Atrophic Pap Smears, Differential Diagnosis and Pitfalls: a Review

doi 10.15296/ijwhr.2018.02 http://www.ijwhr.net doi 10.15296/ijwhr.2015.27 OpenOpen Access Review Review Article

InternationalInternational Journal Journal of Women’s of Women’s Health Health and Reproduction and Reproduction Sciences Sciences Vol.Vol. 3, No.6, No. 3, July 1, January 2015, 126–131 2018, 2–5 ISSNISSN 2330- 4456 2330- 4456

AtrophicWomen on Pap the Smears,Other Side Differential of War and Diagnosis Poverty: Its and Effect Pitfalls:on the Health A Review of Reproduction Ayse Cevirme1, Yasemin Hamlaci2*, Kevser Ozdemir2 Ali Dastranj Tabrizi1* Abstract AbstractWar and poverty are ‘extraordinary conditions created by human intervention’ and ‘preventable public health problems.’ War and poverty have many negative effects on human health, especially women’s health. Health problems arising due to war and poverty are As a unique preventable cancer, invasive cervical carcinoma is the second most common cancer among the women in developing being observed as sexual abuse and rape, all kinds of violence and subsequent gynecologic and obstetrics problems with physiological countries. Change in women’s lifestyle, worldwide spread of HPV infection and women’s lack of effective education and screening and psychological courses, and pregnancies as the result of undesired but forced or obliged marriages and even rapes. Certainly, programs in less developed countries constitute the most important factors for its high incidence and mortality rate. From a diagnostic unjust treatment such as being unable to gain footing on the land it is lived (asylum seeker, refugee, etc.) and being deprived of perspective, atrophic smears may be interpreted as positive malignant smears in postmenopausal and occasionally in premenopausal social security, citizenship rights and human rights brings about the deprivation of access to health services and of provision of women. However, rarely a high grade or malignant smear might be rendered as the atrophic smear. For this reason acquaintance with atrophicservice intended smears forand gynecology their diagnostic and obstetrics. challenges The should purpose be of included this article in pathologyis to address and effects cytotechnology of war and poverty training on courses.the health In of this review, usualreproduction pattern of of women atrophic and smears to offer and scientific differential contribution diagnosis and solutions.of atrophic smears along with mimics will be presented for decision makingKeywords: and Poverty, particularly Reproductive avoiding health, overdiagnosis. War Keywords: Atrophic Pap smear, Invasive cervical cancer, HPV infection Introduction thought that severe military conflicts in Africa shorten IntroductionThroughout the history of the world, the ones who had the expectedfollows: lifetime(a) a brief for inspectionmore than of2 years.usual Inpattern general, of atrophic confronted the bitterest face of poverty and war had al- WHO had calculated that 269 thousand people had died Although cervical cancer incidence has been dramatically smears, (b) main differential diagnosis which can mimic ways been the women. As known poverty and war affects in 1999 due to the effect of wars and that loss of 8.44 mil- declinedhuman health in developed either directly countries or indirectly,due to the theimplementation effects of lion healthyatrophic years smears, of life had(c) occurredpitfalls (2,3).which may lead to over ofthis systematic condition onand health organized and status screening of women into in health the so -care Warsinterpretation, negatively affect and the finally,provision (d )of suggestive health services. strategies for systems,ciety should this not preventable be ignored. Thismalignancy study intends comprises to cast the Healthcorrect institutions decision such making as hospitals, laboratories and secondlight on mostthe effects common of war andcancer poverty in women on the reproductive in developing health centers are direct targets of war. Moreover, the wars countrieshealth of women. (1). Change For this in purpose, women’s the life face style, of war world affect -wide causeI. the Usual migration Pattern of of qualified Atrophic health Smears employees, and spreading the ofwomen, HPV the (human problem papilloma of immigration, virus) inequalitiesinfection and thus Takingthe health Papservices smear hitches. inAssessments postmenopausal made indi - women