J Clin Pathol: first published as 10.1136/jcp.39.9.933 on 1 September 1986. Downloaded from J Clin Pathol 1986;39:933-944 Review article Terminology in gynaecological cytopathology: report of the Working Party of The British Society for Clinical Cytology D M D EVANS (CHAIRMAN),* E A HUDSON (SECRETARY),t C L BROWN,tt M M BODDINGTON,¶T H E HUGHES,¶ E F D MACKENZIE,** T MARSHALL§ From *St David's Hospital, Cardiff, tNorthwick Park Hospital, Harrow, ttThe London Hospital, ¶Royal Berkshire Hospital, Reading, ¶Glasgow Royal Infirmary. **Southmead General Hospital, Bristol, §Central Pathology Laboratory, Stoke on Trent SUMMARY The report defines and recommends terms for use in cervical cytology. Most cervical smear reports are received by medical firm prediction of CIN 3 because the cytologist can- practitioners who do not have specialised knowledge not reliably exclude a microinvasive or invasive of pathology or gynaecology. Therefore it is lesion. The histological prediction is more accurately important that the report is not only scientifically recorded on the National Cytology Form, HMR accurate but also easily understood so that the patient 101/5 (1982), where severe dysplasia or carcinoma in copyright. receives appropriate management and advice. To situ-(C-IN 3), or-carcinoma in situ (CIN 3) or? invasive promote these aims the British Society for Clinical carcinoma are the alternatives provided. Cytology set up a working party to make recommen- dations on the reporting of cervical smears and the INFLAMMATORY NUCLEAR CHANGES AND terms used. It was suggested that common use of a DYSKARYOSIS small but clearly defined vocabulary would improve A continuous range of nuclear abnormalities occurs, the communication of results to users of the cytology from minor changes that are usually associated with services and provide an accurate basis for wider inflammatory conditions and which are believed to be reference. essentially benign, through to more striking nuclear http://jcp.bmj.com/ abnormalities that correlate with CIN. Cytologists The cytology report should be encouraged to say precisely what abnor- mality is present in as many cases as possible, but The cytology report on abnormal findings should there will be some in which the abnormality is on the consist of a concise description of cells in precisely borderline. These abnormalities may be referred to as defined and generally accepted cytological terms. This "borderline nuclear abnormalities." In these circum- may be followed, ifappropriate, by a prediction of the stances follow up with repeat smears usually allows a on October 2, 2021 by guest. Protected histological condition based on the overall picture more exact cytological diagnosis to be made. and should include a recommendation for the further The morphological abnormalities of the nucleus management of the patient. comprise a combination of any number of the follow- When a prediction of histology is included as a sup- ing: plementary statement to a description of the cytology (1) disproportionate nuclear enlargement; use of the terminology, cervical intraepithelial neo- (2) irregularity in form and outline; plasia (CIN) is preferred: it has the advantage of (3) hyperchromasia; relating the histological report more clearly to the (4) irregular chromatin condensation, appearing as prognosis and management than the artificial sepa- stippling, clumps, or strands, and sometimes as con- ration implied by classification into dysplasia and car- densation beneath the nuclear membrane producing cinoma in situ. Caution is advised, however, in the apparent irregularities in thickness of the nuclear membrane; Accepted for publication 18 March 1986 (5) abnormalities of the number, size, and form of 933 J Clin Pathol: first published as 10.1136/jcp.39.9.933 on 1 September 1986. Downloaded from 934 Evans, Hudson, Brown, Boddington, Hughes, Mackenzie, Marshall oS. S Fig I Normal superficial and intermediate squamous cells. Both cell types have abundant translucent cytoplasm with angular borders. Nuclei ofboth intermediate squamous cells have evenly distributedfinely granular chromatin, whereas three superficial cells have smaller pyknotic nuclei. (Papanicolaou.) Original magnification x 1.60, enlarged x 5. copyright. http://jcp.bmj.com/ on October 2, 2021 by guest. Protected Fig 2 Endocervical cells. These columnar epithelial cells are seen lined up in characteristic palisade pattern andfrom an alternative aspect in a sheet with nuclei surrounded by narrow rim ofcytoplasm. Nuclei appear vesicular apartfrom one or more prominent nucleoli. (Papanicolaou.) Original magnification x 160, enlarged x 5. J Clin Pathol: first published as 10.1136/jcp.39.9.933 on 1 September 1986. Downloaded from Terminology in gynaecological cytopathology 935 I I'lL" Fig 3 Normalparabasal squamous cells. These cells usually have rounded outlines with opaque cytoplasm and vesicular nuclei. Chromatin pattern isfinely granular but nucleoli may be prominent. (Papanicolaou.) Original magnification x 160, enlarged x 5. copyright. V Wt:- -'NI( 4 i_8a.4 *S:: e !'s} .'SO '; *S s.4s http://jcp.bmj.com/ _::::: s :*... i *d,S IP w ."ESE.... o. w .