Welcome Glandular workshop 29 th May 2008

1. Welcome Glandular workshop 29th May 2008

2. Glandular Cytology in the BD SurePath® Liquid-based Pap Test Advanced Customer Training And Education BD Diagnostics, Diagnostic Systems – TriPath Anneke van Driel-Kulker Ph.D. Erembodegem, 29-30 May 2008

3. Objectives • Understand the spectrum of normal glandular cells encountered in SurePath liquid-based preparations • Identify morphologic changes seen in glandular lesions of endocervical and endometrial origin. • Review common pitfalls in glandular cytology – tubal metaplasia and lower uterine segment sampling

4. SPECIMEN COLLECTION AND HANDLING

5. Cell Transfer After Sample Collection • Detach device head(s) and place into BD SurePath™vial • 100% of collected sample goes into BD SurePath™vial • Device head(s) remain in BD SurePath™vial throughout entire slide preparation process • 25% ethanol BD PrepStain™ System Product Insert — Doc 779-10002-02 Rev C BD SurePath™ Collection Product Insert — Doc. No. 779-10001-02 Rev C

6. “The Cell Enrichment Process” First centrifugation 2 min @ 200 rcf Second centrifugation 10 min @ 800 rcf Before Cell Enrichment After Cell Enrichment Vortex Mix and Aspirate ≈ 8 ml Layer sample solution over density gradient Photos compliments of Dr. Dugald Taylor Operator’s Manual – PrepStain slide Processor – 780-06181-00 Rev B

7. Slide Preparation and Staining Re-suspend cell pellet Transfer to settling chamber Stain or Prep only 01-554

8. Normal/Reactive Endocervical Cells

9. Normal endocervical cells

10. Reactive endocervical cells/endocervical repair

11. Reactive endocervical cells/endocervical repair

12. Endocervical Cell Abnormalities: Atypical Glandular Cells Adenocarcinoma in-situ Endocervical Adenocarcinoma

13. AIS Atypical endocervical cells

14. AIS

16. Adenocarcinoma in-situ L

17. AIS Adenocarcinoma in-situ

18. Adenocarcinoma in-situ

19. Adenocarcinoma in-situ

20. AIS Adenocarcinoma in-situ

21. Adenocarcinoma in-situ SurePath™ liquid-based Pap test

22. Adenocarcinoma in-situ • Cells occur in hyperchromatic crowded groups, strips, and rosettes with loss of honeycomb pattern • Palisading nuclei with overlap and pseudostratification common • Feathering still occurs, but may be less conspicuous • Single cells more common • Enlarged, variably sized oval or elongated nuclei – nucleoli may be present • Nuclear hyperchromasia with evenly distributed, moderate to coarse “Peppery” chromatin • Nuclear/cytoplasmic ratios increased • Mitotic figures and apoptotic bodies may be seen • Clean background • May have co-existing squamous lesion present

23. Endocervical adenocarcinoma

24. Endocervical adenocarcinoma

25. Endocervical adenocarcinoma Single cells, two-dimensional sheets, or three-dimensional clusters Granular or vacuolated cytoplasm Stratified and palisading nuclear arrangement Enlarged, crowded nuclei with moderate to marked anisonucleosis Fine to coarse, irregularly distributed chromatin, parachromatin clearing and nuclear membrane irregularities Presence of nucleoli and tumor diathesis May have co-existing squamous lesion present

26. Common Pitfalls: Tubal Metaplasia and Lower Uterine Segment Sampling

27. Tubal metaplasia

28. Tubal metaplasia

29. Tubal metaplasia

30. Tubal Metaplasia: Crowded, honeycombed sheets and strips Nuclei are round to oval and may be enlarged, hyperchromatic, and pseudostratified Finely granular, evenly distributed chromatin Presence of cilia most helpful criterion Clean Background

31. Lower uterine segment sampling

32. Lower uterine segment sampling

33. Adenocarcinoma in-situ Adenocarcinoma in-situ Lower uterine segment sampling

34. When in doubt: • Carefully check clinical data • recent pregnancy? • patient wears IUD? • recent conisation? • Presence of stromal cells…..be aware of directly sampled endometrial cells. • Presence of cilia….tubal metaplasia.

35. Endocervical Lesions vs. High Grade SIL Involving Gland Spaces

36. Carcinoma in-situ involving endocervical glands

37. High Grade SIL Involving Gland Spaces • Peripheral pallisading of nuclei, giving the appearance of glandular differentiation • Nucleoli may be present • Nuclei tend to flatten at the periphery of the cluster, creating a smooth border • Loss of central polarity and piling • Definitive glandular features are absent (pseudostratified strips, rosettes)

38. Normal Endometrial Cells

39. Normal endometrial cells “Exodus”

40. Normal endometrial cells

41. Deep stromal cells

42. Atrophy, bare nuclei

43. Endometrial Abnormalities • Atypical Endometrial Cells • Endometrial Adenocarcinoma

44. Atypical endometrial cells: biopsy – Grade II endometrial adenocarcinoma

45. Endometrial adenocarcinoma

46. Endometrial adenocarcinoma – papillary serous

47. Atypical endometrial cells – IUD changes Atypical endometrial cells – IUD changes

48. Endometrial Adenocarcinoma 3-Dimensional groups with scalloped borders, papillary configurations, and single cells Variation in nuclear size; nuclei become larger with increasing tumor grade Nucleoli may be small to prominent and become larger with increasing tumor grade Nuclear hyperchromasia, irregular chromatin distribution and clearing Intracytoplasmic neutrophils and vacuoles common Cleaner background – tumor diathesis may be less prominent

49. Importance of clinical data • 90% of endometrium cancers is post menopausal and cause bleeding. • Almost all endometroid cancers produce estrogen and therefore squamous cells are well matured. • Endometrium cells in smears from highly differentiated adenocarcinoma of the endometrium can be cytomorphologically normal. • IUD can cause severe cytomorphological changes to the endometrium cells: irregularity and hyperchromasia of nuclei, macronucleoli.

50. Rare !! • Glandular abnormalities constitute <2% of all abnormalities in cervical cytology • Glandular lesions are the most interesting AND the most difficult of all cervical cytology • Experience with LBC in combination with sampling device is needed to correctly interpret atypical glandular cells.