Bethesda 2001

Ma. Minda Luz M. Manuguid, M.D.

 Slide prep (Conventional)

• 1 - Smearing of the exocervical sample with a wooden

spatula (Ayre's spatula). Some may have a longer bifid
extremity for a better endocervical sampling.
• 2 - Smearing of the endocervical sample taken with the
thinner extremity of the wooden spatula.
• 3 - Spray fixation: immediate, during a few seconds,
with a spray/slide distance around 20 cm.
 Liquid-based prep

1 2 3 4

• 1 - Different types of brushes allowing to collect cells from the

ectocervix and endocervix. These brushes can be used for
conventional smears instead of the Ayre’s spatula. They are
mandatory for liquid based preparation.
• 2 - The brush is removed and deposited in the liquid medium.
• 3 - Cell suspension homogenisation.
• 4 - Setting of the cytocentrifugation device
 Liquid-based prep

1 2 3 4

• 1 - Different types of brushes allowing to collect cells from the

ectocervix and endocervix. These brushes can be used for
conventional smears instead of the Ayre’s spatula. They are
mandatory for liquid based preparation.
• 2 - The brush is removed and deposited in the liquid medium.
• 3 - Cell suspension homogenisation.
• 4 - Setting of the cytocentrifugation device
Liquid based (thin) prep
• Head of spatula, where cells are lodged, is
broken off into small glass vial containing
preservative fluid, or rinsed directly into
preservative fluid
• Sample is sent to lab, then spun and
treated to remove mucus, pus or other
obscuring material
• Random sample of remaining cells is
taken and deposited onto a slide
• Reduces number of inadequate smears
and need for repeat smears
• Thin-Prep appears to be superior to
convention Pap test in detecting SIL
CytoLayer Liquid Cytology
 Papanicoulaou staining
• 70% Ethanol 2 min
• Water 2 min
• Harris Hematoxylin 4 min
• HCl 0.05% 1min 30sec / Water 5 min
• 95% Ethanol 2 min
• Orange G 3 min
• 95% ethanol 2 min
• EA 50 4 min
• 95% ethanol 2 min
• Absolute Ethanol at least 2 min, 2 changes
Bethesda 2001 cervicovaginal cytology
reporting
• Specimen type:
 Conventional
 Liquid-based
 Other prep
 Bethesda 2001
• Specimen Adequacy
 Specimen rejected/not processed (indicate reason)
• Not labeled
• Broken slide
• Unacceptable method of transport
 Specimen processed and examined, but unsatisfactory
for evaluation of epithelial abnormality (indicate reason)
 Bethesda 2001
• Specimen adequacy
 Satisfactory cellularity
• Adequate: conventional = 8000-12000; liquidbased = 5000
• Borderline adequate
 Transformation zone component:
• Endocervical cells / Squamous metaplasia: 10 well-preserved endocervical
or metaplastic cells
• Atrophy
 Unsatisfactory
• Hypocellular / scant squamous cellularity
• Obscuring RBCs & WBCs > 75% of smear
• Air-drying artifact affecting > 75% of cells
• Extensive Cytolysis
 Adequate smear

• Liquid-based cytology: superficial and intermediate

squamous cells and a cluster of columnar
endocervical cells. (obj. 5x)
 Lactobacilli
• Lactobacilli and occasional cytolysis.
Bacteria get more dispersed in liquid
preparations; the background is thus
cleaner. (contrast with lower right inset
from a conventional smear).
• Lactobacilli (Doderlein bacilli) are
normal flora
• In determining specimen adequacy, Liquid-based
nuclear preservation and visualization Conventional
are of key importance. Changes such as
cytolysis and partial obscuring of
cytoplasmic detail may not necessarily
interfere with specimen evaluation.
This specimen is satisfactory for
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.
Obscuring factors
• Unsatisfactory due to obscuring
inflammation /blood. Greater
than 75% is considered
unsatisfactory if no abnormal
cells are identified.
If 50 - 75% of the slide has this
appearance, obscuring
inflammation/blood should be
mentioned in the quality
indicators section of the report
• This patient should have a repeat
cervical cytology specimen or
other clinical evaluation
 “Cornflakes” artifact

