Diagnostic Cytopathology

Jaroslava Dušková

Inst. Pathol. ,1st Med. Faculty, Charles Univ. Prague

Definition

Historic note

Cytopathology - tasks

– exfoliative

gynecological screening

urological screening and diagnostics

cytodiagnostics of body fluids – diagnosis of

inflammation, diagnostics and staging of

neoplasms

– aspiration diagnostic biopsy

Conclusions and links

Diagnostic cytopathology - contents

Morphological Diagnostic Methods

Clinical

Pathological

Morphological Diagnostic Methods

Clinical:

macroscopy of lesions

visible with the naked eye

invisible with the naked eye -

IMAGING (X-ray, sonography,

scintigraphy, endoscopy, CT,…)

magnifying glass - colposcopy

Morphological Diagnostic Methods

Pathological

macroscopy

microscopy

cytopathology

histopathology

molecular pathology

ultrastructure

IMAGING

Morphological Diagnostic

Methods Pathological

microscopy

cyto(patho)logy

minibiopsy - cytoblock

histo(patho)logy

Morphological Diagnostic Methods

Pathological

macroscopy of lesions

autopsy report

biopsy description

cytology material description

Cytology (FNAB)

often both first and final dg. method

outpatient low cost procedure

done by an experienced

(cyto)pathologist surprisingly effective

has some limits (!)

Georg L. Wied

M.D., D.Sc.(hon), F.I.A.C.

7.2. 1921- 25.7. 2004

Goals of Cytological Investigation

Screening – detection of symptomless

lesions

Diagnosis of pathological lesions found

introductory (followed by histol.)

final

Expectations

Clinician from his pathologist:

confirmation of neoplasm dg.

nosological classification

grading, staging

prognosis

reaction to the therapy

recurrence recognition

Expectations

Pathologist from his clinician:

information: local.,size, duration,

former dg. a treated neo, clin. dg.

diagnostic material acquisition

correct interpretation of the

pathologist´s report

CYTOLOGY

IS VERYEFFICIENT

IN EARLY

NEOPLASM

DIAGNOSTICS

ESPECIALLY,

IF

CLINICO-

MORPHOLOGICAL

COMMUNICATION

WORKS

Getting Cytology Material

surface – smeared, brushed,

scraped

cavities – punctured, aspirated

deep solid lesions - aspirated

Processing Cytology Material

smears

cytospins, cytosedimentation

cytoblock

Minibiopsy -

Cytoblock from

FNAB

advantage of easy material taking together

with more tissue architecture information

histology &, immunohistochemistry

methods available

multilayered tissue phragments readable

Cytology Material Staining

gynaecology smears - polychrome

other materials –MGG, HE, polychrome, all other methods

cytoblock – multiple methods

Gynecological

oncologic

cytology

laboratory investigation standard

Authors: MUDr Alena Beková, MIACMUDr Pavel Tretiník, MIAC

Oponents: doc. MUDr J. Dušková, CSc,FIACMUDr Eva Svobodová

http://www.cervix.cz

Bethesda

- Classification of cervical cytology

1. normal

2. benign cellular changes

3. ASCUS

4. L SIL

5. H SIL

6. Atypia of glandular cells

7. susp. adenoca

General Categorisation

negative

for intraepith. lesion or malignancy

intraepith. lesion or malignancy

squamous or glandular

other pathologyendometral cells in women over 40 yrs

Cytology - Evaluation

staining and evaluation – minutes

Bethesda system :

– material quality and quantity

– group diagnosis

– diagnosis as close to the histology (tissue diagnosis) as possible

– recommendation

0

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01

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15

Ag

e-s

tan

dard

ised

in

cid

en

ce a

nd

mo

rtality

AS

R(E

)

Year of diagnosis/ death

Trends in cervical cancer incidence and mortality „joinpoint analysis“

-1,6 %

-4,9 %

-2,8 %

Organized

cervical cancer

screening

Source: incidence, mortality, prevalance – Czech National Cancer Registry

-0,2 %

38 laboratories (accredited by Ministry of Health)

