Cervical Changes18 4

Intraepithelial Neoplasia, and Invasive Cancer of the Uterine Cervix
Introduction Invasive Cancer of the Uterine Cervix
The Normal Uterine Cervix Epidemiology
Histology and Cytology Microinvasive Carcinoma
Benign Proliferative Reactions Invasive Cervical Cancer
Hyperkeratosis Efficacy of Cervical Cytology in the Detection of

Cervical abnormalities
Parakeratosis
Liquid-Based Cervical Cytology
Squamous Metaplasia
Screening Programs for Cervical Cancer
Atypia
Observer Variability
Reactive and Regenerative Changes
Quality Control
Squamous Intraepithelial Neoplasia
Review
Terminology
Concluding Remarks
Papanicolaou Classification
Dysplasia
Cervical Intraepithelial Neoplasia
Introduction
c Vaginal cytology was primarily directed at the diagnosis of invasive cancer of the
uterine cervix and of the endometrium, but noninvasive epithelial abnormalities of the
uterine cervix could also be diagnosed in the direct scrapings.
cAll epithelial abnormalities of squamous character derive from ectocervical squamous,
basal cells and endocervical reserve cells.
Depending on the strength of the negative stimulus on these cells and on its differentiated
state the ultimately resulting cells have a more or less diffe rentiated aspect. This explains:
1-c common morphologic features in the different variants of dysplasia and in the most
dedifferentiated intraepithelial variant, carcinoma in situ,
c
-c The extremely common co-occurrence of carcinoma in situ and dysplastic change s of
different severity.
The Normal Uterine Cervix

Histology and Cytology
Ectocervix
The vagina and the outer portion of the uterine cervix ²the ectocervix²are lined with
nonkeratinizing squamous epithelium.
èc Embryologically, this epithelium is derived from a solid epithelial plate growing
inward from the urogenital sinus up to the level of the later endocervical canal. This
solid plate replaces, at the level of the vagina and the ectocervix, the primitive
cuboidal epithelium from the fused Mullerian ducts, from which also originates the
columnar epithelium, lining the fallopian ducts, the uterine corpus, and the
endocervical part of the cervix. The fusion site of these two types of epithelium is
called the ÷
- ig. 8.1).
èc The location of ÷
varies depending on physiologic and
pathologic conditions:
1.c During reproductive years, the squamocolumnar junction is located at the
entrance of the endocervical canal, the ÷, but owing to hormonal
influences or as a result of stromal edema that has changed the endocervical
canal or cervix, it may be located inside the endocervical canal or on the
surface of the cervix. When located on the external surface of the cervix, part
of the columnar cell lining of the endocervical canal is present on the
ectocervical face. This causes a usually well -demarcated reddening of the
surface that is easily recognizable at inspection. This outward bulging of the
endocervical mucosa, referred to as , ÷, or ÷ ÷,
should be differentiated from a ÷ of the epithelium, which by
definition is a loss of the lining mucosa, leaving the underlying cervical
stroma barren.
.c During childhood and after menopause, the squamocolumnar junction is
located inside the canal.
Variation of the epithelium according to hormonal state :
1-During reproductive years, the morphology of the stratified squamous epithelium, the
function of which is primarily a protective one, is cyclically changing under the influence of
ovarian hormones. In its fully matured stage, the epithelium of the vagina and ectocervix
can be subdivided into several layers
c
- ig.8.). or correlation with the different cell types present in cervical cytologic
specimens, a subdivision into three layers is most practical. Beginning with the deepest
layer, these are:
-1)cbasal cell & parabasal cell layer,
-) intermediate cell layer, and
-) superficial cell layer.
1)c basal layer, responsible for epithelial regeneration, composed of a single layer of
relatively primitive cells with scarce cytoplasm and large oval-to-round nuclei with
prominent nucleoli. Normally, true basal cells are not present in cervical smears
unless, when the smear is taken; the entire epithelial layer has been removed, leaving
the underlying stroma denuded. The Parabasal cells are unusual in smears from
women in reproductive years, unless certain pathologic processes occur as a reduced
or absent estrogenic hormonal stimulation. They are the predominant cell type in
smears from women in postmenopause and from children. Parabasal cells are round
to oval and have a small cytoplasmic body and relatively large oval -to-round nuclei
- ig. 8.; see also ig. 8.16). The cytoplasm is relatively dense, has distinct borders,
may contain vacuoles, and co mmonly stains cyanophilic. After drying of the vaginal
or cervical surface due to absence of estrogenic stimulation or after exposure to air,
the cytoplasm stains eosinophilic.
)c Intermediate cell layer, form the major part of the thickness of the epithelium. With
maturation of the cells toward the surface, the cells become better differentiated,
reflected by an increase in the cytoplasmic volume and signs of specific functional
qualities of the cytoplasm, such as storage of glycogen or secretory products. Cells
are bound to each other by intracellular bridges called desmosomes. Cytoplasm of
intermediate squamous cells is cyanophilic in staining. Nuclei become only slightly
reduced in size during the passage of the cells through the intermediate cell layers.
The round-to-oval nuclei have a diameter of about 8 to 10 ȝm, have a clearly defined
nuclear membrane - ig. 8.4; see also ig. 8.18), and contain an evenly distributed,
finely granular chromatin.
)c The superficial layers are composed of large polygonal cells loosely attached to each
other. These cells do not proliferate and represent an end stage in the maturation
process of non-keratinizing stratified squamous epithelium. Intercellular
attachments²desmosomes²become loose, and cells cons tantly exfoliate from the
surface. Cells are polygonal and have a clear, translucent, usually pink -staining,
occasionally cyanophilic cytoplasm; sharply defined boundaries; and a small, often
pyknotic central nucleus. Superficial cells have a diameter of approximately 40 ȝm.
The nuclear diameter is to 5 ȝm. The eosinophilic staining of the cytoplasm is
c
caused by the presence of prekeratin proteins. ibrillary strands of keratin can
sometimes be recognized in the cytoplasm of the most superficial eosinophilic
staining cells. Rarely, superficial cells may contain keratohyalin granules in the
cytoplasm. These granules are supposedly derived from the granular cell layer of an
altered²keratinized²stratified squamous epithelium.
c The entire maturation cycle of a normal squamous cell takes approximately 4
days. The maturation process can be accelerated significantly under estrogenic
stimulation. Although the influence of estrogenic hormones is predominantly
evident on the vaginal epithelium, the ectocervical squam ous and endocervical
columnar epithelium, also show a cellular reaction to ovarian hormones.
{c During the reproductive years, reduced maturation of the cervical squamous
epithelium may be found as a result of the action of oral hormonal
contraceptives.
{c Before menarche, the epithelial lining of the vagina and ectocervix is relatively
thin and composed of less mature cells of a parabasal type - ig. 8.5). Cells do
not contain glycogen.
{c During pregnancy, as a result of the relative predominance of progesterone,
maturation of the epithelium becomes reduced. The epithelial lining is then
composed of intermediate-type cells, with cyanophilic-staining
cytoplasm,often with a pronounced outer zone. These rather characteristic cells
are also called ÷. The underlying stroma sometime shows a large-
cell²decidual²reaction, as is physiologic in the endometrial stroma - ig.
8.6). These large stromal cells, when present in smears, may cause differential
diagnostic problems with cells from invasive processes, particularly
adenocarcinomas, because of large, prominent nucleoli - ig. 8.7). Their
occurrence in sheets and as single cells, not in clusters, together with the
evenly distributed, finely granular nuclear chromatin, against the background
of the pregnancy, should provide the correct diagnosis.
{c After menopause²the epithelium reduces in thickness and again becomes
atrophic. The epithelial cells do not contain glycogen, and the epithelium in its
atrophic state becomes highly vulnerable to even slight trauma and often shows
signs of inflammation -see igs 8., 8.16, and 8.17).
{c An absolute or relative reduction in the level of circulating estrogenic
hormones leads to lysis of the cytoplasm of vaginal an d cervical squamous
cells, as is evident:
1.c during the second, or luteal, phase of the menstrual cycle,
.c during pregnancy,
c
.c during lactation, and
4.c after menopause.
Cytolysis may be conspicuousĺa large number of bare nuclei throughout the smear - ig. 8.8).
{c Continuous stimulation by estrogenic hormones causes :
1.c hypertrophy of the superficial layers of the ectocervical squamous
epithelium, composed of large polygonal cells with clear, slightly
eosinophilic staining cytoplasm and very small, almost completely
pyknotic nuclei.
NB: The presence of these cells in smears from women in postmenopause, particularly when
endometrial cells are also found, should be a warning signal of an endometrial abnormality
induced by the continuous estrogenic growth stimulus and requires additional diagnostic
evaluation.
2.c induces hypersecretion of the endocervical columnar epithelium.
Endocervix:
{c The epithelial lining: a single layer of tall columnar pseudostratified cells-the nuclei
on different levels and variability in size of the columnar cells) - ig. 8.9).
{c The surface of the endocervical canal is irregularly shaped, with invaginations
extending up to 8 mm deep into the cervical stroma - ig. 8.10). In tissue sections,
these invaginations are often tangentially cut and appear as round or oval epithelial
stromal inclusions - ÷)
{c In a normal cervical smear endocervical columnar cells :
àc appear as tall columnar cells with a large body of clear, finely or coarsely
vacuolated, faintly cyanophilic, clear cytoplasm - ig. 8.11). Ciliated cells may
be present.
àc arranged in strips of parallel-arranged cells or in tight sheets. When present in
sheet-like arrangements, cell boundaries may create a honeycomb pattern - ig.
8.1). It is not unusual to find stripped, bare nuclei due to lysis of the fragile
cytoplasm. Basally located nuclei are round to oval and often rather variable
in size, with a finely granular, evenly distributed chromatin. In most nuclei,
one or two small nucleoli can be observed.
{c In cases of increased proliferative activity of the endocervical epithelium, the cells
and their nuclei show a rather wide variation in size and shape and nucl eoli may
become prominent and variable in size.
{c Multinucleation of cells is not uncommon. In well-preserved cytologic specimens,
ciliated columnar cells may be recognized. The morphologic variants of ciliated and
mucus producing cells refer to the mullerian origin of the endocervical epithelium.
c
The presence of ciliated cells has no special significance. It is therefore no sign of an
epithelial abnormality.
{c In tissue sections, a single layer of primitive cells can often be observed beneath the
columnar cell layer. These cells, also called ÷ ÷, are thought to be
multipotential germinative cells, which under physiologic conditions produce normal
endocervical columnar cells - ig. 8.1).
{c In pathologic states, reserve cells may proliferate and, depen ding on the severity of
the stimulus, produce abnormal, less well-differentiated columnar cells or, through
the process of metaplasia, squamous metaplastic cells.
Immunocytochemistry of Normal Cervical Epithelium

cÕeratins have been recognized as epithelium-specific intermediate filament proteins and
as comprising a family of at least 19 different polypeptides -not including the hair
keratins).
cThe tissue-specific intermediate filament proteins are retained during malignant
transformation. Tumors of epithelial origin thus retain cytokeratin as the structural
protein for the intermediate filaments.
cÕeratin immunocytochemistry has a value in the routine diagnosis of cancers that pose
problems on morphologic examination. Broad spectrum monoclonal antibodies can be
used to separate epithelial tissues from nonepithelial tissues.
cCombinations of the 19 different keratin proteins are distributed in a more or less tissue-
specific fashion:
ëc Ectocervical epithelium contain keratins 1, 4, 5, 6, 1 15, and 19, with some
variability in the expression of keratins , 8, 10, 11, 16, and 17.
ëc Endocervical cells contain keratins 7, 8, 18, and 19, with variability in the
expression of keratin 4.
ëc Reserve cells show an unequivocal distribution of keratin 18 and contai n keratins
5, 7, 8, and 1419.
c Immature squamous metaplasia has a keratin expression pattern that on the one hand
is characteristic of endocervical columnar cells and on the other hand characteristic of
an epithelium that has undergone squamous differentiation. This change becomes
emphasized when we compare immature squamous metaplasia with mature squamous
metaplasia. The pattern of keratin expression in immature squamous metaplasia was
shown to differ from that in normal squamous epithelium. Õeratin 19 is present in the
full thickness of immature squamous metaplastic epithelium, as opposed to normal
squamous epithelium, in which only the basal cell component reacts positively. Õeratins
8 and 18, indicative of columnar differentiation of the cells , become absent. The
c
expression of keratins 4, 10, 1, and 14 increases with squamous differentiation - igs
8.14 and 8.15).
ëc large number of vimentin-positive and Langerhans cells in normal ectocervical
stratified squamous metaplastic epithelium, a small number in endocervical
columnar epithelium, and a larger number in subcolumnar reserve cell hyperplasia
and in immature squamous are demonsterated .
ëc Mature squamous metaplastic epithelium showed a great resemblance to normal
ectocervical stratified squamous epithelium, in both numbers and distribution of
Langerhans cells.
Atrophy
àc Cells are of the basalparabasal cell type, with a high nucleocytoplasmic ratio. Cells
are often arranged in syncytia with indistinct cell borders. Nucleoli are usually
absent.
àc In senile vaginitis: cell changes due to infection and degeneration may cause
diagnostic problems - igs 8.16 and 8.17), because nuclear chromatin becomes
coarsely granular and hyperchromatic. Owing to erosion or ulceration of the
superficial stromal layers, regeneration of the epithelium is induced. rom these
parabasal-type cells with relatively large nuclei, prominent nucleoli may appear.
In these cases, differentiation from an epithelial abnormality may become
difficult and at times virtually impossible. However, a short course of locally
applied or oral estrogenic hormones induces maturation - ig. 8.18). Because
epithelial abnormalities do not react to the estrogenic stimulus or at least not to
the same degree as normal epithelia do, abnormal cells stand out clearly and
diagnosis can be readily made.
Õey features of atrophy
Smear composed of parabasal type cells;
Cells arranged in aggregates with indistinct cell borders -syncytia-like);
Cytoplasm is cyanophilic to amphophilic;
Round to oval nuclei;
Relatively high nucleus-to-cytoplasmic ratio;
Coarsely granular chromatin with hyperchromasia; and
Nucleoli not present.
Benign Proliferative Reactions
c
c The covering epithelium of the vagina and ectocervix apparently still has the
potential for further ³differentiation,´ as is demonstrated when the epithelium
comes under the influence of chronic, rather severe stimulation. Examples:
1)c prolapse of the uterus
)c with inflammatory processes
)c as a reaction to hyperestrinism of long duration.
c The epithelium increases its protective role by :
1.c Acanthosis: increasing its overall thickness and
.c Vranular cell layer formation
.c Hyperkeratosis .
4.c Parakeratosis:
5.c Squamaous metaplasia
Hyperkeratosis
Def.: formation of several layers of keratinized cells - ig. 8.19) &excessive keratin
over the surface of the stratified squamous epithelium.
NB: keratinization of the stratified squamous epithelium of the vagina and cervix
represents an abnormal differentiation
c At clinical examination , this area may appear as a white patch, a sign of

