Role of Pap Smear as a screening test for cancer

1. PAP SMEAR: BIRD’S EYE VIEWFROM
CYTOPATHOLOGIST
- Dr. Shubhi Saxena
(Dept. of Pathology)

2. What is PAP smear ?
• Screening is a public health intervention on population at risk or
target population.
• The Pap test is the most cost-effective cancer reduction program
ever devised. Credit for its conception and development goes to
Dr George N. Papanicolaou.
• PAP smear is a screening test to identify premalignant and
malignant lesions of cervix so that they can be treated, thereby
reducing Ca Cx rates in the population.
• So far most efficient screening test

4. New Guidelines:
 Target group- All women aged 18-70yrs who
have ever had sex.
 Timing of Initial Screening-
Initial screening at age of 21 years or
within 3 years of sexual activity
PAP SMEAR AS A SCREENING METHOD

5. Pap smear: Guidelines
 Screening interval
-Yearly till the age of 30 then 3 yearly
 When to End Screening
- After 70 yrs
- Post Hysterectomy
- Previous 3 normal PAP reports
- Confirmed complete removal of cervical epithelium

7. PAP Smears - Limitations
Low sensitivity 51%
False negative rates are due to faulty
sampling, improper fixation or
interpretation problems
No consensus regarding testing

8. Test Requisition
• Under the supervision and guidance of
the physician, a laboratory requisition
must be legibly and accurately filled out
before obtaining the cellular sample.
• The laboratory requisition is the main
communication link between the
physician and the laboratory.

9. • Patient’s name (any name change in the past 5 years should be
noted.)
• Age and date of birth.
• Menstrual status (LMP, hysterectomy, pregnant, postpartum,
hormone therapy)
• Previous abnormal cervical cytology result, previous treatment,
biopsy or surgical procedure.
• Patient’s risk status for developing cervical cancer, e.g. “high
risk”. The clinician should expect that the laboratory would rely
upon the information provided on the current requisition in
arriving at an assessment of risk status.
• Source of specimen e.g. cervical, vaginal.
• Hormone/contraceptive use.
• Relevant clinical findings (abnormal bleeding, grossly visible

10. TRANSFORMATION ZONE
• Cervix develops from 2 embryonic sites:
* from Mullerian duct - lined by columnar epithelium
* from urogenital plate - lined by stratified squamous
epithelium
• Point at which columnar and squamous epithelium meet is called as
original squamo-columnar junction.
• Exposure of TZ to carcinogens begins the process of intraepithelial
neoplasia
• While exact role of carcinogens in this process remains poorly understood,
it is clear that HPV and cigarette smoking can cause dysplasia at the TZ
• 95% of cervical cancers develop in TZ.
• Important to take sample from TZ.

11. 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.

13. Fixation
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.

14. Spray with Fixative
• Within 10-15 seconds
• Allow to fully dry
before packaging
• Cytologic Fixative
(hairspray works
acceptably also)

15. Fixation of smear
Fixation is done immediately with fixative like 95% alcohol or
cytofix spray to avoid air drying
Spray should be kept at 10 inches, to avoid destruction of cells
by propellent in the spray
Smear should monolayer for proper penetration of cell surface by
fixative

18. FIXATIVES
• 95% Ethanol.
• 95% Rectified Spirit.
• 100% Methanol.
• 80% Isopropanol or Propanol.
• Ether/95% Ethanol (1:1).
• Spray fixatives contains isopropanol
• Propylene glycol.

19. What is liquid based cytology?
Collection of cellular material into a
vial of preservative fluid.

20. How LBC Different
• Easier method for smear takers
• Technology diminishes blood,
mucus & polymorphs
• Thin layer preparation
• Smaller area of the slide to screen

21. LBC
• LBC for gynaecological cytology has been introduced in Belgium
• Liquid-based cytology techniques:
 FDA approved:
ThinPrep®
Filtration and collection of vacuum-packed cells on a membrane and transferring
to the glass slide.
Surepath®
Centrifugation and sedimentation through a density gradient
 Not FDA approved:
Cytoscreen®
Turbitec®
Cellslide®
Papspin®
Centrifugation and sedimentation by manual techniques