women’sin distribution lack of of effective income based education on gender and screeningand the effects systems cate thatoccasionally the effect showsof destruction a hypocellular in the infrastructure background of and may of all these on the reproductive health of women will be health continues for 5-10 years even after the finalization in less developed countries constitute the most important display the absence of endocervical or transformation addressed. of conflicts (3). Due to resource requirements in the re- factors for the very high incidence and mortality rate in structuringzone investmentscomponents after (6,7) war, the(Figure share allocated1A). Microscopic to lessWar developed and Women’s societies Health (2-4). The most common subtypes healthexamination has decreased of (1). atrophic smears which is typically seen ofFamine, high risk synonymous HPVs involving with war in and cervical poverty, carcinogenesis is clearer for are in postmenopausal women usually shows numerous HPVwomen; 16 andwar HPVmeans 18 deep although disadvantages other subtypes such as offull high de- risk Mortalitiesparabasal and Morbiditiesand intermediate cells that may be arranged HPVsstruction, may loss be of detected future and as uncertaintydominant forcarcinogenic women. Wars agent. The onesin small who areclusters most affected or as fromindividual wars are cells women (Figure and 1B and Onare theconflicts other that hand, destroy low families,sensitivity societies and specificity and cultures of Pap children.C). AWhile small deaths number depending of superficial on direct violencecells may af- be seen. smearthat negatively particularly affect in the conventional health of community type impose and cause serious fect thePresence male population, of a large thenumber indirect of deathssuperficial kill children, cells along with violation of human rights. According to the data of World women and elders more. In Iraq between 1990-1994, in- consequences including false negative and false positive intermediate cells may indicate the need for hormone Health Organization (WHO) and World Bank, in 2002 fant deaths had shown this reality in its more bare form resultswars had (5). been among the first ten reasons which killed with replacementan increase of therapy600% (4). or The uterine war taking prolapse five yearstreatment. In theFrom most aand diagnostic caused disabilities. perspective, Civil lossesatrophic are atsmears the rate may increasesthese the circumstances, child deaths under parakeratotic age of 5 by 13%.cells Alsomay 47% also be seen beof 90%misinterpreted within all losses as positive (1). smears in postmenopausal of all andthe refugeesshould innot the be world considered and 50% asof asylumevidence seekers of low grade andWar occasionallyhas many negative in perimenopausal effects on human women. health. OneHowever, of and displacedsquamous people intraepithelial are women lesion and girls(LSIL). and The 44% parabasal ref- cells rarelythese isa highits effect grade of or shortening malignant the smear average might human be rendered life. ugeesusually and asylum show seekers a relatively are children small amount under the of agecytoplasm of and asAccording an atrophic to the smear. data of Fortunately,WHO, the average introduction human life of is new 18 (5).high nuclear/cytoplasmic ratio. The condensed nuclear techniques68.1 years for in males the andfield 72.7 of years Pap for smear females. including It is being new As thechromatin result of leadswars andto nuclear armed hyperchromasia,conflicts, women however,are no collection devices and automated machines leads to chromatin clumping and no nucleoli is seen. Absence of betterReceived results. 12 December This 2014, review Accepted will 25 April discuss 2015, Available general online cytologic 1 July 2015 chromatin clumping, sharp and regular nuclear membrane features1Department of of Nursing,atrophic Sakarya smears University, and Sakarya, a number Turkey. 2Department of common of Midwifery, Sakaryaand absenceUniversity, Sakarya,of mitotic Turkey. figure are hallmarks of atrophic morphologic*Corresponding author:mimics Yasemin of atrophicHamlaci, Department smears ofwhich Midwifery, can Sakarya lead University, smears Sakarya, which Turkey. Tel:allow +905556080628, easy distinction of these cases from Email: [email protected] to overinterpretation. The structure of this review is as high grade intraepithelial or malignant lesions (Figure