c In the cytologic smear , leukoplakia can be recognized by the presence of :
1)c numerous anucleated squames found singly or in sheets - ig. 8.0). These are often
folded and are pale yellowish pink. Remnants of nuclei may be visible as a central
clear zone, so-called nuclear ghosts.
)c Cells from the granular cell layer may be encountered in the smear, resembling
intermediate or superficial squamous cells, containing eosinophilic or cyanophilic
keratohyalin cytoplasmic granules.
Parakeratosis
c Def. the presence of various numbers of layers of small squamous cells, sharply
demarcated from the underlying superficial zone. The nuclei are small, frequently
pyknotic, and hyperchromatic.
In cytologic specimens, small, superficial squamous cells, either isolated or in sheets - ig.
8.1). Shapes vary from round or oval to polygonal or spindle shaped. Cytoplasmic stainin
usually is dark or light eosinophilic, rarely cyanophilic. Nuclei are small and
hyperchromatic owing to pyknosis.
NB : Although hyperkeratosis and parakeratosis may overlay an abnormal change such as
dysplasia or squamous cell carcinmoma so it is advised to take two smears in succession.
c
The first to remove the superficial abnormally keratinized layers &in the second scrape,
the true nature of the underlying epithelium becomes apparent.
Õey features of parakeratosis and hyperkeratosis
Isolated cells or large sheet-like aggregates with anucleate squames;
Eosinophilic cytoplasm;
Small round-to-oval nuclei, frequently pyknotic;
Slight to moderate hyperchromasia; and
Squamous Metaplasia
c The most common protective mechanism of the endocervical epithelium of the
uterine cervix is squamous metaplasia.
c Def.the transformation of one cell type into another type of cell of a lower
organizational order.
c As applied to the uterine cervix, the ter m refers to the process of replacement of
simple columnar epithelium lining the endocervical canal and glands by a stratified
squamous epithelium.
c It subdivided into:
1)c Reserve cell hyperplasia;
)c Immature squamous metaplasia; and
)c Mature squamous metaplasia.
c Reserve cell hyperplasia is transformed in ĺimmature squamous metaplasia,
which with increasing differentiation gradually evolves into ĺmature squamous
metaplasia.
c The maturation of immature squamous metaplasia tends to be more pronounced
in the distal part of the endocervical canal.
Dactors in the initiation and promotion of squamous metaplasia are
i.c chronic irritation of a physical nature, as caused by -IUD),
ii.c chemical irritants, inflammation with cell destruction, and
iii.c endocrine changes at the beginning of, during, and after reproductive age.
c Some of the chemical stimuli that induce squamous metaplasia in subcolumnar
reserve cells are also capable of inducing cancer in the uterine cervix of
experimental animals.
c Squamous metaplasia do not necessarily and inevitably precedes the development of
cancer, but the concept of squamous metaplasia is of great importance in the
understanding of carcinogenesis in the uterine cervix.
c
Basal Cell Hyperplasia²Reserve Cell Hyperplasia
c defined as the appearance of one or more layers of primitive, undifferentiated cells
in a subcolumnar position between the endocervical lining epitheliuma bove and
the basement membrane below.
c The earliest form of reserve cell hyperplasia is a single layer of subcolumnar cells
- ig. 8.). Proliferation of the subcolumnar reserve cells may involve only one or
two layers of cells beneath columnar epithelium or may attain a considerable
thickness.
c origin hypotheses from :
1. Ingrowth of basal cells of adjacent normal stratified squamous epith elium;
. fetal squamous basal cells in the preexisting stratified squamous epithelium lining of the
urogenital sinus;
. undifferentiated fetal rests;
4. endocervical columnar cells-by a process termed ÷÷); and
5. cervical stromal cells.
c The most logical derivation is from the same coelomic epithelium as that from
which the columnar cells are derived.
c Reserve cells differ from basal cells of the original stratified squamous epithelium:
1- the later are dedicated α˷ήϜϣ to the formation of squamous cells.
- in keratin phenotype.
c Reserve cell hyperplasia per se is not a significant reaction biologically, but it is a
frequently occurring nonspecific reaction of the endocervical mucosa.
Cyy
c Cells arranged in a syncytium - Cell borders are usually poorly defined)
DD: It is lacking the loss of polarity and the disorganization usually observed in
carcinoma in situ &usually to find a single layer of columnar endocervical cells
tightly attached to the margin of a sheet of reserve cells. Pure reserve cells are rare
in cervical smears.
c When the overlying columnar layer has been dislodged, these reserve cells are
arranged in larger syncytial aggregates called microbiopsies.
c Cells are relatively small, irregular, and polygonal. The small amount of cytoplasm,
which is ill defined, is cyanophilic and may be finely vacuolated. Nuclei are small,
relatively uniform in size and shape, and bean shaped, round, or oval and may show
longitudinal grooves. Nuclear chromatin is finely granular. Hyperchromasia is
uncommon, but in marked proliferation, nuclear chromatin may be arranged in
coarser chromatin masses. Nucleoli are not identifiable.
c
Õey features of reserve cell hyperplasia
Cells typically arranged in a -dimensional sheet;
Cytoplasmic borders often indistinct;
Group polarity and organization maintained;
Columnar endocervical cells may be attached to the group;
Cells are small, irregular to polygonal;
Small amount of ill-defined cytoplasm which is cyanophilic and vacuolated;
Nuclei are small, bean-shaped, round to oval, with grooves; and
Nuclear chromatin is finely granular typically without nucleoli.
c The proliferation not only simulates carcinoma in situ but actually may represent a
developmental stage of this process.
c Reserve cell hyperplasia represents theoretically the earlieststage in immature
squamous metaplasia in the uterine cervix.
c The concept of reserve cell hyperplasia as a stage in squamous metaplasia based on
the embryonic rest hypothesis .
c The predominant site of pure reserve cell hyperplasia is in the proximal part of the
endocervical canal, somewhat more proximal than the site of maximal involvement
of immature squamous metaplasia.
c A surface reaction with any degree of differentiation toward a squamous cell type is
more logically placed within the category of immature squamous metaplasia despite
the persistence of an overlying endocervical columnar epithelium.
Immature Squamous Metaplasia
c Immature squamous metaplasia represents epithelial changes from a single or
multiple layers of reserve cells to an epithelium composed of three or more layers of
cells with features of mature non-keratinizing squamous epithelial cells - igs 8.
to 8.5; see also ig. 8.0).
c Unlike reserve cells, cells are isolated - igs 8.6 to 8.8). Their tendency to occur as
single cells is correlated with the degree of maturation of the parent epithelium.
c The majority of cells are round to oval, with the number of polygonal cells
increasing with maturation. The cytoplasm of immature squamous metaplasia cells
is dense, homogeneous but sometimes vacuolated,and c yanophilic - ig. 8.9).
c Cytoplasmic vacuolation is frequently observed in the presence of inflammation or
as a consequence of degeneration. Nuclei, particularly in the more immature cells,
are large, creating a high nucleocytoplasmic ratio -see ig. 8.8).
c In cervical smears , cells from immature squamous metaplasia changes often
demonstrate some degree of atypia. Cells and nuclei show a slight irregularity in
c
size and shape, which is understandable because most metaplastic changes occur
under the influence of some irritating factor - ig. 8.0; see also ig. 8.9).
c Differential diagnosis with dysplastic changes should be made on the basis of the
evenly distributed, finely granular, non -hyperchromatic chromatin.
Õey features of immature squamous metaplasia
Cells in sheet-like aggregates with usually distinct cell borders& single
Densely cyanophilic cytoplasm;
Relatively large round-to-oval nuclei;
Increased nucleus-to-cytoplasmic ratio;
inely granular, evenly distributed normochromatic chromatin;
Conspicuous micronucleoli; and
Macronucleoli sometimes present.
Mature Squamous Metaplasia
c It represent epithelial changes resulting in an admixture of cells of varying maturity
in the cellular sample.
c The ÷
bears no constant relationship to the anatomic
external os, and the external os has no histologic landmarks to delineate it.
c The increase in linear extent of squamous metaplasia in the endocervical canal and
the region of the transformation zone with increasing age is inversely related to the
reduction of the linear extent of reserve cell hyperplasia.
c Mature squamous epithelium encompasses the classic three layers of
nonkeratinizing squamous epithelium, making mature squamous metaplastic
epithelium virtually indistinguishable from the original ectocervical squamous
epithelium. oci of mature squamous metaplasia may be indistinguishable from the
normal ectocervical mucosa. The only clue to its metaplastic origin i s underlying
endocervical glands - ig.8.1).
c The presence of squamous metaplasia in cervical smears was -41 to 8) of
cervices examined histologically.
c The prevalence of squamous metaplasia rises significantly from the third to the fifth
decade -70-85) of cases in this age group.

Cyy:
c isolated Cells, less frequently occurring in loose sheets.
c The number of cells varies with:
a)c the extent of the epithelial change,
b)c the localization of the lesion, and
c)c The method of sampling.
c
c Cells from squamous metaplasia characteristically have distinct borders and are
predominantly round, oval, or polyhedral.
c In immature squamous metaplasia, the cytoplasm is homogeneous and cyanophilic,
whereas in a more mature type of metaplasia, it is more densely staining outer zone
or ectoplasm and a clear central perinuclear zone or endoplasm - ig. 8.).
c At the periphery of the cells, remnants of the fibrillar apparatus, observed in normal
squamous cells, may be demonstrated.
c The nuclei are relatively small, round or oval, usually centrally located, and uniform
in size and have a basically finely granular chromatin in which there are small
aggregates or chromocenters.
c Mature squamous metaplastic cells can sometimes be differentiated from cells
derived from the original ectocervical squamous epithelium by their slightly denser
staining cytoplasm.
Õey features of mature squamous metaplasia
Cells tend to be isolated or less frequently in loosely aggregated sheets;
Cytoplasmic borders are distinct;
Cells are round to oval, or polyhedral;
Cytoplasm displays a densely staining outer zone-ectoplasm) and a central clear
perinuclear zone-endoplasm) ²cyanophilic staining; and
Nuclei are relatively small, centrally located, and uniform in size and shape, and show
finely granular, evenly distributed chromatin with occasional micronucleoli.
c DD:In slightly to moderately atypical squamous metaplasia the cytoplasm gives
information related to the maturity and specific tasks of the cell, whereas the
nucleus reflects not only maturity but also the degree of dedifferentiation of a cell
-malignant potential); large but only relative to the size of the cytoplasm and much
smaller than nuclei in dysplastic change , hyperchromasia is generally absent but
hyperchromasia in nuclei of dysplastic cells reflects an abnormality in DNA
synthesis, for example, an abnormal number of chromosomes .
c Mature squamous metaplasia is also referred to as:
Epidermization - ig. 8.6);
Complete squamous metaplasia; and
Squamous prosoplasia, stage V - luhmann).
c
Atypia
èc Def.: It is a descriptive diagnosis, indicating minimal-to-slight aberrations from
normal.
èc eatures causing slight-to-minimal atypia are nuclear enlargement and aberrations
from the normal configuration of the cells - ig. 8.7).
èc Causative processes most often are:
1-c inflammation,
-c regenerative reactions,
-c certain deficiency as folic acid deficiency, and
4-c the earliest changes in neoplastic transformation.
èc Atypia & contraception, minimal atypia were noted in about15 of smears from
women using oral contraceptives and in 5 of smears from women using lUDs.
èc Diagnoses of minimal-to-slight atypical changes should be followed by a repeat
smear after 1 months, or under surveillance at yearly intervals.
èc Moderate atypia, frequently observed in reparative reactions, should be followed by
a repeat smear after months.
Reactive and Regenerative Changes
ëc A reactive change is an epithelial reaction to injury characterized by the presence
of sometimes highly atypical cells of endocervical and squamous metaplastic origin.
ëc The epithelia covering the uterine ectocervix and endocervical canal are under the
constant influence of physiologic & external stimuli.
ëc Regenerative epithelial reactions are found in patients after:
Radiotherapy;
Recent hysterectomy;
Cautery or biopsy;
Cryocoagulation diathermy;
Past history of severe cervicitis; and
Partial or complete destruction of the epithelium by infection and inflammation.
{c true erosion or ulceration of the cervical stroma, which may be caus ed by:
a)c prolapsed uterus,
b)c pressure necrosis from a ring or a shield pessary, or
c)c An IUD.
ëc These environmental changes result in various morphologic responses, which may
be classified as destructive, protective, or reparative.
ëc All of these reactive changes may result in some form of epithelial atypia.
ëc Repair epithelium in experimental animals has been found to be more susceptible to
the action of carcinogenic agents than nontraumatized tissue.
c
Reparative (regenerative) change can occur in :
1.c squamous epithelium,
.c squamous metaplasia epithelium, and
.c columnar epithelium
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Reparative changes are c haracterized morphologically by :
àc Nuclei are mostly round to oval, with some nuclear enlargement and variation in
nuclear size.
àc Large, prominent nucleoli and multiple macronucleoli are sometimes present as a
sign of active protein synthesis in the fast-growing cells, which try to replace the
damaged epithelialcells - ig.8.8).
àc The nuclear chromatin is finely granular, almost always evenly distributed, and not
hyperchromatic.
àc Cells from reparative epithelium usually desquamate as large, sheet-like aggregates
with indistinct cytoplasmic boundaries in these aggregates,
àc mitoses may be present - ig. 8.9).
àc Rarely, abnormal singly lying cells a re found.
àc The cells have a wide variation in size and shape.
àc The cytoplasm is usually cyanophilic and sometimes is finely vacuolated or may
contain large vacuoles, abundant cytoplasm with ³taffy pull´ appendages.
ëc Cells have essentially the characteristi cs as immature columnar cells - ig. 8.40),
immature squamous cells, or immature squamous metaplastic cells.
ëc Depending on the severity of the stimulus causing the epithelial damage, the
replacing epithelium²regeneration and repair ²will be blocked in its maturation
and show a degree of abnormal configuration or hyperchromasia - igs 8.41 and
8.4).
ëc DD: Differentiating between cells from reparative changes and cells from invasive
neoplastic processes may be difficult.
1.c The predominant arrangement of cells in sheet-like aggregates, even though the
cytoplasmic boundaries may be indistinct, together with
.c the normochromatic, finely granular, evenly distributed chromatin, and
.c the presence of macronucleoli usually can provide the correct diagnosis.
In no other epithelial abnormality and particularly in no invasive process do these
three characteristics occur simultaneously.
Inflammation-Associated Cellular Changes

Inflammation alone causes minor cytologic abnormalities as:
c
1.c a dual staining reaction, lysis or vacuolation of the cytoplasm,
.c slightly disproportionate nuclear enlargement, and an increaseof the
nucleocytoplasmic ratio - ig. 8.4).
Îc Nuclear chromatin is more often hypochromatic than hyperchromatic
Degenerative Changes of nuclei : as folding of the nuclear membrane, karyorrhexis,
karyolysis, and pyknosis - ig. 8.44).
In cases of nuclear alterations, such as nuclear enlargement, binucleation, and
multinucleation, as well as coarse clumping and irregular distribution or a complete
loss of structure of the chromatinic material, the differential diagnosis with true
atypical changes, such as dysplastic lesions or even invasive carcinoma, becomes
relevant - ig. 8.45). The correct diagnosis usually can be made on the basis of the
cytoplasmic vacuolation due to hydropic degeneration and the fading of nuclear
contours due to autolysis.
2÷÷y y
èc Causes of smears unsatisfactory for cytologic diagnosis (Poor quality of the
smears):
1.c Extreme admixture of inflammatory cells can occasionally obscure epithelial cells
or dilute the number of diagnostic cells in a specimen, thus reducing the chance of
detection of abnormal cells,
.c too few epithelial cells present or,
.c strong admixture of erythrocytes.
èc Smears considered evaluable if endocervical columnar cells and squamous
metaplastic cells were found significantly more frequently in smears showing signs
of bacterial inflammatory reaction or 3÷ ÷.
NB: A significant proportion of smears without signs of inflammation were less
reliable for cytologic diagnosis.
An inflammatory exudate has been reported to be associated with approximately of
dysplastic lesions.
èc Smears with no signs of inflammation have:
1)c Higher percentage of smears without signs of epithelial abnormalities.
)c Minimal epithelial atypia was lower than expected.
)c Mild and moderate dysplasia was lower than expected but not so much.
4)c The percentage of smears without a sign of inflammation rose with age.
èc Smears with signs of inflammation have:
c
1.c The distribution of epithelial changes in smears with bacterial infection did not
differ from the expected numbers.
.c Epithelial abnormalities were more common in smears of 3 ÷ - ig. 8.46), as
were changes consistent with severe dysplasia and carcinoma in situ.
.c In smears with ÷ -moniliasis), reactive minimal atypia than a
dysplastic change.
4.c Higher proportion of smears with squamous metaplastic cells
5.c Higher proportion of mild to- moderate dysplastic changes.
èc 0 ÷
{c 3 ÷; more frequently in smears with severe dysplasia and carcinoma in situ.
{c Associations between a history of 3 ÷ and ÷ and cervical
intraepithelial neoplasia -CIN) lesions but not invasive cancer.
{c our of smears originally diagnosed as inflammatory atypia to be under reported,
because in subsequent smears these atypias had ³progressed´ to CIN.
{c Cyd ÷ infection there is:
1.c Increased risk for cervical neoplasia in women with antibodies to it.
.c The progression rate to CIN grade III after years of follow-up was significantly
higher than in a control group with comparable epithelial changes but without
evidence of infections, suggestting that may be a
cocarcinogen or a potentiating agent in the progression of cervical intraepithelial
lesions.
èc In performing colposcopically directed biopsies on patients with persistent
inflammatory atypia, CIN was found in about one-third of the patients; again,
about one third were of greater severity than CIN grade I. so all patients with
persistent inflammatory atypia shuld undergo colposcopic evaluation.
èc Recommendation for a repeat examination after a follow-up interval should be part
of the report, as minimal-to-mild atypia may be followed by the appearance of
cellular changes consistent with mild dysplasia. So smears showing signs of atypia
related to inflammation should therefore be repeated after 1 year.
Immunosuppression
Immunosuppression is a risk for:
1.c Infections with herpes simplex virus type and human papillomavirus-HPV)
.c Developing neoplastic conditions - ig. 8.47).
Patients at risk are :
1.c receiving immunosuppressive drugs -transplants or other conditions),
.c Hodgkin¶s disease, and
c
.c Under treatment with cytostatics following cancer.
4.c Increased risk for cervical cancer with the number of pregnancies -pregnancy is a
transient state of immunodepression).
Intrauterine Contraceptive Devices
The most severe reactive changes closely mimic intraepithelial neoplasia, both of
squamous and of glandular type, are associated with the presence of an IUD.
Composing cells may show :
{c severe cellular and nuclear polymorphism,
{c an increased nucleocytoplasmic ratio, prominent nucleoli, and
{c cytoplasmic vacuolization.
{c Severely atypical cells arranged in clusters are often present.
{c Usually a marked inflammatory reaction.
DD: The cells may be extremely difficult to differentiate from those derived from an
adenocarcinoma, : IUD-related changes usually are found in relatively young women who
are using an IUD -correct and complete clinical information accompanying the request for
a cytologic examination ).
NB: It may sometimes be necessary to remove the device and to repeat the cytologic
examination after an interval of 4 to 6 weeks. The epithelial abnormalities usually will
have disappearedby then.
Human Papillomavirus and Cervical Cancer

Õoilocytotic cells exhibit vacuolization of the cytoplasm with condensation of the
chromatin and slight atypia of the nuclei - ig. 8.48).
Human Papillomavirus cause Cervical Cancer evidences:
1.c viral particles demonstrated in koilocytotic cells of CIN lesions by electron
microscopy
.c molecular techniques as southern blot hybridization and polymerase chain reaction
-PCR), many epidemiological and clinicopathological studies demonstrated that
HPV is associated with the development of CIN and cervical cancer.
{c More than 100 different genotypes of HPV have been identified.
{c Two large groups of HPVs can be distinguished based on the site of infection:
cutaneous and genital -mucosal/cervical).
1.c Most cutaneous HPV types -HPVs1, , , 4, 10, 8, 9, and 8) cause benign
lesions of the skin as verruca plantaris, verruca vulgaris, and verruca plana.
.c genital HPVs is further subdivided based on the behavior of the resulting
cervical lesions.
c
a)c Low-risk cervical HPV types -HPVs 6, 11, 40, and 444) are
predominantly present in condyloma acuminatum, ASCUS, and CIN1
lesions.
b)c Eighteen out of more than 5 genotypes -HPVs 16, 18, 6, 1, , 5,
9, 45, 515, 56, 58, 59, 66, 68, 7, and 8) that infect the mucosal
types of epithelium are considered high -risk HPV since they have been
detected in the cervix of patients with cervical carcinoma. Infections
with HPV 16, 18, and 1 together account for almost 80 of all
squamous cell carcinomas of the cervix.
Pathogenesis:
{c In low-grade cervical lesions the double-stranded circular HPV DNA genome is in
an episomal state.
{c With progression of the cervical lesion, the HPV DNA becomes disrupted and
integrates in the host genome.
{c In cervical carcinoma, HPV is always in an integrated state resulting of:
1.c Blocking of p5 -the ³guardian´ of the genome)and
.c Blocking of pRb -the ³brake´ of the cell cycle).
{c Both effects of HPV, DNA instability and hyperproliferation, may lead to invasive
carcinoma of the cervix.
Method of detection : PCR, and hybrid capture -HC) assays.
Condylomatous Lesions and Epithelial Abnormalities

