[The cytological diagnostics of dysplasia and epidermoid carcinoma of the cervix in studying the nucleolar-organizing regions of chromosomes]

The study of the nucleolar-organizing regions of chromosomes in the cells of dys-plastically modified squamous epithelium and epidermoid cancer of cervix was carried out. The successive increase of quantita-tive content of main morphofunctional types of nucleoli is established including active compact and transient nucleolonemic-compact ones in accordance with in-crease of dysplastic modifications and appearance of signs of epidermoid cancer of cervix. The dominance of percentage content of large argyrophilic granules in nu-cleoli of nucleolonemic type under epidermoid cancer of cervix as compared with dysplasia is established. The algorithm of differentiating cytological diagnostics of the degree of dysplasia and epidermoid cancer of cervix is developed. This algo-rithm reflects the degree of structural functional modifications of nucleolar-organizing regions of chromosomes.

Prevalence of micronuclei in exfoliated uterine cervical cells from patients with risk factors for cervical cancer

CONTEXT AND OBJECTIVE

Pap smears are the most common and inexpensive screening method for cervical cancer. We analyzed micronucleus prevalence in exfoliated cervical mucosa cells, to investigate associations between increased numbers of micronuclei and risk factors for cervical cancer.

DESIGN AND SETTING

Analytical cross-sectional study, at Instituto de Pesquisa em Oncologia (IPON).

METHODS

Exfoliated cervical cells were obtained from 101 patients between September 2004 and November 2005. Patients' ages, habits (passive or active smoking, alcoholism and numbers of sexual partners), age at first sexual intercourse, contraceptive methods used, histories of sexually transmitted diseases, use of hormone replacement therapy, numbers of pregnancies and abortions, inflammatory cytology and cervical intraepithelial neoplasia (CIN) were obtained. Cells were collected using Ayre spatulas, transferred to vials containing 0.9% saline solution for micronucleus tests and analyzed at 1000x magnification. The number of micronuclei in 1,000 epithelial cells per patient sample was counted.

RESULTS

Comparisons between groups with active (7.9 +/- 7.8) and passive (7.2 +/- 10.6) smoking versus no smoking (3.7 +/- 5.1); with/without alcoholism (7.8 +/- 1.4 and 6.9 +/- 10.1); with/without inflammatory cytology (10.7 +/- 10.5 and 1.3 +/- 1.7); and with CIN I, II and III and no CIN (respectively 4.3 +/- 4.3, 10.6 +/- 5.3, 22.7 +/- 11.9 and 1.3 +/- 1.4) found elevated micronucleus prevalence (P < 0.05).

CONCLUSIONS

We concluded that the prevalence of micronuclei in exfoliated uterine cervical cells was greater in patients with one or more risk factors for uterine cervical cancer than in patients without risk factors.

Multinucleation of koilocytes is actually multilobation

In order to clarify the complete cytomorphology of cytopathic changes as a consequence of human papillomavirus (HPV) infection, we performed three-dimensional (3D) reconstruction from confocal fluorescent images. After confirming 22 HPV types using a DNA chip, we performed 3D confocal image restoration in human uterine cervical swab samples and corresponding tumor tissues. On restoration of 3D confocal images, the multinucleated feature of koilocytes was revealed to be multilobation of a single nucleus, as opposed to true multinucleation.

Multinucleation of koilocytes is in fact multilobation and is related to aberration of the G2 checkpoint

AIMS

To clarify the fine structure of koilocytes and correlate this with genetic aberration of the G2 checkpoint.

METHODS

Three dimensional reconstruction from confocal fluorescent images, together with functional assays for key molecules of the G2 checkpoint-cdc2 and cyclin B1-was performed in human uterine cervical samples. After confirming 22 human papillomavirus (HPV) types using a DNA chip from 30 cervical swabs, previously confirmed as 15 cervical low grade and 15 high grade intraepithelial lesions, the activity of molecules involved in the G2 checkpoint was evaluated using western blotting for cyclin B1, cdc2, and phospho-cdc2 (Y15 and T161), a nuclear extraction fractional assay, and a reverse transcription polymerase chain reaction assay. In addition, three dimensional confocal image restoration was performed on confirmed cervical intraepithelial neoplasia tissue samples.

RESULTS

T161 phospho-cdc2 and cyclin B1 expression was higher in HPV infected cervical lesions than in normal samples. Immunofluorescence, revealed that cyclin B1 was present predominantly in the nuclei of HPV infected cells, confirming the results of the nuclear fractional assay. On restoration of three dimensional confocal images, the multinucleation of koilocytes was revealed to be multilobation of a single nucleus, rather than true multinucleation. This multilobation appeared to be associated with chromosomal instability and aberration of the G2 checkpoint.

CONCLUSIONS

The multiple nuclei of koilocytes are in fact multilobation of a single nucleus, and this phenomenon is associated with upregulation of gene products related to the G2 checkpoint.

[ASCUS of metaplastic type. Cyto-histopathological correlations]

We evaluated the cytopathological changes and the prognostic significance of atypical squamous metaplastic cells in cervical smears. 50 ASCUS cases were divided in two groups: 25 cases in different settings and 25 of metaplastic type. All cases were re-evaluated after 6 months and when necessary, verified by biopsy. The second cytological diagnosis was: group I--13 normal, 2 LSIL, 40 ASCUS; group II--6 normal, 2 LSIL, 2 HSIL and 15 ASCUS. The HPV was positive in 5 cases in group I and in 9 cases in group II. In ASCUS persistent cases the biopsy revealed: in group I--3 CIN 1 and 1 CIN 2 cases; in group II--1 CIN 1, 2 CIN II, 2 CIN III and one case of microinvasive carcinoma. In conclusion, atypical metaplastic cells are more frequently involved in serious cervical lesions.