Received 8 August 2016, Accepted 19 December 2016, Available online 10 January 2017

1Women’s Reproductive Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran. *Corresponding Author: Ali Dastranj Tabrizi, MD; Email: [email protected] Dastranj Tabrizi

1D, 1E). Clusters of endocervical cells usually are seen in lesion. In contrast, in a malignant smear from an invasive well-taken atrophic smears although their absence should squamous cell carcinoma, the malignant cells dispersed not be rendered as an insufficient specimen. Usually, haphazardly in the background of some normal appearing the normal atrophic smears show some debris hanging cells. Although the dirty background of the smear is one from the cytoplasmic border. These materials should not of the most distinguishing features of malignant smears be considered as the evidence of malignancy which is due to tumor cell necrosis, some granular material derived seen widely in squamous cell carcinoma. The absence of from degenerating parabasal cells are usually present in polymorphonuclear (PMN) debris, clean background of the background of atrophic smears (10,11). Therefore smears, close adherence of these materials to cytoplasmic close attention should be paid to find marked nuclear membrane and absence of nuclear atypia are helpful pleomorphism, coarse nuclear chromatin, ragged nuclear criteria for distinction between atrophic and malignant membranes and relatively easily found mitotic figures for smears (Figure 1F). the establishment of the diagnosis of invasive squamous cell carcinoma. II. Differential Diagnosis A. Invasive Squamous Cell Carcinoma B. High Grade Squamous Intraepithelial Lesion Although misdiagnosis of an atrophic smear as a malignant Atrophic smears are prone to be misinterpreted as HSIL. smear is uncommon even in inexpert hands, extreme In HSIL the smear background is clean. Reactive parabasal caution should be used to avoid this misinterpretation. cells, especially in atrophic vaginitis, may show some Sheaths of parabasal cells with high nuclear/cytoplasmic nuclear membrane irregularity and more hyperchromasia. (N/C) ratio and hyperchromatic nuclei may simulate Awareness of patient’s clinical history and familiarity malignant cells (8,9). Information about patients’ clinical with reactive changes in an atrophic smear such as history, pelvic examination and colposcopic findings nucleomegaly, the presence of cytoplasmic vacuoles along with careful attention to the appearance of nuclear and cytoplasmic polychromasia usually lead to correct chromatin and nuclear outlines will be useful (Figure diagnosis. Monotonous appearance of smear, evenly 1G). Monotonous appearance of cellular sheaths, uniform distributed chromatin, and smooth nuclear membrane in nuclear chromatin, absence of mitotic figures, lack of the majority of cells are the main clues to make a correct tumor diathesis and nonexistence of tad pole cells all diagnosis (Figure 1D, 1F). In doubtful cases, appreciation are in favor of benign atrophic smear versus malignant of colposcopic appearance of the cervix, patient’s clinical

A B C

D E F

G H

Figure 1. An atrophic smear showing hypocellular background (A). Sheaths of parabasal and intermediate cells that arranged in small clusters (B) or in individual cells pattern (C). Large nuclear/cytoplasmic ratio, clumped nuclear chromatin in high grade squamous intraepithelial lesion (D). Coarse chromatin clumping in a high grade lesion (E). Absence of chromatin clumping, sharp and regular nuclear membrane, absence of nuclear debris and mitotic activity are hallmarks of atrophic smears (F). Typical parabasal cells in an atrophic smear (G). Typical koilocytes in low grade squamous intraepithelial lesions (H).

International Journal of Women’s Health and Reproduction Sciences, Vol. 6, No. 1, January 2018 3 Dastranj Tabrizi setting and HPV typing usually solve the problem. In features are routinely used in cytology. Shidham et al some cases, consultation with a clinician and trying a short (18) suggested that P16ink4 immunocytochemistry course of vaginal estrogen along with repeated smear will may be useful in a precise categorization of Pap smears be needed (12). with ASCUS or ASC-H diagnosis. In the smears taken from elderly patients with uterine prolapse, smears may C. Low Grade Squamous Intraepithelial Lesion contain anucleated superficial and parakeratotic cells due Occasionally some of the atrophic smears may contain to cervix keratinization. For the most part, the parabasal epithelial cells with vacuolated cytoplasm and rarely cells are arranged in large flat sheaths which are typical perinuclear halo. Awareness of patient’s age and her of atrophy. In liquid based smears, more single parabasal sexual activity, the absence of typical koilocytes with cells can be seen (Figure 1C) and these cells are prone raisinoid nuclei and also the monotonous appearance of to be misinterpreted as HSIL (19). Attention to evenly the background assist to avoid overdiagnosis (13) (Figure distributed chromatin, smooth nuclear membrane, and 1H). absence of mitotic figure are relevant cytologic clues leading to correct diagnosis. Any nuclear abnormalities D. Atypical squamous cells of undetermined significance including clumped and coarse chromatin, irregular and Misinterpretation of atrophic smears as Atypical squamous jagged nuclear membrane, mitotic figures and apoptotic cells of undetermined significance (ASCUS) may be the bodies should be interpreted as evidences of premalignant most common mistake in inexperienced hands. Although or malignant lesions and should be confirmed by most of the parabasal cells in atrophic smears show high colposcopy and biopsy. Although atrophic smears may N/C ratio, the absence of chromatin abnormality would contain anucleated cells due to uterine prolapse, the be a helpful sign in a differential diagnosis. It should be presence of atypical parakeratotic cells or cells with mentioned that in the most smears with epithelial cells atypical nuclei and keratinized cytoplasm should be abnormalities, the abnormal cells show sparse distribution interpreted with extreme caution. between normal cells. However, most of the atrophic Although the application of the above mentioned smears show fairly monotonous appearance. It should be cytologic criteria will be useful in most of these difficult mentioned that ASCUS has low positive predictive value cases, some investigators recommended that utilization of for a squamous intraepithelial lesion in perimenopausal immunocytologic markers such as Ki67 would be effective age group and may be overused (14). in some of the problematic cases (20,21). Other studies proposed that immunocytochemical detection of P16 and F. Reactive Changes Induced by Radiation Therapy Most ki67 acts as a more accurate route in establishing a correct of the patients with radiation change in Pap smear have diagnosis (22-24). atrophic smear due to postmenopausal status, previous A granular background which is commonly seen in oophorectomy and radiation-induced atrophic changes atrophic smears should not be confused with the tumor of ovaries. Therefore atrophic smears with radiation- diathesis which is found in the background of malignant induced atypical changes are at risk of overdiagnosis. In smears due to tumor cell necrosis and ulceration (Figure these cases, patient’s past medical history and recognition 1C). Clark hypothesized that in ThinPrep slides, blocking of microscopic appearance of radiation-induced changes of filter coverage by epithelial cells can be mediated by this are valuable diagnostic criteria for ruling out of tumor debris and inflammatory cells which leads to hypocellular recurrence. smears (11).

