Interpreting PAP Smears: Guidelines and Techniques

1. How to interpret a PAP smear 1 Soheir Mahfouz Ph.D

2. Good Management depends on Sound Diagnosis the principle goal of cervical smears is not to diagnose overt clinical cancer but to detect occult carcinomas &precancerous abnormalities that can lead to invasive cancer

3. Requirements for proper PAP smear interpretation & diagnosis • Proper sampling, handling & sending of specimen • Request sheet with relevant clinical data • Cytological diagnostic features • Unified reporting using Bethesda system • Confirmation of diagnosis by colposcopy & biopsy

4. Factors decreasing the diagnostic accuracy in Pap smears • Contaminants • Mislabeled or unlabeled slides • Inadequate clinical history • Inadequate sampling

5. Proper sampling, handling & sending of specimen Taking ,Handling and sending sample • Vaginal speculum: lubricate with water or saline to avoid specimen contamination • All traces of talc powder should be removed from gloves before touching instruments, patients or slides • It is also preferable not to wipe cervix before taking sample so as not to remove the cell -rich mucus layer • If a vaginal pool sample is taken prior douching should be avoided • Spread thinly & evenly • Immediate fixation with 95% ethanol minimum fixation 15 mins maximum 2 weeks or cytospray

6. The Request: Relevant Clinical data • Name age • Sample history: if repeat or follow up . If follow up must mention previous diagnosis & slide number • Name of referring clinician & contact number • Clinical information: • Complaint & Provisional diagnosis • Mention if patient is on hormones or has an IUD • Menstrual cycle phase at time of sampling & if pregnant or lactating • Any Clinical abnormalities that should be mentioned: • Postcoital / inter menstrual bleeding • Discharge if present : character • Apparently benign lesions resistant to treatment • Clinically suspicious lesions(leukoplakia or visible tumouron examination

7. SMEAR EXAMINATION When examining a smear the following should be taken into consideration • Smear background: clean or dirtyie fresh and old blood, degenerated cells, inflammatory cells, proteinaceous material from ruptured endocervical cells, organisms or contaminants. • Pattern of exfoliation: single- in sheets- clusters • Cell types present: maturity & size and which cell type is predominant • Nuclear features: size-chromatin distribution-nuclear membrane & nucleoli-N/C ratio

8. 1-Background Impression (LP) 1- Clean 2- Dirty 3- Organisms 4- Contaminants

9. Background1-Clean 2-Dirty Physiologic/Normal Dysplasia Malignant –tumour diathesis Infection /inflammation

10. 2-Background: Dirty-Inflammatory • PNLs ( physiologic –inflammation/infection) • Small histiocyte ( physiologic –inflammation/infection) • Lymphocytes : Follicular cervicitis/ lymphoma ( abnormal lymphocytes)

11. 2-Background Inflammatory Follicular cervicitis Lymphocytic tangle Small histiocytes Neutrophils

12. 3- Background: organisms • Doderlein bacilli/Lactobacilli • Clue cells G. Vaginalis • Fungal: Candida • Trichomonas

13. 3 – Background organisms Doderlein Gardnerella V Candida Trichomonas

14. 4- Background: contaminants • Epithelial aneucleatedsquamesfrom the perineum, vagina or hands of the technician • Pollenmay be confused with degenerated malignant cells of WDSCC keratinizing type, since they have an orangeophylic cytoplasm, but their nucleus although large is uniform and the cell has a transparent glassy capsule • Lubricantare irregular deep purple masses and should not be confused with mucus which is red or pink • Talcumis also deep purple or transparent, small angular structures with a central cross on polarization • Fungal contaminants and yeast forms may be filamentous or round dark blue-purple bodies • Crystals of sulphaafter treatment of vaginitis • Cells from male urogenital system as sperms, seminal vesicle cells which have little cytoplasm rich in lipofuschin granules and anisokaryoticnuclei • Cotton fibers/Pubic hair • Parasitesas toxoplasma pseudocyst, ascaris,entrobius and parts of pubic louse.

15. Common contaminants 3-TALC GRANULES & lubricant 1-Aneucleated squames 2- Conidia of a Dematiaceous fungus 6- Dust mite 5- Alternaria fungus 4- cotton fiber 7- Pollen

16. Important LP patterns • Single cell patterns • Orange cells /groups • Blue groups/sheets • Pink groups/sheets

17. 1.1-Single cell patterns ( Physiologic /Inflammatory ) • Exodus of endometrial cells during menses • Degenerated PNLs • Small histiocyte • Lymphocytic cervicitis • Small cell carcinoma • NHL

18. 1.1Endometrial cellsstromal glandular

19. 1.2,3,4-Background Inflammatory Follicular cervicitis Lymphocytic tangle What is the difference between inflammation & infection? Small histiocytes Neutrophils

20. 1.5&6 -Neoplastic Single cells Small cell carcinoma Lymphoma

21. L Patterns 2-Groups Orange cells /groups Rule out • Aneucleatedsquames • Benign pearl • Parakeratosis • Dyskeratosis with menopause & atrophy • Keratinization with inflammation , infection e.g. trichomonas& mature metaplasia • Keratinization with HPV Keratinizing dysplasia • Keratinizing SCC

22. 2.1,3,5- Patterns -Orange cells /groups Aneucl squames parakeratosis Inflammation & Keratnizing metaplasia Inflammation Tichomonas

23. 2.6- patterns -Orange cells /groups HPV

24. Patterns 2.4,6,7 Groups -Orange cells /groups Dyskeratotic cells in atrophy Kerat dysp SCC

25. Patterns 2.2,7 Groups -Orange cells /groups Benign pearl Malig pearl