Cytometric features of cell nuclei of adenocarcinoma in situ and invasive adenocarcinoma of the cervix

OBJECTIVE

The goal of this study was to characterize adenocarcinoma in situ (ACIS) and invasive adenocarcinoma (AdCa) of the cervix by using image histometric measurements of nuclear morphometric features.

STUDY DESIGN

Archival pathology slides and tissue blocks from 37 patients with ACIS, 18 with invasive AdCa, and 13 with normal cervical epithelial and glandular histology were reviewed by two pathologists. The controls were matched for age and menstrual status and as closely as possible for the age of the slides; this limited the number of normal cases available. Morphometric, photometric, and textural measurements were made on 4-microm sections of tissue stained with a thionin-SO(2) Feulgen reaction. A mixed analysis of covariance model was used for analysis.

RESULTS

The Integrated Optical Density Index was found between the mean value for normal cells and that for ACIS and invasive AdCa (P <.001). Twenty-two other morphometric features were identified that exhibited differences in their means between at least two of the three tissue types.

CONCLUSION

In the cell populations studied, certain nuclear image features were found to correlate with histologic diagnosis. The features can be measured objectively and could be useful to pathologists in differentiating lesions, although a larger study should be evaluated to confirm these findings. Further, these features may be important as optical technologies are developed that make diagnoses in real time.

Significance of AGUS Pap smears in pregnant and postpartum women

OBJECTIVE

To study the clinical significance of atypical glandular cells of undertermined significance (AGUS) in pregnant and postpartum women.

STUDY DESIGN

We evaluated 35 women who were pregnant (30) or within three months postpartum (5) and had a cytologic diagnosis of AGUS. Twenty-seven (77%) patients had follow-up: 17 (63%) patients underwent colposcopic examination and biopsy, and 10 (37%) had repeat Pap smears. Eight patients were lost to follow-up.

RESULTS

Five (29.4%) patients had a squamous intraepithelial lesion (SIL), including three high grade and two low grade, on subsequent biopsy. The remaining (70.6%) patients had benign pathology, which included 5 chronic cervicitis, 4 endocervical and/or endometrial polyps, 2 Arias-Stella reaction and 1 microglandular hyperplasia. Among the patients with repeat Pap smears, two had persistent AGUS/atypical squamous cells of undetermined significance, the remaining cases were within normal limits.

CONCLUSION

Pregnancy-related changes may present with glandular atypia. In addition, about one-third of pregnant and postpartum women with a diagnosis of AGUS had SIL on subsequent biopsy; that rate is similar to that in nonpregnant women. Therefore, pregnant women with a cytologic diagnosis of AGUS should be followed closely.

Atypical glandular cells of undetermined significance in cervical smears after conization. Cytologic features differentiating them from adenocarcinoma in situ

OBJECTIVE

To evaluate the cytologic features of atypical glandular cells of undetermined significance (AGUS) smears following conization through a comparison with adenocarcinoma in situ (AIS) smears.

STUDY DESIGN

Fifty cervical smears, diagnosed as AGUS based on groups of crowded glandular cells that raised the possibility of AIS, from 38 patients who had conization and 24 AIS smears, histologically confirmed, from 17 patients were reviewed. Subsequent follow-up biopsies or hysterectomies in 38 patients were evaluated.

RESULTS

Nuclear atypia was a more reliable feature than architectural structure in differentiating postcone effect from AIS on cytology. The predominant cytologic features of the postcone smears were crowded glandular cells with a high nuclear/cytoplasmic ratio and relatively small, hyperchromatic nuclei with rather finely granular and uniformly dispersed chromatin, less distinct nuclear membranes, less frequent mitosis and presence of endometrial-type stromal cells in the background. The architecture of the crowded cells in the postcone smears was sometimes similar to that of AIS. No AIS or high grade squamous intraepithelial lesion histology was encountered in follow-up biopsies or hysterectomy specimens.

CONCLUSION

The cytologic features distinguishing AGUS from AIS may be helpful in identifying the postcone effect. Since it is important to avoid miscalling the postcone effect as AIS, it is recommended that one check for a previous history of a cone biopsy.

Polymorphism of Ag(+)-NORs in cervical smears from women with cervical cancer

OBJECTIVE

To evaluate Ag(+)-stained (Ag(+)-NOR) polymorphism in four groups of patients with various grades of cervical lesions and in a control group.

STUDY DESIGN

Forty-five women were selected, diagnosed and classified on the bases of the Pap smear and colposcopy/biopsy at Hospital de Ginecologia y Obstetricia del Instituto Mexicano del Seguro Social in Monterrey, Mexico. Five categories were considered: (1) inflammatory, (2) low grade squamous intraepithelial lesions (LSILs), (3) high grade squamous intraepithelial lesions (HSILs), (4) invasive cervical cancer, and (5) normal. The cervical smears were stained by the Ag(+)-NOR method. One hundred cells per slide were counted and classified according to the polymorphism of Ag(+)-NOR dots: typical (spherical) and atypical (large, kidney shaped and clustered). The four shapes of Ag(+)-NORs were quantified by percentage and transformed using the arcsine root procedure.

