IntroductionThis month's case has been kindly put together by Abed Kader, Dianne Stanley and Jennifer Sigley of Medical Laboratory Wellington. There are seven images to review in this set which is just presented as an interesting case rather than a quiz this month.
You are invited to submit comments to the members' froum about this case. |
A routine smear on a 64 year old patient was received in 1998. This smear (Fig1.), contained all the features of atrophic vaginitis:
Very careful review of this smear (with total review bias!), revealed 2 atypical keratinised squamous cells (Fig2.), which if found at the time of screening, would probably have been reported as atypical squamous cells (repeat in 6 months).
[cont...]
It is easy to assume a global or overall impression of a smear when screening; don’t be complacent! Continue screening any smear carefully for possible occasional abnormal cells.
A second smear was received in late 2001. This smear (Fig3.), showed an atrophic vaginitis pattern, with numerous atypical keratinised squamous cells, including some bizarre forms. It was reported as atypical parakeratosis, with a recommendation to repeat after oestrogen treatment.
The repeat smear submitted in early 2002 showed no evidence of abnormality. The smear pattern was mature, comprising of mainly intermediate and superficial squamous cells. The report was sent out as no evidence of abnormality, with a recommendation to repeat in 12 months (due to the previous atypical smear).
A follow up smear was done in June 2003. This smear showed numerous abnormal cells consistent with high grade squamous SIL. The report was sent out as HGSIL/CIS, with a recommendation of urgent referral for colposcopy/biopsy.
This smear has a relatively clean background (ie: no tumour diathesis), with some inflammatory cells and numerous single lying, highly atypical keratinised squamous cells (Fig4.), and some loosely cohesive fragments of keratinised spindle cells (Fig5.). The nuclei of these cells appear opaque.
A LLETZ was performed in July 2003, and this showed only CIN1/HPV changes
The patient had another smear done in December 2003. This smear showed similar changes to the previous smear (June 2003), and was reported as HGSIL. Most of this smear (as in the previous smear), comprised of normal atrophic squamous epithelial cells. The background, again, was relatively clean. (Fig6.).
In May 2004, the patient had a cone biopsy done at Wellington Hospital, which was reported as '..wide spread denudation of the surface epithelium present. Where visible, the surface epithelium shows transitional metaplasia. There is no evidence of dysplasia or malignancy.'
The patient had a further smear in December 2003 which again showed HGSIL changes and was reported as HGSIL/CIS.
Pathologists at Wellington Hospital who had originally dealt with the cone biopsy in May 2004, phoned Medlab Wellington staff and discussed this case, mainly to ascertain how convincing the reported high grade changes in the smears were. These pathologists were assured of the unequivocal nature of the high grade changes in the smears and a slide mix-up was excluded. Further levels of the cone biopsy revealed no abnormality. It was decided to perform a hysterectomy. This was done in May 2005. This showed '..moderately differentiated squamous cell carcinoma of the endometrium with 50% myometrial invasion.' (Fig7.) There was no cervical or vaginal abnormality; neither was there cervical mucosal or stromal involvement by the tumour.
Thanks to Abed Kader for submitting this case