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APPLICATION OF EXFOLIATIVE

CYTOLOGY IN OBSTETRICS &


GYNAECOLOGY

DR. E.K. OKAGUA


UPTH
INTRODUCTION
 Exfoliative cytology is defined by the Morsby’s
medical encyclopedia as the microscopic
examination of dead cells for diagnosis.
 Epithelial cells of the body undergo a constant
process of maturation/death/regeneration, and
cells that die slough off or exfoliate.
 Four decades ago, Papanicolaou at the Cornell
University Medical College laboratories initiated
the examination of exfoliative material from the
cervicovaginal area that would be valuable as a
screening test for carcinoma of the cervix
 At the present time, cervical cytology is
considered to be the only way to reduce cervical
cancer incidence.
Griechische Wissenschaftler

George N. Papanicolaou was a Greek physician and anatomist in the United States
(1883 - 1962).
SAMPLING TECHNIQUES
 Natural exfoliation – urine, sputum
 Cervical PAP smear
1. Ayres spatula
2. Aylesbury device
3. Cytobrush + extended tip device. One-day
training workshop required.
 Vaginal smear
 Endometrial aspiration cytology
 Smear of vulva lesions
 Fine needle aspiration cytology +/- imaging
 Peritoneal washings
 Buccal smear
USES OF THE PAP SMEAR
 Detection of occult pathologic
abnormalities of the uterine cervix in
asymptomatic women
 Detection of recurrence of known
pathologic abnormalities of the uterine
cervix
 Evaluation of a suspected hormonal
abnormality
 Monitoring of hormonal therapy
PATHOLOGIC ABNORMALITIES
OF THE CERVIX ON PAP SMEAR
 Pre-malignant and pre-invasive malignant conditions
of the cervix

 Infections such as:


 Actinomyces israeli seen with IUCD users
 Lactobacillus species which is normally present in the secretory
phase,
 Gardenerella vaginalis a sexually transmitted coccobacillus,
 Chlamydia trachomatis a sexually transmitted bacterial pathogen
that can be transmitted from the mothers cervix to the conjunctiva of
her child,
 Candida albicans,
 Torulopsis glabrata,
 Trichomonas vaginalis classically presents as a profuse pungent
malodorous vaginal discharge and puritis and is associated with the
condition called strawberry cervix. Presentation my be subclinical or
asymptomatic,
 Enteroaemoba gingivalis,
 Enterobius vermicularis,
 Herpes simplex virus – The virus is not seen but there cytopathic
effects are seen e.g. cell fusion, intranuclear inclusions, nuclear
INTERPRETATION OF
Result
RESULTS
Action Taken
Negative (Normal) None. Repeat in one
Inflammation year.
(infection/rxn) Treat then repeat
Mild Dysplasia Repeat Pap smear in 6
smear
months.
Moderate Dysplasia Colposcopy
Severe Dysplasia Colposcopy with or
without cone biopsy.
Class V - Cancer cells Several types of
surgical techniques are
used depending upon
EFFECTIVENESS OF CERVICAL
SCREENING % NUMBER
SCREENING SCHEDULE
REDUCTIO OF
N IN RISK SMEARS
TAKEN
Every 10 years age 25-64 64% 5
Every 5 years age 20-64 83.8% 9
Every 5 years age 25-64 81.8% 8
Every 5 years age 35-64 69.6% 6
Every 3 years age 20-64 91.2% 15
Every 3 years age 25-64 89.8% 13
Every 3 years age 35-64 77.6% 10