RESULTS

Statistical analysis showed a significant decrease in spherical shape according to neoplastic development. The three atypical shapes showed a significant increase in patients with HSIL and invasive carcinoma in respect to LSIL. Principal components analysis grouped the data at five locations in the plane formed by the first two principal components according to the diagnosis.

CONCLUSION

These findings suggest the potential diagnostic and prognostic value of the determination of Ag(+)-NOR polymorphism in cervical cytology studies.

Atypical glandular cells of undetermined significance on cervical smears. A study with cytohistologic correlation

OBJECTIVE

The incidence of endocervical adenocarcinoma has increased steadily over the past two decades. Since the Bethesda System was introduced, the diagnosis of atypical glandular cells of undetermined significance (AGUS) has also risen and now accounts for 0.46-1.83% of all cervical (Pap) smears. The purpose of this study was to evaluate the significance of a diagnosis of AGUS using cytohistologic correlation.

STUDY DESIGN

A retrospective review of archival material from 1993 through 1996 identified 64 patients who had smears diagnosed as AGUS and had a subsequent surgical biopsy. The smears were reviewed and cytologic features analyzed and correlated with the histologic diagnosis.

RESULTS

On biopsy, 3 (5%) of the 64 cases showed endocervical adenocarcinoma in situ (AIS) (1 case with invasive adenocarcinoma also), 14 (22%) had a benign glandular lesion (endocervical polyp, tubal metaplasia, microglandular hyperplasia, reactive changes), 35 (54%) had squamous intraepithelial lesion (SIL) (15 diagnosed on the original smear), and 12 (19%) had no abnormality. Among the cytologic criteria evaluated, feathering (P = .01), palisading (P < .001) and chromatin clearing (P = .002) were shown to have a significant association with the histopathologic diagnosis of AIS/adenocarcinoma. These features were also useful in distinguishing AIS/adenocarcinoma from SIL and benign glandular changes from AIS/adenocarcinoma but not benign/reactive glandular changes from SIL.

CONCLUSION

A diagnosis of AGUS correlated with a clinically significant lesion in the majority of cases. Squamous dysplasia (SIL) was the most common lesion identified. The presence of feathering, nuclear palisading and chromatin clearing increased the likelihood of a histologic diagnosis of AIS/adenocarcinoma.

Immunohistochemical and ultrastructural study of Langerhans's cells in squamous cell carcinoma of the cervix

OBJECTIVE

To study Langerhans's cells (LCs) in cervical squamous cell carcinoma.

STUDY DESIGN

The study was carried out in the Shatby University Hospital, Alexandria, Egypt. Thirty cases with squamous cell carcinoma, 10 cases with cervical intra-epithelial neoplasia (CIN) and 10 cases with normal exocervix were recruited. Sections from the exocervix were stained with gold chloride, immunostaining with S-100 protein antiserum, adenosine triphosphatase ATPase and electron microscopy. Statistical evaluation was done using the t-test.

RESULTS

Gold chloride staining revealed significantly increased number of LCs in all cases of CIN compared to normal controls and with increasing grade of CIN (p < 0.001). No relationship between LCs number and the grade of carcinoma. Least branched LCs were predominant in the normal tissue while in neoplasia, these cells were of the most branched type, indicating a hyperactivity. S-100 protein positive LCs were almost absent in normal controls while their number were almost lower than the corresponding cases of CIN and invasive carcinoma after gold chloride or ATPase stainings. Signs of hyperactivity were evident in LCs of neoplastic cases after electron microscopy.

CONCLUSIONS

Proliferation and increased number of LCs in CIN is an immune response, while such reaction is suppressed by invasive carcinoma.

Characterization of an HPV-negative cell line (FR-CAR) derived from a cervical squamous intraepithelial lesion

A new cell line, FR-car, has been established from a biopsy of a low-grade human cervical squamous intraepithelial lesion (SIL). We confirmed the epithelial origin of the cells by keratin staining using polykeratin, AE1/AE3 and CAM 5.2 antibodies. Sixty percent to 80% of the cultured cells stained positive for proliferative cell nuclear antigen (PCNA) and Ki-67. There was no overexpression of p53. Karyotyping revealed that the cell line was hypodiploid with clonal abnormalities on chromosome 6 and 16. Sections of a biopsy adjacent to the lesion from which the culture was initiated tested positive for human papillomavirus (HPV) 18 DNA by the polymerase chain reaction, but cultured cells tested at several passages were HPV-negative by either type-specific or consensus PCRs. This HPV-negative SIL line may be useful in studies into the cell biology of dysplastic epithelium.

Progressive dysregulation of proliferation during cervical carcinogenesis as measured by MPM-2 antibody staining

To better characterize the amount and location of loss of proliferation control during cervical carcinogenesis, 44 cervical cone biopsy specimens containing various grades of premalignant and malignant lesions and 12 normal cervix specimens were immunohistochemically examined using MPM-2. This antibody recognizes a phosphorylated epitope on a group of proteins that are preferentially phosphorylated at mitosis. The spatial organization of mitotic figures was determined using a computer-assisted image analysis system. The mitotic figure frequencies/unit of epithelial area were found to increase as the histological type progressed; the numbers of mitoses/square millimeter was 1.7 +/- 0.5 (mean +/- SE) for control normal epithelium (n = 12), 3.1 +/- 1.7 for normal epithelium adjacent to cervical intraepithelial neoplasia (CIN) and cancer (n = 28), 7.9 +/- 1.3 for CIN1 (n = 24), 75.8 +/- 16.3 for CIN2 (n = 11), 127.2 +/- 9.7 for CIN3 (n = 22), 196.9 +/- 33.2 for carcinoma in situ (n = 9), and 156.2 +/- 31.0 for cervical carcinoma (n = 8). The MPM-2 index was higher in high-risk premalignant lesions (i.e., those adjacent to areas of high-grade CIN and carcinoma) than it was in lower risk premalignant lesions (i.e., those with no adjacent higher grade CIN or cervical cancer), even if they exhibited the same histological grade. Moreover, the mean relative distance of the mitotic cells from the basement membrane (i.e., the distance from the basal layer to the surface) also increased as the histological grade progressed. These results suggest that proliferation becomes sequentially dysregulated both quantitatively and spatially during cervical carcinogenesis and that the MPM-2 antibody might be useful as a proliferation biomarker.

