PITFALLS IN DIAGNOSIS OF HIGH GRADE SQUAMOUS INTRAEPITHELIAL

LESION (HSIL)
MUHD ARIFF Z. , QATRUNNADA M.K. , NURUL ANIS A.R. , KHAIRUNNISA M.T. , NORFADILAH I., FAIZAH. I. ,NOOR ATHIRAH M.A .
BACHELOR IN MEDICAL LABORATORY TECHNOLOGY (HONS), FACULTY OF HEALTH SCIENCE, UNIVERSITI TEKNOLOGI MARA, PUNCAK ALAM CAMPUS, 42300, PUNCAK ALAM, SELANGOR

Introduction Diagnostic pitfalls of HSIL Management guidelines

Definition of Pitfalls
and algorithm for pap
Pitfalls in the diagnostic cytopathology, is comparison smear result
with the cells which possessed high possibility to be
misdiagnosed and those which showed similar Pap
figures. smear
(Noriko, 2001)

High Grade squamous intraepithelial HSIL SCC

lesion (HSIL)
• HSIL is a lesion that carries a significant risk for
Figure 2: Follicular cervitis. Differential diagnosis of
progression to cervical cancer.
severe dyskaryosis. The very coarse chromatin
• Usually parabasal - sized cells.
pattern of small lymphocytes and the presence of
• Discrete cells or syntcytial groups.
tangible body macrophages are important features in
correct identification of these cells
(Gray W, McKee G.T, 2003)
Figure 5: Endometrial cell. Differential diagnosis of
severe dyskaryosis. Exfoliated endometrial cells tend to
Refer for Refer to
form 3-dimentional clusters. Distinction of such clusters oncologist or
colposcopy
from fragments of small cell CIN 3 or invasive gynaecologist
carcinoma may require careful scrutiny of the whole
smear for addition diagnostic features
Diagram 1: Management guidelines and algorithm for
(Gray W, McKee G.T, 2003) HSIL and SCC
(Institute of Clinical System Improvement (ICSI), 2005 )

Conclusions
• Factors that influence the accuracy of pap smear
result are inadequate specimen, insufficient training
at all level, insufficient time devoted to screening
program, inadequate supervision and inadequate
follow up procedure.
Figure 1: High grade squamous intraepithelial lesion • Possible pitfalls may occur at all level of process
(HSIL)Severely dysplastic cells on the left display a high • The way to reduce pitfalls are
nuclear to cytoplasmic ratio and irregular nuclear Figure 6: Immature squamous Metaplasia. To be 1.Well written and adhere to procedure
membranes. Moderately dysplastic cells on the right distinguished from moderate dyskaryosis. The 2.Adequate clinical information
have similar nuclei and more cytoplasm Figure 3: Endometrial cell exfoliation due to an IUCD. uniformity of nuclear size and texture, the abundant 3.Good QC monitoring at any level
Differential diagnosis of severe dyskaryosis. This small cytoplasm¹ and pattern of metaplastic is characteristic 4. Continuous training to maintain competency
(Anonnymous, n.d) 3 – dimentional group of endometrial cells with of these normal cells and knowledge
characteristic cytoplasmic vacuolation is easily 5. Audit of the program and peer review
correctly identified (Gray W, McKee G.T, 2003) 6. Colposcopic group discussion with histo-cyto
Nucleus Cytoplasm (Gray W, McKee G.T,2003)
correlation
• The diagnostic pitfalls of HSIL are Endometrial cells,
Immature squamous metaplasia, Endocervical cells,
• Enlargement • Pallor and vacuole Mild and moderate dyskaryosis, Histiocyte, Follicular
• Hyperchromasia • Reduced, may be thick cervicitis, and Endometrial cell exfoliation due to an
IUCD
• Chromatin coarseness or thin
and evenly distributed • Cell border maybe References
• Marked irregularity in angular or rounded Cibas E.S., Ducatman B.S (2003), Cytology Diagnostic
contour • Can appear ‘immature’, Principle and Clinical Correlates. Saunders
Gray W, McKee G.T, (2003). Diagnostic Cytopathology.
lacy and delicate or Figure 7:Histiocyte. The coarseness of clumping of Churchill Livingstone.
densely metaplastic the chromatin¹ in the nuclei of these normal cells. Noriko, S. (2001). Pitfall of cytology in respiratory tract.
Figure 4: Endocervical cells. The uniform size and Failure to identify such cells as histiocytes may lead Journal of the Japanese Society of Clinical Cytology.
distribution of the pyknotic nuclei, distinct cell borders to an erroneous diagnosis of sever dysskaryosis in Kyushu Branch .
and weak heamatoxylin staining of cytoplasmic mucin squamous cells ICSI (2005) Management of initial abnormal Pap Smear
Table 1: Characteristic of HSIL identifies the central group as endocervical cells HSIL Algorithm
(Gray W, McKee G.T,2003) (Gray W, McKee G.T, 2003) http://nih.techriver.net/view.php?patientId=47. Retrieved
(Cibas E.S, Ducatman B.S, 2003) on October 11, 2010