Squamous Lesions (SIL)

including HPV and cancer Terminology

BSCC (UK) current terminology

BSCC (UK) proposed new terminology

Bethesda 2001 terminology

ECTP (European terminology)

Dr. M. Desai
Head of Cytopathology Service/Clinical Lead for Gynaecological Cytology/Consultant
Cytology/Consultant Cytopathologist
& Training School Director
Manchester Cytology Centre
U.K.

BSCC 1986 BSCC Bethesda system 2001 ECTP Terminology

Comparison of BSCC (UK), Bethesda (USA) and ECTP (European) Terminology Proposed new
Terminology
BSCC 1986 BSCC Bethesda system 2001 ECTP Terminology
Proposed new
Terminology
Mild dyskaryosis Low grade dyskaryosis LSIL Mild dysplasia
Negative Negative Negative for Within normal limits (includes all cases of Includes koilocytosis (CIN1)
intraepithelial lesion or koilocytosis provided that
malignancy no high grade dyskaryosis
is present)
Inadequate Inadequate Unsatisfactory for Unsatisfactory due to …
evaluation Moderate dyskaryosis High grade dyskaryosis HSIL Moderate dysplasia
(CIN2).
Borderline nuclear change 1. Borderline change, 1. Atypical 1. Koilocytes (without
Include squamous, but not squamous cells of changes Severe dyskaryosis HSIL 1. Severe dysplasia
otherwise specified. suggestive of (CIN3)
(ASC-
(ASC-US)
intraepithelial
undetermined
neoplasia)
2. Carcinoma in situ
2. Borderline change, high significance (CIN3)
grade dyskaryosis not
excluded. 2. Squamous cell Severe dyskaryosis Severe dyskaryosis ? Squamous cell 1. Severe dysplasia
2. ASC-
ASC-H (cannot changes (not Invasive carcinoma ? Invasive.
? Invasive
exclude HSIL) definitely
3. Borderline change in 2. Invasive
endocervical cells. neoplastic but
merit early squamous cell
3. Atypical
repeat). carcinoma
endocervical /
endometrial / ? Glandular neoplasia ? Glandular neoplasia 1. Endocervical Adenocarcinoma
glandular cells: 3. Atypical glandular carcinoma in situ
NOS or favour cells (qualify).
Endocervical AIS
neoplastic. Non cervical 2. Adenocarcinoma Endocervical
Endocervical Endometrial
From: Revised BSCC terminology : cytopathology Vol19 no.3 June 2008 P.137-157
Endometrial Extrauterine
Extrauterine NOS
NOS

Definition of Dyskaryosis Normal Chromatin Pattern

(SIL) smooth with equal
distribution of nuclear chromatin

Abnormal chromatin pattern is the essential
requirement.

Finely speckled, punctate or coarsely clumped chromatin

Abnormal size,spacing and distribution of chromatin
granules

Hyper or Hypochromasia

Irregular nuclear outline + or –

Minor changes in nuclear outline e.g.single or multiple
folds,wrinkling or serration occur with inflammation and
degeneration.

Large bulbous protrusions,scalloping or deep notches not
associated with linear folds occur in dyskaryosis.

Raised nuclear : cytoplasmic ratio

1
Abnormal Chromatin Pattern - Abnormal Chromatin Pattern -
Finely Speckled Finely Speckled and Punctate Chromatin

Abnormal Chromatin Pattern - Densely Definition of Dyskaryosis

Hyperchromatic with Clumped Chromatin (SIL)

Abnormal chromatin pattern is the essential
requirement.

Finely speckled, punctate or coarsely clumped chromatin

Abnormal size,spacing and distribution of chromatin
granules

Hyper or Hypochromasia

Irregular nuclear outline + or –

Minor changes in nuclear outline e.g.single or multiple
folds,wrinkling or serration occur with inflammation and
degeneration.

