Thank you john 

it's indeed the 

pleasure and privileged to be here 

with you all this morning.

The quality of the 

speakers is reflected in the 

size of our audience.

Our first speaker 

dr Jack Frost.

Yes.

One of our international leaders 

in diagnostic cycle pathology 

and a real soldier in the field.

It was just yesterday at five p.m. in 

Baltimore that he concluded his 

outstanding tutorial 

and without even getting supper,

he took the plane to Houston 

Dr Mile.

Um And I 

thank you as well as the people here,

Jack.

This is the bicentennial year.

This is the year of psychopathology.

We 

just,

some of us just came back from boston 

boston.

The International Academy of Pathology met there this 

year.

I enjoyed my visit there and taking a 

little time to see some of our bicentennial 

sites.

I was reminded of our upcoming meeting here 

this morning.

Now we have excellent speakers 

on our program.

We have four outstanding men and 

one woman.

As the first slide there shows 

you.

Yeah,

I don't know if Eileen is in the audience but 

yet,

but we've got an outstanding retina here 

and going back to boston there while I was there.

I went to bunker hill.

I've never been before to bunker hill and I 

climbed the monument.

There's no Elevator,

there's 200 and 90 steps to the top 

and they had a little panda mom 

there and the next slide shows you 

the scene at Bunker hill.

And I don't know if we condemn this like sir,

but I don't think they can see the slide to with the with the line.

But it said with the Jack Frost up 

there,

he said don't find until you can see 

their nuclear cytoplasmic ratio.

Yeah.

And then I went to the town hall there and I saw him 

again in the next slide and he 

said,

I know not what course others may 

take.

But as for me,

give me psycho pathology or give me death.

And uh with that little brief 

introduction I'd like to ask dr Frost please come 

up 

thank you.

Don for introducing the year of the path.

Mhm.

Okay.

Mhm.

I believe me,

it's a real pleasure to be with you 

while I boarded the plane without any dinner,

I can assure you I had steak aboard so I'm not 

looking at me.

You can see I have no problem keeping the calories.

As a matter of fact.

One of the registers of course was a reverend 

reverend,

MD.

And and one of the registrants took 

great kick out of saying whenever he 

passed around some candy or something,

he would tell.

The other agent said I've had reverend,

bless the 

out of this.

And he says,

of course that's the same as 

calories.

May I have the first slide please?

As a matter of fact,

the first two slides 

and maybe you'd better turn these off.

Yes,

thank you 

of the female genital tract Is of 

course something that one can't even begin to touch in 

45 minutes.

I'm not going to presume to.

And actually your program committee and its wisdom gave me two 

things to touch the cervix and the endometrium and they said you can 

touch on anything else you wish also.

So I took the liberty of that.

Um,

I 

I thought it was important that we looked at some of 

the,

the key highlights that 

present themselves to us today.

Not entirely new 

things,

but the ones that have something new attached to them 

or things that we don't run into quite so often.

Of course,

one of the newest in the last five years or so,

is that which is represented 

by by what you will have as your 

first,

as your first kodachrome here on the left 

from me.

Anyway,

your first one for me,

This is from a 20 year old female nursing 

student,

Hop Hopkins.

She had a slight vaginal discharge.

She had reddening and roughness of the upper vaginal wall 

and this is a vaginal wall 

scraping.

It's a Papanikolaou stain.

Now this this is a very 

frightening thing to have to.

A note that we have added no 

carcinoma 

and we have it and a young girl,

obvious with the,

with the hormonal patterns out of a young girl.

Ah When we look at the criteria,

of course there's no problem telling that this is cancer.

And particularly when we go a little 

higher and look at the details of the 

nuclei,

there's there's no problem telling this is 

cancer.

It's an adenocarcinoma.

The cytoplasm is foamy.

A number of these vacuums have very large 

pouched out.

Secretary features not the very 

thin walled features of ovarian carcinoma.

Such as I think that was I don you had up there 

blowing bubble gum.

His so called bubble gum vacuums of ovarian 

cancer are lacking here,

but there is a tendency 

for the cells to be in a loop.

The loop or probably better call 

hob nail fashion.

And because of this,

the lesions at the beginning were called by 

some measures in africa adenocarcinoma of the vaginal 

wall.

Uhh.

Other areas of this 

are are more 

cytoplasmic.

They have larger amounts of cytoplasm 

and the pattern in those 

areas are more abundant cytoplasm,

the so called clear cell adenocarcinoma,

which is the name by which it goes now in most 

in most usage,

these occur in a 

young woman About 18-21 or 

so around there whose mothers took 

di ethyl still best for all 

During the first trimester of pregnancy 

with the patient as a 

two or 3 month old fetus.

These patients are not 

very frequent,

that of all the the mothers 

who took the athletes to best are all very,

very few of them end up with a malignancy,

a somewhat higher proportion.

