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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

LSIL CHARACTERISTICS

Figure 1: LSIL (60X)

LSIL Characteristics

Formation Singly or sheetsCell changes Confines to cells with mature or superficial type

cytoplasm

Overall cellsize

Large with fairly abundant mature well definedcytoplasm

N/C ratio Increase more than three timesNuclei Hyperchromasia, enlarged nuclei, binucleation,

multinucleationChromatin Fine , uniformly distributed, but coarsely granular;

may appear smudged or densely opaque

Nucleoli Mostly absent or inconspicuous if presentNuclear membrane

Slightly irregular but may be smooth

Koilocytosis Sharply delineated clear perinuclear zone and aperipheral rim of densely stained cytoplasm

DIANOSTIC OF LSIL

Table 1: Characteristics of LSIL(Diane Solomon, 2004 )

Nucleus : disproportionateenlargement, hyperchromasia,irregular membrane, abnormalchromatin patternCytoplasm : reduced and thin,angular cell borders

(Grace T. McKee, 2003)

KoilocytosisEnlarged and hyperchromatic nucleiBi/ m ultinucleationCytoplasmic keratinization

(Grace T. McKee, 2003 )

DIAGNOSTIC PITFALLS OF LSIL ASC-US vs LSIL

Nucleus: enlarge w/out significanthyperchromasia or nuclear membrane i rregularity,bi / multinucleated,chromatinfinely and uniformly granular Cytoplasm: small, non-specifickoilocytosis

(Ed mun S. Cibas, 2003 )

REACTIVE / INFLAMMATORY CHANGES

Nucleus: vary in size, 4-5x larger than normal, large nucleoli

(Ed mun S. Cibas, 2003 )

NAVICULAR CELLS

Figure 4: Squamous Cell

Figure 5: Endocervical Cell

Figure 2: LSIL

Figure 3: HPV changes

Nucleus: eccentric, may behyperchromatic, not enlarge or multipleCytoplasm:distended with yellowglycogen., boat shaped, rim of folded cytoplasm, resemble akoilocyte

(C Scheungraber, 2004 )Figure 6: Navicular cells

Nucleus: 15-25 um, high N/C ratio,Shape: round to ovalCytoplasm: cyanophilic

(Grace T. McKee, 2003 )

ATROPHIC CHANGES

Figure 7: Parabasal cells:

KERATINIZING CELLS

Nucleus: enlarged, hyperchromatic,dense chromatinCytoplasm: orange

(Grace T. McKee, 2003 )-Can be found in anal rectalspecimens-a/w HPV

Figure 8: Keratinizing cells

CYTOMORPHOLOGIC CRITERIA

Nucleus: hyperchromatic, finechromatin,smooth m embranesCell sizes: vary

Nucleius: slightly enlarged, no cri teria for LSILNuclear feature borderline between ASC-US & LSILSeveral cells exhibit changes of koilocytes

Figure 9: ASC-US vs LSIL

There were not enough cells in the sample which meant the cells could not beseen clearly or client were having a period and there are too much blood in smear The cervix was inflamed and so the cells could not be seen clearly enough

1. Inadequate smear DIFFICULTY OF DIAGNOSE LSIL

2. False PositiveA false positive Pap test means that a patient is told she has normal cells, butthe cells are actually abnormal due to lack of train ing or experience of ML T

(Am J Clin Pathol, 2008)

LSIL ALGORITM

REFERENCES

Diane Soloman, Ritu Nayar, The Bethes d a System for Reporting Cervical Cytology; Definitions, Criteria an d Ex planatory Notes, 2 nd Ed ition, 2004:91-92:96-97.Ed mun S. Cibas, Barbara S. Ducatman, Diagnostic Principle an d Clinical Correlates, 2n d ed ition, 2003:24-26.Grace T. Mc Kee, Diagnostic Cytopathology.Winfre d Gray, 2 nd Ed ition , Churchill Livingstone, 2003:726-732.Ibrahim Ramzy, Clinical Cytopathology an d Aspiration Biopsy, Fun d amental Principle an d Practice, 2 nd Ed ition,2001:147-149:155-156 C Scheungraber, Management of Low-Gra d e Squamous Intraepithelial Lesions of the Uterine Cervi x , British Journal of Cancer, 2004:975-978 Am J Clin Pathol, Crum, CP. Laboratory management of CIN : The Consensus is Consensus. 2008:130:162.http://www.a d vpath.com

(Diane Solomon, 2004 )

Pitfalls : Refer to c ells that mimic the morphology of LSIL ( Ibrahim Ramzy, 2001)

INTRODUCTION

(Diane Soloman, Ritu Nayar 2004)

3. Other than MLT errors :Specimen collectionStaining type and qualityPoor fixationStorage time and delivery