} ws _ _ ! pv * v v * _,. on October 2, 2021 by guest. Protected ..: 11 :. 4. i . A p _ . ". `; t~~~~~~~~~~~ 7 Fig 4 Inflammatory changes in parabasal squamous cells. Inflammatory nuclear changes may beparticularly pronounced in smearsfrom atrophic cervical squamous epithelium, as shown here. Hyperchromasia is striking and chromatin is coarsely clumped but clumps are evenly distributed. An impression ofanisonucleosis is created by coexistence ofreactive and degenerative changes in nuclei. (Papanicolaou.) Original magnification x 160, enlarged x 5. J Clin Pathol: first published as 10.1136/jcp.39.9.933 on 1 September 1986. Downloaded from 936 Evans, Hudson, Brown, Boddington, Hughes, Mackenzie, Marshall nucleoli; those associated with inflammation alone. Irregu- (6) multinucleation associated with any of the above. larity of chromatin distribution is the most important Figs I and 3 show examples of normal squamous change in nuclear morphology. It may be accom- cells; fig 2 shows glandular cells. panied by irregularity of form and outline, multi- nucleation, further disproportionate nuclear enlarge- Inflammation ment, and hyperchromasia. Artefactual cell distortion Inflammation alone causes minor nuclear abnormal- must be distinguished from dyskaryosis. ities (fig 4). These are usually disproportionate The Working Party endorses the recommendation nuclear enlargement with or without hyperchromasia. by Spriggs et al' that "dyskaryosis" and "dys- Wrinkling of the nuclear membrane due to degener- karyotic" should be used to describe the nuclear ative change may also be associated with inflam- abnormalities seen in cells from CIN and it recognises mation but must be distinguished from the irregu- that some cases of invasive carcinoma exfoliate simi- larities of form and outline of dyskaryosis. lar cells. Karyorrhexis and pyknosis must also be dis- The term dyskaryosis is appropriate when referring tinguished from nuclear abnormalities with malig- to both squamous and endocervical cell abnormalities nant potential. There is no need to report simple with the same implication of intraepithelial or inflammatory changes. invasive carcinoma. Dyskaryosis CLASSIFICATION OF DYSKARYOTIC CELLS Dyskaryosis literally means "abnormal nucleus" and Spriggs et al' recommended a classification that is liable to be used in different ways-for example, by depends on the cytoplasmic characteristics of the dys- some to describe abnormal cells expected to be karyotic squamous cells. Thus superficial cell, inter- obtained from CIN 1 or CIN 2, and by others it is mediate cell, and parabasal cell dyskaryosis were only used for severely abnormal cells expected to described. After considerable deliberation this Work- come from CIN 3. ing Party prefers to emphasise the overriding Dyskaryosis should be used to describe nuclear importance of nuclear abnormalities. This does not abnormalities more numerous or more severe than exclude cytoplasmic changes from cell assessment, copyright. p http://jcp.bmj.com/ 40010dik AM& ABLII. on October 2, 2021 by guest. Protected Fig 5 Mild dyskaryosis. Nuclei are enlarged and hyperchromatic. Clumps and ridges ofchromatin are unevenly distributed and there are alsofolds in some ofthe nuclear membranes. Three cells are binucleate. Abnormal nuclei occupy less than half area ofcytoplasm ofmost ofthese cells. Cytoplasm retains translucent quality ofnormal, superficial, or intermediate squamous cells. (Papanicolaou.) Original magnification x 160, enlarged x 5. J Clin Pathol: first published as 10.1136/jcp.39.9.933 on 1 September 1986. Downloaded from Terminology in gynaecological cytopathology 937 * .:: . :*.E: *Q9R<-re 4 S Fig 6 Nuclear abnormalities associated with human papiloma virus infection. These koilocytes show typical central clearing andperipheral condensation ofcytoplasm. It is impossible to be certain whether uneven chromatin pattern in larger nucleus is dyskaryotic or degenerate: patient would therefore befollowed up. (Papanicolaou.) Original magnification x 160, enlarged x copyright. 5. 'p. S. I. http://jcp.bmj.com/ on October 2, 2021 by guest. Protected .* 4 ) ...~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~-..-1 Fig 7 Moderate dyskaryosis. Disproportionate nuclear enlargement is greater than that infig5 and morphological abnormalities ofnuclei more severe. Dyskaryosis is classified as moderate in most ofthe cells but could be called