èc Condylomatous lesions defined as koilocytotic warty atypia .
èc Condyloma acuminatum:
{c caused by an infection with HPV 6 and 11 and were thought to be important
sexually transmitted factors in the genesis of cervical cancer.
{c is found in younger age groups than is dysplasia and is common in sexually active
teenagers.
NB: Types 6 and 11 are most commonly associated with condyloma acuminatum of the
cervix and with CIN lesions of mild severity.
DD: with CIN, Condylomata occur at a younger mean age, are found in the
transformation zone and the cervical portio, and are polyploid, often regress, and contain
HPV antigens in the majority of cases.
NB: some prefers to use the term CIN grade I with features of condyloma.64
÷y
èc Cervical lesions are of three types.
c
1.c The most frequent form is a flat, acanthotic epithelial change with well-preserved
basal layers and marked nuclear degeneration with perinuclear halos toward the
surface. It also shows dyskeratotic changes - ig. 8.49).
.c The classic proliferative, papillomatous condyloma is found much less frequently,
.c Endophytic ³inverted´ condyloma -rarer).
NB: The flat and endophytic condylomata represent new lesions previously not noted
on the cervix.
Many of the condylomatous lesions were described as dysplasias -precursor of cervical
neoplasia) undergo malignant transformation in a few cases and that it behaves
epidemiologically similar to carcinoma of the cervix.
Cyy
condyloma and CIN, cannot always be clearly distinguished by morphologic means.
Some features may help in differentiating between them:
dy, Õoilocytes are the predominant cellular features of infection with HPV.
koilocytotic cell is a superficial or intermediate squamous cell that displays a large
perinuclear halo with irregular, clear -cut edges and a dense, often amphophilic, sometimes
almost hyaline cytoplasm in the area surrounding the perinuclear cavity - ig. 8.50).
cells are mature and display an ample amphophilic cytoplasm. The chromatin is poorly
defined, and the nuclei may show various stages of degeneration. The nuclear membrane
is not distinct, and nucleoli usually are absent.
NB: Õoilocytes must be differentiated from cells with perinuclear halos found in other
types of infection, such as trichomoniasis. In these cells, however, nuclear abnormalities
are not as apparent and halos tend to be s maller and less well demarcated.
÷, cells are immature, with scant cyanophilic cytoplasm.
The chromatin details are distinct, the nuclear membrane is clearly visible and somewhat
irregular, and small nucleoli can be recognized.
Abnormal differentiation becomes evident by an underdeveloped cytoplasmic body and a
relatively enlarged nucleus, leading to an increased nucleocytoplasmic ratio - ig. 8.51).
Nuclear shapes are round to oval and often irregular. Particularly i n the more severe
abnormalities, the nuclear chromatin is increased and often irregularly distributed. Cellular
changes originate in preexistent squamous epithelium or more often in squamous
metaplastic epithelium.
Õey features of condylomatous lesions (CIN 1, LSIL)
Õoilocyte is the classic cell²superficial or intermediate type cell with large clear-cut
perinuclear halo;
Cytoplasm is densely cyanophilic and often amphophilic;
c
Nuclei may be degenerated with poorly defined, clumped chromatin and indistinct
nuclear membrane;
Chromatin is normochromic to slightly hyperchromatic unevenly distributed;
Nucleoli are absent;
Multinucleation is common; and
Non-koilocytes may show markedly enlarged nuclei with increased nucleus to
cytoplasmic ratio.
÷y
{c Cytology may detect the majority of lesions with koilocytotic features but may not
detect focal CIN grades I, II, and III lesions associated with these condylomatous
changes.
{c Cellular changes due to low-risk HPV infection may mimic the changes found in
cases of well-differentiated squamous cell carcinoma. The right diagnosis may
usually be made on the basis of the less apparent nuclear abnormalities in low -risk
HPV-induced epithelial lesions.
{c uture diagnosis of HPV by PCR should include also in situ hybridization.
{c Neither cytology nor histology can detect an asymptomatic, colposcopically
negative, latent HPV infection, which can be detected by in situ hybridization tests
only.
Squamous Intraepithelial Neoplasia
c The cytology report should consist of:
1.c concise description of abnormal cellular findings in well -defined and generally
accepted terms, followed, if appropriate, by
.c prediction of the histologic condition,
.c Recommendation for the further treatment of the patient.
c In the Bethesda System the inflammatory diseases, the infectious conditions, and
other reactive cellular changes such as repair -due to trauma, infection, IUCD),
radiation, and atrophy are classified as ³negative for intraepithelial lesion or
malignancy.´
c The NCI working group for intraepithelial cell abnormalities:
A.cLow-grade squamous intraepithelial lesions (LSIL)
1.c Changes consistent with HPV infection: multinucleation, perinuclear halos, and
slight nuclear atypia; and
.c Mild dysplasia -CIN grade
B.cHigh-grade squamous intraepithelial lesion (HSIL)
1.c Moderate dysplasia -CIN grade );
.c Severe dysplasia -CIN grade ); and
c
.c Carcinoma in situ -CIN grade ).
NB: Atypical squamous cells of ³undetermined significance´ implied a significant risk for
an underlying high-grade cervical intraepithelial lesion -SIL).
Main different reporting systems for cervical cytological squamous epithelial

abnormalities
Papanicolaou WHO CIN Bethesda
Class I Negative for
intraepithelial lesion or
malignancy
Class II Atypical squamous cells
Mild dysplasia CIN 1 Low grade SIL
Class III Moderate dysplasia CIN High grade SIL
Sever dysplasia CIN High grade SIL
Class IV Carcinoma ÷ CIN High grade SIL
Class V Carcinoma Carcinoma Carcinoma
(intra)epithelial cell abnormalities :

A.cAbnormalities of squamous cells:
1.c ASC
.c LSIL
.c HSIL
B.cAbnormalities of glandular cells:
1.c atypical glandular cells
.c cervical adenocarcinoma in situ
.c adenocarcinoma
C.cother:disorders as the presence of endometrial cells in a postmenopausal woman
Dysplasia
c ÷÷ means ³disordered form´ -disordered differentiation) or disordered
growth patterns the majority of these intraepithelial changes would regress
spontaneously or persist unchanged if left untreated.
c
c In the definition of the World Health Organization, dysplasia is ³a lesion in which
part of the thickness of the epithelium is replaced by cells showing varying degrees
of atypia.´
c Graded as mild, moderate, and severe on the basis of the proportion of the epithelial
thickness occupied by the abnormal cells, taking into account the degree of atypia
of these cells.
c The behavior of these intraepithelial lesions cannot be predicted with accuracy and
that even mildly abnormal changes, when left untreated, may progress to carcinoma
in situ and invasive cancer.
c The form of dysplasia depend on the maturity of the epithelium that react as t he
morphologic features of a dysplastic lesion involving an immature squamous
metaplastic epithelium are relatively uniform and differ from a similar reaction
involving mature stratified squamous epithelium.
Steps: 1-The stimulus exerts its effect on the cells of the basal layer of mature ectocervical
stratified epithelium or on the reserve cells or immature squamous metaplastic cells in the
endocervical canalĺThis would initially be demonstrated by a defect in the mitotic
mechanism of the cell, resulting in ĺ scattered cells with an abnormal DNA content,
demonstrated by the appearance of enlarged nuclei with an abnormally distributed
hyperchromatic chromatinic material. Differentiation of the cytoplasm is disturbed owing
to an abnormal stimulus from the nucleus.
-With a continuing stimulus, persistence of some of the abnormal cells capable of
complete division and survival lead to ĺ an increase in the number of abnormal cells.
-Continued selection and the persistence of the abnormal cells increasingly involve
multiple layers of the lining epithelium, thus increasing the severity of the lesion.
Cervical Intraepithelial Neoplasia

Because of a great deal of confu sion about the clinical significance of the terms dysplasia
and carcinoma in situ, the term cervical intraepithelial neoplasia was introduced in an
effort to bring a more active approach to the evaluation and treatment of noninvasive
epithelial abnormalities of the cervix.
Electron Microscopy
Although it is possible to subclassify CIN into mild, moderate, and severe
dysplasia and carcinoma in situ by light microscopy, such a subclassification is difficult at
the subcellular level.
c d
c
1.c The nuclear enlargement may reflect the increase in DNA synthesis that
accompanies the decreased generation time in dysplasia and carcinoma in situ.
.c Mitotic figures are rarely observed in normal epithelium but are frequently seen in
dysplasia and carcinoma in situ, in keeping with the more rapid growth rate.
.c The mitotic figures in dysplasias do not generally differ from those in normal
epithelium, but in rare mitotic figures that are observed, the number of
chromosomes in nuclei appear to be increased.
¦c ÷ ÷
Comparing between normal and dysplastic cell using scanning electron microscopy,
demonstrates differences in surface architecture between the basal and luminal side
of normal intermediate squamous cells and between normal and abnormal cells,
both in exfoliated cells and in cells from tissue specimens: The luminal side of
epithelial cells bears microridges, and the basal side contains microvilli.
1.c All cases of histologically established -moderate or severe) dysplasia showed a
remarkable increase in the number of microvilli and a decrease in the number of
desmosomes.
.c Abnormal configuration of microvilli was also observed in epithelial abnormalities.
.c These changes have also been documented in cells from invasive carcinoma.
C.c ÷÷ ÷: The decrease in number of desmosomes is in accord with the finding
that neoplastic cells are more loosely attached to one another than are normal
cells.The lack of adhesiveness between the epithelial cells in dysplasia and
carcinoma insitu could also account for the increased number of leukocytes in the
altered epithelium, because it would facilitate the penetration of the epithelium by
inflammatory cells.
D.cribosomes, mitochondria, and glycogen : Surface cells in dysplasia, although they
may appear flattened under the light microscope, have cytoplasm containing large
numbers of ribosomes, numerous mitochondria, and decreased or absent storage of
glycogen, which is in keeping with their less-differentiated state. Increased numbers
of ribosomes and polyribosomes have also been reported in cervical squamous cell
carcinoma.
Cervical Intraepithelial Abnormalities

^ d
A.cDysplastic lesions occur significantly more frequently on the anterior than on the
posterior lip of the uterine cervix and are usually localized in the endocervical
mucosa at the transformation zone in the region of the cervical os or in the
epithelium covering the ectocervix or portio vaginalis.
c
B.cThe majority of abnormal surface reactions begins w ithin the area of the
endocervical-lining epithelium and mimics in an abnormal fashion various stages in
the process of squamous metaplasia.
c There is some confusion about the exact site and cells of origin of cervical
intraepithelial abnormalities:
1.c Some identify the cell of origin of most of the intraepithelial lesions to be the
basal cell of the original ectocervical squamous epithelium overlying an area
without gland-bearing stroma.
.c Others is more in line with the experience from routine clinical practi ce that
the majority of intraepithelial changes and virtually all of the severe
intraepithelial abnormalities extend into the invaginations of the columnar
epithelium. It is a common observation that the severity of the change in the
invaginations is less than that of the surface change.
y d ^
The potential of reserve cells to differentiate into squamous epithelium through an
intermediate stage of immature squamous metaplasia gradually diminishes in the proximal
direction along the canal. This is reflected in the epithelial abnormalities originating at
different sites:
èc The dysplastic lesions occurring close to the squamocolumnar junction
usually still demonstrate some maturation into squamous-like epithelium in
the superficial layers.
èc Abnormalities occurring proximally in the canal completely lack this
squamous differentiation and seem to be composed entirely of
undifferentiated primitive cells -atypical reserve cells).
The resemblance to squamous epithelium of the more distal lesions does not necessarily
mean that these, although often erroneously named ³better differentiated´ when compared
with classic carcinoma in situ, would have a less malignant potential. In this respect, the
relatively large-cell severe dysplasia should be considered of comparable severity as the
more classic carcinoma in situ and treated accordingly.
Vd
àc Provides a basis for the mode of treatment.
àc Makes these lesions accessible for retrospective and prospective studies, to achieve
more insight into the true nature of these changes.
àc May give more insight into the morphologically different types of dysplasia as well
as into the biologic potential of these types.
The more closely the lesion resembles normal epithelium, the less severe that lesion is
thought to be. The more that primitive cell types that lack signs of differentiation
c
predominate, the more severe a lesion is considered to be. Thus, it is possible to apply the
terms minimal, slight, moderate, and severe to differentiate on a morphologic basis²
phenotypically²one lesion from another.Unfortunately, the degree of morphologic
abnormality does not necessarily correlate with the biologic potential of the epithelial
change.
The intraepithelial neoplastic²dysplastic²reaction is characterized by:
àc Premature keratinization of component cells and abnormal differentiation of a
variable number of cell layers that, in the most severe forms, encompasses all cell
layers throughout the whole thickness of the mucosal lining.
àc In the uppermost layers of the dysplastic epithelium, cells that remain have features
of normal epithelial cells. This is usually more apparent in dysplasia originating in
the original squamous epithelium than in changes involving the squamous
metaplastic epithelium.
àc Cells in the upper layers of dysplasia have features reflecting differentiation.
However, the nuclei are usually enlarged and more hyperchromatic than in normal
squamous epithelial cells and the nuclei of the cells show remarkable variation, in
contrast to the rather uniform size and shape of nuclei in normal epithelial cells at a
comparable level.
àc In lesions involving mature squamous epithelium, individual cell keratinization and
keratohyalin pearl formation are not uncommon.
àc Mitoses are usually found. In less severe lesions, mitoses, both normal and
abnormal forms, are confined to the lower halfor lower two -thirds of the
epithelium. In more severe changes, mitoses can also be found in the upper third of
the mucosal lining.
^
èc The mean age at diagnosis is decreasing. This might be related to changes in sexual
behavior within Western countries and a younger age of first sexual acti vity.
èc Invasive cancers are also diagnosed with greater frequency in younger women; this
has so far not βϴϟ ϥϵ΍ ϰΘΣ resulted in a greater mortality from cervical cancer in
women in younger age groups. The reported increased frequency of intraepithelial
lesions in younger women may in part be due to an increased frequency of cytologic
testing and may not be a true increase in the number of intraepithelial abnormalities.
èc a prevalence of 0.98 in nongravid women.women ages -5-55) years, mild and
moderate dysplasia was found in 1.6 and severe dysplasia and carcinoma in situ in
0. of women at first screening.76
Based on cellular evidence of dysplasia,
ëc The mean age at detection was 4.7 years.
c
ëc Patients with slight dysplasia were found to have a mean age of .0 years.
ëc With moderate dysplasia, the mean age was 5.7 years, and
ëc In patients with severe dysplasia, the mean age was 8.4 years. - igs 8.5and 8.54).