Cytologic features of neoplastic lesions in endocervical glands

Cytologic criteria for classifying atypical endocervical cells on Pap smears are poorly defined. In this study we evaluated cytologic parameters that are useful in predicting the presence of neoplastic lesions (NL) and those that help distinguish squamous intraepithelial lesion (SIL) from glandular neoplastic lesions. The recently proposed Bethesda System (TBS) terminology for reporting atypical glandular cells of undetermined significance (AGUS) was also evaluated for its significance on patient management. Sixteen cases of biopsy-proven endocervical glandular NL that had cytologic smears available for review were included. Thirty-five smears with atypical endocervical cells and follow-up biopsies showing benign/reactive change (n = 22) and SIL involving glands (n = 13) were reviewed for comparison. Our results show that squamous NL often coexist with glandular NL. The presence of rosettes, hyperchromasia and increased N/C ratio is useful in distinguishing NL from benign/reactive conditions. Architectural features are helpful in distinguishing SIL from glandular NL. While a haphazard arrangement is more often seen with SIL, glandular NL are more likely to maintain polarity and to show glandular rosettes. Using TBS criteria, a conservative management seems justified in patients with AGUS-favor reactive and AGUS diagnosis on Pap smear, and colposcopy is indicated for patients with AGUS-favor NL.

p53 protein and tumorigenesis in the uterine cervix

The relationship between molecular abnormalities of p53 tumor suppressor gene product and cancer has been well documented. That correlation may exist between immunocytochemically detectable amount of p53 protein and neoplasia is evidenced by several studies. Detection of p53 protein by immunocytochemistry varies depending on the methods and antibodies used. It has been suggested that the quantitative aspect of p53 protein expression and the proportion of cells expressing p53 may be of clinical importance in human malignancies. In the present study, we have examined the expression of p53 protein in various grades of lesions of the uterine cervix. Statistical analysis showed a good correlation between expression of p53 protein and histologic grade of lesions. Increased expression of p53 in dysplastic and malignant lesions compared to non dysplastic lesions suggests that p53 protein accumulation may be an early event in carcinogenesis.

Activity satellite association and polymorphism of Ag stained nucleolus organizer regions (Ag+ NORs) in lymphocytes from women with cervical uterine cancer

Thirty five female patients with different stages of neoplastic lesions: cervical intraepithelial neoplasia (CIN) or dysplasia (CIN I and CIN II), in situ carcinoma (CIS), and adenocarcinoma, and 27 healthy women (controls) were studied to determine the activity, satellite association, and polymorphism of Ag stained nucleolus organizer regions (Ag+ NORs) in acrocentric chromosomes in metaphases obtained from peripheral blood lymphocytes. For each person, 25 to 50 metaphases stained with ammoniacal silver technique were scored. The average number of Ag+ NORs was higher in women with adenocarcinoma (7.66 +/- 0.72) than in controls (6.65 +/- 0.74). Non-associated chromosomes showing Ag+ NORs were found more frequently in patients (5.85 +/- 0.88) than in controls (4.81 +/- 0.67). Patients aged 30-39 and 60 or more had an increase of Ag+ NORs (7.99 +/- 1.04, and 7.81 +/- 0.71) with respect to their controls (6.36 +/- 0.052 and 6.17 +/- 0.88), but the frequency of satellite association showed lower values in 50-59 year-old patients (0.75 +/- 0.08) than in controls (1.02 +/- 0.19). The most frequent association in patients was the large type (patients = 38.96%, controls = 30.49%). The partial association showed higher values (6.49%) than controls (2.44%). Otherwise, the spherical association was more frequent for controls (37.80%) than for patients (28.57%). All these differences were statistically significant (p < 0.05). The frequency of Ag+ NORs and the type of polymorphism of satellite association could be related to the neoplastic process, while the frequency of satellite association and of polymorphism of Ag+ NORs seems to be irrelevant.

Nucleolar organizer regions (AgNORs) in intraepithelial neoplasia of the uterine cervix

The authors have studied the AgNORs counts in intraepithelial lesions of the uterine cervix. The following values were obtained (mean +/- SD AgNORs/cell): normal specimens--2.11 +/- 0.98; mild dysplasia--2.83 +/- 1.12; moderate dysplasia--3.42 +/- 1.13; severe dysplasia--3.55 +/- 1.28; carcinoma in situ--4.63 +/- 1.34; glandular extensions of carcinoma in situ--4.64 +/- 0.98. The values in moderate and severe dysplasia were similar, an argument for grouping these categories in the high-grade lesions. AgNORs counts in carcinoma in situ were, however, higher than in severe dysplasia, suggesting a continuous evolution of the neoplastic process.

