Female Genital Tract Cytology 1 - UniKL PDF

INSTITUTE OF MEDICAL SCIENCE TECHNOLOGY Topic 3 FEMALE GENITAL TRACT CYTOLOGY 1 Universiti Kuala Lumpur (UniKL) | Where Knowledge Is Applied and Dreams Realised  PROGRAM LEARNING OUTCOME (PLO)...

INSTITUTE OF MEDICAL SCIENCE TECHNOLOGY Topic 3 FEMALE GENITAL TRACT CYTOLOGY 1 Universiti Kuala Lumpur (UniKL) | Where Knowledge Is Applied and Dreams Realised  PROGRAM LEARNING OUTCOME (PLO) 2 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  COURSE LEARNING OUTCOME (CLO) CLO1 Discuss various techniques involved in cytopathology investigations. (C5,PLO6) Integrate the fundamental knowledge and technique in CLO2 cytopathology diagnostic laboratory such as sample collection, staining and screening techniques. (P6,PLO2) CLO3 Prepare cytopathology report according to the specified format. (A2,PLO5) 3 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  LESSON LEARNING OUTCOME At the end of the lesson, students are able to: Describe normal anatomy, histology & physiology of female genital tract Describe cytological features of normal epithelial cells of female genital tract Explain hormonal influences on cervical samples Describe epidemiology, risk factors, signs & symptoms of cervical cancer Discuss techniques of sample collection & preparation for cervical cytology study Explain the purpose of hormonal cytology evaluation and cytological indices 4 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  LESSON OUTLINE Anatomy & histology of female genital tract Physiology of female genital tract Cytological features of normal epithelial cells of female genital tract Hormonal influences on cervical samples Overview of cervical cancer Sample collection & preparation for cervical cytology study Hormonal cytology evaluation and cytological index 5 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  ANATOMY & HISTOLOGY OF FEMALE GENITAL TRACT Ovaries Uterine tubes Uterus Vagina 6 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Gross anatomy of female genital tract 7 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY Vagina 8 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY Vagina The cells lining vagina show cyclical variations according to circulating levels of estrogen & progesterone. 9 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY Uterus 10 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY Uterus: Cervix Endocervical mucosa Ectocervical mucosa Simple columnar Non-keratinized stratified epithelium (glandular squamous epithelium cells, ciliated cells) 4 cell layers – basal, Reserve cells: parabasal, intermediate beneath/between & superficial columnar cells Epithelium of cervix undergoes cyclical variations (less susceptible to hormonal variations than vaginal epithelium) 11 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY Cervix – Squamocolumnar junction (SCJ) SCJ: transition between columnar epithelium of endocervix & squamous epithelium of ectocervix 12 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  PHYSIOLOGY OF FEMALE GENITAL SYSTEM All organs of the female genital system interact by means of hormones. HORMONE FUNCTION SECRETED BY Stimulate release of Gonadotropin releasing gonadotropin (FSH, LH) from Hypothalamus hormone (GnRH) anterior pituitary gland Follicle stimulating Stimulate follicle maturation in Anterior hormone (FSH) ovary pituitary gland Luteinizing hormone Anterior Ovulation (surge of LH) (LH) pituitary gland 13 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  PHYSIOLOGY OF FEMALE GENITAL SYSTEM HORMONE FUNCTION SECRETED BY Stimulate growth of female reproductive organ Maturing Stimulate growth of endometrium Estrogen follicles in during menstrual cycle ovary Stimulate growth & maturation of cervical & vaginal epithelium Prepare endometrium for implantation Progesterone Relax myometrium during gestation Corpus luteum (against miscarriage) 14 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Phases of menstrual cycle in ovary, uterus & cervix Day Ovary Uterus Cervix Menstrual phase ✓ Blood & menstrual debris Follicular phase ✓ Endometrium sheds appear in cervical sample 1-4 ✓ Several follicles after estrogen & ✓ No specific pattern of begin to progesterone levels epithelial cells mature under fall the influence ✓ Endocervix secretes large of FSH amount of mucus Proliferative phase ✓ Squamous epithelium 5-13 ✓ Follicles ✓ Endometrium proliferates; increasing secrete regrows proportion of superficial estrogen cells in sample ✓ Menstrual debris disappears 16 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Day Ovary Uterus Cervix Ovulatory phase ✓ Mucus becomes thin & ✓ LH surge watery, allowing passage of causes Proliferative phase sperm 14 ovulation ✓ Endometrium ✓ Preponderance of superficial ✓ Estrogen regrows cells in sample secretion ✓ ‘Clean’ background maximal ✓ Mucus secretion declines & Secretory phase becomes thick, ✓ Endometrium impenetrable, hostile to Luteal phase secretes fluid rich in sperm ✓ Corpus luteum sugars, acid amino & ✓ Combined effect of estrogen 15-28 secretes