Every year age 20-64


93.3% 45
PAP SMEAR PROCEDURE
 Obtain informed consent
 Request form should include biodata,
obs/ gynae history and details of
prior abnormal smears
 Time test for second half of cycle
 Instruct patient to avoid intercourse/
douching 24 hours prior to test
 Sample is collected by the chosen
spatula after exposing the cervix and
including the squamou-columnar
junction of the cervix
PAP SMEAR PROCEDURE
(cont)
 The material is evenly spread on a glass slide
 Smears are immediately fixed in alcohol
solution
 Smears are thereafter placed in distilled
water
 Stain for 2 - 3 minutes in Harris’ or Mayer’s
Hematoxylin. This stains the nucleus.
 The cytoplasm is thereafter stained with OG6
or EA50.
 Smears which are considered abnormal by
the bioscientist are re-screened and reported
by a consultant cytopathologist
 All negative smears undergo an internal
quality assurance check, called rapid
MODIFICATIONS OF
PROCESSING METHODS FOR
PAP SMEAR
 Liquid based cytology - or thin layer
cytology, is a technique of preparing a monolayer
of cells on a glass slide. The technique involves
suspending the sample in a solution that is both
mucolytic and haemolytic. The sample is
concentrated either by centrifugation or by
filtration, in the former method a monolayer of
cells sediments onto the slide, in the filtration
method a monolayer of cells is pressed onto the
slide from the filter.
 Automated devices
ADVANTAGES OF LIQUID BASED
CYTOLOGY
 Clean background
 Excellent fixation
 Well defined nuclear detail
 Instant preservation with no air drying artefact
 Removal of blood and mucus
 Increased productivity
 Standardisation of collection and laboratory techniques
 Reduction in unsatisfactory as well as low-grade abnormality
rates

 Ability to use sample for other techniques such as HPV typing,


immunocytochemistry or DNA probes.
 Reduction in costs of women unnecessarily referred for
colposcopic assessment and treatment.
DISADVANTAGES OF LIQUID BASED
CYTOLOGY
 Training needed for smear takers
 Lengthy laboratory preparation time
 Training required to operate equipment
 Training required to interpret the smears
 Morphology may be different from conventional
preparations
 Cost and storage of reagents

 Loss of existing screener skills in interpreting


conventional smears
 Loss of ability for future staff to develop skills in
AUTOMATED DEVICES FOR
INTERPRETING CERVICAL SMEARS
GUIDELINES OF THE INTERNATIONAL ACADEMY OF CYTOLOGY task
force, 1997

 100% specificity and sensitivity


 The professional in charge of a clinical laboratory
should continue to bear medical responsibility for
diagnostic decisions made by machines.
 Automation should not lead to a reduction in
standards nor expose the patient to any increased
risk.
 Supervisory personnel should continue a visual
quality control on a percentage of slides diagnosed as
normal, and
 recognition should be made that human expert
opinion represents the gold standard.
 The setting of performance criteria should remain the
responsibility of the regulatory authorities, and not
the manufacturers, and
 the professional cytology community should
participate in the development of procedures that
VAGINAL SMEARS & HORMONAL ABNORMALITY
Examination of vaginal smears for hormonal assessment can be
done with the Papanicolaou stains; rapid Schorr method; other
rapid suparvital stains; Use of phase microscopy in addition
reveals bacterial flora.
Cells demonstrated include:
 Superficial squamous cells are shed from a fully
mature squamous epithelium that has developed its full thickness
under the influence of oestrogen and will be most numerous at the
middle of the menstrual cycle. The cells stain pink with the
Papanicolaou stain, are angular outline, 40-60 micrometres in
diameter, and contain a shrunken hyperchromatic pyknotic nucleus.
Avitaminosis A & C can mimic changes similar to oestrogenic effect.
 Intermediate cells are shed from the surface of a semi-
mature epithelia that shows a diminished response to oestrogen or the
effects of progesterone and are commonly seen at the latter stages of
the menstrual cycle, they are 30-60 micrometres in diameter, contain
glycogen and stain blue/green with the Papanicolaou stain and contain
a clearly defined round or oval vesicular nucleus 8 micrometres in
diameter. Doderleins bacilli destroys these cells preventing maturation
to superficial cells.
 Parabasal and basal cells are seen in the absence of
either oestrogen or progesterone, and are found in pre pubertal
smears, post-menopausal smears or post partum smears. Also seen in
anorexia nervosa. The cells are small, 15 -20 micrometres in diameter,
ENDOCRINOPATHIES ON VAGINAL
 SMEARS
PRIMARY AMENORRHEA
 Gonadal Dysgenesis: In Turner’s syndrome, the smear is atrophic (cf
atypical dysgenesis), and in 80% of cases, sex chromatin (SC) body is -ve (cf
mosacism).
 Pituitary Infantilism: The smear is atrophic/intermediately proliferative.
SC +ve.
 Ovarian Eunuchoidism: The smear is atrophic. SC +ve.
 Testicular Femininization Synd.: The smear is proliferative, but SC
is -ve.
 Simple Congenital Absence of Uterus: The smear shows a normal
cyclic pattern. SC is +ve.
 Congenital Adrenal Hyperplasia: SC is +ve. The smear is atrophic or
intermediate proliferative.