22. ThinPrep® Process
1. Dispersion 2. Cell Collection 3. Cell Transfer

23. SUREpath Method

26. The prepared slide with the new
ThinPrep
Conventional smear

27. What we see under the
microscope. Notice the clean back
ground and how well the cells are

28. Technique Advantages Disadvantages
Conventional
Pap test
•Gold standard for 50 years
•Comfortable with the method
•Ready for staining when arrives in lab
•Inexpensive
•>80% of materials lost
•More cells to screen
•Uneven distribution of cells,
fixation artifacts
Liquid based
cytology
•Minimal loss of collected material
•Ease of use for smear taken
•Limited obscuring material—fewer
unsatisfactory slides
•Even distribution of cells, cleaner
backgrounds
•Fewer but well-preserved cells to
examine—reduction of screening time
•Residual materials for additional
studies
•Enable automated screening
•Training required
•Increased workload in prep
lab
•Increased costs

30. How to stain the smear
• Pap stain is a multichromatic staining cytological technique
developed by George Papanicolaou, the father of cytopathology.
• The classic form of pap stain involves five dyes in 3 solutions:
– Hematoxylin
– Orange staining solution: orange G
– Polychromic staining solutions: Eosin G, Light green SF,
Bismarck brown

32. Reporting of smears
• What is THE BETHESDA SYSTEM ?
– TBS is a recommended system of reporting
cervical/vaginal smears.
– TBS provides a common language, a uniform
terminology to describe findings, so that it is
understood uniformly by one and all, leading to better
management.

33. THE 2014 BETHESDA SYSTEM
 SPECIMEN TYPE
 SPECIMEN ADEQUACY
 GENERAL CATEGORISATION (OPTIONAL)
 INTERPRETATION / RESULT
 ANCILLARY TESTING
 AUTOMATED REVIEW
 EDUCATIONAL NOTES AND SUGGESTIONS (OPTIONAL)

34. SPECIMEN TYPE
Indicate conventional smear (Pap
smear) vs. liquid based
preparation

35. Specimen Adequacy
• Adequate smear:
– An adequate pap smear is one that includes a
sampling from the exocervix, endocervix and
transformation zone.
– An adequate cytologic sample contains more than
300 squamous cells, including at least two
clusters of 5 cells each of endocervical or
metaplastic cells with mucus material.

36. Estimated number of squamous cells
 Liquid based: 5,000
 Conventional: 8,000 – 12,000

37. This specimen is unsatisfactory due to scant squamous cellularity seen at10X

39. Criteria for specimen
adequacy
“Satisfactory for evaluation”
– Appropriate labelling and identifying information.
– When evenly spread will normally cover at least one
third of the clear glass part of the slide.
– Relevant clinical information.
– Adequate numbers of well preserved and well
visualized squamous epithelial cells.
– An adequate endocervical transformation zone
component.

41. Unsatisfactory for evaluation…
• Lack of patient identification on specimen.
• The clinician indicates that the cervix was poorly visualised
• 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 <10% of the
slide surface)
• Obscuring (blood, inflammatory cells, lubricant, thick clumps
of cells, air-drying artefact or poorly fixed cells, spermatozoa,
menstrual debris, bacteria) that precludes interpretation of
approximately >75% of epithelial cells.

42. • If it is entirely composed of separated superficial
squamous cells suggesting a vaginal rather than
cervical origin.
• If the cellular smear is so thickly spread.
• If it is entirely composed of endocervical cells,
unless the only object of the test was to sample the
endocervical mucosa.

43. • 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”

44. Cytomorphologic Criteria: Over 75% of cells are obscured by inflammation and blood

49. Making of Pap Smear
• As thin as possible
• Properly labeled

50. Interpretation/Result
1. Negative for intraepithelial lesion or
malignancy (NILM)
2. Epithelial cell abnormalities
3. Other malignant neoplasms (specify)

51. 1. NEGATIVE FOR INTRAEPITHELIAL LESION OR MALIGNANCY (NILM)
1. ORGANISMS:
- Trichomonas vaginalis
- Fungal organisms morphologically consistent with candida species
- Shift in flora suggestive of bacterial vaginosis
- Bacteria morphologically consistent with Actinomyces species
- Cellular changes consistent with Herpes simplex virus
2. OTHER NONNEOPLASTIC FINDINGS:
* Reactive cellular changes associated with
- Inflammation
- Radiation
- Intrauterine contraceptive device
* Glandular cells status posthysterectscopy
* Atrophy
Interpretation/Result

52. NILM
• Specimens for which no epithelial
abnormality is identified are reported as
NILM.
• If non-neoplastic findings are reported,
NILM should still be included as an
interpretation or as the general
categorization to avoid ambiguity.