Data from laboratories

Vytvořil Institut biostatistiky a analýz, Masarykova univerzita

Central database of cervical

cancer screening

DATA EXPORT

VALIDATION

REPORTING

Expert

Guarantee

Gynekologist Histopathologist

Clinical /Cytology reports

Results of cervical screening cytology

examinations

2. ASC-US

31 162

1,41 %

1. Bez neoplastických

intraepiteliálních změn a

malignity

2 143 834

96,84 %

3. ASC-H

4 165

0,19 %

4. LSIL

21 559

0,97 %

5. HSIL 2 909 0,13 %

8. Glandular atypia

4 148

0,19 %

6. HSIL – cannot exclude invasion

166

0,007 %

7. Squamous cell carcinoma

126

0,006 %

9. Glandular cells atypia

(favour neoplastic)

185

0,008 %

10. Adenocarcinoma in situ

18

0,001 %

11. Invasive adenocarcinoma

48

0,002 %

12. Other malignancy

22

0,001 %n = 2 213 782 womenincl.5 440 other/not recorded/unable to diagnose

Examinations in 2016

The results are abnormal

(mostly ASC-US or LSIL)

in 3% of women

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60+

Agi group

Coverage by

screening

Cervical cancer screening coverage in 2016

Estimated coverage of the population aged 25–29

years in 2016: 57,9 %The rate is calculated as the ratio of the number of women examined by screening cytology in 2016 (in a

given age group) and the number of women in the target population in 2016.

Due to the fact that hash values of birth certificate numbers are not available in the registry, data can be

slightly biased by duplicate records of screening examinations in different laboratories.

Population aged 25-59

Source: Cervical Cancer

Screening Registry, IBA MU

Estimate of population coverage

by screening cytology in 2015-2016

Estimated coverage of the population aged 25–29 years

by screening cytology in 2015-2016: 78,7 %

The rate is calculated as the ratio of the number of women examined by screening cytology in 2015

or 2016 (in a given age group, age at the latest examination) and the number of women in the target

population in 2016.

Due to the fact that hash values of birth certificate numbers are not available in the registry, data can be slightly biased by duplicate

records of screening examinations in different laboratories.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60+

Age group

Coverage by

screeningPopulation aged 25-59

Source: Cervical Cancer

Screening Registry, IBA MU

Interpretation

negative for intraepithelial lesion or malignancy

Microorganisms Trichomonas

mycosis vs. candidosis

shift - bact. vaginitis

bacteria Actinomyces like

cell changes of HSV type

Candida

glabrata

Chlamydia

Chlamydia trachomatis IS CO-CANCEROGEN …..

intracellular parasite

purulent inflammation

can be asymptomatic

morphologica changes „mimicking” SIL H

Source: Program in Epidemiology, Fred Hutchinson Cancer Research Center, Seattle, USA

Madeleine MM, Anttila T, Schwartz SM, Saikku P, Leinonen M, Carter JJ, Wurscher M, Johnson LG, Galloway DA, Daling JR.:

Risk of cervical cancer associated with Chlamydia trachomatis antibodies by histology, HPV type and HPV cofactors.

Int J Cancer. 2007 Feb 1;120(3):650-5.

Chlamydia trachomatis supresses male fertility…

90 millions of infections/yer – the motst frequent bacterial STD in the world

can be asymptomatic

severe complications (acute PID pelvic inflammatory disease,

ectopic pregnancy, infertility, infancy pneumonia)

Source: Department of Biological and Physiological Sciences and Laboratories of Investigation and

Development, Universidad Peruana Cayetano Heredia, Lima, Peru

Gonzales GF, Muñoz G, et al:Update on the impact of Chlamydia trachomatis infection on male fertility.

Andrologia. 2004 Feb;36(1):1-23.

Herpes

Immigrants with a high prevalence of Gardnerella also have a high prevalence of Trichomonas. Such slides should be screened with extra care (increased risk of squamous abnormalities ) …

58,904 Immigrants and 498,405 Dutsch

imigrants from Surinam, Turkey and and the Dutch Antilles had 2,5 times

higher incidence of Gardnerella (clue cells) and Trichomonas

smears with the Gardnerella infection bear the risk of higher frequency

of squamous lesions and require extra screenming care…

Source: Leiden Cytology and Pathology Laboratory, Leiden, The Netherlands.

Boon ME, Holloway PA, Breijer H, Bontekoe TR. Gardnerella, Trichomonas and Candida in cervical smears of 58,904 immigrants participating in the Dutch national cervical screening program. Acta Cytol. 2012;56(3):242-6.