Adenoid cystic (cylindromatous) carcinoma associated with squamous cell carcinoma of the cervix uteri: cytologic presentation of a case with histologic and ultrastructural correlations

BACKGROUND

Adenoid cystic (cylindromatous) carcinoma is a rare tumor. It accounts for approximately < 1-3% of primary adenocarcinomas of the cervix uteri. Its origin is debatable. It has a higher incidence in postmenopausal women but can develop in patients under 40. An association of adenoid cystic carcinoma with squamous cell carcinoma has been reported.

CASE

A case of invasive adenoid cystic (cylindromatous) carcinoma associated with an in situ squamous cell carcinoma of the cervix detected on Papanicolaou smears is reported. Ultrastructural studies provided findings that confirmed that the hyaline material corresponded to the remnants of the lamina densa of the basement membrane of malignant cells.

CONCLUSION

The concurrence of these two tumors supports the hypothesis that adenoid cystic carcinoma of the cervix may develop from multipotent reserve cells.

Grading cervical dysplasia with AgNORs using a semiautomated image analysis system

Colposcopic biopsies were classified according to previously established criteria by a group of three pathologists interested in cervical pathology. Ten cases were identified in each of the following five groups: normal, koilocytosis, low grade squamous intraepithelial lesions (CIN 1), high grade squamous intraepithelial lesions (CIN 2) and high grade squamous intraepithelial lesions (CIN 3). The Crocker technique was used to stain the sections cut 3 microns thick. With ths silver stain the nucleolar organizer regions (NORs) are stained black and referred to as AgNORs. It has been shown that malignant and premalignant changes in cells produce an increase in AgNORs. In each case eight images were captured using a 100x oil-immersion objective and stored in a Datacube Maxvideo system as 512 x 480 pixels in an 8-bit grayscale per image. The images were processed using the NeoPath field-of-view computer to detect the AgNORs and nuclei by using grayscale mathematical morphology algorithms. Color overlays of the AgNORs and nuclei were created using segmentation algorithms. The results show that it is possible to differentiate between low grade squamous intraepithelial lesions (CIN 1) and high grade squamous intraepithelial lesions (CIN 2 and CIN 3) taken together; however, there is no difference between low grade squamous intraepithelial lesions (CIN 1) and koilocytosis. The results support the concept that dysplasia cannot be classified effectively into three grades and that low grade squamous intraepithelial lesions (mild dysplasia [CIN 1]) is indistinguishable from koilocytosis.

Significance of borderline nuclear abnormality in cervical smears

Women with cervical smears showing borderline nuclear abnormality (BNA), or reactive changes in the form of squamous metaplasia (SM) or endocervical cell hyperplasia (ECH), were age-matched with healthy controls to determine the outcome of these conditions. No significant difference in the risk of dyskaryosis was observed in cases showing reactive changes and the controls. In contrast, there was a 23% excess of cases showing dyskaryosis in the repeat smears of cases of BNA over the controls. An odds ratio of 8.3 was obtained, showing dyskaryosis in subsequent smears after a diagnosis of BNA.

Tubal metaplasia. A frequent potential pitfall in the cytologic diagnosis of endocervical glandular dysplasia on cervical smears

The detection of endocervical glandular abnormalities has risen in recent years due to the increased clinical use of improved endocervical canal sampling instruments, such as Cytobrushes. From January 1987 through August 1989, a diagnosis of endocervical glandular dysplasia was initially suggested on cervical smears from 50 women for whom histologic follow-up information was available. Retrospective review of the cytologic smears and histologic slides from these patients revealed tubal metaplasia in 19 of 29 (66%) cases evaluated by cervical conization and/or hysterectomy and in 19 of 21 (90%) cases confirmed by cervical biopsy and/or endocervical curettage. Cytologic criteria for the diagnosis of tubal metaplasia on cervical smears are discussed. Inasmuch as adenocarcinoma in situ of the cervix and endocervical glandular dysplasia are not readily discernible by colposcopy, the responsibility for the diagnosis of these lesions lies with surgical pathologists and cytopathologists. Familiarity with the cytologic features of adenocarcinoma in situ and endocervical glandular dysplasia that distinguish these lesions from tubal metaplasia and other potential mimics is essential.

A model for quantitative follow-up studies of cervical lesions

A model for follow-up studies of cervical lesions is described in which the specimen were taken in a noninvasive way using Cytobrushes and in which automatic measurement of the abnormal nuclei in the sampled epithelial fragments was possible because 2-microns thin Feulgen-stained plastic sections were prepared. The planimetric parameters AREA, PERIMETER, FORM PE, and FORM ELL, and the densitometric parameters optical density (OD) and integrated optical density (IOD) were assessed. The mean total volume and the mean total DNA were calculated using stereological methods. The moderate dysplasias differed from the carcinoma in situs for all the densitometric parameters except for OD, and from the invasive carcinomas for IOD and 5cER. In the moderate-dysplasia group, there were three types of DNA histograms: a highly abnormal type resembling the histograms of the carcinoma group, a normal type, and an intermediate type. Changes in DNA histograms can be established during follow-up studies of dysplasias without having disturbed the lesion due to the efficient and elegant noninvasive sampling method that was not used in earlier quantitative studies.

Cytokeratin intermediate filament pattern and human papillomavirus type in uterine cervical biopsies with different histological diagnosis

The cytokeratin pattern and the presence of human papillomavirus (HPV) were analyzed in 53 uterine cervical biopsies. The biopsies were histologically characterized and the diagnosis ranged from normal through dysplasia to carcinoma. The cytokeratins were identified by their immunological reactivity with the monoclonal antibodies AE1 and AE3. The tissue was typed for the presence of HPV types 11, 16 and 18. We have previously shown that there was no correlation between the expression of cytokeratins No. 14, 15, 16 and 19 (K14, K15, K16 and K19) and the histological diagnosis of cervical biopsies. The present study shows that the cytokeratin pattern cannot be correlated to HPV infection of the cervical tissue either.

