Do you want me to introduce her or is it okay to go ahead with her? Oh, yes. Sorry about that. Yeah, I think we all know her, right? No, actually, we know that she's a, but you'll also have to say her last name for us. Okay. Okay. So let me introduce her briefly. So actually, she's my colleague from Chulalongkorn University, Dr. Nat Krittapothiponthawat. And yes, her last name is so long. So I think please feel free to call her by her name, Dr. Nat Krittapothiponthawat or Dr. Nat. So she's a gynecologic pathologist and also the gynecologic oncologist here in our hospital, Chulalongkorn University in Bangkok, Thailand. And she was a clinical collaborator at Brigham and Women Hospital in Boston and also at Kyoto University in Japan. So we are lucky to have her today. Yeah. Thank you. Thank you so much. Do you want to share your screen? Yes. Okay, are you seeing the slide? Yes. Okay, so this picture is also taken from the park in front of our hospital. So please come to our hospital because we have a big park in front of our hospital that is very significant. And, but now, I mean, I am preparing for the, the, just for the easy cervical cytology for the trainees. So it's not a big call or anything like that just for the trainees. So it's about 10 to 15 minutes. And we will start with the reporting system of the cervical cytology that we are using the Bethesda system. The latest one is the third edition in 2014. And I thought this is the international reporting system that we use for the cervical cytology reporting. And this one is the picture, two pictures of the square meters of the cervix that is, should be the most thing that we will see in the cervical cytology. The hand side picture is the histology of the cervical epithelium that is non-carcinogenizing squamous epithelium. And the right one is drawing the cartoon picture to make you easier understanding about the epithelium of the cervix. The squamous epithelium of the cervix can be divided into four groups that is called the basal cells, the parabasal cells, the intermediate cells and also the superficial cells. And normally it will mature upwardly. I mean, the more superficial cell is the more maturity of the cells. And the most mature cells is the superficial cells that look like this. They look like this on the histology and also look like this on the cytology. And this also the picture of the cervical cytology that is liquid based cytology because you can see the background is quite clear. It's quite clean and clear and easy to see the cells. And all most of these cells in the picture is the superficial cell and the intermediate cells. And when we look closer, you can see that most of the pink cell is the superficial cell but we didn't classify the cell from the color but we define the cell from its shape, its size and also the nuclei of the cells. And the superficial cell and the intermediate cell is the polyclonal cell and the cell is a bit large than other cells in the cytology. The top normally of the superficial cell is the nuclear site. The nuclear site of the superficial cell is very small, it's like a dot. It's like in dots when you see this, all of this is a superficial cell. And this cell is the intermediate cell. You can see that the cell size is the same but the nuclei is different. And the cell size of these intermediate cells and nuclei of these intermediate cells is the reference for the abnormality of the local evolution in the cytology. So this one is the most important cell. So you should remember the intermediate cells for the reference. This picture also a bit closer of the superficial compared to the superficial cell and intermediate cell. You can see how different of the nuclei of both superficial cell and intermediate cell. And this picture, I want to show you how different of the superficial cell or intermediate cell with the metaplastic cells that very small in size. And this cell is also the reference of the hybridization in the cytology. So if you see the abnormality in a big cell, mostly in the big cell, so it might be the low-grade cytology. But if you see the abnormality in the small cell, that is to be more serious cytology. These are sort of three cells that we have to remember. The one is look like the superficial cell and this one is the intermediate cell. And this also is the metaplastic cell. And the intermediate cell and superficial cell is the same cell size, but different in the nuclei. And the metaplastic cell is much more smaller in the cell size. And also the nuclei is not that different from the intermediate cell, but the cell size is very small, so the entry ratio is high. And this is show the endocervical cells in the cytology. So we have two more common pattern of the endocervical cells in the cytology. The left-hand side is what we call honeycomb appearance. And you can see the evenly locating of the nuclei of the endocervix. And another pattern that we call picket vent. And also the bare located nuclei with the top of the mucin producing the endoplasmic. This is the normal endocervix that we can see in the cytology in the pap smear. And this one is also the normal metaplastic cell in the pap smear. And the character, the one we see instead of the normal is when we see the metaplastic cell is like legs and hands that they pushing out together. This one is the character of the metaplastic cell. And what is the metaplastic cell? I think you all know about the metaplastic cell, but I want to say it again. This one is a result cell that will be growing up to be metaplastic cell after the endocell is opposed to the acid in the vagina. And it will become from endocellular cell to be less mature squamous epithelium. And then it will become more mature epithelium by the time. And this is the first abnormality of the cervical cytology with the atypical squamous cell of undetermined significance, or we will call it ASCUS. And the ASCUS is a low-grade cytology, so the abnormality should be in the big cell size, in the cells with the intermediate cell size. And this picture showing the cell of abnormality, about three cells here, that is the same cell size with the intermediate cell, but you can see the nuclei is bigger than the normal intermediate cells. And for the definition of the ASCUS is, the nuclei is bigger than normal about two to three times of the normal intermediate cell nuclei. And this also, that we call ASCUS. And this one, I think it's not the hollow. There's some people will say that, what if it be the hollow and it will be the phallocyte? Should