Large bulbous protrusions,scalloping or deep notches not
associated with linear folds occur in dyskaryosis.

raised nuclear : cytoplasmic ratio

DYSKARYOTIC CELL (SIL) Abnormal Chromatin distribution

Coarse chromatin with unequal
distribution

2

Fine,Speckled and coarse granularity but even distribution of
chromatin in NON-DYSKARYOTIC nuclei
Fine,speckled and coarse but irregularly distributed
chromatin of DYSKARYOTIC (SIL) nuclei
Definition of Dyskaryosis

Abnormal chromatin pattern is the essential
requirement.

Finely speckled, punctate or coarsely clumped chromatin

Abnormal size,spacing and distribution of chromatin
granules

Hyper or Hypochromasia

Irregular nuclear outline + or –

Minor changes in nuclear outline e.g.single or multiple
folds,wrinkling or serration occur with inflammation and
degeneration.

Large bulbous protrusions,scalloping or deep notches not
associated with linear folds occur in dyskaryosis.

Raised nuclear : cytoplasmic ratio

Spot the Difference

Chromasia Definition of Dyskaryosis (SIL)

Abnormal chromatin pattern is the essential
requirement.

Finely speckled, punctate or coarsely clumped chromatin

Hyperchromasia
Abnormal size,spacing and distribution of chromatin
granules

Hyper or Hypochromasia

Irregular nuclear outline + or –

Minor changes in nuclear outline e.g.single or multiple
folds,wrinkling or serration occur with inflammation and
degeneration.

Large bulbous protrusions,scalloping or deep notches not

Hypochromasia associated with linear folds occur in dyskaryosis.

Raised nuclear : cytoplasmic ratio

Minor changes in nuclear outline

in Inflammation
Nuclear folds in
normal cell

3
 Abnormal Nuclear membrane
In Dyskaryosis (SIL)
(Bulbous Protrusion)

Smooth nuclear membrane In

Dyskaryosis (SIL)

Spot the Difference Spot the Difference

Nuclear wrinkling and folding of Nuclear membrane protrusion

and deep notches in
NON DYSKARYOTIC cell
DYSKARYOTIC (SIL) cell

Definition of Dyskaryosis (SIL) Raised Nuclear:Cytoplasmic Ratio

Abnormal chromatin pattern is the essential
requirement.

Finely speckled, punctate or coarsely clumped chromatin

Abnormal size,spacing and distribution of chromatin
granules

Pale vs. Hyperchromatic

Irregular nuclear outline + or –

Minor changes in nuclear outline e.g.single or multiple
folds,wrinkling or serration occur with inflammation and
degeneration.

Large bulbous protrusions,scalloping or deep notches not
associated with linear folds occur in dyskaryosis.

Raised nuclear : cytoplasmic ratio

Used for grading of dyskaryosis (SIL)

Nucleus occupies more than 50% of area of
cytoplasm in High Grade Dyskaryosis (HSIL)

High Grade dyskaryosis (HSIL) is found in less
mature cells

Moderate dyskaryosis is seen in larger and
intermediate size parabasal squamous cells

Severe dyskaryosis is seen in small parabasal
and basal squamous cells

4
 Pitfalls (false positive) - high
nuclear:cytoplasmic ratio with:

Endocervical cells
Immature squamous metaplastic
cells
Endometrial cells
Moderate Dyskaryosis Severe Dyskaryosis
HSIL HSIL Lymphocytes

Immature metaplastics Endometrials

Mild Dyskaryosis (LSIL)
Back to Basics

Cells occur singly and in sheets

Nuclear changes in mature superficial or
intermediate cells

Nuclear enlargement

mild dyskaryotic (LSIL) nuclei at least x3 size
of intermediate nucleus

Chromatin irregularity

Irregularity of nuclear membrane + or -
– Notches
– Protrusions
– Spurs
– Not just folds or wavy outline
Follicular cervicitis Endocervicals

Mild Dyskaryosis (LSIL)

Back To Basics

Dyskaryotic nucleus

Enlarged nucleus <50% of cell area

Bi and multinucleation often seen

Polygonal cytoplasm of mature
squamous cells, individual cell
borders

Strong association with ASCUS or LSIL? LSIL or HSIL?
koilocytosis Spot the difference

5
 Dyskaryosis (SIL)
? Grade

Borderline(ASCUS) Mild to Moderate Dyskaryosis

TO (LSIL TO HSIL)
Mild Dyskaryosis (LSIL)