[The relation of nucleoli to precancerous conditions of the cervix]

Oestrogens act at the nuclear level. To these steroids also a cancerogenic effect is ascribed. By staining for nuclear structures according to Smetana and Busch the authors proved morphological structures of the nucleolus in vaginal epithelia and in cells from cervical lesions. This applies to solid nucleoli -- which are active, annular nucleoli which are resting and nucleoli which have completed their activity -- micronucleoli. Hyperoestrogenic women have in their vaginal epithelia of the upper third of the vagina more active nucleoli (11.4%) than hypooestrogenic women (2.1%). Women suffering from cervical carcinoma during the menopause have more active nucleoli in the vaginal epithelia (30.8%), as compared with healthy hyperoestrogenic women of productive age. Patients during the menopause with grade III dysplasias have fewer active nucleoli in cervical epithelia than women with cervical cancer (25.0%), however, as compared with hyperoestrogenic women of productive age, much more. A large number of active nucleoli was proved by staining by Smetana's method also in cells taken from cervical lesions carcinoma type and grade III dysplasia in postmenopausal patients. Evaluation of morphological changes of the nucleoli suggests their activity, the activity of the whole nucleolus and is a sensitive indicator of the activity of the whole cell.

Microphotometric DNA analysis in moderate dysplasia of the uterine cervix. Correlation to the progression and regression of the lesion

Nuclear DNA content was determined by microphotometry in 27 cases of moderate dysplasia of the uterine cervix. All these cases were followed from one to ten years to study the biological behavior of moderate dysplasia in relation to cervical carcinogenesis. Ten of them showed progression to carcinoma in situ during a period of one to six years (median 34.8 months) and 17 cases showed regression to inflammation and normalcy during a period of one to ten years (median 44.2 months). DNA analysis was performed both on initial cervical smear and on representative smears collected during follow-up. Amongst ten cases which progressed to malignancy, nine had aneuploid DNA pattern and one had polyploid DNA pattern throughout the follow-up period. Amongst 17 cases which regressed to inflammation, 11 had euploid and six polyploid DNA pattern. The observation that moderate dysplasia with aneuploid DNA value often develops into carcinoma in situ in contrast to dysplasia with euploid or polyploid DNA value strengthens the conception that DNA aneuploidy may be considered as 'high risk indicator' for cervical precancerous lesions.

[Ultrastructural observation of human papillomavirus particles in the uterine cervix intraepithelial neoplasia]

Using transmission electron microscopy (TEM), twenty two cases of an intraepithelial lesion in the uterine cervix have been examined for the presence of human papillomavirus (HPV) particles. In 21 of these cases (95%), HPV particles were detected in the nucleus, and in 5 cases, in the cytoplasm. The distribution of the intranuclear HPV particles was classified into 4 types. In only 2 cases did the exhibited particles show a geometrical crystalline array (type I). In most cases, the exhibited particles were either seen to show an aggregate non-crystalline array (type II) or were concentrated around the chromatin (type III). Some cases also were found to show particles that were scattered sporadically in the nucleoplasm (type IV).

Masking effect of hormonal contraceptives on discriminating quantitative features of visually normal intermediate cells in positive and negative cervical smears

In quantitative studies of visually normal intermediate cells in smears from patients with cervical neoplasia, the contraceptive status of the patients has not previously been taken into account. In this study cervical smears from 151 patients with cervical intraepithelial neoplasia (CIN) III or invasive carcinoma and from 360 normal controls were grouped according to week of menstrual or pill cycle and mode of hormonal contraception. The nuclear-cytoplasmic (N/C) ratio of visually normal intermediate cells in smears from patients with neoplasia was significantly different from that of the normal controls (P less than .001). Based on nuclear area and N/C ratio, the percentages of intermediate cells correctly classified as having come from positive or negative smears were significantly better in women with ovulatory cycles (non-users) than in women using hormonal contraceptives (P less than .025). It is concluded that hormonal contraceptives can mask the salient quantitative features of visually normal intermediate cells from patients with CIN and the contraceptive status thus has to be taken into account in such studies.

Immunohistochemical and electron microscopic demonstration of human papillomavirus in dysplasia of the uterine cervix

Twenty-five cases of dysplasia of the uterine cervix were studied for the presence of human papillomavirus (HPV) by means of immunohistochemical and electron microscopic techniques. Serial sections of the same histological specimen were examined in each case. HPV was detected in 14 cases by both immunohistochemistry and electron microscopy, while 10 cases were negative with both methods. In only one case, there was a discrepancy in the results derived from these two methods. It was concluded that the relation between HPV infection and cervical dysplasia was confirmed and that immunohistochemical and electron microscopic methods led almost to the same result in detecting HPV in cervical dysplasia.

Basement membranes in progressing intraepithelial cervical neoplasia. An ultrastructural and immunohistochemical study with antibodies against human type IV collagen and laminin

The occurrence and location of basement membranes (BM) and their constituents were studied in benign, inflammatory, dysplastic and malignant conditions of the uterine cervix by light and electron microscopy and by immunohistochemical analysis with antibodies against human laminin and type IV collagen. The normal squamous epithelium showed a thin subepithelial BM band, which was preserved in dysplasia. Severe inflammatory conditions affecting the epithelium caused disruption and fragmentation of the BM. Well-differentiated carcinomas were frequently surrounded by a BM, whereas anaplastic tumors had a disrupted and fragmented BM, and similar material was also seen in the tumor tissue itself. Thus the presence of a continuous BM seems to be only a relative criterion in distinguishing between benign and malignant conditions.