Discussion Conclusion After menopause, decreased serum estrogen level prevents Although in most cases the diagnosis of atrophic smears is squamous epithelium maturation beyond the parabasal straightforward, in rare cases particularly in inexperienced or lower intermediate cell and induces a thin epithelium hands it may be the source of misinterpretation such as (15,16). These physiologic changes manifested in Pap ASCUS, HSIL or even squamous cell carcinoma. On smears by hypocellularity and monotonous sheaths of the other hand, some cases of cervical squamous cell small parabasal cells with rounded or ovoid cytoplasm. carcinoma may be diagnosed as atrophic smears especially These cells have relatively larger nuclei but overall, the in rapid screening. Therefore, considering patient’s parabasal cells are much smaller than intermediate cells clinical findings along with the colposcopic appearance of and their cytoplasm is dense (17) (Figure 1B). In these the cervix would be useful in problematic cases. Moreover, cells, N/C ratio is relatively high, but the uniform and use of proliferative and oncologic markers such as Ki67 homogenous nuclear chromatin and smooth nuclear and P16 could be valuable in making a correct diagnosis. membrane are useful characters in differentiation from high grade squamous intraepithelial lesion or invasive Conflict of Interests squamous cell carcinoma. However, the above mentioned Author declares that he has no conflict of interests.

