PITFALLS IN THE DIAGNOSIS OF LOW-GRADE SQUAMOUS INTRAEPITHELIAL LESION (LSIL )/(CIN 1)

NURAISHAH A. H, RUZAINI A, KU NORLELA K.A, RAMLAH Y, MOHD ARIF A. T, IZLIN O, ROZAINA A

BACHELOR IN MEDICAL LABORATORY TECHNOLOGY (HONS), FACULTY OF HEALTH SCIENCES, UNIVERSITY TECHNOLOGY MARA, PUNCAK ALAM CAMPUS, 42300 PUNCAK ALAM, SELANGOR

INTRODUCTION
INTRODUCTION DIAGNOSTIC
DIAGNOSTIC PITFALLS
PITFALLS OF
OF LSIL
LSIL ASC-US
ASC-US vs
vs LSIL
LSIL
Pitfalls: Refer to cells that mimic the morphology of
LSIL (Ibrahim Ramzy, 2001)
REACTIVE / INFLAMMATORY CHANGES CYTOMORPHOLOGIC CRITERIA

LSIL
LSIL CHARACTERISTICS
CHARACTERISTICS Nucleus: enlarge w/out significant
hyperchromasia or nuclear
membrane irregularity,
bi / multinucleated,chromatin
Figure 1: LSIL (60X)
finely and uniformly granular
Cytoplasm: small, non-specific
koilocytosis
Figure 4: Squamous Cell (Edmun S. Cibas, 2003) Figure 9: ASC-US vs LSIL
Nucleus: hyperchromatic, fine Nucleius: slightly enlarged, no criteria for LSIL
LSIL Characteristics Nucleus: vary in size, 4-5x larger chromatin,smooth membranes Nuclear feature borderline between ASC-US & LSIL
Formation Singly or sheets than normal, large nucleoli Cell sizes: vary Several cells exhibit changes of koilocytes
(Edmun S. Cibas, 2003)
Cell changes Confines to cells with ‘mature’ or superficial type (Diane Solomon, 2004)
cytoplasm DIFFICULTY OF DIAGNOSE LSIL
Overall cell Large with fairly abundant ‘mature’ well defined 1. Inadequate smear
size cytoplasm  There were not enough cells in the sample which meant the cells could not be
N/C ratio Increase more than three times seen clearly or client were having a period and there are too much blood in smear
Figure 5: Endocervical Cell  The cervix was inflamed and so the cells could not be seen clearly enough
Nuclei Hyperchromasia, enlarged nuclei, binucleation,
multinucleation 2. False Positive
NAVICULAR CELLS
Chromatin Fine , uniformly distributed, but coarsely granular; A false positive Pap test means that a patient is told she has normal cells, but the
may appear smudged or densely opaque Nucleus: eccentric, may be
cells are actually abnormal due to lack of training or experience of MLT
hyperchromatic, not enlarge or (Am J Clin Pathol, 2008)
multiple 3. Other than MLT errors:
Nucleoli Mostly absent or inconspicuous if present
Cytoplasm:distended with yellow  Specimen collection
Nuclear Slightly irregular but may be smooth
membrane glycogen., boat shaped, rim of  Staining type and quality
folded cytoplasm, resemble a  Poor fixation
koilocyte  Storage time and delivery
Koilocytosis Sharply delineated clear perinuclear zone and a
Figure 6: Navicular cells (C Scheungraber, 2004)
peripheral rim of densely stained cytoplasm LSIL
LSIL ALGORITM
ALGORITM
Table 1: Characteristics of LSIL
(Diane Solomon, 2004) ATROPHIC CHANGES
Nucleus: 15-25 um, high N/C ratio,
DIANOSTIC
DIANOSTIC OF
OF LSIL
LSIL Shape: round to oval
Cytoplasm: cyanophilic
Nucleus : disproportionate (Grace T. McKee, 2003)
enlargement, hyperchromasia,
irregular membrane, abnormal
chromatin pattern
Cytoplasm : reduced and thin,
Figure 7: Parabasal cells:
angular cell borders
(Grace T. McKee, 2003) KERATINIZING CELLS
REFERENCES
REFERENCES
Figure 2: LSIL Nucleus: enlarged, hyperchromatic,
Koilocytosis dense chromatin • Diane Soloman, Ritu Nayar, The Bethesda System for Reporting Cervical Cytology; Definitions, Criteria and
Explanatory Notes, 2 nd Edition, 2004:91-92:96-97.
Enlarged and hyperchromatic nuclei Cytoplasm: orange • Edmun S. Cibas, Barbara S. Ducatman, Diagnostic Principle and Clinical Correlates, 2nd edition, 2003:24-26.
(Grace T. McKee, 2003) •Grace T. Mc Kee, Diagnostic Cytopathology.Winfred Gray, 2 nd Edition , Churchill Livingstone, 2003:726-732.
Bi/ multinucleation
Cytoplasmic keratinization -Can be found in anal rectal • Ibrahim Ramzy, Clinical Cytopathology and Aspiration Biopsy, Fundamental Principle and Practice, 2 nd Edition,
2001:147-149:155-156
(Grace T. McKee, 2003) specimens • C Scheungraber, Management of Low-Grade Squamous Intraepithelial Lesions of the Uterine Cervix, British Journal
-a/w HPV of Cancer, 2004:975-978
• Am J Clin Pathol, Crum, CP. Laboratory management of CIN : The Consensus is Consensus. 2008:130:162.
Figure 8: Keratinizing cells (Diane Soloman, Ritu Nayar 2004) • http://www.advpath.com

Figure 3: HPV changes