Immunoperoxidase demonstration of human papilloma virus (HPV) in dysplastic lesions of the uterine cervix

Routinely processed sections of 47 unselected cervical dysplasias and in situ carcinomas (both condylomatous, CO, and noncondylomatous, NCO) were subjected to staining with indirect immunoperoxidase-PAP technique using anti-human papilloma virus (anti-HPV) immune serum to demonstrate HPV antigens in these lesions. Anti-HPV was raised in guinea pigs immunized with highly purified virions from a pool of human skin wart tissues. Positive reactivity for HPV (brown intranuclear precipitates) was disclosed in 72% of the CO dysplasias and in only one case (5.6%) of the NCO group. The frequency of HPV-positive lesions was inversely related to the degree of epithelial dysplasia, being consistent with the disappearance of ultrastructurally detectable virus particles in lesions turned malignant. HPV-containing cells were characteristic koilocytes or dyskeratotic superficial cells. The present technique provides definite evidence for the HPV etiology of the flat, inverted, and papillomatous condylomas, and seems to offer an advantage as a diagnostic tool of these lesions. When applied to malignant tumors in the near future, the method will undoubtedly bring more light on the suggested role of HPV in the etiology of human squamous cell carcinomas of the uterine cervix and other sites as well.

Atypical indifferent (reserve) cells in the cervical epithelium and their exfoliative pattern

The ultrastructure of light microscopically selected atypical indifferent (reserve) cells in cervical smear preparations is described and compared with their ultrastructure in histologic sections. These atypical indifferent cells have a blastlike chromatin pattern and an intact nuclear membrane. The cytoplasm, however, was often damaged or absent; if present, it showed no sign of differentiation. In the histologic sections, these atypical indifferent cells were found in reserve-cell hyperplasia, in small numbers in squamoid dysplasia and as basally located cells in atypical endocervical epithelium. In contrast to the indifferent cells, the squamoid dysplastic cells and atypical endocervical cells in smear preparations had intact cytoplasm; however, the nuclear membrane of the squamoid dysplastic cells was often interrupted. This study indicates that atypical indifferent (reserve) cells can be recognized by light microscopy in smear preparations and that the fact that the cytoplasm is often damaged or absent is probably due to its undifferentiated nature. These cells can originate in pure atypical reserve-cell hyperplasia, dysplasia or atypical endocervical epithelium. In view of the great importance of these cells in the morphogenesis of squamoid and adenomatous carcinoma of the cervix, it seems of paramount importance that they be identified in cervical smears.

Two types of cells in the normal and atypical squamous epithelium of the cervix. II. Light microscopic study in human subjects

The occurrence of two morphologically distinct cell types in the human cervical epithelium is reported. One of the two cell types had a large nucleus with scant chromatin, two to three chromocenters and a thin chromatinic membrane. Cells with these characteristics were called cells with "lucid nuclei." The other cell type had a small, dark nucleus. These types of cells were present in film-coated autoradiograms of specimens that had been fixed in Carnoy's solution; they were readily observed by altering the quality of the light illuminating the preparations. Micrometric determinations confirmed that cells with "lucid nuclei" were larger than cells with "nonlucid nuclei." There was significant variation in the proportion of cells with "lucid nuclei" among the various individuals investigated; these variations were not age dependent. Individual variations in the proportion of cells with lucid nuclei were also observed among cervical dysplasias and carcinoma in situ.

[Ultrastructural characteristics of cervical dysplasia and carcinoma in situ]

Some ultrastructural features of cervical dysplasia and carcinoma in situ were revealed by electron microscopic studies of cervix specimens from 24 women. Both types of preinvasive disorders are characterized by alterations in the distribution of nuclear chromatin, the outline of the nuclear membrane, the amount of cytoplasmic organelles, and the mode of cellular attachment. Unlike dysplasia, a great variety of morphological patterns was found in carcinoma in situ which could be subdivided into squamous and reserve cell types. In carcinoma in situ, there was no increase in differentiation of cells and the cell surface up to the outermost layers. The basal membrane was altered only in carcinoma in situ epithelium. The ability of the epithelial cell processes to penetrate through the altered basal membrane and to invade the underlying stroma may be the evidence of the malignancy of cells in carcinoma in situ but not in dysplasia where the basal membrane was unaltered.

Papillomavirus infection of the cervix I. Correlation of histology with viral structural antigens and DNA sequences

Eight cervical biopsies showing mild dysplasia and one showing squamous metaplasia were studied for the presence of papillomavirus (PV) antigens using an immunoperoxidase method having immunospecificity against the genus-specific (common) structural antigen(s) and for PV-specific DNA sequences by molecular hybridization under nonstrigent conditions. Of the eight cases showing mild dysplasia, both PV antigens and PV DNA sequences were detected in five, PV antigens only in one, and PV DNA sequences only in one; viral antigens and DNA sequences were not detected in the remaining lesion. A characteristic cellular atypia (PV-induced atypia) was present in the superficial and intermediate layers of the epithelium in the six cases positive for viral antigens, and a proliferation of basal and parabasal cells (PV-induced hyperplasia) occurred in five of these. PV structural antigens were localized within nuclei of some of the cells displaying atypia but not in the proliferating cells. The PV-specific DNA sequences in all six cases had the properties of unintegrated PV-DNA. In view of the demonstration of both PV antigens and DNA sequences in this distinctive lesion (PV-induced atypia and/or hyperplasia), traditionally regarded as a form of dysplasia, it is proposed that this lesion be referred to as "papillomavirus infection of the cervix."