Subjectivity Still Persist : Not a full proof Science

Spot The Spot The

Difference Difference

Mild Dyskaryosis (LSIL)

Borderline changes (ASCUS)

Features of high-
high-grade dyskaryosis
(HSIL)
Back To Basics

Increased depth of focus

Irregularity of nuclear membrane (walnut)

Increase in single, isolated and small abnormal
cells

Few abnormal cells

Isolated abnormal cells present in empty spaces
between cell clusters

Rounding up of cells resulting in smaller size and
higher N:C ratio

Cleaner background

6
 Features of high-
high-grade dyskaryosis
(HSIL)
Back To Basics

Increased depth of focus

Irregularity of nuclear membrane (walnut)

Increase in single, isolated and small abnormal
cells

Few abnormal cells

Isolated abnormal cells present in empty spaces
between cell clusters

Rounding up of cells resulting in smaller size and
higher N:C ratio

Cleaner background

Features of high-
high-grade dyskaryosis
(HSIL)

Increased depth of focus

Irregularity of nuclear membrane (walnut)

Increase in single, isolated and small
abnormal cells

Few abnormal cells

Isolated abnormal cells present in empty spaces
between cell clusters

Rounding up of cells resulting in smaller size and
higher N:C ratio

Cleaner background

7
 Features of high-
high-grade dyskaryosis
(HSIL)

Increased depth of focus

Irregularity of nuclear membrane (walnut)

Increase in single, isolated and small abnormal
cells

Few abnormal cells

Isolated abnormal cells present in empty spaces
between cell clusters

Rounding up of cells resulting in smaller size and
higher N:C ratio

Cleaner background

Features of high-
high-grade dyskaryosis
(HSIL)

Increased depth of focus

Irregularity of nuclear membrane (walnut)

Increase in single, isolated and small abnormal
cells

Few abnormal cells

Isolated abnormal cells present in empty
spaces between cell clusters in LBC and in
streaks in conventional smears

Rounding up of cells resulting in smaller size and
higher N:C ratio

Cleaner background

Features of high-
high-grade dyskaryosis
(HSIL)

Increased depth of focus

Irregularity of nuclear membrane (walnut)

Increase in single, isolated and small abnormal
cells

Few abnormal cells

Isolated abnormal cells present in empty spaces
between cell clusters

Rounding up of cells resulting in smaller size
and higher N:C ratio

Cleaner background

8
 Features of high-
high-grade dyskaryosis
(HSIL)

Increased depth of focus

Irregularity of nuclear membrane (walnut)

Increase in single, isolated and small abnormal
cells

Few abnormal cells

Isolated abnormal cells present in empty spaces
between cell clusters

Rounding up of cells resulting in smaller size and
higher N:C ratio

Cleaner background in LBC

Grade the Dyskaryosis (SIL) ?

Grading of dyskaryosis (SIL)
Useful Tips

Higher N:C ratios / areas / diameter with
increasing grade of dyskaryosis (SIL).

HSIL (Moderate between ½ to 2/3
Severe > 2/3)

Mild (LSIL) in superficial and Intermediate cells

HSIL( Moderate in Large and intermediate size
parabasal and Severe in Small parabasal and
basal cells.)

Dyskaryosis (SIL) in immature squamous cells
most likely represents high-
high-grade dyskaryosis
(HSIL)

9
 Grade the Dyskaryosis (SIL) ?
Grade the Dyskaryosis (SIL)

Moderate and Severe

Dyskaryosis
(HSIL)

Mild and Moderate

Dyskaryosis
(LSIL AND HSIL)

Grade the Dyskaryosis (SIL)

Grade the Dyskaryosis (SIL)

Mild Dyskaryosis/LSIL

Grade the Dyskaryosis (SIL)

Grade the Dyskaryosis (SIL)

Moderate Dyskaryosis/HSIL

10
Grade the Dyskaryosis (SIL)
Grade the Dyskaryosis (SIL)

Severe Dyskaryosis/HSIL

Grade the Dyskaryosis (SIL)

Low grade or High Grade?

