PART TWO
Diagnostic Cytology
fo u n d up to 7 weeks after carbon d ioxid e laser c on iza tio n m ore
p rob ab ly represent regenerating cells, whereas active cells fo u n d
late r stron g ly suggest cervical in tra e p ith e lia l neoplasia.124
Loop Electrosurgical Excisional Procedure
Loop electrosurgical excisional procedure (LEEP), also referred
to as lo o p d iath erm y treatm ent, lo o p excision o f the tra nsfo rm a -
tio n zone, and large lo o p excision o f the tra n sfo rm a tio n zone, is
a new technique fo r o u tp a tie n t diagnosis and tre atm e nt o f cer-
vical in tra e p ith e lia l neoplasia. It is ra p id ly replacing the tra d i-
tio n a l cold kn ife and carbon d ioxid e laser c on iza tio n procedures
because it is p urported to be faster, sim p le r to p erform , and w e ll
tolerated, w ith few side effects and good hem ostatic properties.
LEEP is also believed to be a viab le alternative to ablative tech-
niques, because it provides histo lo g ic m aterial fo r c o n firm a tio n
o f the diagnosis rather th a n destruction o f the lesion.
Loop electrosurgical excisional procedure uses low-voltage,
hig h-frequency w ire lo o p electrodes to rem ove cervical lesions.
A n electric cutting arc is created between th e lo o p and the tissue,
and it ra p id ly heats the cells to tem peratures exceeding 100°C,
causing them to vaporize. Therefore the m eth od o f tissue
a b la tio n is the same as w ith electrocautery and laser therapy
(i.e. th erm al in ju ry ).
As w ith laser conization, LEEP induces tw o zones o f th erm al
in ju ry: a n arrow peripheral zone o f carb onization and a larger,
desiccated-coagulated zone b eneath.123 LEEP causes detachm ent
o f the e p ith e liu m fro m the basem ent m em brane; alterations o f
preexisting structures, such as glands, cells, o r nuclei; and s h rin k -
age o r enlargem ent o f cellular details.127 A lso noted is vascular
throm b osis. LEEP causes less th erm al damage th an laser con-
iza tio n (m ean depth 0.22 ± 0.09 m m versus 0.49 ± 0.16 m m ).128
T he sequence o f cytologic changes induced b y LEEP is presum ed
to be s im ila r to th a t observed after cryotherapy, electrocautery,
and laser vap orization.
Foreign Body: Intrauterine Devices
T he exact m echanism o f action o f the in tra u te rin e device (IU D )
accounting fo r its contraceptive prop erty is n o t kno w n . The
IU D initia te s an in fla m m a to ry response o n the surface o f the
e nd o m e triu m , and th is m ay in h ib it im p la n ta tio n o f the fe rti-
lized ovum . T he use o f an IU D is often associated w ith exfo-
lia tio n o f atypical cells th a t m ay be m istaken fo r end om etrial
adenocarcinom a, end o m e tria l hyperplasia, o r squam ous cell
carcinom a. H is to ry o f IU D use, especially in a w o m a n o f repro-
ductive age, sho uld always be considered in the inte rp reta tion
and rep orting o f th is type o f atypia.
T he u terine cervix shows chronic cervicitis w ith various
degrees o f squam ous m etaplasia. N o d istin ct atypia is id entified .
T he end o m e tria l tissue has chronic e nd o m e tritis w ith endocer-
vical and squam ous m etaplasia. H yperchrom asia and cellular
atypia o f a reparative type are fo u n d in the e n d o m e triu m .129
Cytology
T he cytologic changes are also described in Chapter 7
(M ic r o b io l-
ogy, In fla m m a tio n , a n d V ir a l In fe c tio n s ).
