PART TWO
Diagnostic Cytology
Fig. 8.49 Condylomatous change
with slight nuclear atypia and irregular
arrangement of the cells in the squamous cell layer (H&E x HP).
Fig. 8.50 Koilocytotic cells.
Large perinuclear halo. Dense outer zone
of the cytoplasm and an enlarged nucleus with finely granular nuclear
chromatin (Papanicolaou x HP).
In the differential diagnosis with CIN, it is relevant that con-
dylomata occur at a younger mean age, are found in the trans-
formation zone and the cervical portio, are polyploid, often
regress, and contain HPV antigens in the majority of cases. Koss,
contrary to what most authors favor, prefers to use the term CIN
grade I with features of condyloma.64
For a more detailed overview of the relation between HPV
and epithelial abnormalities of the cervix, see Chapter 7,
Microbiology, Inflammation, and Viral Infections (as well as the
previous section on HPV).
Histology
Cervical lesions are of three types. The most frequent form is a
flat, acanthotic epithelial change with well-preserved basal layers
and marked nuclear degeneration with perinuclear halos toward
the surface. It also shows dyskeratotic changes (Fig. 8.49). The
classic proliferative, papillomatous condyloma is found much
less frequently, and the third type, even rarer, is an endophytic
"inverted" condyloma. The flat and endophytic condylomata rep-
resent new lesions previously not noted on the cervix. Many of
the condylomatous lesions were described as dysplasias. Meisels
and co-workers were thus led to believe that this sexually trans-
mitted viral lesion represented a precursor of cervical neoplasia
in view of the fact that condyloma acuminatum has been proved
to undergo malignant transformation in a few cases and that it
behaves epidemiologically similar to carcinoma of the cervix.65
Cytology
Although certain features are characteristic of condyloma and
CIN, these two lesions cannot always be clearly distinguished by
morphologic means. Some features may help in differentiating
between them.
Koilocytes are the predominant cellular features of infection
with HPV.66 Koilocytes must be differentiated from cells with
perinuclear halos found in other types of infection, such as
trichomoniasis. In these cells, however, nuclear abnormalities
are not as apparent and halos tend to be smaller and less well
demarcated. Once the cellular pattern is recognized, condyloma
acuminatum becomes the most frequent epithelial lesion diag-
nosed in a mass screening program.63
Fig. 8.51 Condylomatous change in mature squamous epithelium.
Irregularity in nuclear size and shape and conspicuous nuclear halos
(H&E x HP).
The pathognomonic change is the koilocytotic cell. This is a
superficial or intermediate squamous cell that displays a large
perinuclear halo with irregular, clear-cut edges and a dense,
often amphophilic, sometimes almost hyaline cytoplasm in
the area surrounding the perinuclear cavity (Fig. 8.50). In con-
dyloma, cells are generally mature and often display an ample
amphophilic cytoplasm. The chromatin
is usually poorly
defined, and the nuclei may show various stages of degenera-
tion. The nuclear membrane is not distinct, and nucleoli usu-
ally are absent. In intraepithelial abnormalities, cells are mostly
immature, with scant cyanophilic cytoplasm. The chromatin
details are distinct, the nuclear membrane is clearly visible and
somewhat irregular, and small nucleoli can be recognized.66,67
Abnormal differentiation becomes evident by an underdevel-
oped cytoplasmic body and a relatively enlarged nucleus, lead-
ing to an increased nucleocytoplasmic ratio (Fig. 8.51). Nuclear
shapes are round to oval and often irregular. Particularly in the
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