Download Case provided by: Miss Sonali Mane

Thank You,
Correct Answer is
NILM, Atrophy
Clinical Details
This is a cervico-vaginal smear from a 70 year post menopausal female who presented with complaint
of vaginal bleeding.
Description
Haemorrhagic smears show singly occurring and groups of small squamous cells. Cytoplasm is
moderate and dense. Nuclei are enlarged slightly hyperchromatic with smooth nuclear membrane and
finely granular chromatin. Nucleoli are absent. Few fibre-like cells are also noted.
Background is haemorrhagic. Necrosis is absent.
Discussion
In atrophy, the decreased estrogenic activity is reflected in cervico-vaginal smears as scanty exfoliated
cells consisting mainly of parabasal cells. The cervical epithelium also atrophies and mucus secretion
decreases which leads to increased air-drying problems with conventional smears.1 This may lead to
uniform enlargement of cells with a characteristic uniform grey discoloration of degenerated nucleus,
pseudo-eosinophilia of cytoplasm with nuclear pyknosis and karyorrhexis.2
In case of atrophy accompanied with inflammation, diagnostic problems may occur. This is due to
erosion and ulceration of the thin epithelial layers which induce regenerative changes. These
regenerative cellular changes are reflected in the parabasal type cells with relatively large nuclei and
prominent nucleoli. There may be a marked variation in their size and shape.3
In this case few parabasal type cells with enlarged nuclei are seen. The nuclear cytoplasmic ratio is
altered. The nuclei though hyperchromatic show smooth regular nuclear membrane and smudged
chromatin pattern. Nucleoli are not seen.
Nuclear enlargement without nuclear contour irregularities is a normal reactive change in cervicovaginal smears of post menopausal women.4
Orderly cell arrangement, indistinct nuclear borders and pale to hyperchromatic smudgy chromatin
help to differentiate atrophy from HSIL.6
Scraping of severely atrophic mucosa may produce sheets of spindly cells with elongated, pyknotic
nuclei.5 The nuclear pyknosis may be striking and often simulates squamous carcinoma cells.2 Similar
cells are seen in this case.
To differentiate these from cancer cells look for transparent cytoplasm, vesicular benign looking
nuclei and karyorrhexis. However in this case the cytoplasm cannot be appreciated due to
haemorrhage and nuclear chromatin is not crisp.
Also the background does not show tumor diathesis.
In equivocal cases, smears may be repeated after a short course of estrogen. Abnormal cells if
persisting after estrogen therapy indicate dysplastic changes.
Follow Up The patient underwent a colposcopy and a biopsy. The histology showed ulcerated,
chronically inflamed squamous mucosa with granulation tissue.
References
1. Color Atlas of Cancer Cytology – Masayoshi Takahashi, page 58.
2. Diagnostic Cytology and its Histopathologic Basis – Leopold G Koss, page 279.
3. Comprehensive Cytopathology – Marluce Bibbo, page 160.
4. Squamous Atypia in the Atrophic Cervical Vaginal Smear. A New Look at an Old Problem.
Abati A, Jaffurs W, Wilder A. Cancer (Cancer cytopathol) 1998;84:218-25
5. Cytopathology - Z Naib, page 107.
6. Color Atlas of Differential Diagnosis in Exfoliative and Aspiration Cytopathology – Sudha R
Kini, page 55.
Case provided by: Miss Sonali Mane