• Also called “brown artifact”, cornflaking

• Distinctive appearance is due to evaporation of xylene before
cover slipping, with deposition of air on superficial squamous
cells
• More common on conventional than liquid based preparations
 Air-drying artifact
• Note pale, enlarged nuclei
with indistinct nuclear
features.
Air drying causes cells to
flatten out on the slide
instead of being fixed in a
more round or 3-
dimensional configuration.
A specimen is
unsatisfactory if >75% of
cells show air drying. If less
extensive, air drying may be
mentioned as a quality
indicator.
 Bethesda 2001
Interpretation/Result
• Negative for Intraepithelial Lesion or Malignancy
(NILM)
• Organisms
 Trichomonas vaginalis
 Fungal organisms morphologically consistent with Candida spp.
 Shift in flora suggestive of bacterial vaginosis (Gardnerella)
 Bacteria morphologically consistent with Actinomyces species
 Cellular changes associated with Herpes simplex virus
 other
 Bethesda 2001
• Reactive cellular changes associated with:
 inflammation (includes typical repair)
 irradiation
 Intrauterine contraceptive device (IUD)
• Glandular cells status post hysterectomy
• Atrophy
• Endometrial cells (in a woman greater than or equal
to 40 years of age; specify if “negative for squamous
intraepithelial lesion”)
 Bethesda 2001
• Epithelial Cell Abnormalities
• SQUAMOUS CELL
 Atypical squamous cells
• of undetermined significance (ASC-US)
• cannot exclude HSIL (ASC-H)
 Low grade squamous intraepithelial lesion (LSIL) encompassing
HPV / mild dysplasia /CIN I
 High grade squamous intraepithelial lesion (HSIL) encompassing:
moderate and severe dysplasia / CIN2 / CIN3 / CIS
• with features suspicious for invasion (if invasion suspected)
 Squamous cell carcinoma
 Bethesda 2001
• GLANDULAR CELL
 Atypical
• endocervical cells (NOS or specify in comment)
• endometrial cells (NOS or specify in comment)
• glandular cells (NOS or specify in comment)
 Atypical
• endocervical cells, favor neoplastic
• glandular cells, favor neoplastic
 Endocervical Adenocarcinoma in situ
 Adenocarcinoma
• Endocervical
• Endometrial
• Extrauterine
•  not otherwise specified (NOS)
• OTHER MALIGNANT NEOPLASMS (Specify)
 Bethesda 2001
• ANCILLARY TESTING: Describe briefly the test
method(s) and report the result so that it is easily
understood by the clinician
•  
• AUTOMATED REVIEW: If case is examined by
automated device, specify the device and result
•  
• EDUCATIONAL NOTES/SUGGESTIONS: If
provided, should be concise and consistent with
clinical guidelines published by professional
organizations
• Squamous metaplasia