Subjectivity persist

Grade the Dyskaryosis (SIL)

Grade the Dyskaryosis (SIL)

Low Grade or High Grade?
Patterns of Dyskaryosis (SIL)
Pattern recognition and experience

Subjectivity persist

11
 Patterns of dyskaryosis (SIL)

Ungraded Dyskaryosis (SIL)

Large cell non-
non-keratinising (Syncitial
(Syncitial))

Keratinising

Mixed

Scanty dyskaryosis (SIL)

Small cell dyskaryosis (SIL)

CIN microbiopsies (HCGs
(HCGs))

Flag cells

Pale cell dyskaryosis (SIL)

Bland cell dyskaryosis (SIL) In Thinprep
High Grade Dyskaryosis with
bare nulcei
Ungraded Dyskaryosis
Large cell non-keratinising severe dyskaryosis
Syncytial variety
Ungraded Dyskaryosis
(SIL)

Dyskaryotic bare nuclei

Loss of cytoplasm due to cytolysis or atrophy

Loss of cell boundaries

Grade as High grade dyskaryosis (HSIL)
Large cell non-
non-keratinising (syncitial
(syncitial))
High gradeDyskaryosis (HSIL)

Loose syncytial groupings

Nuclei four to six times diameter of
polymorphs

Nuclei rounded and pale staining

Finely speckled chromatin

Cytoplasm relatively abundant, delicate and
indistinct

N/C ratio difficult to assess, usually less than
half, misinterpreted as mild diskaryosis (LSIL)

Misinterpreted as CGIN when in continuity
with endocervical cells
Keratinising High grade
Dyskaryosis (HSIL)

Cytologically indistinguishable from
keratinising squamous cell carcinoma
12
 Small Cell Dyskaryosis
(HSIL)

Monotonous cell population

Abnormal chromatin pattern

Nuclear diameter less than twice of
polymorphs or lymphocyte

High nuclear:cytoplasmic ratio

Can have regular nuclear membrane

D/D immature metaplastic
cell,EM,Histiocyte,Follicular
cervicitis,atrophic EC and atrophic parabasal
squamous cells

Small cell dyskaryosis

Screening and Interpretation Error
Small cell dyskaryosis
Misinterpreted as

Normal endometrial cell

Immature metaplastic cells

Lymphocyte

Follicular cervicitis

Normal Histiocyte

Atrophic endocervical cells

Normal parabasal squamous cell

HISTIOCYTES,
Small cell severe dyskaryosis

Sparse (Scanty) dyskaryosis (SIL)

Litigation cell

Easily overlooked in routine screening

More difficult to recognise if pale,small and
FOLLICULAR CERVICITIS
single

LYMPHOCYTES ENDOMETRIALS

13
 Scanty dyskaryosis

Scanty Dyskaryosis (SIL): overlapping of the Litigation cell

fields is essential in screening

Scanty Dyskaryosis (SIL) Flag Cell

Small keratinised cell with pyknotic,

India ink nucleus

On its own should not be reported as
High grade dyskaryosis

Search for High grade dyskaryosis in
other areas

Flag cell Associated High grade dyskaryosis

Flag cells : Search for High grade dyskaryosis

(HSIL) or invasive features

14
 Pale cell Dyskaryosis (SIL)
Pale cell Dyskaryosis (SIL)

Hypo chromatic nuclei

May be a staining artefact

Identified by abnormal chromatin
pattern

Can be seen in all grades of
dyskaryosis (SIL) and types of cells

Often present mixed with some
“normal”
normal” staining cells

Nuclear membrane irregularity + or -

Pale dyskaryosis /SIL Pale dyskaryosis/SIL

Pale dyskaryosis/SIL

Bland Dyskaryosis/SIL:
A New Pitfall in Liquid Based
Cytology (ThinPrep)
Dr. D.N.Rana,Dr.K.Denton,
D.N.Rana,Dr.K.Denton,
Dr. M. Desai & Dr. M. Lynch
Cytopathology May-
May-June 2008,
19(3) P162-
P162- 166

