High class squamous intraepithelial lesion ( HSIL ) ( Fig 1 ) is a term used in the Bethesda system for describing cervical or vaginalA cytologicA diagnosing to depict a spectrum of noninvasive cervical epithelial abnormalcies, including moderate and terrible dysplasia, carcinoma in situ, and cervical intraepithelial neoplasia ( CIN ) grades 2 and 3. The presence of HSIL in patient does non intend of any malignant neoplastic disease, but it is more to precancer phase. However if it is non treated, the precancer can come on to malignant neoplastic disease that could take to fatal or decease.
During the diagnosing of HSIL, the screener needs to cognize the age and history of the patient. The screener besides needs to cognize the booby traps of HSIL that can take to incorrect diagnose.
The diagnostic features of HSIL are high karyons to cytoplasmic ( N/C ) ratio with pantie cytol, irregular karyon membrane and absent of nucleole. The job arises when other dysplasia or other abnormalcies give similar morphological cell as the HSIL.
Pitfalls in naming the HSIL mean the incorrect diagnosing that happen during the reading of HSIL. These due to the cell that can mime the features of it. Few cells that will be discussed below demoing the mimicking cell of HSIL such as endometrial cell, histiocyte, immature squamous metaplastic, endometrial cell exfoliated due to an IUCD ( intrauterine cell device ) , Follicular cervicitis and endocervical cell, mild and moderate dyskaryosis.
Immature Metaplastic Cell
Metaplastic cell ( Fig 2 ) can be found in transmutation zone. It arises in between the passage of the columnar cell to squamous epithelial cells. Nucleus of the metaplastic are somewhat enlarged from the normal cells and appears every bit unit of ammunition to oval in form uniformity with the presence of individual nucleole. However, it ‘s become hard to name the HSIL when the immature metaplastic nowadays in the vilification.
( M.D. , m. A. , 1999 )
The job occur when the immature metaplastic shows hyperchromatic cell with clumped chromatin that miming the HSIL. Koilocytes sometimes may show in the immature metaplastic cell. However, there are certain features that can be used to distinguish the HSIL from immature metaplastic. Although the N/C ratio for both HSIL and immature metaplastic cells are higher, they differ in cytol feature. For HSIL, the cytol is bare, while in immature metaplastic, the cytol is abundant. Therefore, the atomic membrane of HSIL is thick and irregular compared to immature metaplastic cells. Therefore, it is necessary to detect the whole cells based on their atomic form, chromatin form, and the cytol.
( M.D. , m. A. , 1999 )
Intrauterine Cell Device ( IUCD ) cells
Intrauterine cell device ( IUCD ) ( Fig 3 ) cells are consistent with alterations associated with the nowadays of intrauterine device ( IUD ) . Normally these cell found in endometrium in the nowadays of IUCD. The present of IUD is associated with sloughing of endometrial cell at a mid rhythm which can do terrible cytologic alterations to the endometrial cells. The IUCD is a individual cell with high N/C ratio, finely vacuolated cytol, smooth atomic membrane and unvarying karyon. Normally individual cell with this type of alterations may be confused with HSIL. These cells can be distinguished from HSIL by the presence of rare unnatural cells, deficiency of atomic membrane abnormality, hyperchromatism, syncytial fragment and cytoplasmatic vacuolization.
( Malcolm Potts Ph.D. , M. B. , 2005 )
Follicular cervicitis ( Fig 4 ) or lymphocytic cervicitis is one of the booby traps in diagnosing HSIL. Follicular cervicitis defined as polymorphic of benign lymph cells, ‘tingible ‘ organic structure macrophages, mitoses, differential diagnosing includes malignant lymphoma which shows monomorphic lymph cells and no ‘tingible ‘ organic structure macrophages. ‘Tingible ‘ organic structure macrophages are macrophages that contain many phagocytized, apoptotic cells in assorted provinces of debasement. In other beginning, the follicular cervicitis may ensue in runs of lymph cell cells in a vilification. The cells frequently focally but sometimes ruling big countries or even the whole of a vilification. The cells characteristically are dispersed, include larger follicle Centre cells which may demo mitotic figures, little lymph cells and mature plasma cells with harsh chromatin, and macrophages incorporating touchable organic structures.
( www.angelfire.com/art3/gynae_cytology/theory3.htm )
In the booby traps in diagnosing of HSIL state of affairs, normally follicular cervicitis is readily recognized in well-preserved readying but there are confused with other little cell lesions for illustration HSIL. The job occurs when there is hapless saving or devolution. Furthermore, little lymph cells with their features, really little karyons should non misidentify for HSIL. However, larger originative Centre lymph cells may be mistaken for HSIL. Germinal Centre cells are frequently accompanied by tingible organic structure macrophages. They besides do non hold membrane notching of HSIL and have a more coarsely farinaceous chromatin form compared to HSIL.
Histiocyte ( Fig 7 ) is known as macrophage in the organic structure tissue, while in the blood stream it is known as monocytes. General morphology of histiocytes is round to reniform or bean molded karyon, light cytol and mulct to coarse chromatin and uniformly distributed. By observation under microscope, the vilification shows that histiocytes normally appear as individual cells. Merely on certain instances they may look in bunchs particularly if they are legion, as in the late catamenial “ exodus vilification ” . The term “ exodus vilification ” is used to depict histiocytes that may cast at the terminal of menses. Histiocytes in this vilification may demo degenerative alterations that make them highly hard to distinguish from little cell terrible dyskaryosis or HSIL.