histogram
 Trichomonas
• pear-shaped, flagellated,
blue-green cytoplasm,
ovoid eccentric nucleus
• Frequently associated
with Leptothrix :
“spaghetti & meatballs”
• Squamous cell changes
in Trichomoniasis
 Minimal nuclear
enlargement
 Cytoplasmic polychromasia
Trichomonas
 NILM: Trichomonas vaginalis and
Leptothrix
• Leptothrix are slender, long
bacteria.
The finding of Trichomonas
and Leptothrix together has
been referred to as "spaghetti
and meatballs" When
leptothrix are seen, one
should search for the possible
presence of trichomonads. In
liquid based preparations, the
leptothrix organisms may
tend to clump (arrow) as
opposed to conventional
smears
 Candida albicans
• Candida: Pseudohyphae, formed by elongated
budding, with spearing of epithelial
cells--"shish kebab" effect.
Bacterial vaginosis
• Individual squamous
cells covered by a layer
of bacteria that obscures
the cell membrane (clue
cells). Background is
usually clear in liquid
based preparations.
 Actinomyces
• Tangled clumps of filamentous
organisms, often with acute angle
branching, sometimes showing
irregular “wooly” appearance.
Swollen filaments may be seen
with clubs at periphery. A cotton
ball-like acute inflammatory
response is common.
Actinomyces is often associated
with intrauterine device (IUD)
usage. Organisms may alert
clinician to look for evidence of
pelvic infection.
 Herpes
• Nuclei showing "ground-glass"
appearance. Multinucleation,
nuclear molding, and dense
eosinophilic intranuclear
inclusions surrounded by a halo
are also seen.
 intranuclear, ?Cowdry type?
inclusions.
"Ground-glass" appearance is due
to intranuclear viral particles and
enhancement of nuclear envelope
caused by peripheral chromatin
margination.
 herpes
• multinucleated cells with dense,
intranuclear Cowdry-type viral
inclusions; nuclei have ground glass
appearance due to accumulation of
viral particles, which causes
peripheral margination of chromatin;
also nuclear molding (arrow)
• “Three M’s of herpes”
- margination of nuclei, molding and
multinucleation
• Cowdry: intranuclear eosinophilic
amorphous or droplet-like bodies
surrounded by a clear halo, with
(type A, herpes) or without (type B,
adenovirus or poliovirus)
margination of chromatin on the
nuclear membrane
 Chlamydia
• an obligate intracellular parasite
with elementary bodies (infectious
but incapable of cell division) and
reticulate bodies (multiply within
cytoplasm, but not infectious until
they transfer back into elementary
bodies)
• Presence of infection is not
associated with symptoms
• Diagnosis is based on molecular
tests (PCR or ligase chain reaction)
• Cytology: morphologic changes
(intracytoplasmic inclusions with
central small coccoid bodies) are
not specific
 Non-neoplastic findings
• Atrophy
• Glandular cells status post hysterectomy
• Reactive cellular changes associated with
 Inflammation (including typical repair)
 Radiation
 Intrauterine contraceptive device
• Others
 Tubal metaplasia
 Keratotic cellular changes
 Lymphocytic (follicular) cervicitis
 other
 Atrophy
• Parabasal cells with mostly bland
nuclei (some showing air drying).
Some degenerated cells with pyknosis
also present. Basophilic granular
background with inflammation also
present.
• Parabasal cells with some nuclear
degeneration. Background shows
granular debris which can mimic
tumor diathesis, i.e. by 'clinging' to
cell groups.
• Partly air dried parabasal and
abundant inflammation present.
Decreased mucus leads to increased
air drying problems with conventional
smears.
 Repair
• Increased nuclear size and
prominent nucleoli. Cells in
monolayer sheet with nuclei
oriented in the same direction
(streaming).
Absence of single cells with
nuclear changes and lack of
marked anisonucleosis or
irregularities in chromatin
distribution or variation in
size and shape of nuclei
indicates this is typical repair
(as opposed to "atypical
repair")
 Repair
• Monolayer sheet of endocervical cells
with orderly arrangement. Streaming
effect is observed. Nuclei are enlarged
with nucleoli but have smooth borders
and are not hyperchromatic.
Repair is characterized by cohesive cell
groups with few or no single cells. In
liquid preparations, the groups may