15
 BLAND CELL DYSKARYOSIS (SIL)
Bland Dyskaryosis (SIL) •Chaotic group
• Mimicking endocervicals

Dyskaryotic/SIL cells appear deceptively bland
on low - power examination

Misinterpreted as squamous metaplastic cells

or endocervical cells

Seen in groups

Disorganised architecture within the group

Bland Dyskaryosis (SIL)

Variation in cell size

Raised nuclear:cytoplasmic ratio

Speckled / punctate chromatin pattern

Chromatin may be evenly distributed

Bland cell dyskaryosis (SIL)

Smooth nuclear outlines Overcrowding
• Speckled chromatin pattern
• Smooth nuclear membranes

CIN Microbiopsies (HCGs

(HCGs))

3D groups

Nuclear crowding

Disorderly chaotic architecture

Steep relief at edge of group

Evaluate the cells at edge

Abnormal nuclear chromatin

Hyperchromatic nuclei

Nuclear membrane irregularities less pronounced

Increased mitotic activity

Nucleoli more visible

16
ALL of the following cells are
normal !

ALL of the following cells are

abnormal !

17
 High-
High-grade dyskaryosis (HSIL)
Pitfalls

Metaplastic cells

Endometrial cells

Histiocytes

Atrophy

Blue blobs

IUCD cells

Reactive inflammatory sheets

Glandular neoplasia (cervical type)

Invasive Squamous
Carcinoma

Different types of Invasive

Squamous Cell Carcinoma Microinvasive

Micro invasive
* Can not be diagnosed reliably

Keratinising
* Indistinguishable from severe

Non keratinising large cell
dyskaryosis

Non keratinising small cell
* Macronucleoli in syncitial

Verrucous carcinoma
aggregates of severe dyskaryosis
* Irregular chromatin distribution

18
 Invasive Squamous cell Invasive squamous cell
Carcinoma: carcinoma :
Architectural features Cellular features

* Tumour diathesis
* Large numbers of dyskaryotic cells
(severe dyskaryosis)
* Very bizarre cell shapes
* Single cells, loose aggregate
* Fibre and tadpole cells
* Sheets of undifferentiated cells
HCCG * Cell embracement ( cell into cell
pattern)

Invasive Squamous cell Tumour Diathesis

Carcinoma:
Nuclear features
• Marked pleomorphism
( Different size & shape)
• Irregular Nuclear Membrane
• Coarse, granular chromatin pattern
• Hyperchromasia with windowing
(parachromatin clearing)
• Angulated chromatin
• Mitotic figure
• irregular macronucleoli
*Grey/blue granular material
clinging to malignant cells
* Blood fresh and old (haemosiderine
(haemosiderine))
* Fibrin and protein
* Cell necrosis and debris
* Nuclear and cytoplasmic fragment
* polys ,inflammatory dirty background
Diathesis is rare, reflects ulceration of surface mucosa and
associated with late stage disease
Absent in microinvasive and verrucous carcinoma

Benign Diathesis
Benign Diathesis

*Inflammatory,dirty background
*Absence of Malignant cells
*Severe infection e.g.Trichomonas Tumour Diathesis
*Severe atrophy
*Abscess
*Necrotic,ulcerated polyp

19
 Abnormal nucleoli Nucleoli

These can be single or multiple

If single, they are usually large and
abnormal with windowing

If multiple the nucleoli vary in size and
shape

They may be red staining

Nucleoli Nucleoli
Malignant Reactive

Small Cell Non-

Non-keratinizing Differential Diagnosis of Small Cell
Squamous Carcinoma Squamous cell carcinoma

*Tumour cells occur singly or in small

* Normal and abnormal endometrial cells
discohesive syncitial like groups. * Lymphoid lesions
* Cells small, cuboidal or round * Small cell severe dyskaryosis
* Scanty cytoplasm * Reserve cell hyperplasia
* High N/C ratio
* No keratinization
* Nuclei large, round to oval
* Hyperchromatic, coarsley granulated chromatin
* Nucleoli small, may be obscured

20
 Large Cell
Non-
Non-Keratinizing Differential Diagnosis of Large cell, Non-
Non-
Squamous cell carcinoma keratinizing Squamous cell carcinoma