Sensitivity and specificity of the Fournier device test was comparable to Papanicolaou smears tests obtained using the traditional method with speculum examination. ….

immigrants, muslims and other minority populations participate less in cervical screening

self-sampling device Fournier(®) represents an alternative for women who do not tolerate assisted vaginal sampling

Source: Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brasil.

da Silva Rocha A, Schaeffer PG, Meurer L, et al.: Assessment of the Fournier(®) cervical specimen self-sampling device using the Papanicolaou method.

Acta Cytol. 2012;56(5):520-6.

Zdroj: Department of Family Medicine and Community Health, University of Medicine and Dentistry of New Jersey, USA.

Friedman AM, Hemler JR, et al.:Obese Women's Barriers to Mammography and Pap Smear: The Possible Role of Personality.

Obesity (Silver Spring). 2012 Feb 28. doi: 10.1038/oby.2012.50. [Epub ahead of print]

Obese women are at increased risk of developing and dying from cervical and mammary cancer, but are less likely than nonobese women to receive cancer screening

Detection of HR HPV and cytology should be combined….

study of 705 women with cytology and HC2 HR HPV

HR HPV higher sensitivity 84.5% vs. 69.7% compared to

cytology

HR HPV lower specificity 49.90 vs. 88.78% compared to

cytology

(p <

0.0001)

Zdroj: Departments of Obstetrics and Gynecology, Clinics Hospital, School of Medicine, University of São Paulo,

Brazil

Beldi MC, Tacla M, Caiaffa-Filho H, Ab'saber A, Siqueira S, Baracat EC, Alves VA, Longatto-Filho A : Implementing human papillomavirus testing in a public health

hospital: challenges and opportunities.Acta Cytol. 2012;56(2):160-5.

L SIL

Condyloma accuminatum

CIN I

SIL H

0,0

2,0

4,0

6,0

8,0

10,0

12,0

14,0

Examination of hrHPV by age groups

Věk při vyšetření

Vyšetření na

1000 žen

Testing the presence of high-risk HPV (95201) (N = 26 506 examinations in 2016; data from healthcare payers)

))

Overall rate (25-59 years, 2016): 9,0 examinations per 1,000 women

Screening karcinomu děložního hrdla

Užší cílová populace, 25-59 let

N = 23 066 vyšetření

In 2015, the overall rate was 6,5 examinations per 1,000 women

adenocarcinoma

www.cervix.cz

Májek, O., Dvořák, V., Dušek, L., Mužík, J., Šnajdrová, L., Gregor, J. Cervix.cz – Cervical Cancer Screening Programme in the

Czech Republic [online]. Masaryk university, Brno, 2016. [cit. 2016-04-14]. Available at WWW: http://www.cervix.cz. ISSN

1804-087X. Version 1.6f.

Definition

Historic note

Cytopathology - tasks

– exfoliative

gynecological screening

urological screening and diagnostics

cytodiagnostics of body fluids – diagnosis of

inflammation, diagnostics and staging of

neoplasms

– aspiration diagnostic cytopathology

Conclusions - links

Diagnostic cytopathology - content

urine PAP V

Candidosis – BAL polychrome // methenamine silver)

Cytomegalovirosis

Peritonitis carcinomatosa

Pleuritis

carcinomatosa

AgNOR

Alc. Blue pH2,5

F

N

A

B

Cytology (FNAB)

often both first and final dg. method

outpatient low cost procedure

done by an experienced

(cyto)pathologist surprisingly effective

has some limits (!)

Cytology getting sample

needle 0.6-0.8mm

min. 2 punctionsaspiration

nonaspiration – reduction of the blood content

cyst: evacuate and aspirate with the

second punction the periphery

fluid: whole volume for cytology

Abscessus linguae - Actinomycosis vs.

FNAB - yield evaluation

Staining and yield evaluation takes minutes

ROSE

Rapid On Site Evaluation

Cytoblock

cytoblock

Carcinoma papillare glandulae thyreoideae

psammoma

respiratory

epithelia

muscle

fatty

tissue

Angiosarcoma

CD34

Adenoma corticis glandulae suprarenalis

Metastasis adenocarcinomatis gl. suprarenalis

Adenoma pleomorphe

Cystadenoma papilliferum lymphomatosum Warthin

Cystis lateralisMetastasis ca

spinocellularis

Adenoid cystic carcinoma

Adenoid cystic carcinoma

Lymphadenopathia inflammatoria

Meningitis purulenta

CSF

Liquor cerebrospinalis

oil red

Fe

Carcinosis meningum

Carcinoma diffusum ventriculi (ad meningos metastaticum)

MEETING of Papanicolaou

Society of Cytopathology

Martha Bishop Pitman (Boston)

EUS-FNA cytology of the pancreas

2

0

0

6

Geneve 2014

EUS-FNA Ca pancreatis

C1240/06

EUS-FNA Ca pancreatis

C7/07

Morphological Diagnostic Methods

Clinical:

macroscopy of lesions

visible with the naked eye

invisible with the naked eye -

IMAGING (X-ray,

sonography, scintigraphy, endoscopy,

CT,…)

magnifying glass - colposcopy

Not a good practice….