it be called low-cell? So I think this one, the nuclei is not that called low-cell. I mean, and this, sometimes we can see like two, we call that pseudo-hollow, it's not the true hollow for this cell. And it should be only ASCUS. This one also shows you the cell with a bigger nuclei about two to three times that we call for ASCUS. The next for low-cell, the definition is only nuclei larger more than three times. So it's just only different in the nuclei size from ASCUS and low-cell. And sometimes it's just a subjective decision for you that it's two to three or it's more than three. And sometimes it may be a bit intermediate. I mean, it's from interpersonal decision, maybe sometimes it's different. And this picture I get from the Bethesda book and it shows you the normal intermediate cells, the cell which we will call ASCUS and also the cell that we will call L-cell. So it's different in only the nuclei size and a bit of the nuclei detail, like the hyperchromatic, from hyperchromatia and also some irregular nuclei membrane. And this picture is one that I will call it low-cell and you can see the nuclei is more bigger and the nuclei detail is there and it's from chromatin and hyperchromatia also a little bit irregular nuclei membrane. This one should be L-cell for me. This is also a bit, sometimes you can see this and call it ASCUS and sometimes you can see this and you can call it L-cell and that's what I told you that sometimes it's a bit subjective the composition of L-cell and ASCUS but this one is definitely L-cell for me too and this is the L-cell. And there is some mimickers of L-cell that the right one, the right-hand side picture is showing you intracellular tricotin that we can see in normal squamous epithelium of the cell and it looks like some dirty or some material inside the cell and sometimes the people will worry about it but it's only the tricotin in the cell. And this also, some people call it halo but it's not a halo and you can see the nuclei size is just a small size and it's not low skin cell. For high-cell, the abnormality should be in the small cell size and it should be the same size with the metaplastic cells. And the nuclei should be bigger than normal than a regular nuclear membrane and hypothalamic nuclei. So this is a sample of the high-cell cell and you can see that the cell of the abnormality is the small cell size when you compare to the superficial cell and the intermediate cell. And also you can see the photoplatformatic hypothalamic and also irregular nuclear membrane. Sometimes you can see nucleoli but it's not that prominent. This one is also the sample of the high-field cell. And the high-field mimic is the most important one, I think, because sometimes we have a tachycardia on the immediately after delivery or after carrier of abortion. So you can see some cells that look like high-field cells. If you did not have the history of pregnancy before doing the pap smear, sometimes we can miss this and call it high-field or ASDH and we'll have the trouble with the premature. And this is showing the squamous cell carcinoma. Then when we are talking about squamous cell carcinoma in your psychology, the first one, I think is the trick for me too, is the background. If you see this background, it's like a dirty background. That's what we call tumor dietic background. So if you see that, you will think about, oh, is this cancer or not? And next you will see the cells and the detail of the cells or the abnormality of the cells. And this one, you can see most of the abnormal cells is the single cell and the third cell. And the nuclei of the cell is the hyperhomophobes, severely asymptomatic that we have seen from the previous abnormality. And sometimes it will turn to be the spindle-shaped cell like this or like this. This cell will have a tail and a head and a tail and we call this a tadpole cell. That is what we call in the squamous cell carcinoma. And also you can see the cytoplasm of the cell is more orange or like red. Cytoplasm is a carcinogenizing cell that these carcinogenic cells that have abnormalities. And after the squamous epithelium abnormality, so we will move to the atypical glandular cells. And the first one is the atypical endocervical cells. And this one, you can see in compare with this, that is the normal endocervical. You see how evenly located of the normal endocervical nuclei, but this one is not that patterned. It's nearly the same, but it's not that one. And the nuclei is more bigger, it's bigger and the nuclei detail is changed. So the Samko-Martin and Aretula nucleotide membrane, you can see here is the microcyst. And this is also an abnormality of the endocervical cell. If it's the atypical endocervical cell, the epithelium, the aphasia, the pattern of the cell will be more changed and the architecture is more, they will be feathering, a bit feathering, it's not full feathering, but it should be like trying to be feathered at the edge of the cell. And this one is the adenopatinoma encyclopedia. Those that like architecture and also feathering of the cell is a character of the adenopatinoma encyclopedia. And about endocervical adenopatinoma, they can be any architecture, but the thing that is more prominent is the pulmonary pleuralis and the abnormality of the cell. And also you can see a bit here is the tumor that I see in this background. This is also the endocervical adenopatinoma. And lastly, besides endocervical adenopatinoma, sometimes we can see adenopatinoma from somewhere else, like from endometrium or from the ovarian adenopatinoma. So if we have the history and the chair and the cell is not fit in for the endocervical adenopatinoma, but it's still adenopatinoma, so we have to ask for more information. And this one, this patient, she has an ovarian adenopatinoma and we get this in the pathology. So this is all for me. Thank you. Thank you. Well, thank you so much, Athanath. Those are beautiful pictures of cytology. Wonderful. Very good. Anything else? And what an appropriate topic, our first cervical dysplasia case ever, then we get followed. So Natasha and Linda planned it well to have Dr. Nat speak to us today. It was perfect. All right. Very good. Yes, I was thinking the same. Very good. Anything else? Or else we better let the U.S. physicians go to sleep and the Asian physician go to work. All right. Thank you so much, everyone. See you next month. Thank you. Bye-bye. Thank you. Bye-bye. Thank you, everybody.

cervical cytology

abnormalities

cytology

squamous cell carcinoma

diagnosis