* Numerous single cells and discohesive * Repair cells

syncitial groups of cells * Endocervical Adenocarcinoma
* Cellular and nuclear pleomorphism is
less than keratinizing SCC
* High N/C ratio
* Nuclear overlapping

Repair Cells

* Cohesive, flat, monolayered sheets of polygonal

squamous cells
* Distinct cytoplasmic boundaries
* Frequent cytoplasmic projectious (pseudopodia)
* Tumour diathesis ABSENT
cont……

Differential Diagnosis of
Repair Cells Repair Cells vs Non-keratinizing SCC

Features Favour Repair

* Inflammatory benign diathesis * Flat sheet arrangement of cells rather than

* Cytoplasm delicate, cyanophilic, no keratinization syncitia or three dimensional clusters
* Cytoplasmic vacuoles containing neutrophils and nuclear * Lack of nuclear overlapping
debris * Lack or rarity of single cells
* Nuclei enlarged * Lack of tumour diathesis
* N/C ratio is only slightly or moderately Increased * Fine Chromatin
* Nuclear chromatin finely granular and evenly distributed
* One or several prominent eosinophlilic nucleoli
* Mitotic figures may be present

21
 Quiz Time

Invasive Carcinoma

Atypical repair

Keratinizing Differential Diagnosis

Squamous Cell Carcinoma of Keratinizing SCC

* Highly discohesive cells

* Spindle keratinized cells
* Keratinised cells with bizarre cytoplasmic
forms
* Tadpole and caudate Cells
* Nuclei hyperchromatic with coarsely clumped,
irregularly distributed chromatin
* Indistinct nucleoli
* Tumour diathesis maybe absent
Atypical parakeratosis/ dyskeratosis
- individual cell may look malignant but are
too small
- can occur in Sq.cell ca, inflammation,
condyloma (wart) and keratinizing CIN

Keratinizing SCC
Verrucous
False negative result Carcinoma
*Rare tumour
*Infected,ulcerated tumour *Slow growing, exophytic tumour,
*rarely metastasize
*Scanty malignant cells
*Cytology misleading
*Verrucous carcinoma *Hyperkeratosis and parakeratosis
*Scanty dyskaryotic cells
*Absence of Malignant nuclei

22
 Acknowledgement
My special thanks to
Dr. Rana,Dr.
Rana,Dr. Denton & Dr. Bijal Shah
From UK
&
Mr.Andrew Evered
From Wales Training School
For
Producing images and drawings
and
Writing some of the texts

I have also used Hologic Cytyc Thinprep Images, BD

Surepath Images Images from NHSCSP atlas and images
and the tables from arts and Science of cytology book from
Prof. DeMay for this presentation

Koilocytes
Cytology of HPV
Koilo = Hollow or cavity

Cytopathic effect of HPV infection
Two Pathognomic cell pattern
Intermediate or superficial squamous cells
containing large perinuclear cavity with

Koilocyte sharply cut borders
 Dyskeratocyte
Dense eosinophilic or cyanophilic cytoplasm
Other Non-
Non- specific cell patterns peripheral to the cavity

Enlarged abnormal nucleus
 Cells – Macrocytes , Kites, balloons

Chromatin varies from degenerate (smudged
 Cytoplasm – Polka dots, cracks pyknotic,
pyknotic, fragmented) to normal or slight
 Nuclei – Bi and multinucleation,
multinucleation, spindling, coarsening
smudging
Nuclear membrane NOT apparent

Inconspicuous nucleoli

No inclusion bodies

Bi and Multinucleation is common

Koilocytotic Atypia Group of Koilocytes

Back To Basics

Clear well defined area around
nucleus

Thickened edge, sharply
demarcated border

Some nuclear atypia

23
 Koilocyte Simulation
Diagnostic Dilemmas
Koilocyte Simulation (Pseudokoilocyte
(Pseudokoilocyte)) Figure 162 Figure 163 Figure 164

Non HPV changes

Rolling edge of cytoplasm (common with LBC)

