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• Reactive change

oppure• More than reactive change ; to send for second

opinion

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Image 1 – Changes more than reactive: to send for a second opinionASC-US: cell with enlarged nucleus and small perinuclear halo; chromatin clumped: this changes are not sufficient to classify this cell as L-SIL, but a subsequent biopsy definitively demonstrated an extensive CIN 1. Image 2 - Changes more than reactive: to send for a second opinionL-SIL: dysplastic nuclei and abundant mature cytoplasm are consistent with mild dysplasia (LSIL): remember that it is the amount of cytoplasm and not the degree of nuclear atypia that determines the grade of a dysplastic lesion. Image 3 – Reactive changesRepair: squamous cells in flat monolayer sheet with maintenance of nuclear polarity and prominent nucleoli in most cells but still dispersed chromatin: among cells, many leukocytes.  Image 4 – Reactive changesThis was very difficult, too! A group of endocervical cells with slight increase in nuclei size, variation in size and shape of nuclei with prominent nucleoli, fine chromatin. This feature of chromatin may help you to recognize this image as reactive. Image 5 - Changes more than reactive: to send for a second opinionSquamous cell carcinoma: numerous isolated cells display nuclei with irregular membranes, uneven chromatin distribution, hyperchromasia, and irregular membranes. While the cells display all the features of HSIL, they also contain nucleoli, and markedly irregular distribution of chromatin. An associated tumor diathesis is often present, but is not pictured. It has been suggested that large numbers of isolated cells may be a clue as to the severity a squamous epithelial lesion.

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Image 6 - Changes more than reactive: to send for a second opinionAdenocarcinoma, endocervical: cluster of cells in a papillary fashion with large round or oval nuclei, irregular chromatin and prominent nucleoli. Cytoplasm is poorly defined and finely vacuolated. Bloody smear background. Prominent of macronucleoli and tumor diathesis are classic findings in adenocarcinoma of the endocervix.  Image 7 - Changes more than reactive: to send for a second opinionAtypical glandular cells (AGC): sheet of atypical cells of glandular type with enlarged nuclei and a regular chromatin pattern. Compare with normal columnar cells. Nucleoli are occasionally visible. Image 8 - Changes more than reactive: to send for a second opinionASC-US: binucleation and subtle koilocytosis are displayed in the absence of obvious nuclear changes; features are not supportive of an interpretation of LSIL. Image 9 - Changes more than reactive: to send for a second opinionL-SIL: in this case, there is also binucleation and really subtle koylocytosis, but the nuclear features of binucleated cells (marked hyperchromasia) are already consistent with a diagnosis slightly worse than previous case. Image 10 - Changes more than reactive: to send for a second opinionASC-US: cells with slight nuclear enlargement/ hyperchromasia and keratinized cytoplasm: these cells minimally exceed "typical parakeratosis".

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Image 11 – Reactive changesCellular changes consistent with Herpes simplex virus: the multinucleated squamous epithelial cell (top) shows degeneration of nuclei, whereas the multinucleated squamous cell (below center) shows the typical molded nuclei of HSV infection (“pomegranate seed” appearance). Faint nuclear inclusions are evident in this cell and in a mononucleate cell beneath. Nuclei have "ground glass" effect due to intranuclear viral particles and enhancement of the nuclear envelope caused by peripheral margination of the chromatin. Remember also that, in HSV infection, multinucleated cells are not always present. Image 12 - Changes more than reactive: to send for a second opinionAdenocarcinoma, endocervical: large group of abnormal cells with round to elongated hyperchromatic nuclei and granular chromatin. Note pseudostratified strips with feathering at the edges. Nuclear crowding and overlap are prominent. Smear background is bloody.

Image 13 – Reactive changes Repair: squamous cells in flat monolayer sheet with maintenance of nuclear polarity and a prominent nucleolus in almost every cell. Again, never forget that if marked anisonucleosis, irregularities in the chromatin distribution, or variation in size and shape of nucleoli are present, so-called "atypical repair", the changes should be categorized as atypical glandular cells (AGC) or atypical squamous cells (ASCUS).But not in this case…. Image 14 - Changes more than reactive: to send for a second opinionL-SIL: this fields shows almost two intermediate cells with increased N/C ratio and hyperchromatic nuclei. Image 15 - Changes more than reactive: to send for a second opinionSquamous cell carcinoma: keratinized cells with pleomorphism of size and shape. The nuclei also show marked variation in size and dense, opaque nuclear forms are seen in which chromatin may be difficult to discern (nuclear hyperchromatosis). However in other cells, the chromatin is irregularly distributed.