÷y
èc In the dysplastic lesion, abnormal cells are present throughout all layers of the
epithelium.
èc Signs of differentiation occur in inverse relation to the severity of the lesion, from
the basal layers to the surface.
èc The morphology of cells composing the superficial layers of a dysplastic lesion is
related to the severity of the dysplastic lesion.
èc The dysplastic lesion is characterized by:
1.c premature keratinization of component cells,
.c abnormal differentiation of the cells composing the epithelial lin ing,
.c abnormally large nuclei
4.c various degrees of cytoplasmic maturation -usually various degrees of abnormal
maturation of the cytoplasm).
èc Cells present in the upper layers of the mucosa reflect in their morphology the entire
cascade of maturation steps throughout the epithelium. The more dedifferentiated
the cell in the most basal layersĺ the less influence maturation stimuli have during
this cell¶s passage through the layers of the epitheliumĺ and the greater the
remaining abnormality of the cell that finally reaches the superficial layers.
èc rom the morphology of these superficial cells, which are mechanically removed
from the superficial layers of the mucosa, an experienced cytopathologist can
rebuild an image of the histopathologic appearance of the mucosal lining at the site
of the scrape and thus give an impression of the severity of the abnormality at that
site.
Cyy
c The number of abnormal cells differ from one depending on:
1.c The method of collection
.c The skill of the person taking the sample.
.c The severity -and the extent) of the lesion: The lesser the abnormality, the fewer
abnormal cells are found in the specimen. The more severe the lesion, the higher the
number of abnormal cells.
c On the basis of cell population evaluation, one can obtain rather specific
information on differentiation characteristics of the parent lesion.
c
c With experience, a more definitive interpretation can be made on the basis of
cellular specimens, because both cancerous and noncancerous changes in the
surface mucosa of the uterine cervix are reflected in the desquamated cells.
c Abnormal cells originating from the surface of epithelial abnormalities may be
subdivided morphologically into two groups.
1)c Those showing signs of differentiation of squamous type have, depending on
the degree of maturation, features reminiscent of superficial, intermediate, or
parabasal squamous cells - igs 8.55 and 8.56).
)c When signs of differentiation are almost completely absent, cells bear a
resemblance to reserve cells.
Subclassification Of Dysplasia: to provide a morphologic terminology applicable to
both histologic and cellular material and might provide evidence for biologic potential,
-1) keratinizing -ectocervical) dysplasia,
-) nonkeratinizing dysplasia, and
-) metaplastic dysplasia.
{c The nonkeratinizing variant was observed approximately 7 times more frequently
than the metaplastic type and 5 times more frequently than the keratinizing
variant.
{c Admixtures of these different types are most often represented by the simultaneous
occurrence of cells consistent with the nonkeratinizing and metaplastic variants.
{c About 85 of dysplasias in a 5-year period progressed to carcinoma in situ.
{c The reactions are further classified according to severity { minimal, slight,
moderate, and marked -severe)}.
C ÷
èc Usually appear singly and have well-defined cell borders.
èc Also in sheets. Cell borders usually are still recognizable.
èc Cell aggregates with indistinct cell borders -a reduced tendency to maturation in the
mucosal lining. This reduced maturation is a reflection of the dedifferentiation of
the component epithelial cells that lack the stimulus to mature. In such an aggregate,
the component cells are regular ly arranged with relation to one another.
èc Less frequently, cells may be arranged in syncytial masses. Here the component
cells are irregularly arranged with relation to one another and have indistinct cell
borders.
NB: A syncytial arrangement is more commonly associated with carcinoma in situ
and invasive cancer.
èc In almost all cases of dysplasia, sheet-like arrangements are found.
c
èc Syncytial masses are found in only 10 of specimens and are always associated
with a severe epithelial abnormality.
C :
{c The volume and the condition of the cytoplasm are a reflection of the state of
maturation and differentiation of the cells.
{c Usually found is an admixture of cells of various stages of maturity.
{c In view of the site of origin of dysplasias and the prec eding metaplastic process in
the endocervical canal, the size of cells involved in dysplastic changes may vary
from almost the size of a normal superficial squamous cell in minimal abnormalities
to the size of an immature basal cell or a very immature squamous metaplastic cell
in more severely abnormal changes.
{c Relating cell size to the severity of the histopathologic change in dysplasias:
1.c those samples containing dysplastic cells with cell areas predominantly in
the range of normal squamous cells tend to originate from a less atypical
-less severe) dysplastic lesion. These reactions are more frequently located
on the portio vaginalisor in relation to the external cervical os.
.c Those samples with dysplastic cells possessing cell characteristics more
reminiscent of squamous metaplastic cells are more likely to have arisen in
the area of the distal portion of the endocervical canal -transformation zone).
Most of the abnormal cells observed in the presence of dysplasia, carcinoma
in situ, and invasive cancer possess cell sizes as observed in cells from
immature squamous metaplasia and reserve cell hyperplasia. The relative
nuclear area, nuclear shape, and particularly intranuclear chromatin
architecture should then provide the basis for the right diagnosis.
C C
{c The shape of an abnormal cell in a sample may also reflect the maturity of the
parent tissue reaction.
{c Dysplasia is characterized by :
1.c Predominance of polygonal cells accounting for about 55 of the abnormal
cell population.
.c Round or oval forms, indicative of a less mature reaction, represented about
40 of the abnormal cells in samples studied
{c A predominance of polygonal forms, often found together with eosinophilic staining
of the cytoplasm, suggest an origin from a dysplastic lesion, originating in original
squamous stratified epithelium.
c
{c A predominance of oval forms is suggestive of a dysplastic lesion in an area of
squamous metaplasia, most likely the transformation zone of the endocervical canal.
{c The presence of spindle-shaped or elongated cells may indicate the presence of
-abnormal) keratinization at the surface of the epithelium. The elongated cells often
show fibrillary structures in the cytoplasm. The presence of these fibrils is indicative
of keratinization in the dysplastic process. Õeratinization overlying a dysplastic
lesion most often occurs in the ectocervical epithelium, but a keratinizing dysplasia
may occasionally be found in the endocervical canal in a metaplastic epithelium.
{c Anucleated squames, sometimes with pale yellow cytoplasm, may also be found.
When contamination from the vulvar mucosa can be precluded, the presence of
these squames should always lead to an extra awareness on the part of the
cytopathologist.
{c Severe dysplastic lesions or even keratinizing squa mous cancer may sometimes be
covered by a thick layer of hyperkeratosis.
öc NB: When making a scrape from this area, the cellular material obtained may be
restricted to keratinized squames. Owing to the resistant cover, deeper layers have
not been sampled and the true lesion remains obscure.
öc NB: When anucleated squames are diagnosed in a cell sample, even without
atypical cells being observed, a repeat smear should be advised and the physician
should be specifically instructed to sample any area of leukoplakia -literally
) very carefully, preferably by taking successive smears from the same area, thus
gradually uncovering the nonkeratinized part of the lesion.
y
c Nuclear characteristics are the main determinants for the grading and the severity of
an epithelial abnormality.
c Nuclear atypia should be classified as mild, moderate, or severe.
c Cytoplasmic changes should be classified according to quantity, density, staining
quality, and shape.
The morphology of the cell nuclei in c ases of epithelial changes comprises a combination
of any number of the following:
Disproportionate nuclear enlargement;
Irregularity in form and outline;
Hyperchromasia;
Irregular chromatin condensation;
Abnormalities of the number, size, and fo rm of the nucleoli; and
Multinucleation.

c
c The relative nuclear area is the nuclear area in relation to cytoplasmic area.
c The relative nuclear area increases with the severity of the lesion from minimal
dysplasia to carcinoma in situ.
c Nuclei of dysplastic cells are relatively large when compared with their normal
counterparts.
c The greater size of the nuclei is a reflection of the reduced maturation of the cell,
indicated by a relatively large nucleus and a relatively small amount of cytoplasm.
c Actual nuclear area is of less practical importance in routine diagnostic cytology
because of the lack of a possibility for an accurate comparison with an object of
known size.
Mild Dysplasia (CIN Vrade 1, Low-Vrade SIL)

÷y
Slight disturbance of the regular arrangement of cells is seen. The upper two-thirds of the
epithelium show a relatively regular arrangement of cells with preserved stratification.
These layers are composed of cells, recognizable as intermediate-type and superficial
squamous-type cells, with:
{c Slightly reduced cytoplasmic volume and
{c Slightly increased nuclear size.
{c Nuclei are usually of normal round-to-oval shape
{c Minimally hyperchromatic nuclear chromatin.
{c Aberrations of the nuclear morphology are predo minantly limited to the most basal
layers of the epithelium.
Cyy
Cells from mildly atypical lesions such as mild dysplasia -CIN grade 1)have:
Vc plentiful clear, translucent cytoplasm with well-defined angular borders.
Vc Cells resemble intermediate- and superficial-type squamous cells with a somewhat
reduced cytoplasmic body and a slightly enlarged nucleus, occupying less than one-
third of the total area of the cell - ig. 8.57; see also igs 8.55 and 8.56).
Vc Nuclear chromatin is finely granular, evenly distributed, and only slightly
hyperchromatic - ig. 8.58).
Õey features of mild dysplasia (CIN 1, LSIL)
Singly lying cells of superficial and intermediate type²slightly reduced cell size;
Abundant cyanophilic and eosinophilic translucent cytoplasm with well-defined
angulated borders;
c
Cells resemble intermediate or superficial squamous cells;
Enlarged nucleus -5× intermediate cell nucleus) occupies one-third of cytoplasmic
area;
Chromatin finely granular, evenly distributed, with slight hyperchromasia; and
Moderate Dysplasia (CIN Vrade 2, High-Vrade SIL)

÷y
Moderate disturbance of stratification
The upper third of the epithelium still shows evidence of stratification of cells of
superficial and intermediate cell size.
The uppermost layers are still composed of flat squamous cells,
Nuclei may be enlarged and slightly hyperchromatic - ig. 8.59).
The surface layers occasionally are keratinized, with loss of nuclei and the formation of a
granular layer.
Nuclear abnormalities may be seen throughout the epithelium, particularly in the more
basal layers.
Cell arrangement is disturbed in as much as two-thirds of the thickness of the epithelium
- igs. 8.60 and 8.61). In these disturbed layers,
mitoses, sometimes abnormal, are present in increased numbers.
Cyy
Vc Variable size of abnormal cells - superficial squamous cell type, smaller cells of the
intermediate and parabasal cell type) are usually found - ig. 8.6).
Vc Most cells are round to oval, but spindle cells and elongated and bizarre shapes may
occasionally be found.
Vc Cytoplasmic staining is cyanophilic, but a relatively high number of cells may show
eosinophilia of the cytoplasm.
Vc Nuclei, enlarged and round to oval, sometimes elongated or irregularly shaped - ig.
8.6). Nuclear chromatin is evenly distributed and slightly to moderately
hyperchromatic - ig. 8.64).
Vc Nucleoli are usually absent.
Vc The nucleocytoplasmic ratio is i ncreased, both by nuclear enlargement and by
reduction of the cytoplasmic volume - igs 8.65 and 8.66). The nucleus generally
occupies less than half of the total area of the cell.
Õey features of moderate dysplasia (CIN 2, HSIL)
Singly lying cells and cells in sheet-like arrangement of superficial, intermediate, and
parabasal type;
c
Moderately reduced cell size;
Cells predominantly round to oval, but occasional spindled, elongate, or bizarre cells
may be seen;
Cytoplasm is cyanophilic, but more mat ure cells may be eosinophilic with distinct cell
borders;
Nuclei enlarged, round to oval, with some irregular or elongate;
Chromatin irregularly distributed with slight to moderate hyperchromasia;
Nucleoli usually not present; and
Elevated nucleus-to-cytoplasmic ratio usually one-half of cytoplasmic area.
NB: moderate dysplasia -CIN grade ):
c must be considered as neoplastic events in the squamous epithelium.
c : resemble flat condylomata, HPV may be documented -in situ
hybridization)
c Need eradicatation under colposcopic control. This also applies to the atypical
condylomata associated with other forms of CIN.
Severe Dysplasia and Carcinoma In Situ (CIN Vrade 3, High-Vrade SIL)

÷y
{c Greatly disturbed arrangementin all three layers of the epithelium - ig. 8.67).
Stratification is present in only the most superficial layers - ig. 8.68).
{c Throughout the entire epithelium, cells show a reduced maturation with loss of
cytoplasmic volume and an increased nuclear size.
{c Cells and nuclei vary in size and shape and often have irregular forms.
{c Differentiation in intermediate-type and superficial squamous type cells may be lost
- ig. 8.69).
{c Nuclei have a hyperchromatic, irregularly distributed, coarsely granular chromatin.
Mitoses may be found throughout all epithelial layers.
{c The abnormal changes often extend into the stromal invaginations of the
endocervical epithelium - ig. 8.70).
Cyy
Vc The size of the cells is comparable with the parabas al cell type.
Vc Cytoplasm is sparse, forming a small rim around the nucleus - ig. 8.71).
Vc Cells are round to oval and often irregular or elongated - igs 8.7 and 8.7).
Vc The keratinizing squamous lesions sometimes contain large cells with plentiful,
often eosinophilic, cytoplasm.
Vc Cells are seen singly as well as in aggregates. In the most severe intraepithelial
lesions, aggregates have a syncytial composition, with indistinct cell borders and
c
irregularly arranged nuclei - ig. 8.74). The morphology of these aggregates is
consistent with the histologic evidence of the lack of cell maturation and the
irregular arrangement of nuclei in the most superficial layers of severely abnormal
epithelium - igs 8.75 and 8.76).
Vc The nucleus usually occupies at least two -thirds of the total area of the cell.
Vc Nuclei have a hyperchromatic, irregularly distributed, coarsely granular chromatin
- ig. 8.77).
Vc In actively proliferating lesions, eosinophilic -staining nucleoli may be observed, but
these more often are obscured by the dense hyperchromatic chromatin.
Vc Some severe dysplasias show an extreme irregularity in shape and size of the
composing cells.
Vc May present with large, bizarre -shaped cells with highly abnormal hyperchromatic
nuclei. Differentiation from invasive squamou s cell cancer may at times be
extremely difficult - igs 8.78 and 8.79).
Õey features of severe dysplasia (CIN 3, HSIL)
Cells similar in appearance to parabasal cells;
Sparse cytoplasm in rim around nucleus;
Cells isolated or in syncytial groups with indistinct cytoplasmic borders and loss of
polarity;
Enlarged nucleus occupies three -quarters of cytoplasmic area;
Dense hyperchromatic chromatin often with irregular coarseness;
Nucleoli usually absent; and
Spindled, elongate, or bizarre forms may be present.
Biologic Significance Dollow-up
The evolution of invasive squamous cell cancer involves a number of stages with
increasing intraepithelial abnormality designated as: dysplasiaĺ carcinoma in situĺand
microinvasive carcinoma. Although it is not usually possible to predict the malignant
potential of an epithelial abnormality -premalignant lesion), evidence suggests that mild
dysplasias are more prone to regress spontaneously, and conversely, severe dysplasia and
carcinoma in situ are more likely t o persist or progress.
Dysplasia may follow a variable course.
÷÷
Vc A lesion may disappear in weeks or a much longer time,or becoming gradually less
abnormal in months or even years.
Vc Caused by: 1- desquamation of the abnormal epithelium due to minimal trauma.
c
A dysplastic epithelium tends to separate more easily from the supporting stroma than the
normal epithelium does. This may account in part for the disappearance of dysplastic
lesions after initial cytologic diagnosis in women during cytologic follow -up.
In these instances, the diagnostic test essentially becomes a cure for the lesion.
cSingle biopsy could eradicate an area of intraepithelial neoplasia. There can be no
doubt that punch biopsies can eradicate areas of CIN completely, either directly
by complete removal or indirectly by altering the balance between the host and
the neoplasm so that areas of residual CIN regress, thus producing an immediate
cure, a delayed cure, or a change in the distribution of an area of CIN.
½ ÷÷
Dysplasia may also persist during a variable period of time before regressing or
progressing to a more severe lesion, such as marked dysplasia, carcinoma in situ, or
invasive cancer. Documented cases of marked d ysplasia have persisted for as long as 0
years without showing malignant progression. There is unanimity among investigators that
dysplasia in certain circumstances can progress to carcinoma in situ and finally to invasive
cancer.
½ ÷÷
Slight dysplasias may also antedate the appearance of a severe intraepithelial lesion or an
invasive cancer by many years. Most prospective studies, when carried out without
intercurrent intervention through biopsies or frequent repeat smears, indicate that fewer
than 15 of dysplasias progress.
½ ÷÷ ÷
The rate of progression of dysplastic lesions is strongly related to the severity of the
lesion: the majority of mild and moderate intraepithelial changes eventually regress or
persist for a prolonged period so conservative treatment of these patients.
½ ÷÷ The median transition time was:
{c 86 months for patients with very mild dysplasia,
{c 58 months for mild dysplasia, and
{c 8 months for moderate dysplasia
{c 1 months for severe dysplasia.
{c 44 months for all dysplasias to carcinoma in situ.
In a 10-year period, moderate dysplasia was calculated to progress to a more severe lesion
in about 90 of the cases.
Almost all cases of dysplasia would in time develop into carcinoma in sit u if left untreated.
Cy !
c
èc Mild and moderate dysplasias cases should be monitored by regular cytologic
smears for various periods of time before further therapy is recommended. Only
after persistence of the lesion has been confirmed are further follow -up procedures,
including colposcopy, warranted.
èc Severe dysplasia or carcinoma in situ cases is usually followed by colposcopy and
biopsy, which at confirmation of the process are followed by deep excision,
cryocautery,laser treatment, conization, or hysterectomy.
!
{c Minimal epithelial abnormaliti es, a repeat smear should be advised after 1 months.
{c Mild dysplasia or a more severe lesion detected, an immediate referral for
colposcopic evaluation
C÷y
Vc The colposcope is well suited for follow-up studies of CIN because of its lack of
influence on the natural history of the disease.
Vc An optimal cancer detection system for preclinical asymptomatic cervical lesions
should combine a cytologic examination with a colposcopic follow -up examination.
Vc The principal goal of cervical cytology is to detect precancerous lesions and
asymptomatic, preclinical cancer.
Vc The purpose of cytologic screening is to signal these abnormalities and to induce
further evaluation of lesions that have proved to be persistent or that may progress.
Vc Colposcopy could have an important place in the evaluation of these patients.
Colposcopically guided biopsies:
{c may clarify inconclusive cytologic findings and
{c give an assessment of the location, size, and extent of a lesion.
There is a good correlation between the presence of abnorm alities detected by colposcopy
and histologically but little correlation between colposcopic categories and histologic
grades of intraepithelial lesions.
Cellular Reactions Simulating Dysplasia

Certain stimuli may cause reactions in the cervical mucosa that may stimulate dysplasia:
1.c Chronic inflammatory processes and instrumental treatment for erosion or other
surface abnormalities of the cervix: -electrocautery, cryotherapy, laser treatment)
may induce changes that may be confused with dysplastic changes when relevant
clinical information is lacking.
c
.c Certain medications, particularly those used in the systemic treatment of
malignancies or in the course of immunosuppression in organ transplant re cipients,
may also induce cellular changes of a dysplastic nature.
.c folic acid deficiency may cause an increase of both cytoplasm and nucleus. Even
though extremely large nuclei may be found, the nucleocytoplasmic ratio remains
within the limits of a minimal abnormality because of a correlated increase of the
cytoplasmic body, often creating rather characteristic giant cells. In contrastto
dysplastic changes, nuclei are hypochromatic.
4.c an effect of radiotherapy or treatment with alkylating drugs.
Postirradiation Dysplasia
After a latent period -6 m. to 0 y.) following radiotherapy for a malignancy of the
cervix, a small percentage of patients develop a dysplasia of the cervical or vaginal
mucosa.
The characteristics of a postirradiation dysplasia:
{c classic dysplasia+
{c increased maturation of squamous cells, -as estrogen -induced maturation) +
{c irradiation changes as -multinucleation, dual staining reaction, and vacuolation of
the cytoplasm).
Accuracy
ëc There is no single pathognomonic feature of cancer in the cell or the epithelial
lesion of origin, so more than one change must be present to warrant νϮϔΗ an
interpretation of cancer.
ëc Cell samples usually show dysplastic cells with a variable degree of atypia.
ëc A prerequisite for the study of cellular pathology is a knowledge of the component
cells in the parent tissues to learn the origin of cells.
ëc the presence of a lesion can be precluded ωϮ˵Ϩ˸Ϥϣ˴ only when the pathologic study is
comprehensive ϞϣΎη.
ëc ÷ ÷ d÷÷ :When comparing cytologic and histologic findings, a
severe lesion diagnosed cytologically was overestimated.
ëc d ÷ ÷ y ÷J due to low number of cells
-depending on the extent of the epithelial change and the method used for collecting
the cells) so in a less adequate sample in which only part of the circumference of the
ectocervix and the endocervical canal is represented by the cells in the sample, only
part of the abnormal changes may be recog nizable.
ëc ÷ d÷÷ when the sample is highly inadequate.
c
«c The initial cellular sample collected from the cervix usually contains the greatest
number of abnormal cells. Subsequent samples may contain few abnormal cells
even after an interval of to weeks.
«c Because after only a short interval samples are taken from less -matured lesions,
diagnoses on repeat studies made after too short an interval are likely to
overestimate the severity of the lesion. Therefore, when follow -up of the lesion is
done cytologically or when confirmation of the lesion is required before biopsy, the
repeat study should not be performed within 4 weeks.
«c In all cases of discrepancies between cytologic and histologic diagnoses, both the
cytologic and the histologic spe cimens must be reviewed. When the original
cytologic diagnosis is confirmed at review, a repeat histologic examination should
be requested.
Carcinoma In situ
c Ii is an epithelial lesions composed entirely of cells that have all the features
of malignant cells but that do not exhibit invasive growth.
c Other terms in use are incipient cancer, surface cancer, Bowen¶s disease of the
cervix, intraepithelial cancer, carcinomatoid change, and preinvasive or noninvasive
cancer.
c It is a precursor of invasive squamous cell carcinoma.
^" " d 0
àc There is a common pathway in the development of dysplasia and carcinoma in situ.
àc The basic factor in pathogenesis of carcinoma in situ is reserve cell hyperplasia:
1.c The stimulus induce a proliferation and blocks the differentiation of reserve cells
into immature and then mature squamous metaplastic cellsĺ small primitive
undifferentiated cells finally compose the entire lesion -more in the proximal part of
the endocervical canal) .
.c If some differentiation occurs in the epithelial substrate before conversion to
carcinoma in situ, as occurs in squamous metaplasia or dysplasia of metaplastic
typeĺ lesion is of large cell type-more in the distal part of the endo-cervical canal).
àc The majority of cases of carcinoma in situ originate in the area of the transformation
zone.
àc The farthest limit of CIN is determined by the farthest limit of reserve cell
hyperplasia -squamous metaplasia, repair epithelium).