appear more rounded with less
streaming.
• Flat monolayer sheets with distinct
cytoplasmic outlines, streaming nuclear
polarity, prominent nucleolus in almost
every cell.
Endocervical
cells
• Endocervical cells,
reactive
Nuclear enlargement
with some bi- and
multinucleation. Nuclear
outlines are smooth and
uniform. Chromatin is
fine with small nucleoli.
Cells are present in flat
orderly sheet.
 Radiation
• Enlarged nuclei with abundant
polychromatic cytoplasm with
vacuolization. Mild nuclear
hyperchromasia without coarse
chromatin, prominent nucleoli
(coexisting repair). Note
multinucleation (upper right corner
insert).
• Nuclear and cytoplasmic
enlargement, smooth nuclear
outlines with mild hyperchromasia
but chromatin is finely granular.
Cytoplasmic polychromasia and
vacuolization.
• Single partially degenerated epithelial cells
with increased nuclear size and high N/C ratio. 
Single cells may also mimic high grade SIL;
however the morphologic spectrum of
abnormalities usually present with squamous
IUD
intraepithelial lesions is absent in cases with
single atypical cells due to IUD effect. Also the
presence of nucleoli in isolated cells with a
high N/C ratio (right) are not typical of HSIL.
• Small cluster of glandular cells with
cytoplasmic vacuoles displacing nuclei in a
clean background.
The amount of cytoplasm varies and frequently
large vacuoles may displace the nucleus,
creating a signet -ring appearance. The cells
may be shed as clusters or singly. Clusters such
as these may mimic cells from
adenocarcinoma. One should diagnose
adenocarcinoma with caution in the presence
of an IUD. If in doubt, consider repeat
sampling after removal of the IUD. Single cells
may mimic high grade SIL. One needs to look
for the morphologic spectrum of abnormalities
associated with SIL.
 IUD
• Note small cluster of glandular
cells with cytoplasmic vacuoles
displacing nuclei. The cytoplasmic
vacuoles may displace the nucleus,
creating a signet-ring appearance.
Explanatory Notes: 
The cells may be shed as clusters
or singly. Clusters such as these
may mimic cells from
adenocarcinoma. One should
diagnose adenocarcinoma with
caution in the presence of an IUD.
If in doubt, consider repeat
sampling after removal of the
IUD.
Glandular cells post-Hysterectomy
• Goblet cell metaplasia and
bland cellular features.
• On occasion benign
appearing glandular cells
may be seen post-
hysterectomy.
• Adenosis may occur after
traumatic stimulation of
mesenchymal cells. This can
be mentioned in the cytology
report.
• The most important point is
to exclude malignancy.
 Squamous
• metaplasia
Normal polygonal squamous
metaplastic cells with round
to oval nuclei and bland
chromatin pattern. On liquid
based preparations cells may
appear more rounded, and
nuclei may appear smaller.
• The presence of squamous
metaplastic cells indicates
that the transformation zone
has been sampled (a
minimum of 10 well-
preserved endocervical or
metaplastic cells is required
for this quality indicator).
 Tubal
metaplasia
•  Columnar endocervical cells may
occur in small groups or
pseudostratified, often crowded groups.
Nuclei are round to oval and may be
enlarged, pleomorphic and
hyperchromatic Chromatin is evenly
distributed and nucleoli are usually not
seen. N/C ratio can be high. The
cytoplasm can show discrete vacuoles
or goblet cell change (seen here).
Tubal metaplasia is a normal
phenomenon in endocervical canal and
includes ciliated columnar cells, peg
cells and goblet cells. It is important to
recognize that enlarged and/or crowded
nuclei and nuclear stratification may
lead to an interpretation of atypical
endocervical cells unless terminal bars
and cilia are identified Histopath – endocervical gland
lined by ciliated columnar cells;
Goblet cells seen also
 Parakeratosis
• Keratotic cellular changes: "typical
parakeratosis" 
Note keratin pearl. Nuclei within it are
small and bland.
"Typical parakeratosis" by itself is a
benign cellular change. In this case it is
likely an example of post-treatment
effect in the Pap smear.
• On the left (conventional smear ) is an
orangeophilic cluster, and on the right
(LBP), are more eosinophilic
squamous cells with small, opaque
nuclei