The in fla m m a to ry response fo u n d in cervicovaginal smears o f
w o m e n using IU D s varies depending on the length o f tim e the
IU D s have been in place.130 T he in itia l in fla m m a to ry response
is acute, w ith m an y neutrop hils. By the th ird day, macrophages
are recognized. They are abundant b y the seventh day. The
macrophage p o p u la tio n increases in p ro p o rtio n to the d u ra tion
o f IU D use. It is postulated th a t macrophage p ro life ra tio n and
accum ulation m ay be the p rim a ry effect o f the IU D . Erosions
o f the end o m e triu m and und e rlyin g strom a b y the IU D prob-
ably cause shedding o f histiocytes and end om etrial cells.129 O cca-
sional foreign b od y giant cells are fo u n d fro m the th ird day on
(Fig. 30.16) . Plasm a cells and lym phocytes also increase. N eu-
tro p h ils are alm ost com p letely absent b y the fo u rth week. Phago-
cytosed foreign m aterial, inc lu d in g hem osid erin and degenerated
sperm atozoa, m ay be found. Atypical gland ular cells appear on
ap p roxim ately day 10. Between 12 weeks and up to 7 years,
macrophages and giant cells rem ain conspicuous. Fragments o f
refractile foreign m aterial fro m the IU D are fo u n d surrounded
by macrophages o r embedded w ith in end om etrial cells. Atypical
ep ithelial repair is fo u n d and m ay be caused by the large num b er
o f in fla m m a to ry cells th a t m igrate fro m the uterus o r fro m the
ulceration at the site o f cervical contact w ith the carrier thread.
Three types o f atypical e p ith elial cells— squam ous, g landu-
lar, and in d e te rm in a n t— have been described.129 T he squam ous
atypia is in m etaplastic cells w ith m acronucleoli. Several reports
have described the atypical changes fo u n d in g land ular cells o f
endocervical125,131 and end om etrial o rig in. The atypical g landu-
la r cells u su a lly occur in clusters c on tain in g fro m 3 to 15 and
as m an y as 30 cells. A n occasional single atypical c o lum na r cell
m ay be fo un d . T he g land ular cells have a variable a m o u n t o f
cytoplasm . Som e have dense, scanty cytoplasm w ith d istinct cell
borders. The nuclei are enlarged and show m oderate va ria tio n in
size and shape. T he c h ro m a tin is coarsely g ranular and clum ped.
The nucleocytoplasm ic ra tio is high. T he nucleus contains single
to m u ltip le ro u n d nucleoli. The cytoplasm has m an y large vacu-
oles p ushing the nucleus aside. These cytologic changes cause
the atypical c o lu m n a r cells to strong ly m im ic adenocarcinom a
o f e ith er endocervical o r end o m e tria l origin.
The th ird atypical e p ith elial cell type is the so-called ind e-
te rm in a n t cell. These cells fit in to no d e fin ite m orp h olog ic cell
type, a lth ou g h th ey are postulated to be end o m e tria l in orig in.
The cells resem ble the cells shed fro m carcinom a in situ. M ost
are single and enlarged and have a hig h nucleocytoplasm ic ratio
and scant cytoplasm . The nuclei have hyp erchrom atic g ranular
c h ro m a tin w ith irreg ular nuclear m em branes. U n lik e carcinom a
in situ, the cells are u su a lly binucleated o r trinucleated and
contain nucleoli. The n u c le oli m ay be inconspicuous and m u l-
tiple. A n a d d itio na l cytologic feature separating these atypical
in d e te rm in a n t cells fro m those o f carcinom a in s itu is the
hom og e ne ity o f the cell p o p ulatio n. In carcinom a in situ, cells
displaying a fu ll spectrum o f dysplastic changes, fro m m ild to
severe, are found . G upta and colleagues observed th is cytologic
atypia to revert to n o rm a l 1 -1 3 m o n th s after rem oval o f the
IU D .132 A n o th e r feature associated w ith IU D s is the presence o f
A c tin o m y c e s
spp. in the cervicovaginal smears (see Ch. 7,
M ic r o -
b iolog y, In fla m m a tio n , a n d V ir a l In fe c tio n s ).133
Surface reactions
w ith hyperkeratosis and parakeratosis m ay also be present.
Transurethral Resection and Core Needle
Biopsy of the Prostate
Transurethral resection o f the prostate (TU R P) is an endoscopic
surgical procedure c o m m o n ly used to relieve u re th ral obstruc-
tio n secondary to enlargem ent o f the prostatic p eriurethral
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