Most researchers report an average age at de tection of about 40 years. Recently earlier
may be due to an earlier sexual activity or more intense cytologic screening.
c
the age-distribution curve showed bimodal pattern, with peak incidences at 5 and 50
years. These peaks were correlated with peak inci dences of invasive squamous cancer at
about 48 years and after 60 years of age.
÷y
The whole thickness of a surface epithelium shows no differentiation in the absence of
invasion, - ig. 8.81). The process may involve the cervical glands without creating a new
group. ÷ ÷ ÷ ÷ ÷
A reaction replacing the normal surface epithelium or the epithelium of the invaginations
of the surface epithelium or both, in which all the layers of the epithelium are composed of
abnormal poorly differentiated or largely undifferentiated cells.
The lesion may be composed of large or small cells -see ig. 8.8). may find moderate-
to-severe dysplasia -of squamous metaplastic type) in the invaginations of the
endocervical canal. Both normal and atypical mitoses are present at all levels of the
epithelial reaction -see ig. 8.8).
DD: in moderate and severe dysplastic lesions mitoses are absent in the most superficial
layers.
Vc Subclassification of carcinomain situ into small, - intermediate) and large-cell
variants not proved to be paralleled by a change of morphologic variants of
invasive cancer.
Vc The lesion is characteristically located in the area of the transformation zone. The
overall extent and distribution of carcinoma in situ are comparable to that observed for
reserve cell hyperplasia and immature squamous metaplasia.
Vc Extension of the surface change into:
the invaginations -90 of cases).
the portio vaginalis - 55 of cases )and
the vaginal fornix- of cases ).
Cyy
The number of abnormal cells in cellular samples is usually greater in cases of carcinoma
in situ than in dysplasias.
C ÷
{c Undifferentiated : lacks the characteristic cytoplasmic changes of differentiation
-maturation).
{c the cells are isolated or, because of a disturbance in cytoplasmic division during cell
division, are adherent together and arranged as syncytial aggregates - igs. 8.8 and
8.84). Most samples do contain isolated cells, but aggregates of abnormal cells
predominate - multiple microbiopsies). In a syncytial group, cells are arranged
irregularly and have indistinct cell borders and overlapping nuclei - ig. 8.85).
c
carcinoma in situ dysplastic epithelium
arrangement of cells irregular regular
cell borders indistinct distinct
{c C d J
«c small compared to stratified squamous epithelium or dysplastic cells.
«c large-cell variant are in the range of small immature squamous metaplastic cells.
«c small-type carcinoma in situ are in the range of reserve cells.
«c The cells are round to oval, reflecting their immature character.Irregular or
elongated cell forms are related to a specific superficial change of the lesion.
«c The sparse cytoplasm stains predominantly basophilic, a cytoplasmic staining
reaction thatreflects the lack of keratinization in these undifferentiated cells. The
few cells showing an eosinophilic staining reaction are most likely derived from a
coexisting dysplasia.
«c Owing to the highly vulnerable cytoplasm in cases of carcinoma in situ, the finding
of cells with damaged cytoplasm or with bare nuclei is frequent - ig. 8.86).
{c y
«c The lack of a differentiation stimulus, usually associated with relatively rapid
cell growth, ĺround-to-oval shape of the nuclei usually smaller than nuclei
derived from dysplastic cells.
«c well defined nuclear membrane in isolated cells; at higher magnification,
nuclear grooves may be seen and ar e rather characteristic of these
undifferentiated cells, even though they are most likely artifacts due to
fixation - ig. 8.87; see also ig. 8.86).
«c The chromatin varies from finely granular and unevenly distributed to
coarsely granular and hyperchromatic -see ig. 8.87). The number of small
nuclei with coarse hyperchromatic chromatin is correlated with the degree of
dedifferentiation of the cells from the carcinoma in situ.
«c Another characteristic of carcinoma in situ cells, recognizable at high
magnification, is the interrupted nuclear membrane due to irregular
sedimentation on the membrane of the coarsely granular chromatin.
«c It is rare to find eosinophilic-staining nucleoli, but chromocenters or ³false´
nucleoli are rather common -see ig. 8.87). ³True´ nucleoli may be obscured
by the coarse hyperchromatic chromatin but are definitely present, because
they are related to the high proliferation rate of the lesion. The absence of
nucleoli would be in contradiction to the relatively high proliferative activity,
which is evident from the presence of mitoses even in the uppermost layers of
the epithelium.
c
«c Macronucleoli, which are usually present in nuclei from invasive cancer cells,
are only rarely seen in carcinomas in situ.
The relative nuclear area -nuclear area in relation to cytoplasmic
area) with an average value of 50 better reflects the primitive character of these cells
from carcinomas in situ than just the size of the cell or the nucleus.
Õey features of carcinoma in situ
Larger number of abnormal cells than other grades of dysplasia;
Cells arranged predominantly in syncytial aggregates with indistinct cell borders;
Some isolated cells;
Small cells with little cyanophilic cytoplasm and without signs of maturation;
Round-to-oval nuclei occupy half of cellular area;
Bare nuclei are commonly noted;
Even to irregular chromatin distribution with fine to coarsely granular texture;
Nuclear membrane is commonly disrupted and irregular -cerebriform); and
Micronucleoli rarely noted²obscured by dense chromatin.
Inflammatory exudate are found in specimens from cancers in situ more thaas well as in
specimens from dysplasias.
Biologic Significance
c It is actively proliferating lesions that, if left alone, will finally evolve into invasive
cancer.
c it is impossible from cytologic, histologic, or clinical data to predict which
c reaction will regress and which will progress to a more severe lesion.
c all invasive cancers of the uterine cervix develop from a carcinoma in situ or from
severe dysplasia.
c not all carcinomas in situ or severe dysplasias progress into an invasive process;
many regress into a lesion of less severity or disappear completely. This means that
these lesions diagnosed as intraepithelial cancer are essentially not malignant in
nature.
carcinoma in situ progress slowly to invasive carcinoma. the length of the preinvasive
stage is on the order of 1 to 15 years.
Developmental Carcinoma in Situ

Compared with classic carcinoma in situ´;
{c cells more frequently lie singly than in arranged syncytial masses. When present in
aggregates, cells more often had a sheet-like rather than a syncytial arrangement.
admixture of dysplastic cells was found in the smears.
c
{c Average cell size was between the mean sizes for dysplastic cells and carcinoma
in situ cells.
{c Also, for the distribution of cell shapes, values proved to be between the values
found for dysplasias and those for carcinomas in situ.
{c Nuclear chromatin was predominantly finely granular and unevenly distributed.
{c The lesions usually showed a more orderly growth pattern and a relatively low
mitotic activity.
Cyy like cells found in proliferating reserve cells.
c The mean age at which this developmental cancer in situ was found antedated the
mean age of classic carcinoma in situ by 5 years.
³early recurrences´ of carcinoma in situ within
a year after hysterectomy in 0.9 of women who had a hysterectomy
after a diagnosis of carcinoma in situ.150 During subsequent
long-term follow-up, invasive squamous cell carcinomas
of the vaginal vault were found in 0. of patients. These figures
emphasize the importance of
c cytologic follow-up by vaginal vault smears in women who have had a
hysterectomy for a severe epithelial abnormality of the cervix is important due to
recurrence.
Co-occurrence of Dysplasia and Carcinoma in Situ
èc Differentiate as much as possible between severe dysplasia and carcinoma in situ
èc In routine diagnosis such a strictseparation is not very relevant.
èc Both changes are considered to be of a high potential for progression to an invasive
lesion, and clinical management is usually identical.
Dysplasia Carcinoma in situ
Epithelial stem cell origin Ectocervical Endocervical canal
Degree of maturation some -squamous cells in No sign of maturation
most superficial layers)
èc Approximately 80 of carcinomas in situ coexist with dysplasia, where

dysplasia lies distal from carcinoma in situ.
èc Both dysplasia and carcinoma in situ occur more frequently on the anterior lip of the
cervix -more frequently traumatized).
èc The radial extent of CIN on the portio epithelium is greatest in the population with
carcinoma in situ.
c
èc The size and distribution of carcinoma in situ on the exposed portion of the cervix
are more constant than in dysplasia.
èc Of patients with carcinoma in situ, 45 had only dysplasia on the exposed portion
of the cervix.
èc The hypothesis that dysplasia represents a younger -smaller and less extensive)
precursor of carcinoma in situ is supported by the colposcopic and cytologic
observation in the individual case.
èc The lesions are not biologically different, but a patient with a carcinoma in situ has a
lesion that has been present for a longer time and involves a larger area of the
cervix.
èc Our knowledge of the biologic behavior of carcinoma in situ is still incomplete; an
untreated lesion may develop into an invasive cancer, regress to a less severe lesion,
completely disappear, or persist for an indeterminate time.
èc Both dysplasia and carcinoma in situ occur in the area of the transformation zone.
Co-occurrence of Squamous and Columnar Intraepithelial Abnormalities
Vc the carcinogenic stimulus does not exert its action on an isolated cell that becomes
the stem cell of a malignant proliferation but on a larger area of the epithelium. This
may be the explanation for
1-c next to a severe lesion, changes of different, often lesser severity are found.
-c common multifocal occurrence of epithelial abnormalities.
Vc This field stimulus apparently influences :
1-c Squamous and squamous metaplastic epithelium
-c the columnar epithelium of the endocervical canal.
Vc The co-occurrence of abnormal columnar cell changes together with abnormalities
of the squamous and squamous metaplastic epithelium is becoming increasingly
frequent.
Vc The reduction in the incidence of squamous cell carcinoma of the uterine cervix and
mortality from cervical cancer is a result of cytological screening and the
subsequent detection and removal of precursor lesions.
Vc The diagnosis of cervical glandular cell lesions or combined squamoglandular cell
lesions is based on the same cytological principles.
Vc The increased prevalence of these atypical columnar cell changes may be due to:
1-c a new factor that also causes columnar cell abnormalities.
-c screeners¶ increased sensitivity to columnar cell changes, correlated with a growing
awareness of the significance of endocervical columnar cells as a quality parameter
for cervical smears.
c
Vc Glandular cell abnormalities were frequently overlooked or underestimated in the
cytological specimen due to
1-c it is less common than cervical squamous cell lesions.
-c many cytotechnologists and cytopathologists are focused on the cytological
characteristics of squamous cell lesions, whereas characteristics of glandular cell c
lesions -GCLs) are less familiar and therefore are likely to be overlooked in a
relatively high number of cases.
Vc in approximately 50 of severe GCLs, a coexisting squamous cell lesion was
present.
Vc cytotechnologists and cytopathologists must always consider the possibility that two
various cytologic, architectural, cellular, and nuclear characteristics proved useful in
diagnosing intraepithelial cervical GCLs and adenocarcinoma and in assessing the
severity of these lesions - ig. 8.9):
1-c pseudostratification,
-c cellular crowding,
-c glandlike structures,
4-c feathering,
5-c vacuolated cytoplasm, and
6-c nuclear and chromatin features.
Vc Cytological identification of cervical glandular cell abnormalities is important for
patients with coexisting squamous cell lesions, because the treatment of these
combined lesions differs from the treatment of pure squamous cell lesions - igs
8.9 to 8.97).
Vc Diagnosis of only a squamous cell abnormality may result in insufficient surgical
treatment. Even circular biopsy -shallow conization) may not reveal glandular
abnormalities, which typically are located more proximally in the endocervical
canal.
Vc Because the prognosis for patients with adenosquamous carcinoma or carcinoma
with glandular differentiation is said to be poorer than the prognosis for patients
with squamous cell carcinoma,every effort must be made to increase the reliability
of cytological diagnosis and the quality of cervical specimens, as cytological
screening is likely to remain for the foreseeable έϮψϨϣ future the most widely used
method for detecting cervical abnormalities -both squamous and glandular).
Vc More accurate identification of intraepithelial GCLs or combined squamoglandular
lesions of the cervix may eventually lead to a decrease in the incidence of cervical
adenocarcinoma, just as increases in diagnostic accuracy have led to decreases in
c
the incidence of squamous intraepithelial lesions and invasive squamous carcinoma
of the cervix.
Dysplasia and Carcinoma in Situ during Pregnancy
{c In general, the cellular features of dysplastic changes in pregnant women are
identical to the changes observed in nongravid women.
{c Dysplastic changes often remain undetected in view of the significantly larger
number of smears of unsatisfactory quality. Particularly during the first trimester of
pregnancy, smears may contain a large number of relatively small, immature,
atypical cells.
{c In general, dysplastic lesions during the first months of pregnancy tend to be
composed of relatively small ce lls, thus suggesting a severe abnormality. These
relatively immature dysplastic changes may lead to a dilemma: whether the patient
should undergo histologic evaluation.
{c In most instances, with progression of pregnancy, a reduction of the severity of a
dysplastic lesion occurs as about half of lesions to regress, one third to persist, and a
quarter to progress to a more severe abnormality after a variable period of time.
{c As a general rule, unless clinical symptoms suggest a severe lesion, routine
cytologic diagnosis should be avoided during the first trimester.
{c there is no evidence that dysplastic lesions and carcinoma in situ behave differently
during pregnancy.
{c The morphologic features of carcinoma in situ do not differ from those presented for
nongravid patients.
{c The growth rate of preinvasive epithelial changes is not greater during pregnancy.
{c Surgical procedures may induce over stimulation or may damage the cervix and thus
may interfere with the pregnancy.
{c It is advised to monitor the abnormality carefully during pregnancy, even in cases of
carcinoma in situ, and to postpone treatment of the epithelial change until after
childbirth.
{c It is advocated that surgical treatment be instituted only after cytologic
reconfirmation of the lesion, when normal menstrual cycling has resumed and
epithelial atrophy has been reversed.
{c In some of the cases, the epithelial abnormality disappears after childbirth, possibly
owing to the passage of the newborn through the cervical canal or because of a
change in hormonal influence on the cervical epithelium, potentially altering the
balance -or imbalance) between the host tissue and the abnormal epithelium.
c
Dysplasia and Carcinoma in Situ in Postmenopausal Patients
c Dysplasia and carcinoma in situ occurring during postme nopause are often difficult
to diagnose because of the lack of mature squamous and columnar cells in the
smears.
c Owing to the lack of estrogenic stimulation, cells remain rather small, often the size
of parabasal cells or relatively immature squamous metaplastic cells.
c Aggregates of small cells with densely staining nuclei are a common finding in
smears from women in postmenopause.
c Relative nuclear enlargement due to a reduced development of the cytoplasm, which
is in turn caused by a low estrogenic stimulus, may mimic the nucleocytoplasmic
ratio found in epithelial lesions - igs 8.98 and 8.99 ). These cells are often
erroneously diagnosed as dysplastic cells or cells consistent with carcinoma in situ.
c To avoid unnecessary biopsies, it is advisable to repeat the cytologic examination
after a short course of oral or local hormonal estrogenic medication. In the majority
of cases, the supposedly dysplastic change will have disappeared through
maturation of the epithelium under the estrogenic stimulus - ig. 8.100; see also ig.
8.18).
c Because abnormal epithelial cells are less sensitive to the maturation stimulus from
the estrogenic hormones, true abnormal cells can be recognized much more easily
between the now-matured surrounding epithelial cells - ig. 8.101).
c With this relatively simple procedure in cases of epithelial atrophy with
pseudoabnormalities, unnecessary biopsies can be avoided. In view of the higher
rate of complications in cases of surgical interventions involving atrophic tissues,
this must be considered an important benefit to these women.
c A strong association between epithelial abnormalities and atrophy was found in
women above 50 y. After correction of the estrogen deficiency:
1.c the lesion disappeared completely in one fifth of cases,
.c moderate-to-severe atypia was reduced to slight atypia in more than half of cases.
.c The estrogenic stimulus induced a marked increase in maturation in two thirds of
smears.
4.c The smears were easier to read because of a reduction in the admixture of
inflammatory cells and the degree of cytolysis of the cytoplasm of atrophic cells
resulting in a clear background against which truly abnormal cells stand out clearly.
c
Invasive Cancer of the Uterine Cervix
Epidemiology
c Worldwide, cancer of the cervix is the second most common cancer in women.
c In developing countries, this type of cancer even ranks first, whereas
c in developed countries it ranks tenth.
c In most developed countries, the frequency of cervical cancer and the mortality rate
for cervical cancer have declined since the 1950s.
c Cervical smears are important in the prevention of cancer of the cervix.
c Regular screening reduced the relative risk for invasive cancer in the screened
population.
Risk factors:
1-c Age :In recent years, an increase in the incidence of cervical cancer in younger
women has been suggested. This may well be an effect of more frequent
screening and screening in younger age groups, because mortality rates have not
-yet) shown an increase in these age groups. In some countries, ho wever, an
increase in mortality rates for cervical cancer in young women has been reported
since the late 1960s, suggesting the effect of the introduction of some new risk
factors in recent years, particularly among young women.Independently of her
age, a
-c Sexual activity, more specifically with the number of partners and with
age at first intercourse.
3-c other factors as long-term use of oral contraceptives, smoking, specific dietary
factors, and immunosuppression .
4-c the sexually transmitted agent that may be the main cause of cervical cancer
a.c herpes simplex virus type conclusive evidence of a causal role has never
been obtained.
b.c HPV is etiologically involved. Although laboratory studies provide evidence to this
effect, it will be very difficult to prove this hypothesis epidemiologically.
Microinvasive Carcinoma
ëc It is the earliest stage in the genesis of an invasive cancer recognized histologically.
ëc These cancers with limited extent have a very favorable prognosis. Because these
cancers occur several years before the average age of detection of frankly invasive
cancers, patients are often still younger than 40 years and request to have as
conservative a treatment as possible.
c
ëc Microinvasive carcinoma in its early stages is often found originati ng from an
overlying severe epithelial abnormality -CIN grade : severe dysplasia and
carcinoma in situ), but occasionally, particularly in more extensive lesions, invasion
seems to arise from a lesion of lesser severity. This, however, may be a
pseudodifferentiation in an originally severe lesion. This phenomenon may have
caused the confusion about the potential for progression of mild -to moderately
atypical epithelial lesions.
ëc Def.: in a microinvasive cancer, the depth of invasion, measured from the base of
the epithelium from which it develops, should not exceed 5 mm and the largest
diameter -lateral extent) should not exceed 7 mm.
ëc Vascular involvement should not alter the staging but should be specifically
recorded, because it may affect treatment decisions in the future.
ëc The depth of invasion should be measured from the basement membrane of the
neighboring noninvasive epithelium.
ëc Preclinical carcinoma of the cervix should include:
1-c minimal microscopically evident stromal invasion
-c small cancers of measurable size.
ëc Staging: Based on the histologic evaluation of the tissue removed, which should
include the entire lesion:
1-c stage IA:
a)c stage IA1 tumors, minute foci of invasion visible only
microscopically
b)c stage IA2 tumors, macroscopically measurable.
-c staged IB: Lesions of greater size
ëc it is impossible to estimate clinically whether a cancer of the cervix has extended to
the corpus, so extension to the corpus should be disregarded.
Histology
The diagnosis of microinvasive carcinoma should be made only on a histologic specimen
that contains the entire lesion. Punch biopsy samples taken under colposcopic control and
endocervical curettage specimens are inadequate to provide a reliable diagnosis of
microinvasion.
Histologically, two separate entities may be rec ognized:
Early stromal invasion; and
Microinvasive carcinoma.