53. What to see in a PAP smear?
 Adequacy of material
 Arrangement of cells
 Cell types
 Cell shape
 Cell size
 Type of cytoplasm
 Nuclear features:- Size, shape, number
- N/C ratio
- Nuclear contour
- Chromasia
- Chromatin texture
- Nucleolar features
 Organisms

55. The Normal PAP
• Squamous cells
• The ectocervix is lined by a stratified squamous epithelium that matures under
the influence of estrogen.
• Superficial squamous cells: They have a small, pyknotic nucleus that is 5–6
μm in diameter.
• Intermediate squamous cells: have a larger nucleus measuring 8 μm in
diameter, which is not pyknotic but instead has a finely granular texture.
Both superficial and intermediate cells are large polygonal cells with
transparent pink or green cytoplasm.

57. • Immature squamous cells are called parabasal cells and
basal cells.
• Parabasal cells: are round or oval rather than polygonal
and have a variably sized nucleus that is usually larger
than that of an intermediate cell.
• Basal cells: are even smaller and have very scant
cytoplasm.

58. Different types of squamous cells:
A. Superficial (arrow) B. Intermediate
C. Parabasal D. Metaplastic

59. Transformation zone component Endocervical cells demonstrating both picket
fence and honeycomb arrangements compose a transformation zone component.
20X

60. ESTROGENPHASE

61. OVULATORY SMEAR

62. PROGESTERONE PHASE

63. Endometrial cells
• Exfoliated endometrial cells occur in ball-like clusters and rarely
singly
• Nuclei are small, round and similar to the area of normal
intermediate cell nucleus
• Occur in 3D clusters so chromatin pattern is difficult to identify
• Nucleoli are inconspicuous
• Cytoplasm is scant, basophilic and occasionally vacuolated
• Cell borders are ill defined
• During first half of menstrual cycle, double contoured clusters of
endometrial cells (exodus pattern) may be seen

65. LACTOBACILLI
• 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.

66. ORGANISMS
TRICHOMONAS VAGINALIS
Criteria:
– Pear shaped, oval, or round cyanophilic organism
– 15 to 30 µm in size
– Eosinophilic cytoplasmic granules are often evident
– Flagella are usually not seen
– Nucleus is pale, vesicular and eccentrically located

69. Trichomonas
vaginalis

70. Candida species
Criteria:
– Budding yeast (3-7µm); pseudohyphae are eosinophilic to
gray-brown on pap stain
– Pseudohyphae, formed by elongated budding, show
constrictions along their length
– Fragmented leukocyte nuclei and rouleax formation of
squamous cells “speared” by hyphae may be seen

71. Liquid-based preparation:
– “Spearing” of epithelial cells is more common in
LBPs and can be seen at low power even if the
pseudohyphae are not prominent (“sheesh kebab
effect”)
– Candida (Torulopsis) glabrata consist of small,
uniform, round budding yeast forms surrounded by
clear halos on pap stain. Unlike other candida
species, it does not form pseudohyphae in vivo or in
culture

75. The figure above shows fungal organism morphologically consistent with Candida glabrata.
Candida glabrata consists of small, uniform, round form surrounded by clear halo

76. Shift in flora suggestive of bacterial vaginosis
Criteria:
– Filmy background of small coccobacilli is evident
– Individual squamous cells may be covered by a layer of bacteria
that obscure the cell membrane, forming so-called Clue Cells
– There is a conspicuous absence of lactobacilli
Liquid-based preparation:
– Squamous cells are covered with coccobacilli in clean background

78. BACTERIAL VAGINOSIS

79. Actinomyces
Criteria :
– Tangled clumps of filamantous organisms, with acute angle
branching, are recognizable as “cotton ball” clusters on low
power
– Filaments sometimes have radial distribution or have an
irregular “wolly body” appearance.
– Masses of leukocytes adherent to microcolonies of the
organisms, with swollen filaments or “clubs” at the periphery,
may be identified.
– An acute inflammatory response with polymorphs is often +nt.

81. Herpes simplexvirus
Criteria:
– Nuclei have “ground glass” appearance due to intranuclear
viral particles and enhancement of nuclear envelope caused
by peripheral Margination of chromatin.
– Dense eosinophilic intranuclear inclusions surrounded by
a halo or clear zone are +nt.
– Large Multinucleated epithelial cells with Molded
nuclei are characteristic but not always present;
mononucleate cells with the nuclear features may be the
only finding.