conventional liquid-based
 Hyperkeratosis
• Anucleate mature polygonal
squamous cells with ghost-like ?
nuclear holes?.
By itself, hyperkeratosis is a
benign cellular change. Extensive
hyperkeratosis may correlate with
colposcopic findings.
• Anucleate but otherwise
unremarkable mature polygonal
squamous cells.
They usually represent a benign
process or result from inadvertent
contamination of the specimen
with vulvar material.
 Bethesda 2001
• Endometrial cells in a woman aged 40 years or older
• Atypical Squamous cells
 Of undetermined significance (ASCUS)
 Cannot exclude HSIL (ASC-H)
• Epithelial abnormalities (squamous)
 Low-grade squamous intra-epithelial lesion (LSIL) encompassing
HPV, mild dysplasia, CIN 1
 High-grade squamous intraepithelial lesion (HSIL) encompassing
moderate & severe dysplasia, CIN 2, CIN 3, CIS
• With features suspicious for invasion
 Menstrual smear
• Three-dimensional cluster with slightly
larger nuclei and nucleoli.
Endometrial cells are only reported in
women 40 or over if the glandular
component is present. In this case the
age is 36 years and the patient is
menstruating: thus the endometrial cells
do not need to be reported. Endometrial
cells on liquid based preparations may
look more worrisome than conventional
Pap smears because nuclear details are
preserved and more easily detected.
 Endometrial cells
in a woman over
40yrs old
• Endometrial cells after age 40, particularly out of
phase or after menopause may be associated with
benign endometrium, hormonal alterations and less
commonly, endometrial /uterine abnormalities.
Clinical correlation is recommended
• Three dimensional groups with depth of focus. Dark
stromal cells are present internally. Epithelial cells
surround the cluster in a "double contour." Nuclear
features of epithelial and stromal cells are more
readily apparent in ThinPrep specimens than
conventional smears.
• Cells are in a three dimensional "above the plane" of
squamous cells. Nuclei are larger and vacuoles are
seen at the periphery of the cell group. Apoptosis is
seen easily as dark nuclear material (individual cell
necrosis).
 Endometrial cells in a
woman over 40 yrs old
• Exfoliated glandular endometrium may be seen
when evaluating Pap tests. When endometrial
cells are encountered in a woman 40 or older,
they are uncommonly associated with
significant pathology. Rarely, typical
endometrial cells may be associated with an
asymptomatic endometrial carcinoma in this
age group. Because of this association, all
glandular endometrial cells are reported in
women 40 years and over.
• Exodus pattern is characterized by a double
contour pattern of external glandular
epithelium with internal stromal cells. The
stroma in this group is slightly eccentric.
Nuclear features are easily appreciated, despite
this being a conventional Pap smear. The nuclei
have delicate even chromatin. Histiocytes are
often seen in association with the double
contour fragments of exodus.
 Endometrial cells in a woman over
40 yrs old
• Cells occur in small clusters. Small, round nuclei similar in size to a
normal intermediate cell nucleus. Inconspicuous or absent nucleoli.
Cytoplasm is scant, basophilic and sometimes vacuolated. Cell borders
are ill-defined.
Explanatory Notes: 
Endometrial cells may be encountered when evaluating Pap tests. Prior
to age 40, exfoliated endometrial cells are not associated with
significant endometrial pathology. In women 40 years or older, a small
number of women may have uterine abnormalities and usually have
symptoms of bleeding. Because menstrual history, menopausal status,
clinical symptoms, and endometrial cancer risk factors are often
unknown to the laboratory, endometrial glandular cells are reported in
all women 40 years and older.
 ASCUS
• Mature squamous cells showing
mild nuclear enlargement, bi-
nucleation, and even chromatin.
Note benign endocervical cells at
bottom of field.