c
Early Stromal Invasion
dc cell nests protrude from the basal layer of the overlying epithelium into the
surrounding stroma or single nests are located within 1 mm of the overlying
epithelium - ig. 8.10).
dc These changes are usually too small to be measured accurately and reproducibly.
dc The earliest sign of invasive growth is a well-circumscribed small nest of cells
³dropped´ from the severely abnormal, essentially noninvasive surface epithelium
into the stroma.
dc The cells composing seem better differentiated owing to a relatively large body of
eosinophilic staining cytoplasm, lower nucleocytoplasmic ratio in the invading cells
than in the cells of the epithelium of origin - ig . 8.10).
dc The invading body of cells is well demarcated and surrounded by a dense infiltrate
of lymphocytes and plasma cells, which characteristically leave a loose, edematous
clear zone free of inflammatory cells around the invading cell groups.
dc The increased amount of eosinophilic cytoplasm is probably not a sign of improved
differentiation but, on the contrary, a reflection of dedifferentiation enabling a cell
to break through the basement membrane and to proliferate despite the host¶s
immune response in the surrounding stroma.
dc This rather characteristic histologic profile usually enables a pathologist to
differentiate between extensions of the abnormal epithelium into invaginations,
noninvasive nests of abnormal surface epithelium due to tangential sect ioning, and
truly invasive cells in an early stromal invasion.
Microinvasive Carcinoma
c The depth of invasion in microinvasive carcinoma originally was determined to be
less than 5 mm.
c The prognosis of the disease is most clearly determined by the volume of the
tumor. Thus, the extent of invasion in microinvasion carcinoma should not be
measured in one direction only.
c Measurements should also encompass the spread of the lesion parallel to the surface
epithelium, analyzed in multiple parallel sections - ig . 8.104). This enables a
pathologist to get a fairly accurate impression of the volume of the tumor, which is
directly related to the chance of vascular invasion and thus to prognosis.
c Measurements should be made with an ocular micrometer calibrated for e ach
objective. A practical approach is to measure the diameter of field of vision for each
objective once with a stage micrometer and to relate these measurements to a
specimen under study.
c
c A diagnosis of a microinvasive cancer should not be made unless the entire
histologic specimen has been carefully examined. The presence of tumor tissue in
the resection margins of the specimen should be precluded in view of the high risk
of residual cancer in patients with conization specimens with tumor tissue present in
the resection margins of the cone.
c residual cancer was found in most patients with tumor in the resection margins of
the conization specimen. In about half of these patients, residual tumor growth in
the uterus was more extensive than in the cone.
c The risk of distant spread of a microinvasive carcinoma is related to:
1-c the depth of invasion,
-c the lateral extent of the lesion,
-c the lymphatic channel involvement.
c The single most important histologic parameter for prognostication of microinvasive
cancer is the extension of tumor growth into capillary like spaces -lymphatic
channels or microarterioles).
4-c the growth pattern of the lesion and the host¶s immune response to the
tumor are less important in the determination of prognosis.
c A diagnosis of invasion of capillary-like spaces should be supported by the presence
of an endothelial lining of these spaces and a continuous growth from the tumor into
such a space - ig. 8.105).
c NB: In many specimens, tumor cell nests are found in tissue spaces. These,
however, lack an endothelial lining; there is no evidence of a continuous growth
from the tumor into these spaces. They are the result of shrinkage of the stroma
during fixation.
c Some believes that true involvement of capillary-like spaces should exclude the
tumor from the category of microinvasive cancers, irrespective of the depth of
invasion.
c Although the results of many studies are conflicting, capillary-like space
involvement should be considered an important risk factor and warrants more
radical treatment.
Cytology
dc It is very difficult to interpret.
dc Some emphasize that a diagnosis of microinvasive carcinoma cannot be reliably
made from a cytologic specimen. However, some cytologic features are strongly
associated with a more advanced epitheli al abnormality than that of a CIN grade
type of lesion.

c
C ÷
- in syncytial aggregates - ig. 8.106).
-the number of abnormal cells is lower than in invasive cancer.
y
Nuclear chromatin is uniformly finely or coarsely granular and less often irregularly
distributed or opaque than in invasive cancer - ig. 8.107).
Nucleoli are usually found, but macronucleoli are infrequent - ig. 8.108).
DD:The most consistent nuclear feature associated with invasive growth is the
appearance of irregularly shaped nucleoli, together with a relative increase in the amount
of cytoplasm.
0d ÷÷ ÷
c It is less frequently found than in invasive cancer.
c the amount of tissue destruction is related to the depth of invasion and the invading
process.
c Cellular features are more reminiscent of either carcinoma in situ or frankly invasive
cancer:
{c cellular characteristics of microinvasive cancers with an epithe lial infiltration of
0.1 .0 mm to resemble those of carcinoma in situ and dysplasia,
{c Cellular features consistent with microinvasive cancer are most distinctive with a
depth of invasion between and mm.
{c microinvasion of .15.0 mm were more reminiscent of frankly invasive cancer.
Õey features of microinvasive squamous carcinoma
Round to oval cells arranged predominantly in syncytial aggregates;
Cyanophilic cytoplasm with relative increase in cytoplasmic volume;
Round to oval nuclei with considera ble size variation;
Nuclear chromatin fine to coarsely granular with uneven distribution;
Micronucleoli are typically present; macronucleoli are rare;
Tumor diathesis may be present, but typically less than in invasive carcinoma -dependent
on depth of invasion); and
N/C is lower than in carcinoma in situ.
y;
èc Many studies demonstrate that, the cytologic diagnosis of microinvasive carcinoma
can be made with high accuracy.
èc It is, however, advisable to mention the possibility of a microinvasive cancer rather
than to give such a diagnosis with certainty.
èc In general, in routine cytodiagnosis, making a firm diagnosis of a microinvasive
carcinoma should be avoided.
c
èc In addition to a diagnosis of an invasive cancer, the possibility that the process
might be microinvasive may be mentioned.
èc Such a diagnosis is based on very delicate differences between the characteristics of
carcinomas in situ and invasive cancers.
èc A suggestion of too high a precision would be misunderstood against the
background of the relatively high rate of false diagnoses, which unfortunately are
still being made and may potentially reduce clinical acceptance of diagnostic
cytopathology.
Invasive Cervical Cancer

{c Invasive carcinoma is defined as any lesion in which epithelial formations invade
the underlying stroma by infiltration or destruction.
Distribution of histologic types in invasive cancers of the cervix
Type Distribution
Squamous cell cancer
Nonkeratinizing .
Õeratinizing 9.1
Small cell cancer 10.9
Adenosquamous carcinoma 7.0
Adenocarcinoma 6.
Clear cell carcinoma 1.5
Adenocanthoma 0.8
Adenoid cystic carcinoma 0.
{c Õeratinizing and nonkeratinizing squamous cell cancer may originate from the
original nonkeratinizing stratified ectocervical squamous epithelium and from
metaplastic epithelium in the endocervical canal.
{c Small-cell carcinoma originates in undifferentiated precursor cells of the
endocervical columnar epithelium, which lack every differentiation into columnar or
squamous epithelium.
{c The group of small-cell cancers is probably not a homogeneous group, based on the
ultrastructural demonstration of neurosecretory granules in the cytoplasm of these
cells, suggested that part of these tumors were of neuroendocrine origin and
probably originated from amine precursor uptake and decarboxylation cells in the
cervix. This finding is supported by the demonstration of argentaffin -Õultchitsky)
cells in small-cell cancers of the cervix, which suggests a relationship with smallcell
cancers of the bronchus -extrapulmonary small -cell cancer).
c
{c Adenocarcinomas with the subtype of clear cell carcinoma originate from the
endocervical columnar epithelium, derived from the embryologic mullerian
epithelium. Adenocarcinomas are also found to originate from mesonephric duct
remnants, known as mesonephric carcinomas.
{c Adenocarcinomas with an admixture of a benign or a malignant squamous
component² adenoacanthoma and adenosquamous carcinoma²most likely
originate from undifferentiated precursor cells of the endocervical columnar
epithelium, with a dual development into columnar epithelium and squamous
epithelium.
Age at Detection
mean age around 50 years -see ig. 8.80).
Clinical Considerations
{c In its earliest stages, invasive cancer may not disturb the configuration of the cervix
and may remain undetected during palpation or even at colposcopic inspection.
{c In women age 55 years and older, invasive cervical cancer is almost always
diagnosed in a more advanced clinical stage. Because 9 of invasive cancers were
diagnosed in this age group, a considerable reduction in mortality could be realized
if these women were screened periodically.
Macroscopically , malignant cervical tumors can be divided into two categories.
1.c Exophytic growth, consisting of papillary excrescences or wart-like masses,
protrudes above the surface originating in the epithelium of the ectocervix or
the portio vaginalis.
.c Endophytic growth is a growth pattern most commonly found in tumors
originating proximally from the external os.
{c In squamous cell carcinoma, the most important prognostic factors are:
a)c the extent of the tumor,
b)c differentiation grade, and
c)c histologic type or subtype.
{c The extent of the neoplasm at the time of diagnosis is still the most important factor
in prognosis.
{c Women with lymph node involvement have only half the life expectancy of women
without distant spreading of the tumor.
{c Accurate determination of the extent of the tumor at the time of diagnosis is thus of
utmost importance.
{c The type of the tumor, the degree of differentiation, and the host¶s immune response
are of only secondary importance in the final outcome of the disease.
c
{c Cervical carcinoma may spread along the mucosal surface and by direct growth into
adjacent structures and along tissue spaces.
{c Distant spread occurs via the lymphatic system and less frequently via blood
vessels.
{c Local growth of the tumor is;
1.c upward into the body of the uterus or downward into the vagina.
.c horizontally, the tumor may grow into the wall of the bladder and the rectum
.c laterally, reaching the wall of the pelvis.
{c The extent -stage) of the disease is determined according to the IGO staging
system, based on finding from physical examination -Table 8.).
Table 8.3 000 Modification of IGO staging of carcinoma of the cervix uteri
Stage Description
0 Carcinoma in situ -preinvasive carcinoma).
I Carcinoma strictly confined to the cervix -extension to the corpus should be

disregarded).
IA Preclinical carcinomas of the cervix, i.e., those diagnosed only by microscopy.
IA1 Stromal invasion no greater than .0 mm in depth and

7.0 mm or less in horizontal spread.
IA Stromal invasion more than .0 mm and not more than
5.0 mm with a horizontal spread of 7.0 mm or less.
IB Clinically visible lesion confined to the cervix or microscopic lesion greater than
IA.
II Invasive carcinoma that extends beyond the cervix but has not reached either
lateral pelvic wall; involvement of the vagina is limited to the upper two-thirds.
III Invasive cervical carcinoma that extends to either lateral pelvic wall, or the lower
third of the vagina, or both.
IVA Invasive carcinoma that involves the urinary bladder or rectum or both, or extends
beyond the true pelvis.
V Distant metastasis
IGO: Staging classifications and clinical practice guidelines of gynecologic cancers by
IGO Committee on Gynecologic Oncology
c
{c Involvement of vascular structures by the primary tumor is related to the frequency
of lymph node involvement.
{c lymph nodes involved are the external iliac, obturator, and hypogastric nodes,
followed in order of frequency by the common iliac, parametrial, and paracervical
nodes.
Histology
«c Tumors composed of poorly differentiated cells are more aggressive than tumors
composed of well-differentiated cells.
«c Vrading : The most widely used grading system was based on the proportion of well
differentiated cells in the total cell population composing a tumor -Table 8.4).
Table 8.4 Grading system for malignant tumors
Percentage of differentiated cells Vrade
75100 I
5075 II
550 III
05 IV
«c In tumors of the uterine cervix, there was no counterpart for the grade I epidermoid
cancer of the skin and recommended using three grades with keratinization as the
decisive parameter for differentiation.
«c However, in squamous cell carcinomas of the cervix, signs of keratinization were
interpreted as a characteristic of differentiation. This may be correct in cases of
carcinomas originating in ckeratinizing epithelium. In the uterine cervix, with its
nonkeratinizing stratified squamous epithelium, keratinization should be regarded as
a sign of abnormal differentiation.
«c Õeratinized cells are not sensitive to radiation . This is the underlying cause of the
discrepancy between histologic grade of differentiation, which suggests a relatively
favorable prognosis for a patient, and the poor reaction of the tumor to radiotherapy.
«c Wentz and Reagan¶s Classification of squamous cell cancers of the cervix based
on ÷ ÷÷
«c Subclassification of the tumors was based on
1.c growth pattern,
.c cellular characteristics, and
c
.c stromal reaction at the site of infiltration.
«c Advantages of this grading system
1.c it permits a morphologic correlation between cytologic and tissue specimens and
.c it refers to the cells from which the malignant tumor was derived.
.c Based on the reaction to radiotherapy, this classification correlates better with the
biologic behavior of the neoplasms.
Prognosis:
type 5-year survival
large-cell nonkeratinizing 78.6
cancers
keratinizing cancers 47.8,
small-cell cancers 0
Cytology
C d
{c The cells are smaller than normal squamous cells.
{c Round and oval forms are more numerous than in dysplasia.
{c Elongated cells are common in invasive cancer,
{c many of them containing intracytoplasmic fibrils.
{c The configuration of a cell depends in part on :
1.c surface tension,
.c the viscosity of cytoplasm,
.c the mechanical action exerted by adjoining cells,
4.c the rigidity of the cell membrane, and
5.c the functional adaptation.
C ÷
{c in syncytial masses in which cells have indistinct boundaries. This aggregation
form is also a ³microbiopsy´ demonstrating altered cellular polarity.
{c Cytoplasmic eosinophilia is more often observed in the cells of invasive cancer.
y
{c The nuclear configuration is in part related to the shape of the cell. Invasive cancer
has the largest proportion of nonisodiametric nuclear forms.
{c Cytologic specimens do not always reflect underlying disease. This is particularly
important in regard to invasive cancer. In improperly made smears, the sampled
material may be composed almost exclusively of the debris covering the invasive
lesion owing to necrosis of the most superficial layer and may thus fail to reflect the
true nature of the disease.
c
{c Scattered abnormal cells may remain undetected during routine screening, leading
to a false-negative diagnosis. This is still not very well recognized.
{c Specimens of unsatisfactory quality because of admixture of debris, blood, and
leukocytes should be carefully rescreened by a second observer, and the cytologic
examination should be repeated shortly.

