8
Benign Proliferative Reactions, Intraepithelial Neoplasia, and Invasive cancer of the Uterine cervix
Fig. 8.45 Degenerative changes in endocervical columnar cells.
Hyperchromasia due to condensation of the chromatinic material. Loss of
nuclear structure. Differential diagnosis with a severe epithelial lesion on the
basis of clearly outlined cytoplasmic borders (Papanicolaou x HP).
cells. In women participating in a large population-screening pro-
gram, the number of smears unsatisfactory for cytologic diagnosis
was 6.8%.26 Poor quality of the smears was caused by too few
epithelial cells present or a strong admixture of erythrocytes or
inflammatory cells. Of the smears considered evaluable, endocer-
vical columnar cells and squamous metaplastic cells were found
significantly more frequently in smears showing signs of bacterial
inflammatory reaction or the presence of
Trichomonas vaginalis.
A significant proportion of smears without signs of inflammation
were less reliable for cytologic diagnosis.
An inflammatory exudate has been reported to be associ-
ated with approximately 32% of dysplastic lesions.27 In a large
population study, a significantly higher percentage of smears
without signs of epithelial abnormalities were found in the
absence of signs of inflammation.26 In these smears, the occur-
rence of minimal epithelial atypia was even significantly lower
than expected. The prevalence of mild and moderate dysplasia
was also lower than expected but not significantly so. The per-
centage of smears without any sign of inflammation rose sig-
nificantly with age. The distribution of epithelial changes in the
groups of smears with signs of bacterial infection did not differ
significantly from the expected numbers. In contrast, epithelial
abnormalities were significantly more common in smears show-
ing evidence of
T. vaginalis
(Fig. 8.46), as were changes con-
sistent with severe dysplasia and carcinoma in situ. In smears
with evidence of
Candida albicans
(moniliasis), significantly
more minimally atypical epithelial changes were found, which
seemed more a reaction of the epithelium to the inflammatory
stimulus than a dysplastic change. This was not paralleled by a
higher proportion of smears with squamous metaplastic cells
present, nor was there evidence of a higher proportion of mild-
to-moderate dysplastic changes.
Epithelial Abnormalities
The finding that the presence of inflammatory signs or microor-
ganisms is more common in smears consistent with dysplasia
or carcinoma, and the lack thereof to be suggestive of atypia
or dysplasia,28,29 was not confirmed. The exception to that find-
ing was
T. vaginalis;
this parasite was found four times more
Fig. 8.46 Evidence of
Trichomonas vaginalis
infection. Trichomonads
can be recognized next to a slightly atypical squamous metaplastic cell with
vacuolated cytoplasm (Papanicolaou x OI).
frequently than expected in smears consistent with severe dys-
plasia and carcinoma in situ.
La Vecchia and co-workers also found significant associations
between a history of
T. vaginalis
and
C. albicans
and cervical
intraepithelial neoplasia (CIN) lesions but not invasive cancer.30
Frisch found 4% of smears originally diagnosed as inflamma-
tory atypia to be underreported, because in subsequent smears
these atypias had "progressed" to CIN.28
Schachter and colleagues reported a significantly increased
risk for cervical
neoplasia in women with
antibodies to
Chlamydia trachomatis
31 and Hanekar and associates found in
patients with
Chlamydia-associated
epithelial abnormalities that
the progression rate to CIN grade III after 2 years of follow-up
was significantly higher than in a control group with compara-
ble epithelial changes but without evidence of
Chlamydia
infec-
tions.32 They suggest that
Chlamydia
may be a cocarcinogen or
a potentiating agent in the progression of cervical intraepithe-
lial lesions. In performing colposcopically directed biopsies on
patients with persistent inflammatory atypia, Noumoff found
underlying CIN in about one-third of the patients; again, about
one third were of greater severity than CIN grade I. On the basis
of these data, he advises that all patients with persistent inflam-
matory atypia undergo colposcopic evaluation.33
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