 PRECOCIOUS PUBERTY SYNDROME


 Constitutional or Idiopathic: The smear is proliferative and may show
cycling.
 Lesions of CNS: The degree of proliferation varies.
 Granulosa & Theca Cell Ovarian Tumors: The smear is highly
proliferative.

 2o AMENORREA of HYPOTHALAMIC ORIGIN


 Psychogenic: Smears vary. The degree of estrogen effect is a guide to the
ENDOCRINOPATHIES ON VAGINAL
 SMEARS
Syndromes of Oligomenorrhea
SMEARS
and Hirsutism
 Stein-Leventhal syndrome: The proliferation of the smear varies from
intermediate to good. Large parabasal and intermediate cells of the navicular
type may be present.
 Adrenogenital syndrome: The smear may vary from atrophic to small
intermediate cell proliferation.
 Cushing’s syndrome: Generally, cell proliferation is intermediate.
 Masculinizing tumors of the ovary: Generally, the smear is atrophic.
 Genetic: The smear is proliferative and may be cyclic.

 Syndromes of Amenorrhea and Galactorrhea


 Chiari-Frommel syndrome. Typically, the smear is markedly atrophic.
 Pituitary tumors and CNS lesions (Forbes-Albright syndrome): The smear
varies.
 Del Castillo’s syndrome (nonpuerperal, dysfunctional): Usually, small
intermediate cells predominate.
 Pseudocyesis: Proliferation often with progestational characteristics.

 Menopausal Syndrome
 Great individual variation. Early in the climacteric, the smear may show high
proliferation, but no cycling. In some cases, atrophic changes may occur
abruptly, whereas in others, varying degrees of proliferation may be evident for
years, with a gradual shift in the maturation index to the left.
FINE NEEDLE ASPIRATION
CYTOLOGY
This is frequently used to provide a rapid diagnosis with or without the
use of imaging from ascitic fluid, ovarian tumours, lymph nodes, vulva
cysts etc.
Advantages of FNA over open surgical biopsy
 Diagnosis with a simple, cheaper, outpatient procedure

 Avoids biopsy in some cases and may allow treatment of cancers at a


planned surgery
 Surgical team and theatre time not required
 Avoids frozen section
 Reduces patient uncertainty and anxiety
 Low complication rate.
Disadvantages of FNA over open surgical biopsy
 Errors in diagnosis may lead to over treatment or delay in making the
correct diagnosis
 Occasional complications such as bleeding or pneumothorax
 Requires skilled personnel to take the sample
ASPIRATION NEEDLE &
SYRINGE
OTHER APPLICATIONS OF
CYTOLOGY IN
OBSTETRICS/GYNECOLOGY
 Cytology of serous fluid – Most exudates
are metastatic and without good clinical
information it is not possible to ascertain the
primary site by cytology.
 Cytology of peritoneal washings
important for staging ovarian & endometrial
malignancies
 Cytology of nipple discharge for diagnosis
of breast malignancy
 Exfoliative vaginal cytology with cervical
mucus studies is a dependable non-invasive
method for assessment of ovulation.
Endometrial Cytology is however required
for conclusion.
 Vulva cytology for vulva dystrophies,

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