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Ethical Issues 2009;16(4):765-769. doi:10.1097/gme.0b013e318193e7cd Not applicable. 13. Jovanovic AS, McLachlin CM, Shen L, Welch WR, Crum CP. Postmenopausal squamous atypia: a spectrum including Financial Support “pseudo-koilocytosis”. Mod Pathol. 1995;8(4):408-412. 14. Keating JT, Wang HH. Significance of a diagnosis of None to be declared. atypical squamous cells of undetermined significance for Papanicolaou smears in perimenopausal and References postmenopausal women. Cancer. 2001;93(2):100-105. 1. Torre LA, Bray F, Siegel RL, Ferlay J, Lortet-Tieulent J, 15. Repse-Fokter A, Takac I, Fokter SK. Postmenopausal Jemal A. Global cancer statistics, 2012. CA Cancer J Clin. vaginal atrophy correlates with decreased estradiol and 2015;65(2):87-108. doi:10.3322/caac.21262 body mass index and does not depend on the time since 2. Vaccarella S, Lortet-Tieulent J, Plummer M, Franceschi menopause. Gynecol Endocrinol. 2008;24(7):399-404. S, Bray F. Worldwide trends in cervical cancer incidence: doi:10.1080/09513590802217290 impact of screening against changes in disease risk factors. 16. Robboy SJ, Anderson MC, Morse A. Cervical precancer Eur J Cancer. 2013;49(15):3262-3273. doi:10.1016/j. (intraepithelial neoplasia). In: Robboy SJ, Anderson MC, ejca.2013.04.024 Russell P, eds. Pathology of the female reproductive tract. 3. Bruni L, Diaz M, Castellsague X, Ferrer E, Bosch FX, de London: Churchill Livingstone; 2002:165-93. Sanjose S. Cervical human papillomavirus prevalence in 5 17. Reichert RA. Diagnostic Gynecologic and Obstetric continents: meta-analysis of 1 million women with normal Pathology: An Atlas and Text. Philadelphia: Lippincott cytological findings. J Infect Dis. 2010;202(12):1789-1799. Williams Wilkins; 2012. doi:10.1086/657321 18. Shidham VB, Mehrotra R, Varsegi G, D’Amore KL, 4. Forman D, de Martel C, Lacey CJ, et al. Global burden Hunt B, Narayan R. p16 immunocytochemistry on cell of human papillomavirus and related diseases. Vaccine. blocks as an adjunct to cervical cytology: Potential reflex 2012;30 Suppl 5:F12-23. doi:10.1016/j.vaccine.2012.07.055 testing on specially prepared cell blocks from residual 5. Chen C, Yang Z, Li Z, Li L. Accuracy of several cervical liquid-based cytology specimens. Cytojournal. 2011;8:1. screening strategies for early detection of cervical cancer: doi:10.4103/1742-6413.76379 a meta-analysis. Int J Gynecol Cancer. 2012;22(6):908-921. 19. Kalof AN, Cooper K. Our approach to squamous doi:10.1097/IGC.0b013e318256e5e4 intraepithelial lesions of the uterine cervix. J Clin Pathol. 6. Davey DD, Cox JT, Austin RM, et al. Cervical cytology 2007;60(5):449-455. doi:10.1136/jcp.2005.036426 specimen adequacy: patient management guidelines and 20. Ejersbo D, Jensen HA, Holund B. Efficacy of Ki-67 optimizing specimen collection. J Low Genit Tract Dis. antigen staining in Papanicolaou (Pap) smears in post- 2008;12(2):71-81. doi:10.1097/LGT.0b013e3181585b9b menopausal women with atypia--an audit. Cytopathology. 7. Waddell CA. The influence of the cervix on smear quality. I: 1999;10(6):369-374. Atrophy. An audit of cervical smears taken post-colposcopic 21. Fakhrjou A, Dastranj-Tabrizi A, Ghojazadeh M, et al. management of intraepithelial neoplasia. Cytopathology. Diagnostic value of protein Ki67 (MIB-1) in atypical pap 1997;8(4):274-281. smears of postmenopausal women. Asian Pac J Cancer 8. Selvaggi SM. Atrophic vaginitis versus invasive squamous Prev. 2013;14(8):4815-4818. cell carcinoma on ThinPrep cytology: can the background be 22. Rokita W, Skawinski D, Zmelonek-Znamirowska A, et al. reliably distinguished? Diagn Cytopathol. 2002;27(6):362- [Results of pap smears and immunocytochemical detection 364. doi:10.1002/dc.10204 of the p16 and Ki67 proteins in women with cervical 9. Bulten J, de Wilde PC, Boonstra H, Gemmink JH, Hanselaar intraepithelial neoplasia and cervical cancer]. Ginekol Pol. AG. Proliferation in “atypical” atrophic pap smears. Gynecol 2012;83(11):822-826. Oncol. 2000;79(2):225-229. doi:10.1006/gyno.2000.5943 23. Wentzensen N, Fetterman B, Tokugawa D, et al. 10. Ziabkowski TA, Naylor B. Cyanophilic bodies in cervico- Interobserver reproducibility and accuracy of p16/Ki-67 vaginal smears. Acta Cytol. 1976;20(4):340-342. dual-stain cytology in cervical cancer screening. Cancer 11. Clark SB, Dawson AE. Invasive squamous-cell carcinoma Cytopathol. 2014;122(12):914-920. doi:10.1002/cncy.21473 in ThinPrep specimens: diagnostic clues in the cellular 24. Trutnovsky G, Kolovetsiou-Kreiner V, Reich O. p16/Ki- pattern. Diagn Cytopathol. 2002;26(1):1-4. 67 dual-stained cytology testing may predict postpartum 12. Bateson DJ, Weisberg E. An open-label randomized outcome in patients with abnormal papanicolaou cytology trial to determine the most effective regimen of vaginal during pregnancy. Acta Cytol. 2014;58(3):293-296. estrogen to reduce the prevalence of atrophic changes doi:10.1159/000358817 reported in postmenopausal cervical smears. Menopause.

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