Upper New York State Society of Cytology, Inc.

Interesting Case 1

Submitted by: Mary Ann Rutkowski, CT(ASCP), CMIAC

University of Rochester Medical Center, Rochester, NY

History:

Routine Pap Smear from an 86-year-old postmenopausal female. No unusual clinical findings.

Cytologic Findings:


This pap smear was less than optimal due to marked, obscuring inflammatory exudate. Scattered isolated, large cells with prominent macroucleoli and finely granular nuclear chromatin were present in fair numbers. The nuclei of these atypical cells were often eccentric. The cytoplasm was amphophilic and rather dense. Occasionally, these abnormal cells were found in close association with benign appearing reactive histiocytes and giant cell histiocytes.

 

Diagnosis/Discussion:

Atypical cells present derived from a reparative/inflammatory process, probably secondary to pessary use.

The pessary is a medical device that dates back to ancient times. It is still used today for the treatment of uterine prolapse(1). Indwelling pessaries (ones that remain in place for several years) may cause an inflammatory environment with distinctive cytologic findings(2). The cytology lab at the UofR has observed several cases of atypia associated with pessary use. Often times the clinician will fail to give complete clinical history and will omit telling the lab that the patient wears a pessary. "Cytologic clues" that may warrant a phone call to rule out pessary use include the following(3):

· Average patient is age is over 80 years old
· Smear exhibits a marked inflammatory exudate with "wall-to-wall" polys. Additionally, multinucleated foreign body giant cell histiocytes (FBG's) and loosely cohesive histiocyte aggregates may be present
· Actinomyces-like organisms may be encountered (the pessary acts similar to an IUD)
· Hyperkeratosis
· Atypical cells which are isolated, with large nuclei and prominent macronucleoli and finely granular chromatin

It is these often times these cytologically bizarre cells that must be distinguished from cancer in the postmenopausal patient. Differential diagnoses for these atypical pessary cells include origin from malignant neoplasm (e.g., sarcoma, malignant mixed mullerian tumor). These cells most likely represent reactive fibroblasts associated with granulation tissue secondary to a long standing inflammatory process.

References:

1. Wood NJ, The use of vaginal pessaries for uterine prolapse. Nurse Prac. 1992:17:31-38.
2. Christ ML, Haja J. Cytologic changes associated with vaginal pessary use with special reference to the presence of actinomyces. Acta Cytol. 1978:22:146-149.
3. Rutkowski MA, The pessary as a potential pitfall in assessing papanicolaou stained smears in patients who are postmenopausal. ASCP Tech Sample Cy-4, 2003.