Cytopathology lab receives a sample

with a „self explanatory “ text:

„puncture for cytology” …???

http://www.patologie.info

http://www.cyt.cz/

http://www.eurocytology.eu

Eurocytology 2013-15

Partners Imperial College Healthcare NHS Trust

European Federation of Cytology

Societies

Turkish Cytology Society

Czech Cytology Society

Inbrooks Ltd

Interfase

Target groups

– Cytotechnologists in training

– Cytopathologists in training

– tutors and instructors of cytology

– medical students

1

1

Projekt EUROCYTOLOGY je podporován z programu Leonardo da Vinci s cílem zlepšit přístup

k materiálům pro výcvik klinické cytologie a harmonizovat výcvik v této důležité subspecializaci

patologie v Rámci EU. Vezměte prosím v úvahu, že jednotlivé národní jazykové verze se mohou

v souvislosti s různým curriculem mírně lišit.

https://www.eurocytology.eu/

What is peculiar to this project?

Transnationality

Validation through a European Network

Dynamic tests through the use of a

specific software and image database

Use of virtual slides

Translated in several languages

Eurocytology Project 2013-2015:

The Contribution of the Czech Republic.Duskova J.1, Badger A.2, Capitanio A.3, Fassina A.4, Önal B.5, Bonora R.6, Poznanski J.7,Tötsch M.8, Dina R7.

1Prague, Czech Republic,

2Leamington Spa, United Kingdom,

3Stockholm, Sweden,

4Padova, Italy,

5Ankara, Turkey,

6Trieste, Italy,

7London, United Kingdom,

8Gent,

Belgium

Introduction: The Eurocytology website was

originally developed with Leonardo funding in

2005-7. It was formerly available in 6

languages (English, Spanish, Italian, Greek, Polish and Hungarian).

The Czech Association for Clinical Cytology

participated in the Leonardo Da Vinci

Programme 2011 initiative and became an

official partner in the second phase of the

Eurocytology project 2013-2015.

Objective: To update the Leonardo –

Eurocytology Project 2013-15 and the Czech

Society for Clinical Cytology contribution.

Methods: Description of activities undertaken

–collaboratively and internationally.

www.eurocytology.eu

Referen

ce

Conclusion: The updated website

www.eurocytology.eu increases the level

of cytopathology education

in the Czech Republic.

Results:

• All current modules of the former website

have been translated and incorporated into

the curricula of the cytotechnology and

cytopathology education.

• Prague hosted in September 2014 the

international working session.

• The Czech partners have reviewed the

updated chapters of gynaecology cytology

written by Amanda Herbert.

• The details of the platform are disseminated

during the national cytology and pathology

congresses, workshops and seminars.

• The feedback from the website users

proves increasing interest among the Czech

specialists.

• Due to lack of a language barrier the Czech

language version may serve the Slovak

colleagues tutorials as well.

The use of the

original

Eurocytology

website has

significantly

exceeded

expectations.

In 2013 it received

on average 50,000

visits and 75,000

pages downloaded

/ month.THE NEW WEBSITE

will provide during 2015

updated content of the

former chapters

The Czech

and

Slovak Republic

specialists

start to emerge

among

the website users

ADDITIONAL

PLANNED

CHAPTERS

• Colposcopy

• Self assessment

for each chapter• 10 Virtual slides for

each chapter

• Immunocytochemis

try in cytology

• Molecular

diagnostic tests in

cytology• Flow Cytometry

• The role of

Cytotechnologists

in FNA cytology

• CSF cytology

• Joint Fluid cytology

• On line

examination in

cervical cytology

• On line

examination in

diagnostic cytology

• QUATE mock

examination on

line

http://www.efcs.eu

www.eurocytology.eu

Dyskaryosis

http://www.efcs.eu

CYTOLOGY

LOVE IT or

LEAVE ITL. Cardozzo