• Mild nuclear enlargement and

binucleation.
Nuclear changes may be reactive
due to Trichomonas, however a
low grade lesion cannot be entirely
excluded.
 ASCUS
• Nuclei are hyperchromatic with fine
chromatin and smooth membranes. Nuclear
features are borderline between those required
for ASC-US and LSIL.. Cell sizes vary with
the smallest cell resembling a benign
metaplastic cell. Some cells contain enlarged
nuclei but chromatin is similar in all cells.
While there is some "atypia" , clear cut
evidence for an interpretation of LSIL is
lacking.
• Several cells in this group exhibit changes
suggestive of koilocytes. Nuclei are only
slightly enlarged and do not meet the criteria
for LSIL (3 times larger than an intermediate
nucleus). Nuclear features are borderline
between those required for ASC-US and
LSIL. Some of these cellular alterations can
be seen in a reactive process; however, due to
the slight nuclear enlargement,
hyperchromasia, and cytoplasmic changes, an
interpretation ASC-US may be more
appropriate.
 ASC – H
• Metaplastic cells with
slightly enlarged nuclei and
binucleation.
Findings may suggest either
nuclear irregularity or bi-
nucleation. Focusing "up and
down" may be necessary to
appreciate binucleation.
• Metaplastic cells, some with
enlarged or slightly irregular
nuclei.
Differential includes
reactive/reparative
metaplastic cells, and HSIL.
High grade CIN was found
on biopsy
 ASC – H
• Less mature squamous cells/metaplastic
cells with polygonal shape, and slightly
enlarged nuclei with occasional nuclear
contour irregularities.
Boundary of ASC-US and ASC-H;
differential includes CIN 2.
• Atypical multinucleated cell.
Atypical cells may be seen in atrophy, but
the differential includes a high grade
lesion. Repeat sampling following a course
of estrogen may clarify the findings.
Vaginal cuff biopsies and repeat Pap test 2
months later showed severe dysplasia/CIS
(CIN 3)
 ASC-H versus
HSIL
•

Cytomorphologic Criteria: 
Metaplastic cells with
increased N:C ratios and
nuclear contour
irregularities.

Follow-up: 
HSIL on repeat Pap; CIN3
on LEEP
 LSIL - HPV
• Nuclear features are consistent with
LSIL. HPV cytopathic effect or ?
koilocytosis? is also seen. .
Morphologic criteria for LSIL are similar
to those on conventional preparations.
The depth of field for SurePath
preparations with clusters may require
focusing up and down for adequate
visualization.
• Mature squamous cells displaying
enlarged nuclei with a granular chromatin
distribution meet the criteria for
interpretation as LSIL. Binucleation and
koilocytosis are consistent with HPV
cytopathic effect.
Nuclei are 3 to 4 times the size of normal
intermediate cell nuclei. Nuclear
hyperchromasia may not be as obvious in
LBP?s as compared to conventional
smears, however other criteria for
interpretation of SIL are present.
LSIL – CIN 1
HSIL – CIN 2
 HSIL – CIN 3 / CIS
• Severely dysplastic cells on the left
display a high nuclear to cytoplasmic
ratio and irregular nuclear
membranes. Moderately dysplastic
cells on the right have similar nuclei
and more cytoplasm. Note the nuclear
membrane irregularities and
abnormally distributed chromatin. In
liquid based preparations,
hyperchromasia may not be as
prominent as in conventional smears.
• Isolated abnormal cells with evenly
distributed coarse chromatin,
centrally placed enlarged nuclei, and
dense / "metaplastic" cytoplasm are
consistent with HSIL. A mitotic
figure is evident.
 HSIL susp Inv
• Numerous abnormal cells are present in varying
sizes and shapes. Nuclei vary from round to oval to
spindle shaped. This type of pleomorphism suggests
invasive carcinoma. However, the absence of
nucleoli and necrosis are consistent with CIS. 
The distinction between CIS and invasive
carcinoma may be difficult when cells are numerous
and display variation in nuclear size and shape.
• Keratinized dysplastic cells with nucleoli, and
angulated or ?carrot? shaped nuclei that may
raise suspicion for invasion and qualify for an
interpretation of HSIL, cannot rule out
invasion. 
Cells consistent with CIS are generally round
to oval and of similar size. When the lesion is
"keratinizing" it is often more difficult to
classify the degree of abnormality present
with certainty.
Biopsy- CIN 3 (severe dysplasia, keratinizing)
• Epithelial abnormalities (Squamous)
 Squamous cell carcinoma
 Others
• Keratinizing lesions
• Squamous intraepithelial lesions (SIL) – borderline
• SIL with Glandular involvement
 Squamous cell
• Tumor carcinoma
diathesis , variation in cell size and
shape, evidence of keratinization, and
nuclear abnormalities are all demonstrated
in this image from a squamous cell
carcinoma.
In liquid-based preparations, tumor
diathesis may be more subtle and often
tends to collect at the periphery of cell
groups; a pattern that has been referred to
as ?clinging diathesis?.
• Cells on the left with scant cytoplasm
display nuclei with irregularly distributed,
coarsely granular chromatin and prominent
nucleoli. On the right, lysed blood and a
stripped nucleus, tumor diathesis, is
evident. Invasive carcinoma with
prominent nucleoli may suggest
adenocarcinoma; however, in this case
centrally located nuclei and flat
arrangement of cells is consistent with
squamous 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.
• At low magnification, nuclear
abnormalities such as irregularly
distributed coarse chromatin,
hyperchromasia, and high nuclear to
cytoplasmic ratio can be appreciated.
Ragged borders favor carcinoma, not
SIL.
 
