Case Presentation - December, 2003

THINPREP^® PAP TEST

Age: 51 Year Old, Female

History: HR HPV +

Case provided by Drs. Harenberg and Konrad of Homburg, Germany. The images and diagnosis for this case study were provided by an independent laboratory.

Cytologic Interpretation: Atypical Endocervical Cells of Undetermined Significance. Histologic Interpretation: Negative. Cervical Polyp.

Reminder: You may click on any slide image for an enlarged view.

Slide Description:

Atypical Endocervical Cells (0311)
Note the group of enlarged endocervical cells with an increased N:C ratio and prominent nucleoli (5:00 position) present in an inflammatory background. At the 10:00 position, notice the appearance of pseudostratification, nuclear enlargement and elongation and chromatinic irregularity.
20X

Atypical Endocervical Cells (0312)
In this high power image, nuclei appear markedly enlarged and seem to be present from base to tip within the group. There is also multinucleation as well as a disturbance in the chromatin pattern.
40X

Atypical Endocervical Cells (0313)
Again, an increased N:C ratio is evident as well as disorganization within the group.
40X

Atypical Endocervical Cells (0314)
These clusters contain enlarged, elongated nuclei with an ominous stippled appearance to the nucleus and margination of the chromatin. Though clearly a crowded group, it is difficult to determine whether nuclei are overlapping or present in different planes of focus.
40X

Atypical Endocervical Cells (0315)
These clusters contain enlarged, elongated nuclei with an ominous stippled appearance to the nucleus and margination of the chromatin. Though clearly a crowded group, it is difficult to determine whether nuclei are overlapping or present in different planes of focus.
40X

Atypical Endocervical Cells (0316)
The cells pictured at the 12:00 position in this image show enlarged, irregular nuclei and occasional multinucleation yet have a relatively normal N:C ratio and a crisp edge to the edge of the cytoplasm.
40X

Atypical Endocervical Cells (0317)
This cluster again shows crowding, anisonucleosis, nuclear membrane irregularities and stippled chromatin.
40X

The presence of endocervical polyps often causes identifiable reactive and proliferative cellular changes on a pap test. Even occasional mildly atypical changes may be deemed within acceptable limits in an otherwise reactive background. In contrast, significant endocervical cell atypia, although rare in occurrence, may cause cytologists significant concern and difficulty. While normal and reactive endocervical cells can sometimes undergo extremes of alteration, they typically maintain acceptable N:C ratios, nuclear membrane regularity, active but velvety chromatin patterns and lack of true nuclear overlap. The cells presented in this case, however, do not adhere to many of these rules that generally apply to reactive endocervical processes.

In retrospect, the inflammatory background and degenerative features present in this case probably indicate an inflammatory component of this patient's cervical polyp as opposed to the necrosis and degeneration of a high grade pre-invasive endocervical lesion. Multinucleation, as demonstrated in Slides 0312 and 0316 also may support a diagnosis of a reactive endocervical process over atypia. Slides 0314 and 0316 show sharp cytoplasmic borders, another often benign characteristic of endocervical cells. While some rare cells show an increased N:C ratio and some nuclei are markedly enlarged, the majority of cells in these groups maintain a normal N:C ratio.

To learn more about glandular look-alikes and differential diagnoses, consult Section 5 of the ThinPrep^® Pap Test Morphology Reference Atlas.