glycoprotein → & progesterone → estrogen & nourish early maturation of squamous progesterone embryo (in the event epith. to intermediate layer of fertilization) ✓ Intermediate cells dominate the sample 17 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  CYTOLOGICAL FEATURES OF NORMAL EPITHELIAL CELLS OF FEMALE GENITAL TRACT Ectocervical mucosa Endocervical mucosa Non-keratinized Simple columnar stratified squamous epithelium (glandular epithelium cells, ciliated cells) 4 cell layers – basal, Reserve cells: parabasal, beneath/between intermediate & columnar cells superficial 18 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY Ectocervical cells 19 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY Ectocervical cells: Parabasal cells Round/oval cells, 12-30 µm (diam.) Dense green cytoplasm Round/oval nucleus, 8 µm (diam.), occupying half of the cell Evenly distributed vesicular chromatin 20 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY Ectocervical cells: Intermediate cells Polygonal cells, 30-40 µm (diam.), folded edges (sometimes) Cytoplasm usually cyanophilic (sometimes eosinophilic) Round/oval nucleus, 8 µm (diam.) Low NCR Fine vesicular chromatin 21 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY Ectocervical cells: Superficial cells Polygonal cells, 35-45 µm (diam.) Eosinophilic cytoplasm Small pyknotic nucleus, 5 µm (diam.) Low NCR 22 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY Endocervical cells Honeycomb sheets / palisaded Cilia occasionally visible at 1 end strips / loose single columnar Oval nucleus with fine cells chromatin pattern, 1 or more Finely vacuolated cyanophilic small nucleoli (occasionally) cytoplasm 23 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  HORMONAL INFLUENCES IN CERVICAL SAMPLES PROLIFERATIVE / SECRETORY / LUTEAL MENSTRUAL PHASE FOLLICULAR PHASE PHASE Characterized by ↑ proportion of ↑ proportion of presence of blood, superficial intermediate inflammatory squamous cells squamous cells exudates & (effect of (effect of estrogen endometrial cells → estrogen), fewer & progesterone), menstrual debris intermediate cells, lactobacilli & less menstrual cytolysis Menstrual debris – difficult to debris screen cervical sample (not advisable for sample collection) 24 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  HORMONAL INFLUENCES IN CERVICAL SAMPLES 25 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  HORMONAL INFLUENCES IN CERVICAL SAMPLES DURING PREGNANCY POST-PARTUM Samples not ideal → difficult Show lactating pattern to interpret (breastfeeding mum) → Contain navicular cells (boat- epithelial atrophy, sample shaped; glycogenated consists primarily of parabasal intermediate cells, glycogen & immature intermediate cells appears brownish) → mimic viral infection Atrophy of cervical epithelial cells & inflammatory changes (due to prolonged exposure to progesterone) 26 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY Navicular cells (during pregnancy) Navicular cells Boat-shaped Glycogenated intermediate cells → glycogen appears brownish 27 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY Post-partum lactating pattern Parabasal cells & immature intermediate cells 28 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  HORMONAL INFLUENCES IN CERVICAL SAMPLES MENOPAUSE Atrophy of epithelium (lack of estrogen) → pure population of parabasal cells (single/sheets) Difficult to interpret due to raised NCR & granular pattern Blue blobs may present → degenerative parabasal cells → easily mistaken for a marked hyperchromatic nuclei 29 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  OVERVIEW OF CERVICAL CANCER Cervical cancer is the 4th most common cancer in women, globally. It is the 3rd most frequent cancer in women in Malaysia (2021). Estimated 570,000 new cases in 2018 representing 6.6% of all female cancers. Among all cancer deaths, cervical cancer ranked 5th (Malaysia) Prevention, early diagnosis & treatment able to  mortality 2 main types of cervical cancer Squamous cell carcinoma 30 LABORATORY HDB30303 CLINICAL Adenocarcinoma CYTOPATHOLOGY  Risk factors of cervical cancer Major risk factor Other risk factors Infection with certain types >3 sexual partners of Human Papilloma Virus Early sexual intercourse (HPV)- type 16 & 18 >10 years’ use of oral (transmitted sexually) contraceptive 1st delivery < age of 17 High parity (≥7 full term pregnancies) Smoking Lower socioeconomic status 31 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY Signs & symptoms Most patients are asymptomatic Common presenting symptoms - fatigue, weight loss, loss of appetite More severe symptoms may arise at advanced stages 32 HDB30303 CLINICAL LABORATORY CYTOPATHOLOGY  Screening of cervical precancerous lesion Screening methods Cytology → Papanicolaou (Pap) smear/ Pap test Most effective strategy HPV test Visual inspection with acetic acid (VIA) →white line: immature squamous metaplastic epithelium Recommendation for Pap smear testing (in Malaysia) Women who are, or who have been sexually active, between the ages of 30-65 years (