82. Ground glass appearance of nuclei due to accumulation of viral particles

83. HPV (human papilloma virus)
Large squamous
cell with
enlarged
hyperchromatic
nucleus & large
sharply
demarcated
perinuclear
clear
zone

84. PSEUDOKOILOCYTES
• Glycogen in squamous
cells can give the
appearance of
"pseudokoilocytosis“
• Nuclear abnormalities
required for an
interpretation of ASC-
US/LSIL are absent.

85. Other Non-Neoplastic Findings
Reactive cellular changes:
– Reactive cellular changes that are benign in nature,
associated with inflammation, radiation, an IUD or
other nonspecific causes.

86. Reactive cellular changes associated with Inflammation (includes typical
repair)
Criteria:
– Nuclear enlargement (one and one-half to two times the area
of a normal intermediate cell nucleus or more)
– Endocervical cells may show greater nuclear enlargement
– Nuclear outlines are smooth, round and uniform

87. - Mild hyperchromasia may be present
– Prominent single or multiple nucleoli may be present
– Cytoplasm may show polychromasia, vacuolization, or
perinuclear halos but without peripheral thickening
– Similar changes may be seen in squamous metaplastic
cells, cytoplasmic processes (spider cells) may also be
seen

88. Reparative
process with
inflammatory
changes. The
cells are
arranged in
monolayers
and contain
enlarged
nucleoli.

89. NILM: Reactive cellular changes, RepairMild nuclear enlargement
without significant chromatin
abnormality

90. Reactive cellular changes associated with Radiation
Criteria:
– Cell size is markedly increased without increase in N:C ratio
– Bizarre cell shape may occur
– Enlarged nuclei may show degenerative changes like nuclear pallor,
wrinkling or smudging of chromatin, and nuclear vacuolization
– Binucleation or multinucleation is common
– Cytoplasmic vacuolization and/or cytoplasmic polychromatic staining
may be seen

91. Cells with enlarged nuclei, abundant vacuolated polychromatic cytoplasm,
mild nuclear hyperchromasia and prominent nucleoli

93. Reactive cellular changes associated with IUD
Criteria
– Glandular cells may be present singly or in clusters
of 5 to 15 cells in a clean background
– The amount of cytoplasm varies, and large vacuole
may displace the nucleus, creating a signet ring
appearance

94. – Nuclear degeneration is evident
– Nucleoli may be prominent
– Calcification resembling psammoma
bodies are variably +nt

95. Small clusters
of glandular
cells with
cytoplasmic
vacuoles
displacing
nuclei

97. Atrophy with/without inflammation
Criteria:
– Flat, monolayer sheets of parabasal-like cells with preserved nuclear
polarity
– Dispersed parabasal like cells may predominate
– Generalised nuclear enlargement up to 3 to 5 times the area of normal
intermediate cell nucleus with slight increase in N:C ratio
– Chromatin is uniformly distributed
– Autolysis may result in naked nuclei

98. – Intermediate cells are normochromic but parabasal cells show
mild hyperchromasia and have more elongated nuclei
– An abundant inflammatory exudate and basophilic granular
background that resembles tumor diathesis may be +nt
– Globular collection of basophilic amorphous material (blue
blobs) +nt either due to degenerated parabasal cells or
inspissated mucus
– Degenerated orangeophilic or eosinophilic parabasal cells with
nuclear pyknosis resembling “parakeratotic” cells may be +nt.
– Histiocytes may be seen with varying size and shape.

99. Granular debris in background,
degenerating parabasal cells
Multinucleated histiocytic giant cells,
often seen in postmenopausal and
postpartum specimens
Degenerated parabasal cells in a clean
background
Granular debris is clumped and
adheres to cell clusters

103. Epithelial cell abnormalities
(1) Squamous cell
• Atypical squamous cells
– of undetermined significance (ASC-US)
– cannot exclude HSIL (ASC-H)
• Low grade squamous intraepithelial lesion (LSIL)
(HPV /mild dysplasia/CIN 1)
• High grade squamous intraepithelial lesion (HSIL)
(moderate and severe dysplasia, CIS, CIN 2 and CIN 3)
With features suspicious for invasion (if invasion is suspected)
• Squamous cell carcinoma