èc The mean nuclear area of tumor cells is more than twice the mean area of normal
squamous cells. This is significantly different from the larger mean nuclear area of
cells in dysplasia and carcinoma in situ. Cells in dysplasia have the highest absolute
nuclear size, but their relative nuclear area is relatively low. In general, the relative
nuclear area is larger in more primitive cells and smaller in mature cells.
Nonkeratinizing Cancer
Vc It invades with large masses that have round, well-demarcated, blunt borders and
that are separated by thick bands of stromal cells - ig. 8.109).
Vc The surrounding stroma usually contains a moderately cellular mononuclear
infiltrate.
Vc Epithelial pearl formation by definition is absent.
Vc Individual cell keratinization may occur.
Vc Light microscopically, it may be difficult to classify these tumors as squamous in
origin so the immunocytochemical demonstration of keratin 14 may be of
assistance. Õeratin 14 can be demonstrated only in keratinizing cells. In
nonkeratinizing cancers, positivity in scattered cells can often be demonstrated,even
when individual cell keratinization is not recognizable by light microscopy.
Vc A moderate number of mitoses.
Cytology:
{c Cells occur in syncytial aggregates with ill-defined cytoplasmic borders - ig.
8.110).
{c Owing to the often extensive necrosis of these neoplasms, cellular debris, blood
cells, and proteinaceous material cause a dirty background in the smear, which even
in the absence of diagnostic tumor cells should raise suspicion of a malignant
process - ig. 8.111).
{c Cells are round to oval, sometimes polygonal.
{c Moderate variation in size and shape is usually present.
{c Tumor cells having phagocytosed inflammatory cells or epithelial cells are
relatively frequent.
c
{c The cells have a relatively large body of cyanophilic cytoplasm and have large
round to-oval nuclei - ig. 8.11).
{c The nuclear chromatin is hyperchromatic, irregularly distributed, and usually
coarsely granular - ig. 8.11).
{c Nucleoli are frequently observed.
{c Macronucleoli are found in less-differentiated tumors and can be considered an
expression of the high proliferative activity of the tumor cells. Particularly in cases
of moderately to poorly differentiated nonkeratinizing squamous cell carcinomas,
cytologic distinction from a poorly differentiated adenocarcinoma may be difficult
DD: In adenocarcinomas ,
{c the cells are often aggregated as clusters with overlapping nuclei.
{c The nuclei are eccentrically located, and nuclear chromatin is only slightly to
moderately hyperchromatic and very irregularly distributed, leaving intranuclear
clear spaces - ig. 8.114).
{c Nuclear chromatin is often sedimented against the nuclear membrane, which then
becomes sharply outlined.
Õey features of nonkeratinizing squamous cell carcinoma
Round-to-oval cells predominantly arranged in syncytial aggregates;
Cyanophilic cytoplasm with relative increase in cytoplasmic volume;
Round-to-oval nuclei with considerable variation in size;
N/C is lower than in carcinoma in situ due to larger volume of cytoplasm;
Unevenly distributed, coarsely granular hyperchromatic nuclear chromatin;
Irregularly shaped micronucleoli are present, macronucleoli are frequently found; and
Possible association with unsatisfactory specimens due to tissue necrosis and bleeding.
Õeratinizing Cancer
èc are composed of irregular masses of cells sharply demarcated against the
surrounding stroma - ig. 8.115), infiltrating nests are irregular in shape and often
elongated - ig. 8.116). Blunt borders of infiltrating masses are less frequently seen.
èc Cytoplasmic keratinization of individual cells and formation of epithelial pearls are
characteristic features.
èc rom a practical standpoint, a single well -formed epithelial pearl includes a
neoplasm in the category of a keratinizing carcinoma.
èc Superficial hyperkeratosis and atypical parakeratosis may be present.
èc The surrounding stroma usually shows a mononuclear infiltrate of moderate density.
Typically, a small rim around the
c
èc infiltrating nests is free of inflammatory cells.
èc Squamous cell differentiation is conspicuous.
èc Mitotic activity may be variable and is low in those parts of the tumor with a
relatively large number of cells showing signs of cytoplasmic keratinization.
èc Necrosis isoften conspicuous.
Cytology:
ëc Singly, elongated, caudate, or bizarre cell forms - ig. 8.117).
ëc Admixture with cellular debris and blood cells due to their often exophytic growth,
is less frequently seen than with large-cell nonkeratinizing cancers.
ëc Cells have a large amount of eosinophilic cytoplasm, which often is abundant in the
large, bizarre cells - igs 8.118 and 8.119).
ëc Together with the presence of numerous large irregular cells, cytoplasmic
eosinophilia is characteristic of keratinizing cancer.
ëc Nuclei may be round to oval but more frequently are elongated or irregular.
ëc Bizarre nuclear forms may be present.
ëc Nuclear chromatin is hyperchromatic and coarsely granular.
ëc Nuclei with a very dense hyperchromatic ²opaque²chromatin are especially
frequent in highly keratinized cancers.
Õey features of keratinizing squamous cell carcinoma
Round-to-oval cells predominantly arranged in syncytial aggregates with indistinct cell
boundaries;
Singly lying cells with densely eosinophilic cytoplasm and bizarre shapes;
ibrillar cytoplasmic strands can be seen;
Cells in syncytia have cyanophilic cytoplasm;
Round-to-oval nuclei, with considerable variation in size;
Bizarre shaped and elongated nuclei;
N/C ratio is lower than in CIS due to larger volume of cytoplasm;
Unevenly distributed, coarsely granular densel y hyperchromatic nuclear chromatin; and
Micro- and macronucleoli are frequently found in cells in syncytia.
Verrucous Carcinoma
c It is an uncommon variant of keratinizing squamous cell carcinoma.
c This unusual, locally invasive, slow-growing tumor is characterized by its warty
appearance.
Histologically , the tumor is composed of papillary excrescences of well-differentiated,
only minimally atypical squamous cells, often with surface keratinization - ig. 8.10).
c
Invasive parts of the tumor lack the atypia characteristic of keratinizing squamous cell
carcinoma, and it may be difficult to prove frank invasion.
c In view of the very high recurrence rate of verrucous carcinoma, wide excision is
necessary.
c The reaction of the tumor to radiotherapy is doubtful
Cytology:
The cells from a verrucous carcinoma may not be indicative of a severe epithelial
abnormality, and cytologic diagnosis of the clinically overt lesion is often negative for
malignancy.
Adenosquamous Carcinoma
c has a malignant squamous component and a malignant adenomatous component
- ig. 8.11).
c The squamous component usually is of the nonkeratinizing or small-cell type.
Rarely a keratinizing squamous component may be found.
c The cytologic features of cells from the squamous cancer component and cells from
the adenocarcinomatous component are similar to those described for these
respective cancer types - ig. 8.1).
Cytology: both cell types can be found within the same cell cluster. This is in contrast to
the rare situation in the cervix when both a squamous cell carcinoma and a separate
adenocarcinoma occur.
Õey features of adenosquamous carcinoma
Cells in syncytial arrangement and singly lying cells of squamous cell type next to
glandular type cells in large dense clusters;
Cells have a predominantly cyanophilic cytoplasm with scattered cells showing
eosinophilic cytoplasm;
Round-to-oval nuclei, with considerable variation in size;
N/C high;
Unevenly distributed, coarsely granular, and densely hyperchromatic nuclear chromatin
in cells of squamous cell type;
Cells in clusters usually have less hyperchromatic nuclear chromatin;
Nucleoli are present but frequently obscured by hyperchromatic nuclear chromatin in
squamous type cells; and
Macronucleoli are frequent in glandular type cells.
c
Small-Cell Cancer
ëc Small-cell cancer is neuroendocrine derivation. They should therefore be grouped
together with the carcinoid tumors.
ëc In comparison with keratinizing and nonkeratinizing squamous cell cancer, small-
cell cancer usually has a more proximal location in the cervical canal. c
ëc Small-cell cancer grows rather diffusely in large masses separated by thin strands of
stromal cells - ig. 8.1).
ëc Boundaries with the surrounding stroma are often ill defined.
ëc Cells show a high variation in size.
ëc There is no evidence of individual cell keratinization or epithelial pearl formation.
ëc Mitoses usually are numerous.
ëc In some tumors, cells show a positive reaction to neuroendocrine markers.
Cytology:
{c Relatively small cells and large nuclei and scanty cyanophilic cytoplasm, causing a
high nucleocytoplasmic ratio - ig. 8.14).
{c Nuclei may be round to oval but more often are irregular and have a
hyperchromatic, coarsely granular chromatin.
{c Nucleoli are usually present but may be obscured by the dense chromatinic material.
Õey features of small cell carcinoma
Small round-to-oval cells predominantly arranged in syncytial aggregates;
Within the syncytia cells show great variation in size;
Cells have scant often indistinct cyanophilic cytoplasm;
Round-to-oval nuclei with considerable variation in size;
N/C high;
Unevenly distributed, coarsely granular, densely hyperchromatic chromatin;
Micronucleoli are present but frequently obscured by hyperchromatic nuclear chromatin.
Immunocytochemistry in Intraepithelial Neoplasia

and Invasive Cancer
Vc Immunocytochemistry predicts regressive or progressive behavior of cervical
lesions on direct wet cytological specimens such as liquid -based cytology- mild
short fixation in alcohols or acetone).
Vc The development of chain-specific monoclonal antibodies -mAbs) to individual
keratins allows the immunocytochemical distinction between reserve cells,
immature and mature squamous metaplasia, and normal ectocervical squamous and
c
endocervical columnar epithelium as well as between different types of epithelial
abnormalities -CIN grades 1, , and ).
Vc By using several monoclonal antibodies directed against different epitopes of the
same keratin polypeptide -e.g. different mAbs against keratin 18), it is possible to
detect structural alterations resulting from biologic activity or neoplastic
transformation.
Cytokeratins:
Vc The degree of differentiation in a squamous cell cancer can be determined by the
use of keratin 10 or 1 antibodies.
Vc Õeratin 10 is a marker of keratinization. It may be expressed in cells of the more
superficial layers of squamous epithelium, even when no signs of keratinization are
detectable light microscopically.
Vc Broadly cross-reacting mAbs give positive reactions in virtually all epithelial tissues
and primary and metastatic epithelial cancers, including squamous cell carcinomas
of different differentiation grades and small-cell anaplastic carcinomas.
Vc The antibodies to keratin 18 can, among others, recognize adenocarcinomas but do
not normally react with squamous cell carcinomas.
Vc Adenocarcinomas almost always are negative for keratins 5, 10, 1, and 16.
Vc Squamous cell carcinomas almost always are positive for keratins 5, 10, and 1.
Vc Expression of keratin 16 is restricted to keratinizing squamous cell carcinomas .
Vc Õeratin 7 mAbs in general gave no staining reaction with -keratinizing) squamous
epithelia. This antibody reacts with columnar cells in the cervix.
Vc Cytokeratins 5, 7, 8, 17, 18, and 19 in immature squamous metaplasia
Vc Changed pattern of keratin expression in mature squamousepithelium and mild
dysplasia - ig. 8.15).
Vc Similar pattern in invasive carcinoma as in mature squamous epithelium.
Vc In abnormal cervical epithelium, cytokeratins 10, 11, 1, and 16 are irregularly
distributed in CIN grade -patchy pattern of distribution of positivity i.e; areas of
positivity alternated with negative areas ). While no change in cytokeratin content
from normal epithelium through CIN grades 1 and , so an abrupt change occurred
at the time of development of the lesion morphologically described as CIN grade .
Vc CIN grade lesions in invaginations of the endocervical canal had a pattern
identical to lesions on the surface of thecanal.
Vc The staining pattern in CIN grade was comparable to that found in invasive
squamous cell carcinoma.
c
Vc Differences in the number of Langerhans cells might be correlated to differences in
the dysplastic processes, as well as to differences in host response, and thus could
potentially be an indicator of a tendency to regression or progression.
Vc During the transformation of reserve cells into immature squamous metaplasia, this
epithelium acquired keratins typical of the ectocervical squamous epithelium,
whereas keratins typical of reserve cells and columnar cells were lost. This change
continued during further differentiation into mature squamous metaplasia.
Vc Premalignant transformation resulted in a partial loss of the keratins typical of
squamous epithelium and acquisition of keratins of atypical simple epithelia.
Vc In the course of increasing epithelial atypia through grades 1 to of intraepithelial
neoplasia, keratins characteristic of simple epithelia appear in dysplastic lesions
- ig. 8.16).
Vc Dysplastic epithelium progressively lost its squamous keratin phenotype and
acquired keratin characteristics of simple epithelium - igs 8.17 and 8.18).
Vc Õeratins 8, 18, and 19 have been found in cervical squamous cell carcinomas as
well as in adenocarcinoma. The expression of these keratins in reserve cells might
indicate that these cells are the common progenitor cells with a dual differentiation
potential. The dual expression of squamous cell-type and columnar cell -type
keratins in immature squamous metaplasia seems to support this hypothesis.
Õi-67 and p16INÕ4a

c In cervical cytology and histology, two widely used cell cycle related oncoproteins
are Õi-67 and p16INÕ4a.
c These proteins are up-regulated in the dysplastic cervical epithelial cell through the
actions of high-risk HPV -for instance: HPV 16, 18, 1, , 45,51, 56, and 68).
c Infection with high-risk HPV is an early event in the multistep process of cervical
carcinogenesis.
c Because of integration of high-risk HPV in the host genome, the E region of the
HPV DNA is disrupted and the E6 and E7 viral proteins are expressed.
c E6 and E7 proteins interfere with two pathways of the host cell that are critical in
tightly regulating cell division: the pRb pathway and the p5 pathway.
c E6 disrupts the activities of p5, the ³guardian of the genome.´ This degradation of
p5 makes repair of DNA synthesis errors impossible.
c Enhanced expression of the E7 oncoprotein leads to inactivation of pRb, which
induces cell proliferation of the cervical dysplastic e pithelium.
c
c Both effects of HPV²genetic instability and hyperproliferation of the cervical
epithelium²may finally lead to an invasive phenotype or cervical cancer.
Õi-67:
{c The monoclonal antibody Mib1 recognizes a formalin fixation-resistant epitope on
the cell proliferation- associated Õi-67 antigen.
{c Õi-67 is expressed in dividing or proliferating cells and is normally expressed in
basal or suprabasal cells of the cervical epithelium.
{c Atrophic cells do not proliferate and can be distinguished from dysplastic and
neoplastic cells by loss of Õi-67 expression. This phenomenon can be used in the
evaluation of Pap smears of postmenopausal women that may be difficult to
interpret. Atrophic cell groups show no staining with Mib1, whereas dysplastic
-highly proliferative) cervical cells will stain strongly positive.
Cytomorphologically, these cell groups may not be differentiated easily. A simple
restaining procedure of the difficult Pap smear with Mib1 may aid in the diagnosis
and thus prevent an unnecessary es trogen treatment followed by a second Pap
smear.
{c The extent of Mib1 expression correlates very well with the grade of CIN in
histology - ig. 8.19) as well as with the severity of cytological abnormalities in
cytological specimens.
#$%&:
{c HPV E7 blocks pRb function and via a negative feedback-loop mechanism
p16INÕ4a will accumulate in the dysplastic cervical cell -nucleus and cytoplasm).
Overexpression of p16INÕ4a protein -p16) is considered to be a marker for
progression of CIN to cervical carcinoma.
{c In fact, the extent of p16 staining resembles the Mib1 expression in dysplastic
squamous epithelium as well as in atypical endocervical epithelium.
{c A good explanation for this phenomenon is given by the viral oncogenesis model.
When both types of epithelium around the cervical transformation zone become
infected with high-risk HPV, the viral oncoproteins will simultaneously induce
hyperproliferation -Mib1 positive) and p16 overexpression in both types of
epithelium - ig. 8.10).
{c As enhanced expression of p16 is highly associated with dysplastic and neoplastic
changes of the cervical epithelium, it has been demonstrated that p16 makes it easier
to recognize dysplastic cells on a cytological slide.
{c Positive nuclear and cytoplasmic staining in liquid-based cervical specimens had a
sensitivity for HSIL or worse of about 90100.
c
{c Specificity, however, is much lower since individual normal squamous metaplastic,
endometrial, and tubal metaplastic cells in a cytological specimen sometimes may
show some slight staining.
In conclusion, in histology as well as cytology, Mib1 and p16 are sensitive markers for
dysplastic squamous and atypical glandular cells of the cervix. However, up till now the
studies with Mib1 and p16 are performed on rather small and very selective series and are
clearly not representative for screening situations.
NB: Before these markers can be used in -automated) mass screening, criteria regarding
the extent of positivity and staining intensity that define real ³positive´ cases must be s et
up. It may even turn out that a combination of these two markers is better suited to triage
indistinct cervical abnormalities than high -risk HPV testing such as now being performed.
Moreover, if cytological slides contain positive cells with these two markers, it is always
possible to simultaneously judge the morphology of doubtful cells.
Efficacy of Cervical Cytology in the Detection