Measurement of number and cross-sectional area of basal cell pseudopodia: a new morphometric method

A method of morphometric quantitative of the number of pseudopodia per individual basal cell and the ratio of the total cross-sectional area of the pseudopodia to the base area of the basal cell, using the transmission electron microscope, was developed. The diameters and areas of the bases of basal cells and the pseudopodia were also obtained. The number of pseudopodia per basal cell (N) and the ratio of the areas (F) measured in normal human uterine cervical epithelium were 34.22 and 0.338, respectively. The values observed in reactive atypia were 23.62 and 0.188; and those in mild dysplasia of the cervical epithelium (the earliest premalignant condition of the cervical epithelium), 26.98 and 0.226. There were statistically significant reductions in the number of pseudopodia per cell (N) and the ratio of areas (F) in the latter two pathological conditions compared to the controls. This morphometric method provides higher sensitive means by which one can quantify the characteristics of pseudopodia in various premalignant epithelia.

Nuclear DNA content and the number of Barr bodies in premalignant and malignant lesions of the uterine cervix

A study was conducted to determined whether it might be possible to screen for carcinoma in cells of the uterine cervix by determining the number of Barr bodies present. This determination was correlated with the measured values of nuclear DNA content. Cell samples were taken from 41 cases of premalignant and lesions of the uterine cervix as diagnosed by the Papanicolaou procedure. Slides were stained with acetic orcein, and the incidence of single and double Barr bodies as well as nonspecific chromatin was scored on 100 cells per case. DNA values were determined after Feulgen staining using a microspectrophotometer. The incidence of double Barr bodies showed a significant increase in cases of dysplasia, carcinoma in situ and invasive carcinoma. Correlated with this, the DNA histograms showed a decrease in the diploid mode and an increase in the tetraploid mode in those cases. Most cases that showed an excessive increase in nonspecific chromatin were early invasive carcinoma of the cervix. This technique could be used to predict the presence of invasive carcinoma of the cervix.

Desmosomes and gap junctions in precarcinomatous and carcinomatous conditions of squamous epithelia. An electron microscopic and morphometrical study

By means of morphometrical techniques we have studied the distribution of gap junctions and desmosomes in uterine epithelial cells during normal, preneoplastic and neoplastic conditions, and in skin and oral cavity during normal and neoplastic conditions. The percentage of cell surface occupied by gap junctions as well as the surface to volume ratio of these structures decreases progressively from normal to metaplastic and moderately dysplastic cervical epithelium and is practically null in more severe conditions. The percentage of cell surface occupied by desmosomes decreased significantly from normal to metaplastic epithelium; the decrease is less sharp from metaplastic epithelium to dysplastic epithelium and carcinoma in situ; it then becomes again abrupt from carcinoma in situ to invasive carcinoma. In skin and oral cavity, there is no significant change between the percentage of cell surface occupied by gap junctions as well as the surface to volume ratio of these structures in normal epithelium and basal cell carcinoma. There is a significant change between normal epithelium and squamous cell carcinoma as well as between basal cell carcinoma and squamous cell carcinoma. The percentage of cell surface occupied by desmosomes and the surface to volume ratio of desmosomes decreases significantly between normal epithelium and basal or squamous cell carcinomas as well as between basal and squamous cell carcinomas. It is probable that a lack of chemical and electronic coupling as well as a lack of mechanical adhesion play a role in determining the invasive behavior of malignant cells.

Basal cell pseudopodia in cervical intraepithelial neoplasia; progressive reduction of number with severity: a morphometric quantification

An application of a morphometric model is used to study the stroma epithelial interface in human cervical epithelium. This model derived by Okagaki and associates estimates from two dimensional transmission electron photomicrographs the number of basal cell pseudopodia per basal cell. The investigation of the full spectrum of cervical intraepithelial neoplasia (CIN) focusing on the basal cell-stroma interface with the "multiple cell-single section" model is discussed. Significant decreases in histopathologic grades of CIN are noted in the number of pseudopodia per basal cell (N) and the ratio (F) of the area of the stems of pseudopodia to the area of the base of the basal cell.

Chromatin appearance in intermediate cells from patients with uterine cancer

This paper presents the differences found by the computer analysis of digitized images of visually apparently normal intermediate cells from patients with normal cytology and patients with uterine cancer. There exist differences in the absolute amount of nuclear staining, the average density of staining, cell shape and size and also differences in spectral contrasts of the nuclear chromatin. Visual cytologic detection of these changes became more conspicuous when the photomicrographs were arranged in order of their discriminant function scores.

Koilocytosis in dysplastic and reactive cervical squamous epithelium. An ultrastructural study

Koilocytosis was studied in eight cases of dysplasia and reactive atypia with conventional transmission electron microscopy. The ultrastructural features were compared to the process of maturation of normal cervical epithelium. Koilocytosis was observed as abnormal karyopyknosis as represented by irregular nuclei, coarse chromatin clumping, the less dense ellipsoid perinuclear zone, and the increased tonofilament bundles in the outer zone of the cytoplasm accentuating the margin of the perinuclear zone of the cells.