104. (2) Glandular cell
• ATYPICAL
o Endocervical cells(NOS or specify in comments)
o Endometrial cells (NOS or specify in comments)
o Glandular cells (NOS or specify in comments)
• ATYPICAL
o Endocervical cells, favor neoplastic
o Glandular cells, favor neoplastic
• ENDOCERVICAL ADENOCARCINOMA IN SITU (AIS)
• ADENOCARCINOMA
- Endocervical
- Endometrial
- Extrauterine
- NOS
3.Other Malignant neoplasms (specify)

105. Squamous cell
Atypical squamous cells
– of undetermined significance (ASC-US)
– cannot exclude HSIL (ASC-H)
ASC:
Cytologic changes suggestive of SIL, which qualitatively or
quantitatively insufficient for definitive interpretation.
• 3 essential features:
1. Squamous differentiation
2. High N:C ratio
3. Multinucleation, irregularity, minimal nuclear hyperchromasia,
chromatin clumping, smuding

106. ASC-US
Criteria:
• Nucleus:
– Size- increased (two and half to three times)
– Slight increased N:C ratio
– Minimal nuclear hyperchromasia
– Irregular chromatin distribution
– Irregular nuclear shape
• Cytoplasm:
– Dense orangeophilic (“Atypical Parakeratosis”)

107. Plaque of cells
with dense
orangeophilic
cytoplasm and
minimally
irregular,
hyperchromatic
nuclei

108. ASC-H
• ASC-H cells are usually sparse and seen in pattern.
• Small cells with high N:C ratios: “Atypical (immature)
Metaplasia”
Criteria:
– Cell arrangement: single, small fragment of <10 cells, stream
in mucus (occasionally)
– Cell size: that of metaplastic cells
– Nuclear size: 1&1/2 to 2&1/2 times larger than normal
– N:C ratio: slightly increased

109. Cells with metaplastic cytoplasm showing variation In shape, size and high
N:C ratio

110. Interpretation:
ASC-H
Cytomorphologic
Criteria:
Thick aggregate of
loosely cohesive,
overlapping cells
containing enlarged
nuclei with even
chromatin, variation
in size and shape
and obscured cell
boundaries.

111. LSIL
Squamous cell changes associated with HPV infection
encompass “Mild Dysplasia” and “CIN 1”.
Criteria:
– Singly or in sheets
– Superficial squamous cells
– Cell size: Large cells
– Abundant mature well-defined cytoplasm
– Nuclei enlarged: >3 times with slight increased N:C

112. – Variable degree of nuclear hyperchromasia
– Variation in nuclear size, shape and number
– Binucleation and multinucleation
– Uniform chromatin distribution, but coarsely granular,
smudged or densely opaque
– Nucleoli –nt
– Nuclear membrane: slightly irregular or may be smooth
– Perinuclear cavitation (“koilocytosis”)

113. Nucler enlargement and
hyperchromasia
Large cell size, smudged nuclear
chromatin, well defined cytoplasm,
multinucleation

116. HSILCriteria:
• Singly, in sheets or in syncytial like aggregates
• Less mature cells
• Variable cell size
• Nuclear hyperchromasia
• Degree of nuclear enlargement is more variable
• Marked increased in N:C ratio
• Evenly distributed chromatin, fine or coarsely granular
• Nuclear membrane is quite irregular, prominent indention
or grooves-frequently

117. • Nucleoli –nt, but may be seen when HSIL extends into
endocervical gland spaces
• Variable appearance of cytoplasm: immature, lacy, delicate,
densley metaplastic, occasionally mature and densely
keratinized

118. Dysplastic cells in syncytial
clusters

121. Variation in nuclear size
and shape and delicate
cytoplasm
Metaplastic or dense
cytoplasm

123. SCC
Malignant invasive tumor showing
differention toward squamous
cells.

124. Keratinizing SCC
Criteria:
• Marked variation in cell size and shape---caudate and spindle
cells
• Dense orangeophilic cytoplasm
• Marked variation in nuclear size
• Numerous dense opaque nuclei
• Irregularly distributed chromatin, coarsely granular with
parachromatin clearing
• Macronucleoli
• Hyperkeratosis or pleomorphic parakeratosis
• Tumor diathesis

