K1-Perubahan Sitologi Reaktif, if Reparatif

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Perubahan Sitologi Reaktif, Regeneratif, Reparatif

Oleh:Harniyatie Mohamad

KSKB Kuching

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Objektif Kuliah

• Menerangkan definisi bagi sel perubahan reaktif, regeneratif, dan reparatif

• Menerangkan morfologi sel perubahan reaktif, regeneratif dan reparatif

• Menerangkan perubahan nukleus dan sitoplasma sel reaktif, regeneratif dan reparatif

• Menerangkan differential diagnosis

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Pengenalan

• Permukaan uterin servik dilapisi oleh:– Epitelium stratified skuamus (ektoservik)– Epitelium kolumnar ringkas (endoservik)

• Pendedahan kepada ransangan dalaman (internal stimuli) seperti perubahan hormon atau kepincangan penyakit dan ransangan luaran (external stimuli) seperti luka dan perubahan pH dapat mempengaruhi sitomorfologi sel pada permukaan uterin servik

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• Perubahan morfologi ini dikategorikan sebagai:– Pertahanan (protective)– Kemusnahan (destructive)– Reparatif– Regeneratif– Neoplastik – boleh menjadi epitelial atypia/ kanser

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Definisi perubahan sel dalam saluran pembiakan wanita

• Perubahan sel reaktif – keadaan sel yang aktif• Perubahan sel reparatif – keadaan sel yang

menunjukkan keadaan pembaikpulihan• Perubahan sel regeneratif – pertumbuhan

semulajadi• Faktor fisiologi dan ransangan luaran boleh

merangsang perubahan reaktif, reparatif dan regeneratif pada sitologi sel yang melapisi permukaan uterin servik

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• Perubahan-perubahan reaktif, reparatif dan regeneratif ini dapat dilihat pada smear pesakit yang menjalani rawatan:– Radioterapi– Pembuangan servik (recent hysterectomy)– Cautery and biopsy,curettage– Cryocoagulation, diathermy– Pressure necrosis from use of IUCD or ring pessary– Severe inflammation lesion causing partial or total destruction

of epithelium

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Gambaran sitomorfologi perubahan sel

• Gambaran secara umum – menyerupai immature columnar cells, immature squamous cells atau immature metaplastic cells

• Sel dikeluarkan (exfoliate) dalam large sheets atau syncytial aggregates dengan pinggiran sitoplasma yang tak jelas (indistinct cytoplasmic boundaries)

• Binucleation

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• Mitotic figure boleh kelihatan (kromosom yang sedang membahagi)

• Leucocytic infiltration kerap berlaku• Single atypical cells kadang-kadang boleh

dijumpai• Latarbelakang smer – pelbagai bergantung

kepada sebabnya• Boleh salah diagnose sebagai malignansi

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Morfologi nukleus

• Saiz nukleus membesar sehingga 3 kali ganda• Bulat, bujur, tepi licin/ rata (smooth)• Kedudukan di tengah (centrally placed)• Nisbah N/C meningkat• Kromatin – tidak hiperkromatik, bergranul halus – kasar

dengan taburan kadang-kadang tidak sekata• Nukleoli – hadir, besar, boleh berganda (multiple

macronucleoli) , ungu kemerahan• Kromosenter – hadir, biru keunguan

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Sitoplasma

• Lapisan sel (cohesive monolayer) dengan sitoplasma yang tidak bertindih (filmsy)

• Gabungan sitoplasma kelihatan renggang dan terbuka

• Kadang-kadang bentuk bizarre, kelihatan ada ekor

• Kadang-kadang terdapat vakuol• Sempada sitoplasma ada kalanya tidak jelas

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Type of Preparation: Conventional

Magnification: Medium

Interpretation: NILM: Reactive squamous metaplasia

Cytomorphologic Criteria: Higher N/C ratio than mature cells. Nuclear membranes smooth and chromatin finely granular and evenly distributed. Small round nucleoli/chromatin centers present.

Explanatory Notes: Note the "spidery" cytoplasmic processes, a feature that may be seen in conventional smears.

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Interpretation: NILM: Repair

Cytomorphologic Criteria:

Squamous cells in flat monolayer sheet with maintenance of nuclear polarity and a prominent nucleolus in almost every cell.

Explanatory Notes: If marked anisonucleosis, irregularities in the chromatin distribution, or variation in size and shape of nucleoli are present, so-called "atypical repair", the changes should be categorized as atypical glandular cells or atypical squamous cells.

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Type of Preparation: ThinPrep/ LBP


Clinical History: 32 year old female.



Changes are similar to those seen on conventional smears, but cell streaming may be less apparent due to rounding of cell clusters. Note the intracytoplasmic polymorphonuclear leucocytes, another feature seen in repair.