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Image 16 - Changes more than reactive: to send for a second opinionASC-US: a dyskeratotic cell, some parabasal cells and some intermediate cells with enlarged nucleus and slightly clumped chromatin. Image 17 - Changes more than reactive: to send for a second opinionAGC: sheet of atypical endocervical cells with enlarged nuclei and a regular chromatin pattern. Compare with normal columnar cells. Nucleoli are occasionally visible. Image 18 - Changes more than reactive: to send for a second opinionH-SIL: sheet of parabasal cells with highly hyperchromatic nuclei (chromatin distribution is not discernible). Image 19 - Changes more than reactive: to send for a second opinionL-SIL: basophilic and a few eosinophilic squamous cells with a perinuclear empty cavity surrounded by cytoplasmic thickening and with moderate nuclear enlargement: typical koilocytes. Image 20 – Reactive changes"Typical parakeratosis": a group of squamous cells with keratotic changes. Note plaque of parakeratotic cells with persistence of nuclei. The nuclei lack any evidence of increased staining and size, and have a normal outline.

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Image 21 - Changes more than reactive: to send for a second opinionASC-US: intermediate cells with a slightly increased N/C ratio, clumped chromatin but regular nuclear outline. Image 22 – Reactive changesAtrophy: sheets of uniform orderly parabasal cells are observed representing deep parabasal cells. Some nuclei show grooves, but chromatin pattern is fine. Image 23 - Changes more than reactive: to send for a second opinionH-SIL: sheet of parabasal cells with highly hyperchromatic nuclei; this image is quite similar to image 18.  Image 24 - Changes more than reactive: to send for a second opinionAGC: sheet of slightly atypical metaplastic or endocervical glandular cells with slightly enlarged nuclei (N/C ratio not much disturbed), with irregular outlines but homogenous chromatin pattern. Compare with normal counterparts.

Image 25 - Changes more than reactive: to send for a second opinionL-SIL: squamous cells with an enlarged nucleus, surrounded by an ill-defined clear halo, associated with parakeratotic cells.

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Image 26 - Changes more than reactive: to send for a second opinionSquamous cell carcinoma: tumor diathesis and lysed blood provide the background for numerous small, hyperchromatic malignant cells. Two large nuclei with coarsely granular chromatin and prominent nucleoli are consistent with squamous cell carcinoma.

Image 27 – Reactive changesFungal organisms morphologically consistent with Candida spp. In left image there are also abundant lactobacilli and intermediate squamous cells, many of which show cytolysis (bare nuclei with partial or complete stripping of cytoplasm). The nuclei are bland and well-preserved.Remember that in determining specimen adequacy, nuclear preservation and visualization are of key importance, and changes such as cytolysis and partial obscuring of cytoplasmic detail may not necessarily interfere with specimen evaluation. Abundant cytolysis(>~50%) may be mentioned as a quality indicator, but most such specimens do not qualify as unsatisfactory unless nearly all of the nuclei are devoid of cytoplasm.Note also, in right image, apart from small, uniform ,round budding yeast forms, the capsule with the yeast in the center giving a "halo appearance". Image 28 - Changes more than reactive: to send for a second opinionEndocervical adenocarcinoma: more or less cohesive malignant columnar cells next to a less (whatever malignant) atypical cell group. Image 29 - Changes more than reactive: to send for a second opinionASC-US: it is often very difficult to distinguish an “undetermined significance” lesion from an L-SIL: this case falls in ASC-US category only because the outlines of nucleus are very regular, and because the thin, clear halo around them is obviously reactive.

Image 30 – Reactive changesPseudokoilocytes: intermediate and superficial cells with basophilic or eosinophilic cytoplasm, with complete cytoplasmic clearing without nuclear atypia. Artefact!!

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Fine del test

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Fine del test

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