• Dysplastic squamous
cells with anisocytosis
and anisonucleosis
including
keratinization and
tadpole cells are
diagnostic of invasive
squamous cell
carcinoma.
• Epithelial abnormalities (Glandular)
 Atypical, NOS / specify in comments
• Endocervical / Endometrial / Glandular
 Atypical, favor Neoplastic
• Endocervical / Endometrial / Glandular
 Endocervical adenocarcinoma in situ
 Adenocarcinoma
• Endocervical / Endometrial / Extrauterine
• Not otherwise specified (NOS)
• Endocervical adenocarcinoma in situ
(AIS) /HSIL
Co-existing glandular and squamous
lesions should always be considered
when making an interpretation of
endocervical adenocarcinoma in situ.
HSIL (moderate dysplasia) and
endocervical adenocarcinoma in situ
occurring at the transformation zone
• Hyperchromatic crowded group of
AIS (upper right) and small
aggregate of HSIL (lower left).
Endocervical adenocarcinoma in situ
with invasive adenocarcinoma and
HSIL
 Endocervical
adenoCA
• Cluster of cells with enlarged round or
oval nuclei, irregular chromatin
distribution and prominent nucleoli.
Irregular chromatin distribution and
prominent or macronucleoli are classic
findings in invasive endocervical
adenocarcinoma.
• Cluster of cells enlarged nuclei,
macronucleoli and some nuclear
membrane irregularities; poorly defined,
finely vacuolated cytoplasm; ghost of
RBC's and cell debris noted at the edge of
the cluster ("clinging diathesis").
In liquid-based preparations, tumor
diathesis may be seen as coagulated
necrosis or as debris clinging to the
periphery of clusters of abnormal cells.
 Endometrial
adenoCA
• Loose aggregate of small epithelial cells
with slightly enlarged nuclei, small
nucleoli, and vacuolated cytoplasm;
"watery diathesis" and histiocytes also
noted.
In conventional smears, endometrial
adenocarcinoma is more commonly
associated with a thin watery diathesis in
the smear background in contrast to the
bloody, necrotic background associated
with endocervical adenocarcinoma.
• Three-dimensional papillary cluster of
abnormal cells with irregular nuclear
membranes and nucleoli. No evidence of
feathering.
 Extrauterine
adenoCa
• This group of atypical glandular cells
with nuclear pleomorphism,
hyperchromasia, and cellular overlap is
diagnostic of adenocarcinoma. The tall
columnar cells and scattered goblet cells
with distended mucin-filled vacuoles are
characteristic of colon carcinoma.
Explanatory Notes: 
Colon carcinoma is one of the most
common secondary tumor encountered
in cervical cytology samples. Although
metastatic carcinomas to the cervix lack
tumor diathesis, direct extension of this
tumor from the rectum may be
associated with such diathesis.
• Other malignancies
 Carcinomas
 Sarcomas
 Others
 carcinosarcoma
• This single giant cells with malignant nuclear
features is present in a bloody background.
Uterine sarcomas exfoliate scant cellular material
in cervical cytology samples. Although
malignant giant cells may be seen in high grade
carcinomas, their association with a spindle cell
component point towards a sarcomatous
differentiation. The differential diagnosis may
include choriocarcinoma.
• This loose syncytial group of malignant cells
with variable nuclear features and prominent
nucleoli shows no characteristic epithelial or
mesenchymal features.Most sarcomas present
with undifferentiated cells and may be
recognized as malignant neoplasms that cannot