Intracytoplasmic glycogen lacking yellow-
yellow-brown
staining

Non HPV inflammation
Terminology Figure 165 Figure 166

USA-
USA-Bethesda – LSIL

UK – BL vs. Mild dysk

ECTP-
ECTP-European-
European-Separate category

Diagnostic Dilemma
Terminology
Koilocyte Terminology
U Turn
Theories of pathogenesis

Koilocyte is cellular changes of HPV infection Bethesda Explanatory Notes
that mimics dysplasia but is not genuine
Koilocytic nuclear changes that fall short of
dysplasia a definitive SIL interpretation may be

Koilocyte is precursor to dysplasia categorised as ASC-
ASC-US

Koilocyte is dysplasia Revised BSCC (UK) Terminology
Current Terminologies
In koilocytosis,
koilocytosis, it is difficult to achieve

USA-
USA- Bethesda-
Bethesda-Koilocyte is dysplasia = LSIL consistency in the differentiation of nuclear
changes between BNC and Mild Dyskaryosis,
Dyskaryosis,

UK-
UK- Koilocyte is precursor to dysplasia = therefore combine them as Low- Low-grade
BNC or mild dyskaryosis dependent squamous dyskaryosis
on nuclear abnormality

ECTP – koilocyte is cellular changes of
infection=
infection= separate entity

T
E Spot The
R Difference
M
I
N
O
L
O
G
BNC vs. Mild dysk ASCUS vs. LSIL
Y

24
 Dyskeratocytes
HPV Cytology In The Absence Of HPV
Dyskeratocytes Infection

Small keratinized pearls, rafts or spikes

Abnormal Keratinization

Cells arranged in orderly pattern

Keratinized squamous cells staining

Small,uniform,widely spaced nuclei that
brilliant orange with OG-
OG-6 of pap stain
flattens towards the edge to lie along the
( Pink with Surepath LBC ) long axis of the group

Single or in thick, 3D clusters
No nuclear abnormality

Clusters without discernible polarity

Nuclear enlargement with condensed or
granular chromatin details

Other Non-
Non-specific cell
patters

Macrocyte Kite Cells

Dyskeratotic cells Dyskeratotic cells

Without HPV With HPV

Balloon Cells Polka Dot

Cytology of HPV infection

Incidence of HPV Infection

Incidence 4 % by cytology diagnosis
and 20-
20-30% by molecular diagnosis

Koilocytes are covered by dyskeratotic cells
and not shedding in many cases of HPV
infection
Cytology severely underestimates the true
incidence of HPV infection
After HPV Test

Cytology Negative / HPV positive

Cytology BNC with Koilocyte (LSIL) /
HPV positive

Cytology BNC without koilocyte
(ASCUS) / HPV positive

Cytology Dyskaryosis (LSIL OR HSIL)/
HPV positive

25
 Cytology reporting HPV reporting
after HPV Test Cytology vs Molecular test
Should we be reporting Koilocyte Should we be replacing cytology
in cytology? with HPV Molecular Test?

Koilocyte demonstrates complete
infective viral particles

Pathognomic of HPV infection

Koilocyte with HPV test neg. is
confusing for pt

UK decided not to report koilycyte in
cytology report at sentinel sites for HPV
triage with low grade abnormality
Dilemma of Cytology negative BUT HPV positive Molecular
Test

Epithelial cells are not producing virus particles

Patient is likely to be in immunologic equilibrium with
the virus

Virus will eventually disappear

Transmission of virus to sexual partner (s) at this stage
is doubtful

Eventual outcome of the infection is not known

Require long term follow-
follow-up study to establish long
term FU protocol
ARTISTIC Trial is extended for further 6 years

Modern Koilocyte is
Moving The End
To
The Molecular LBC Smears
with HPV Test

AND
NOT Retiring Yet!

Acknowledgement
My special thanks to
Dr. Rana,Dr.
Rana,Dr. Denton & Dr. Bijal Shah
From UK
&
Mr.Andrew Evered
From Wales Training School
For
Producing images and drawings
and
Writing some of the texts

I have also used Hologic Cytyc Thinprep Images, BD

Surepath Images and
Images from NHSCSP atlas
For this presentation

26