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Clinical History: 32 year old; routine Pap test

Interpretation: NILM: Reactive squamous cell


Mature squamous cell.

Explanatory Notes: While there is nuclear enlargement in the cells on the right side, the smooth nuclear contours and finely distributed chromatin favor reactive change over ASC-US.

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Magnification: High

Interpretation: NILM: Reactive squamous metaplasia


Enlarged nuclei in metaplastic cells but fine uniform chromatin. N/C ratio is usually 50% or less.

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Magnification: High

Interpretation: NILM: Reactive squamous cells

Cytomorphologic Criteria: Reactive squamous cells showing mild nuclear enlargement without any significant chromatin abnormalities

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Type of Preparation: SurePath/ LBP

Magnification: High

Clinical History: Routine Pap test


Cytomorphologic Criteria: The cell cluster shows inter-cellular windows (school-of-fish appearance) and a streaming pattern. Nuclei are uniformly large, and contain prominent nucleoli. Chromatin abnormalities are absent.

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Magnification: High



Squamous cells in flat monolayer sheet with maintenance of nuclear polarity and prominent nucleoli in most cells

Explanatory Notes: If marked anisonucleosis, irregularities in the chromatin distribution, or variation in size and shape of nucleoli are present, so-called "atypical repair", the changes should be categorized as atypical glandular cells or atypical squamous cells

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Magnification: High


Cytomorphologic Criteria: Increased nuclear size and prominent nucleoli. Cells in monolayer sheet with nuclei oriented in the same direction (streaming).

Explanatory Notes: Absence of single cells with nuclear changes and lack of marked anisonucleosis or irregularities in chromatin distribution or variation in size and shape of nuclei indicates this is typical repair (as opposed to "atypical repair") which would be categorized as atypical glandular cells or atypical squamous cells.

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Clinical History: 32 year old woman

Interpretation: NILM: Endocervical cells: reparative

Cytomorphologic Criteria: Monolayer sheet of endocervical cells with orderly arrangement. Streaming effect is observed. Nuclei are enlarged with nucleoli but have smooth borders and are not hyperchromatic.

Explanatory Notes: Repair is characterized by cohesive cell groups with few or no single cells. In liquid preparations, the groups may appear more rounded with less streaming.

Follow-up: No abnormal follow-up

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Clinical History: 24 year old female

Interpretation: NILM: Endocervical cells, reactive

Cytomorphologic Criteria: Nuclear enlargement with some bi- and multinucleation. Nuclear outlines are smooth and uniform. Chromatin is fine with small nucleoli. Cells are present in flat orderly sheet.

Follow-up: No abnormal follow-up

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Magnification: High

Interpretation: NILM: Reactive endocervical cells


Cohesive orderly sheet of endocervical cells with enlarged nuclei and nucleoli. There is some variation in nuclear size. Nuclei are generally round and smooth without significant hyperchromasia.

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Cytomorphologic Criteria: Increased N/C ratio. Prominent nucleoli but delicate chromatin and even nuclear membranes.

Explanatory Notes: Endocervical repair.

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Magnification: High


Cytomorphologic Criteria: Reactive endocervical cells showing nuclear enlargement and prominent nucleoli. A few intracytoplasmic polymorphonuclear leukocytes are visible

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Clinical History: 67 year old woman with uterine prolapse

Interpretation: NILM: Reactive cellular changes, Repair

Cytomorphologic Criteria: Flat monolayer sheets with distinct cytoplasmic outlines, streaming nuclear polarity, prominent nucleolus in almost every cell.

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Perbezaan diagnosis antara sel reparatif dengan displasia

Ciri Sel reparatif Sel displasia

Jenis sel Banyak sel kolumnar dalam lapisan

Skuamus, isolated, loosely cohesive group

Sitoplasma Sianofilik, lompang kecil

Siano – eosinoflik, tiada lompang

Nukleus Hipokromatik, binucleated, kromatin granul halus

Hiperkromatik, single, kromatin granul kasar

Nukleoli Prominent, biasa ada Tiada, kalau ada kecil

Mitosis Ada Jarang

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Perbezaan diagnosis antara sel reparatif dengan large cell carcinoma25

Ciri Sel repairatif Large cell carcinoma

Tumour diathesis Tiada Ada

Isolated cell Jarang kelihatan Banyak, ¾ sel kelihatan berasingan

Syncytium ½ sel kelihatan syncytium

¼ sahaja

Kromatin Taburan rata dan halus

Taburan tidak rata dan kasar

Makronuclei Boleh dilihat dalam semua nukleus, irregular

Jarang

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K1-Perubahan Sitologi Reaktif, if Reparatif

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