be further subclassified. The differential
diagnosis includes a poorly differentiated
carcinoma.
 Carcinosarcoma
•
MMMT
These spindle cells with round or oval pleomorphic
nuclei, slightly irregular nuclear membranes, and
multiple prominent nucleoli constitute the
sarcomatoid component of this tumor. These cells
are admixed with the more obvious epithelial
component of the tumor (left upper corner). The
bloody background and tumor diathesis are also
represented in this picture.
Sarcomatoid elements are usually spindle cells. they
may appear stromal, fibroblastic or
leiomyosarcomatous. Occasional heterologous
elements may include rhabdomyosarcoma,
chondrosarcoma or osteosarcoma. In a poorly
differentiated tumor a separate sarcomatous and
epithelial component may be difficult to identify. A
uterine sarcoma should be considered in the
differential diagnosis. (combine as split screen with
Misc-c-st8).
• A three-dimensional cluster of epithelial cells with
enlarged round nuclei, macronucleoli and moderate
amount of finely vacuolated cytoplasm has features
of adenocarcinoma. Granular debris consistent with
tumor diathesis is noted at the edges of the cluster.
• Histologic section of the endometrial
MMMT has both a spindle cell
sarcomatoid component and an
adenocarcinomatous component. The
cytomorphologic features of the
tumor are similar to those displayed
in the cervical cytology sample.
Explanatory Notes: 
Recent clinicopathologic,
immunohistochemical and molecular
genetic studies support the
classification of MMMTs as variants
of carcinoma.
 Melanoma
• The presence of brown cytoplasmic pigment consistent with melanin in these
malignant cells supports the interpretation of malignant melanoma.
• 40 year old woman s/p resection of melanoma of the thigh presents with a small
discolored submucosal lesion on the cervix; LMP 4 weeks
• polygonal cells with large eccentrically placed, hyperchromatic nuclei and
prominent nucleoli.
• Large single or loosely cohesive cells with round nuclei, irregular nuclear
membranes, coarsely clumped irregularly distributed chromatin and prominent
nucleoli are compatible with a poorly differentiated neoplasm.
The presence of intranuclear pseudoinclusion and melanin pigment is helpful in
arriving at a definitive diagnosis. Additionally if material from LBP sample is
available, immunostains for S-100 protein, HMB-45 and Melanin-A may help
confirm the diagnosis. Malignant melanoma in the cervix may arise as a primary
tumor but is most frequently encountered as a metastasis in patients with known
primaries.
 Malignant
lymphoma
• Scattered atypical lymphoid cells with clumped
chromatin and conspicuous nucleoli.
Notice the resemblance of these cells to the single cells
of small cell undifferentiated carcinoma in liquid
preparations. The possibility of follicular cervicitis that
presents with a polymorphous lymphocytic population
and tingible body macrophages should also be
considered in the differential diagnosis.
• These single cells in a bloody background have
enlarged hyperchromatic nuclei and irregular nuclear
membranes. Chromatin is coarse, and irregularly
distributed with prominent nucleoli. 
Involvement of the cervix by malignant lymphoma is
rare, and secondary involvement is more common than
primary tumors. A large number of atypical lymphoid
cells should elicit the diagnosis. The main differential
diagnosis is follicular cervicitis.