sexually transmitted
Actinomyces - IUD
Candida - HIV, diabetes, pregnancy, OCP, h/o antibiotics
Gardenerella - douches
HPV 16 - endocervical adenocarcinoma

Hyperchromatic syncitial groups:
CIS are round at the edges
AIS is elongated at edges, pulling, "feathering"

DMN = double mirror nucleus = melanoma ("Demon")

OCP (pill effect) : pink monolayer of small, round, pyknotic, degenerate metaplastic-looking cells (don't call it atypical PK)

BAL If you see cilia on one edge: think reserve cell hyperplasia or creola bodies; BAC bouquets lack cilia.

Bare, hyperchromatic nuclei:
lymphoma
small cell
melanoma

CSF: if you see lots of blood you can't call it Leukemia - repeat!
Most common malignant cells in a CSF: metastatic adenocarcinoma, lymphoma, medulloblastoma
Most common organism: cryptococcus

Traumatic LP - megakaryocytes or chrondrocytes from nucleus propulsus

Review normal: salivary gland, gastric FNA honeycomb, bile duct, seminal vesicles
Cirrhosis - assoc with signet ring degeneration of reactive mesothelial cells. CHF should also raise threshold for adenoca if you see vacuoles (reactive).
Mesotheliomas: CEA- Calretinin +
PCP - "D" or comma-shaped organisms.
Coccidioidomycosis: Indented ping-pong