of Cervical Abnormalities
«c Mortality due to cervical cancer has declined significantly during the past decades
because of the widespread use of preventive cervical cytologic screening.
«c or the detection of cervical cancer, cytologic testing is most appropriate. Squamous
cell carcinoma is highly vulnerable to detection technology and therefore secondary
prevention. Highrisk groups have been defined, and cancer precursors -i.e. dysplasia
of the cervix and carcinoma in situ) have been described.
«c Criteria that define the suitability of cervical cancer for routine screening and
detectability by a reliable test that is easy to perform and acceptable to patients, a
prolonged preclinical phase, and the availability of effective therapy that is more
efficient and less of a burden to patients than treatment for a clinical cancer.
«c The purpose of screening cytologic samples is to identify amidst a multitude of
normal cells those cells consistent with a premalignant or malignant change.
«c The samples may also disclose functional characteristics of the cells or important
findings such as infections and infestations.
«c The detection system of a cytologic cervical smear examination leading to the
discovery and treatment of precancerous lesions and early cancer of the cervix has
been shown to beeffective in reducing the rate of morbidity and mor tality from
high-stage invasive cervical cancer in appropriately screened populations.
«c Ample evidence shows that the cervical smear has contributed in a remarkable
fashion to the prevention of invasive carcinomas of the uterine cervix.
c
«c After the implementation of well-organized screening programs, remarkable
reductions in the incidence and mortality rates were documented. However, there is
no evidence that the Papanicolaou test has succeeded in the complete eradication of
this theoretically preventable disease, thus emphasizing the importance of
identifying the potential failures of this detection system and of analyzing the
reasons for them.
«c Cytologic case finding may fail because of :
1.c Inadequate samples,
.c insufficient training,
.c insufficient time devoted to screening -excessive workload),
4.c inadequate clinical information,
5.c inadequate supervision of laboratory procedures,
6.c relatively high intraobserver and interobserver variability of cytologic
diagnoses,and
7.c inadequate follow-up procedures.
öc The cervical smear is a safe, easy, and inexpensive method for screening large
numbers of sexually active women.
öc When a cervical cytologic report states the presence of an epithelial abnormality, it
has a high rate of accuracy.
öc ³The cytologic screening of cervical specimens is a complex matter and, regardless
of its problems, has contributed in a tangible and statistically significant way to the
reduction of morbidity and mortality from carcinoma of the uterine cervix.´
öc It can be stated that the cervical smear test is perhaps the only effective screening
test known today.
öc To reduce the problem of false-negative diagnoses, quality control of the taking of
the cytologic sample and the cytologic diagnostic procedure is important.
öc To reduce the consequences of false-negative results, it may be advisable to make a
repeat smear 1 year after the initial smear. After two negative smears, a longer
interval of years or even 5 years seems justified.
öc The number of preclinical asymptomatic invasive cancers and preinvasive cancers
diagnosed depends largely on :
1.c the prevalence of these abnormalities in the population under study,
.c the sensitivity and specificity of the cytologic test, and
.c the efficacy of follow-up procedures.
c
c
c
G c
c c
c The conventional cervical Pap smear has several disadvantages:
1-c the occurrence of both false-negative and false-positive results caused by diagnostic
errors and poorly standardized sample taking and preparation.
-c the cells are unevenly distributed and cell overlapping makes interpretation difficult.
-c Cells can be obscured by mucus, blood, and inflammatory cells and
4-c cell fixation is often insufficient.
c The liquid-based cytology -LBC) or thin layer technique does not have these
disadvantages.
c Procedure:
1-c The physician samples the cells with a traditional device or cervical brush and
-c the cell material is rinsed into a vial with preservation solution rather than
smeared on a slide.
-c In the laboratory, a representative sample from the cell material in the vial is
obtained and subsequently transferred to a slide, resulting in a thin layer of
well-preserved non-obscured cells - ig. 8.11).
c Despite the considerably higher costs of liquid-based techniques, these advanced
methods of cell preparation may turn out to be cost -effective when the standardized
cell preparations result in a higher diagnostic accuracy.
c Claims have been made that screening time is reduced due to better recognition and
preservation of the cells and reduction of the total area to be screened.
c Cytotechnicians favor to look at thin-layer specimens as the clean and less obscured
pictures are much less stressing and laborious than conventional smears.
c Also, additional diagnostic procedures such as HPV testing, DNA- and RNA-based
analyses, and immunocytochemistry can be carried out without the need to take a
repeat smear since there is residual cell material left in the vial.
c inally, the thin layer of cells may facilitate automated prescreening.
èc Worldwide, different LBC procedures are in use. The two most widely used liquid-
based systems are:
1-c ThinPrep system -Hologic, Marlborough, MA) and
-c AutoCytePrep system -currently known as SurePath; BD-Tripath, Burlington,NC).
èc Both systems were approved for cervical screening programs by the US ood and
Drug Administration - DA)
èc In general, LBC specimens must contain a minimum of 5,000 well-preserved
squamous cells -conventional smears: 8,0001,000) before evaluation can be
³satisfactory.´
èc Also, like conventional smears, LBC specimens must contain :
c
1.c cells from the transformation zone -endocervical or squamous metaplastic
cells),
.c satisfactory statement, & quality that the transformation zone component is
present.
èc The overall quality and the morphological pattern of thin layer specimens are
somewhat different from that of conventional smears:
1.c The preservation of epithelial cells is well comparable for both thin-layer
techniques.
.c There are no air-drying artifacts and the cellular material is more concentrated
and evenly distributed within the circular area - ig. 8.1).
.c The background is clean and there are more single cells to evaluate because
of less obscuration by inflammatory cells or blood cells.
4.c Cell sheets and cells in a syncytium are still present, as in the case for
inflammatory cells. The latter are often attached to epithelial cells or
concentrated in small clusters.
5.c Cytomorphologically microorganisms, radiation changes, repair, ASCUS, and
LSIL are comparable to that of conventional smears.
6.c Tumor diathesis is preserved.
7.c Atrophy is characterized by a background of degenerative cellular debris with
dispersed atrophic cells.
8.c Normal endometrial cell groups are better preserved than in conventional
smears and present as well-preserved, small rounded, -dimensional groups
of which the nuclei show small chromocentra and chromatin clearing.
9.c Because of wet fixation the cells will round up and may exhibit more nuclear
and cytoplasmic detail - ig. 8.1).
10.cThe cells may appear smaller and it is necessary to evaluate hyperchromatic
small metaplastic cells carefully for nuclear atypia and look for normal
reference cells to avoid overdiagnosis.
11.cDysplastic cells frequently lie isolated, in contrast to the clustering seen in
conventional smears.
1.cHighly diagnostic for HSIL cells is the presence of -dimensional nuclear
structural abnormalities -³cerebriform´ indentations) clearly seen by
microfocusing the specimen - ig. 8.14).
c
uuality Control
The cytologic report should encompass the following items1,70,
74,751,14,18,75,76:
A statement about the adequacy of the specimen,
including an explanation of the problems encountered
for less than fully satisfactory specimens and a determination
of whether a repeat specimen is necessary;
A descriptive diagnosis comprising the presence a nd
character of any inflammatory changes, the expected
histopathologic change in the squamous or squamous
metaplastic cervical mucosa, and changes in columnar
cells from the endocervical mucosa or an abnormality
related to the endometrium; and
A recommendation for further action to be taken on
the basis of the cytologic diagnosis.
uuality control by the laboratory seems the best way to reduce
sampling and screening errors.1,14,18,75 Gay and associates
found that for all types of malignancy, the majority of errors were
due to poor sampling.77 They found an overall false-negative
rate of 0 for invasive processes. They further stated that if all
the errors made by laboratory personnel could be eliminated,
in their material the false-negative rate in the presence of malignancy
could have been reduced from 0 to 1, the latter value
simply due to inadequate cell samples. Reporting inadequate
smears is an important step in ensuring the quality of laboratory
performance. An adequate cytologic sample is a smear that discloses
abnormalities of epithelial cells from the uterine sample
and thus triggers further action.57 Such a sample includes a sufficient
number of cells representative of the area sampled, fixed
and stained in a manner that allows inter pretation.78
In an adequate cervical smear, endocervical columnar cells,
squamous metaplastic cells, and squamous cells should be
present. The cytopathologist should evaluate whether the specimen
submitted is of sufficient quality to enable an adequate
diagnosis. This evaluation encompasses the cellular composition
of the sample, the quality of the cellular material, and technical
aspects of the smear, such as staining, cellularity, admixture of
c
blood and inflammatory cells, and adequacy of the specimen in
relation to the clinical information. If the specimen is less than
optimal, the consulting cytopathologist has an obligation to

inform the referring physician of such a conclusion and the reasons
for it. A significantly lower number of epithelial abnorma lities
were diagnosed in smears without endocervical cells present
than in smears that did show endocervical cells. 70,7,18,58
In a cohort study, we showed that the absence of endocervical
cells could not be ascribed to a physiologic phenomenon but
was a result of inadequate sampling of the uterine cervix. 7 It is
generally assumed that obtaining a cervical smear is an easily
executed, clinically simple procedure. This is not true. In our
experience, well-trained paramedical sample -takers perform far
better than most physicians who are relatively untrained. 6 Taking
duplicate smears could possibly reduce the error, but this is
a very costly procedure when routinely practiced in large -scale
screening programs.79
Many variables influence the detection rate of abnormalities
in cervical smears, including the sampling technique used,
the preparation of the patient, the fixation and staining of the
smears, the accuracy of the screening, the daily workload, and
the interpretation of morphologic changes. All smear s should
be screened according to a strict laboratory protocol. We have
adopted the procedure that smears with diagnoses of even
minor abnormalities made by a cytotechnologist with shortterm
experience are always checked by a cytotechnologist with
long-term experience. A protocol for multiple screening by more
than one observer of specimens at high risk for a false diagnosis
should also be instituted. Included in this high -risk category are
smears from women in postmenopause, women with clinical
symptoms of irregular bleeding, and women with a previous
history of cancer.
Smears of unsatisfactory quality for cytologic diagnosis
should also be screened by more than one observer, because in
cases of severe epithelial lesions the proportion of unsatisfactory
smears is significantly higher.1,14,76
c
As a procedure for quality control, it is often advocated that
10 of smears initially judged to be negative be rescreened.
Considering that 10 of smears at most show an abnormality,
rescreening normal specimens is a very unrewarding and
time-consuming procedure. It may take several years before an
unreliable
observer is detected.118,14,18,184,71,7,80 Much more
effective in reducing the number of screening errors are quality -
promoting
procedures such as good supervision of daily workload
to avoid too large a volume to be screened per working
day; a screening protocol for multiple screening of selected specimens,
which because of anamnestic, clinical, or cytomorphologic
reasons are thought to be at high risk for a false diagnosis;
and good supervision and training of both cytotechnologists
and cytopathologists.11,1,14,18,76
The cytologic report should contain properly worded recommendations
for further patient evaluation.1,74,75,1,14,18 To be
able to provide proper recommendations, all clinical information
is essential to a cytopathologist. A clinician should take the
advice of a cytopathologist as a strong recommendation but
should institute a different treatment strategy when intercurrent
clinical information or special circumstances warrant this. 14
Review
A useful procedure for quality control is a review of previous
cytologic and histologic material. 14 The degree of abnormality
may differ between the cytologic sample and the subsequently
taken biopsy. Nevertheless, it is usually very possible to
determine the causes of discrepancies. Because cytologic diagnosis
is highly dependent on the observer¶s ability to refer the
cellular and nuclear changes to a complex histologic architecture
of the lesion, comparison between cytologic and histologic
characteristic is very instructive. With Õoss and Hicklin,
we consider a comparison of cytologic findings with histologic
findings and vice versa and with long-term follow-up of
patients one of the best metho ds of quality control.81
Inadequate sampling of the cervix can account for about
c
half of the false-negative cytologic diagnoses. Taking smears
should be avoided during the first 4 days of the menstrual
cycle. In women using oral contraceptives, the number of inadequate
or less reliable smears is significantly increased. In all
instances, the best collection time is from day 5 through day 14
of the menstrual cycle.6,8,8 The best smears submitted to our
laboratory were taken with a relatively recently d eveloped
ectocervical
brush -Cervex Brush; Rovers B.V., Oss, the Netherlands).
The percentage of smears containing endocervical
columnar cells was higher, and the number of unsatisfactory
smears was significantly lower than those of spatula -made
smears151,75 and combined spatula and endocervical brush
smears.84
Concluding Remarks
Worldwide, cancer of the cervix is the second most common
malignancy in women. In developing countries, this type of cancer
even ranks first in frequency, whereas in developed countries
it ranks as high as tenth. In most developed countries, the frequency
and the mortality rate for cervical cancer have declined
since the 1950s. Cervical smears have played an important role
in its prevention.
Many epidemiological and clinicopatho logical studies have
demonstrated that HPV is associated with the development of
intraepithelial and invasive cervical lesions, and the mechanisms
by which it affects the carcinogenic sequence are being
carefully elucidated.
Most reactions occurring in the cervix can be recognized on
the basis of cellular changes alone. The number of cells diagnostic
for a specific, benign proliferative reaction depends on the
extent of the epithelial change and the method used for collecting
the cells.
Carcinogenic changes in the uterine cervix are considered to
be part of a field effect neoplastic process. This means that the
carcinogenic stimulus does not exert its action on an isolated
cell that becomes the stem cell of a malignant proliferation, but
actions occur on a larger area of the epithelium. This may be the
c
explanation for the common observation that next to a severe
lesion, changes of different, often lesser degrees of dysplasia are
found. It also explains the common multifocal occurrence of
epithelial abnormalities.
The evolution of invasive squamous cell cancer involves a
number of stages with increasing intraepithelial abnormality
designated as dysplasia, carcinoma in situ, and microinvasive
carcinoma.
The morphologic variations that can be observed w hen
studying the spectrum of lesions directly associated with carcinoma
in situ suggest a common pathway in the development
of dysplasia and carcinoma in situ. The basic factor in
the mechanism of the genesis of carcinoma in situ is reserve
cell hyperplasia.
The stimulus that has induced a proliferation of reserve cells

as such also blocks the differentiation of these reserve cells into
immature and then mature squamous metaplastic cells.
Depending on the strength of the negative stimulus on the
ectocervical squamous basal cells and endocervical reserve cells,
and in a later stage, immature metaplastic cells, the ultimately
resulting epithelial lining cells have a more or less differentiated
appearance. This explains not only common morphologic
features
in the different variants of dysplasia and ultimately in
the most dedifferentiated intraepithelial variant, carcinoma in
situ, but also the extremely common co -occurrence of carcinoma
in situ and dysplastic changes of different severity.
It is well known that the majority of cervical epithelial abnormalities
regress to a less abnormal change after a variable time.
In this respect, it is justified to monitor these changes cytologically,
when the cytodiagnostic service is of high quality.
Although it is not usually possible to predict the malignant
potential of an epithelial abnormality -premalignant lesion) on
a purely morphologic basis, evidence suggests that mild dysplasias
are more prone to regress spontaneously, and conversely,
severe dysplasia and carcinoma in situ are more likely to persist
c
or progress.
Microinvasive carcinoma is the earliest stage in the genesis
of an invasive cancer that can be recognized cytologically and
histologically. The negative field stimulus described above
also apparently influences the columnar epithelium of the
endocervical canal. The co -occurrence of abnormal columnar
cell changes together with abnormalities of the squamous and
squamous metaplastic epithelium is becoming increasingly frequent.
The cytology report should consist of a concise description
of abnormal cellular findings in well-defined and generally
accepted terms, followed if appropriate by a prediction of the
histologic condition. It should also include a recommendation
for the further treatment of the patient. Where possible, the
classification
should relate to the biologic significance or potential
of the process.
The cytologic report should thus encompass the following
items:
A statement about the adequacy of the specimen,
including an explanation of the pr oblems encountered
for less than fully satisfactory specimens and a determination
of whether a repeat specimen is necessary;
A descriptive diagnosis comprising the presence and
character of any inflammatory changes, the expected
histopathologic change in the squamous or squamous
metaplastic cervical mucosa, and changes in columnar
cells from the endocervical mucosa or an abnormality
related to the endometrium; and
A recommendation for further action to be taken on
the basis of the cytologic diagnosis.
The reduction in the incidence of squamous cell carcinoma
of the uterine cervix and mortality from cervical cancer is a
result of cytological screening and the subsequent detection and
removal of precursor lesions. The diagnosis of cervical glandular
cell lesions or combined squamoglandular cell lesions is based
on the same cytological principles.
Diagnostic cytology of the uterine cervix is the most widespread
c
and best known application of cytology in clinical diagnosis
of diseases. Mortality due to cervica l cancer has declined
significantly during the past decades because of the widespread
use of preventive cervical cytologic screening.
Despite a relatively high proportion of incorrect diagnoses
in large-scale population-screening programs, cervical cytology
has been proven to be the most effective tool for the diagnosis of
cervical cancer, primarily because of the frequency of testing and
the long precancerous stages of the disease prior to development
of invasive carcinoma.

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Intraepithelial Neoplasia, and Invasive Cancer of the Uterine Cervix

Introduction Invasive Cancer of the Uterine Cervix

The Normal Uterine Cervix Epidemiology

Histology and Cytology Microinvasive Carcinoma

Benign Proliferative Reactions Invasive Cervical Cancer

Hyperkeratosis Efficacy of Cervical Cytology in the Detection of

Cervical Intraepithelial Neoplasia

The Normal Uterine Cervix

Immunocytochemistry of Normal Cervical Epithelium

Benign Proliferative Reactions

Inflammation-Associated Cellular Changes

èc Smears with signs of inflammation have:

Human Papillomavirus and Cervical Cancer

Condylomatous Lesions and Epithelial Abnormalities

Main different reporting systems for cervical cytological squamous epithelial

(intra)epithelial cell abnormalities :

Cervical Intraepithelial Neoplasia

Cervical Intraepithelial Abnormalities

Mild Dysplasia (CIN Vrade 1, Low-Vrade SIL)

Moderate Dysplasia (CIN Vrade 2, High-Vrade SIL)

Severe Dysplasia and Carcinoma In Situ (CIN Vrade 3, High-Vrade SIL)

Cellular Reactions Simulating Dysplasia

Developmental Carcinoma in Situ

èc Approximately 80 of carcinomas in situ coexist with dysplasia, where

Invasive Cervical Cancer

0 Carcinoma in situ -preinvasive carcinoma).

I Carcinoma strictly confined to the cervix -extension to the corpus should be

IA Preclinical carcinomas of the cervix, i.e., those diagnosed only by microscopy.

IA1 Stromal invasion no greater than .0 mm in depth and

Immunocytochemistry in Intraepithelial Neoplasia

Õi-67 and p16INÕ4a

Efficacy of Cervical Cytology in the Detection

optimal, the consulting cytopathologist has an obligation to

The stimulus that has induced a proliferation of reserve cells

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