( Mark H. Stoler, M.D. 1999 )
Challenges occur when merely a few top-quality cells are present in the background of the slide. These cells are frequently little and may come close the size of a little histiocyte. To guarantee that the cells are histocytes ( non HSIL ) , some of the cells in the group at least, should hold typical bean-shaped karyon and recognizable spread histiocytes should be found elsewhere in the vilification. If the feature of foaming cytol and reniform karyons can non be observed, differentiation of histiocytes from badly dyskaryotic squamous cell can be made by comparing with neighbouring cells which show more typical features.
It could be simplify that those histiocytes in an “ hegira vilification ” miming dyskaryosis. Since histiocytes and terrible dyskaryosis may both be present on the same vilification, a careful observation and research should be made for dyskaryotic cells when pervert histiocytes are found.
( Mark H. Stoler, M.D. 1999 )
Exfoliated Endometrial Cells
Exfoliated endometrial ( Fig 3 ) cells are normally seen in specimens obtained during the catamenial rhythm. Abraded endometrial cells from the lower uterine section and cells that can be identified as histiocytic or stromal in beginning should non be reported as endometrial cells as they do non transport the same hazard for endometrial pathology. However, endometrial cells have been considered a possible forerunner of endometrial glandular cancer when seen in cervical cytology of postmenopausal adult females or exterior of the proliferative stage of the catamenial rhythm. In the first half of the catamenial rhythm, endometrial cells frequently have a dual contour with glandular cells environing a nucleus of stromal cells.
( Mamatha Chivukula, 2007 )
During detecting the specimen, endometrial cells can be mistaken with HSIL. Normal endometrial karyon are little, no larger than an intermediate karyon, and are either unit of ammunition or bean-shaped. The chromatin form may be hard to spot in the cell groups, but nucleoles are normally invisible and nuclei may be degenerated. The cytol is bare, basophilic, and frequently wisplike or on occasion vacuolated. Cell boundary lines are unclear, and the cells often appear to be packed together. The background is frequently bloody and may incorporate histiocytes and endometrial stromal cells. In liquid based readyings, 3-dimensional cell bunchs are common, with the plane of focal point frequently above the plane of the normal squamous cells. Single cells may be more normally seen, and the background is normally clear with less blood. Nuclear chromatin item may be more easy discerned, and individual cell mortification ( programmed cell death ) is common within exfoliated cell groups. Normally they are non hard to separate from cells of CIN or invasive carcinoma but it is necessary to be cognizant that clustered, and sometimes individual cells from little cell non-keratinizing HSIL or invasive carcinoma may look similar to endometrial cells.
( Mamatha Chivukula, 2007 )
The features of endometrial cells that can be observed are little hyperchromatic karyon with bare cytol and nowadays in bunchs. This can be incorrect construing as HSIL. The presence of the feature of the biphasic endometrial cell groups is helpful to corroborate endometrial exfoliation, but if there is a possibility of coexisting HSIL or carcinoma, farther probe should be necessary.
In cytology, it is a common serious mistake to do error between HSIL in crowded sheets for endocervical cells ( Fig 5 ) or frailty versa. Several features that make the endocervical cells can be mistaken as HSIL in crowded sheets are when the columnar cell forms are sick defined or absent and the sheets appear every bit syncytial as cell boundary lines within the sheets are invisible. Endocervical cells that miming HSIL cell sheets are about alwaysA three or more nuclei midst, while the normal endocervical cell sheets are about ever less than three nuclei midst.
( Renshaw et al.,2006 )
Most of the factors that make the HSIL in crowded sheets can be mistaken as endocervical cells are when their cytoplasmatic textures resemble to that of endocervical cells. The picket, fragile and foaming cytol of the HSIL therefore can be dismissed as endocervical cells. Although cytoplasmatic texture may resemble that of endocervical cells, the groups do non hold long tallies of smooth apical or luminal cytoplasmic border, across several cells, and nuclei set back a changeless distance, repeated, ordered ‘six around one ‘ honeycomb agreements of karyon. Nuclei in crowded HSIL sheets are frequently really crowded, reflecting a really high atomic N/C ratio. This is a really conspicuous testing characteristic when nowadays. However, the N/C ratio is non ever high in endocervical-like HSIL sheets where the cytol may be comparatively abundant in some sheets or in portion of a sheet.
( Renshaw et al. ,2006 )
This seems to belie the rule that high N/C ratio is an indispensable characteristic of a HSIL. However, the existent footing of the ‘High N/C ratio equates to High class ‘ rule is that high class unnatural cells have scant cytol because they have failed to maturate usually.
We conclude that it is of import to separating HSIL from its mimics during describing the consequence. HSIL can non be holding if the to the full characteristic found. By the manner, acquiring equal clinical information and uninterrupted preparation to keep competence and cognition are some of the suggestion to cut down booby traps. Therefore, incorrect diagnose of untypical glandular cells cause consequence over intervention. The diagnostic booby traps of HSIL are endometrial cells, immature squamous metaplasia, endocervical cells, mild and moderate dyskaryosis, histiocyte, follicular cervicitis, and endometrial cell exfoliation due to an IUCD.
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