Oncocytologic investigation and interpretation
of cervix smear

Rounded Rectangle: C Skills Group    C Skills Group    C Skills Group    C Skills Group 

E. Skrodenienė, A. Vitkauskienė

Rounded Rectangle: This chapter presents and explains the generally accepted and used the evaluation system of oncocytological smear. You are expected to discuss the cytologic findings with your tutor during your practical sessions. 


The oncocytologic results of a cervix smear have been evaluated in respect to the Bethesda System since 2001. The Bethesda System recommends a certain form of result presentation, which is composed of 3 main important parts:

1. Papanicolaou (Pap) smear adequacy assessment.
The smear is considered to be suitable if:

2. Interpretation of cytologic results/conclusion
Negative for intraepithelial lesion or malignancy (NILM) (Fig. 1).


Fig. 1. Negative for intraepithelial lesion or malignancy – NILM
1 – superficial squamous epithelial cells;
2 – intermediate squamous epithelial cells;
3 – endocervical (glandular) epithelial cells.



Fig. 2. Candida spp. infection – arrow points out characteristic hyphes

Fig. 3. Trichomonas vaginalis infection – note the characteristic view


Fig. 4. Bacterial vaginosis (BV)
Indicator cells also known as “Clue Cells” form the characteristic picture of BV.
Note the presence of multiple microorganisms, which are attached to a single squamous epithelial cell.



Fig. 5. Cellular changes consistent with HSV infection
1 – „milk glass“ nuclei;
2 – multinucleated cells; fused nuclei;
3 – nuclear chromatin is present only close to the nuclear membrane.


Fig. 6. Para- and hyperkeratosis

A. Parakeratosis: 1 – orange, keratinizing cytoplasma; 2 – small nuclei with an increased chromatin concentration (pyknotic nuclei).

B. Hyperkeratosis: keratized-anucleated cells.


Fig.7. Cell repair
1 – layers of flattened cells, their structure appears as floating;
2 – enlarged nuclei with large nucleoli.


Fig. 8. Atrophy
1 – parabasal squamous epithelial cells (increased number);
2 – basal squamous epithelial cells (increased number);
3 – intermediate squamous epithelial cells (scattered).


Fig. 9. Cellular changes induced by radiation therapy / exposure: vacuolization; cytomegaly; multinucleated cells; signs of cellular repair / reparation.


Fig. 10. Cellular changes caused by the presence of IUD
1 – prominent large cytoplasmic vacuole;
2 – small cells can mimic HSIL.


Pathology of squamous cells:


Fig. 11. ASC-US
1 – binucleated cells, mild nuclear hyperchromia and low N and C ratio.



Fig. 12. ASC-H
1 – cells appear similar to HSIL.


Fig. 13. LSIL
1 – enlarged nuclei (approximately 5 x intermediate cell nucleus);
2 – multinucleated cells;
3 – irregular nuclear margins;
4 – presence of rough chromatin deposits;
5 – presence of koilocytes.


Fig. 14. HSIL
1 – increased number of parabasal cells, enlarged nuclei, irregular nuclear margins, expressed hyperchromia and the presence of rough chromatin deposits.



Fig. 15. Squamous cell carcinoma
1 – signs of HSIL;
2 – large nuclei and irregular chromatin deposits;
3 – tumor diathesis;
4 – cellular polymorphism.


Pathology of glandular cells:



Fig. 16. Atypical glandular cells: AGC-NOS
1 – endocervical (glandular) cells arranged in piles, hyperchromasia.


Fig. 17. Atypical glandular cells, which are more neoplastic: AGC-FN
1 – nuclear hyperchromia, nuclei can almost not be visualized.


Fig. 18. Adenocarcinoma in situ – AIS
A characteristic arrangement of cells in a “rosette-shaped-pattern” is common; increased N and C ratio; nuclei appear oval-shaped; irreglar chromatin deposits “Salt-Pepper”; mucosal cells are diversified.


Fig. 19. Adenocarcinoma
1 – round and large nuclei; increased cellular cytoplasma;
2 – macronucleoli are common;
3 – tumor diathesis.


3. A comment/recommendation obtained from pathologist/cytologist

Is optional. A detailed presentation following the guidelines recommended by Obstetricians and Gynecologists as well as Pathologists-Cytologist organizations. It may be suggested when the Pap smear has to be repeated or the test for detection of the Human Papillomavirus (HPV) has to be performed.


Rounded Rectangle: The oncocytologic cervix smear investigation represents a very important method for detection of pre-cancerous cervix changes. In order to investigate a smear sample correctly, the following steps should be performed:    §	The material of investigation has been sampled and fixated according to internationally provided guidlines.    §	Adequate collection of medical data (anamnesis) and filling in the cytologic form. 



  1. Čigriejienė VM, Tarnauskas E. Kolposkopijos pagrindai. Kaunas; 1998.
  2. Čigriejienė VM, Juozaitytė E, Kajėnas S, Inčiūra A, Vaidotienė L, Vaitkienė D. Onkoginekologijos vadovas Kaunas: Spindulys; 2003. p. 34-64.
  3.  Cytopathology of the uterine cervix - digital atlas [žiūrėta 2012-05-18]. Access to Internet: http://screening.iarc.fr/atlascyto.php?lang=1
  4. The Bethesda system website atlas [žiūrėta 2012-05-18]. Access to Internet: http://nih.techriver.net/atlas.php
  5. BD SurePath™ liquid-based Pap Test. BD, BD Logo & all other trademarks are the property of Becton, Dickinson and Company; 2007 BD. [žiūrėta 2012-05-18]. Access to Internet: http://www.bd.com/tripath/products/surepath/index.asp