125. Marked pleomorphism of cell size and shape, cytoplasmic
keratinization and tumor diathesis in background

126. SCC: Tumor Diathesis

127. Non-Keratinizing SCC
Criteria:
• Cells occur singly or in syncytial aggregates with
poorly defined cell borders
• Cells are smaller than HSIL cells but display
most of the features of HSIL
• Coarsely clumped irregularly distributed
chromatin
• Tumor diathesis often +nt

128. Pleomorphic cell shapes, dysplastic cells

129. ATYPICAL GLANDULAR
CELLS

130. Atypical endocervical cells: NOS
Criteria:
– Cells in sheets and strips with some cell crowding and
nuclear overlap
– Nuclei enlarged 3 to 5 times
– Some variation in nuclear size and shape
– Mild hyperchromasia
– Nucleoli +nt
– Mitotic figure are rare
– Abundant cytoplasm but high N:C ratio
– Distinct cell borders are often discernible

131. Sheet of cells with nuclear enlargement, prominent nucleoli

132. Atypical endocervical cells, favor Neoplastic
Definition:
cell morphology, qualitatively or quantitatively, falls just
short of an interpretation of endocervical
adenocarcinoma in situ or invasive adenocarcinoma.

133. Criteria:
– Abnormal cells in sheets and strips with nuclear
crowding and overlap
– Rare cell groups may show rosetting or feathering
– Nuclei: enlarged with some hyperchromasia
– Occasional mitosis
– N:C ratio increased
– Quantity of cytoplasm diminished
– Cell borders ill defined

134. Sheet of crowded cells with high
N:C ratio, feathering at the
edges of the sheet
Pseudostratified strip of endocervical
cells with enlarged, elongated
nuclei,some chromatin granularity

135. Atypical endometrial cells
Criteria:
– Small groups: 5 to 10 cells per group
– Nuclei: slightly enlarged
– Mild hyperchromasia
– Small nucleoli
– Scanty vacuolated cytoplasm
– Ill defined cell borders

136. Three dimensional groups of small cells with mildly
hyperchromatic nuclei, small nucleoli,

137. Endocervical adenocarcinoma in situ
Definition:
high grade endocervical glandular lesion c/b nuclear enlargement,
hyperchromasia and mitotic activity but without invasion.
Criteria:
– Cells in sheets, clusters, strips, and rosettes with nuclear crowding and
overlap, loss of honeycomb pattern.
– Some cell have definite columnar appearance
– Cell clusters have palisading nuclear arrangement with nuclei and
cytoplasmic tags protruding from periphery (feathering)

138. – Nuclei: enlarged, variable sized, oval or elongated in shape & stratified
– Nuclear hyperchromasia with evenly dispersed, coarsely granular
chromatin
– Nucleoli: small or inconspicuous
– Mitoses and apoptotic bodies seen
– N:C ratio high
– Clean background
– Abnormal squamous cells may be present

139. Oval nuclei are crowded with
nuclear overlapping and
hyperchromasia, evenly
distributed coarsely granular
chromatin
Three dimensional cluster
with feathering

140. Endocervical adenocarcinoma
• Cytologic criteria overlap those for AIS, but may show
features of invasion.
• Criteria:
– Abundant abnormal cells with columnar configuration
– Single cells, sheets, clusters, syncytial aggregates
– Nuclei: enlarged, pleomorphic, irregular chromatin distribution,
parachromatin clearing, nuclear membrane irregularities
– Macronucleoli
– Cytoplasm: finely vacuolated

141. Adenocarcinoma,
Endocervical
Cytomorphologic Criteria:
Cluster of cells enlarged
nuclei, macronucleoli and
some nuclear membrane
irregularities; poorly defined,
finely vacuolated cytoplasm;
ghost of RBC's and cell debris
noted at the edge of the cluster
("clinging diathesis").

142. Other malignant neoplasms
• Uncommon primary tumors of cervix and uterine corpus:
• CARCINOMAS
– Spindle squamous cell carcinoma
– Poorly differentiated squamous cell carcinoma with small cells
– Small cell undifferentiated carcinoma
– Carcinoid tumors
– Malignant mixed mesodermal tumor or carcinosarcoma
• SARCOMAS

143. • Other primary tumors:
– Primary cervical germ cell tumors including choriocarcinoma,
yolk sac tumor and teratomas
– Lymphoma and malignant malanoma are rare primary tumor of
the cervix

144. • Secondary or metastatic tumors:
– 3 routes
1. Direct extension
2. Lymphatic and/or hematogenous spread
3. Through fallopian tube
Malignant melanoma from vulva or vagina