End up with with vaginal a gnosis.

How the usual uhh tumor 

of the vagina is,

of course,

epidermal carcinoma,

highly characterized,

usually,

That occurs in the older patient,

40 plus 50,

60.

The adenocarcinoma we're speaking of now is 

is relatively rare,

not rare,

but relatively rare in the older patient at 

it occurs in Barcelona's glands,

peri urethral glands and such as that but occurring in the 

vaginal wall uh 

is relatively rare in the older 

patient,

but is that which is occurring now in these young 

patients?

These are in the vaginal wall up near the 

the portion of the wall near the servings.

Now a larger number of them whose 

mothers took to ethel's to best Raul don't have 

adenocarcinoma but have a diagnosis.

Abner sis has been known 

for many,

many years,

but it was a rarity because the 

vaginal epithelium does not have mucous glands 

and to find mucous glands in the vaginal epithelium was 

an abnormality and was called vaginal a 

gnosis.

Actually,

the 

the appearance of the vaginal wall with the fairly 

extensive a diagnosis that some of these young women have 

tend to be fairly typical when it's 

relatively extensive.

Now this is light spots,

these brilliant areas,

or light spots in the areas 

which are significant are these pale white areas.

And the more normal areas are the reddened 

areas.

But the pale white areas of the areas that are 

significant.

It's under the epithelium.

In these areas that one has the ab no 

sis.

The putting on of this of 

iodine.

So called schiller's iodine nicely 

outlines the areas that normally the darker 

areas that have normal glycogen,

and then the lighter areas that are 

are less normal in that the overlying epithelium 

of this of this lesion.

This is the overlying epithelium and this is the 

lesion of the diagnosis that the overlying 

epithelium does not have the amount of glycogen that the 

normal epithelium has,

and therefore we see areas which are 

devoid of the of the eid and 

staining.

We therefore are not staining the abdiasis 

were actually not staining the overlying epithelium.

Now,

it's important from the point of view of psychology that the 

the lesion,

the ad Nanosys,

they usually lies underneath the surface,

and the very small neck of the gland 

sometimes comes to the surface,

but very frequently will not cover the 

surface.

In order to obtain the 

the psychologic evidence that we do have a diagnosis.

One has to a fairly 

briskly uh 

scrape the vaginal wall in that area.

So this is actually to make the diagnosis 

a localized vaginal 

vaginal wall scraping,

not just a non descript lateral vaginal wall,

such as we do to obtain a good side of hormonal pattern,

which is about this area,

the vaginal wall.

Uh This is not for the side of hormonal pattern.

This is in an area where there is a lesion and the 

lesions usually run up around near the 

cervix.

I want to make a couple of points at this 

point,

because the our types of cells 

we get from the A diagnosis,

not the adenocarcinoma,

but from the A diagnosis looked just like very 

reactive,

very pro plastic endo 

cervical cell degenerating,

regenerating and those cervical 

cells.

And so if we were to take a cervical scraping,

we'd expect sell something like that in the presence of 

service itis there's somewhat active and 

sometimes fairly active.

It is very important therefore,

that we know from the clinician that he took this as 

a as a local um 

local specimen from a lesion on the vaginal 

wall.

Or we don't have to know it's a lesion 

but he took it as a vaginal wall specimen.

Now another thing that may be a tip off,

if the if the clinician 

doesn't tell us where he took it,

we don't have the vaginal component with this.

We don't have the mucus stream that 

that almost always accompanies the vaginal component.

These are not coming the cervical,

I'm sorry,

we don't have the cervical component with this.

We don't have the cervical component.

The cervical mucus isn't there?

And if these were cervical cells and the cervical 

cells that were very reactive,

we would expect to find a lot of Polly's and a lot 

of inflammatory to bring in the background 

and we don't.

So these occur not in the cervical 

component but they occur in the nondescript 

vaginal component which tends to be more watery 

and of 

as you know from experience,

you can tell the background from the cervical 

material as it sits in the vaginal pool from the material that 

comes from the vaginal wall as it sits in 

the vaginal pool.

These cells tend to be 

associated with that type of a background of the vaginal wall.

So number one,

they're very reactive.

# two,

they are not in the cervical component.

And number three,

if we have a clinician who 

who understands the other importance of giving 

us good history,

he will tell us this is a a 

vaginal wall scraping and 

so he won't think it's as usual,

whatever he takes a combined faster a pan 

cervical or a pool or something else.

Okay,

I want to briefly go into the lesions on the cervix,

which are of the epidermal I.

Type and we begin with the 

Petipa's and work up to the invasive cancers 

rapidly because this is not 

a a session on the epidermal 

lesions on the cervix exclusively.

And as you know,

one could wax on this for days and yet not have the 

answers out.

There are so many.

But I want to point out that a few of the major 

features to me in assessing these lesions lie 

in the nuclei and lie in the 

cytoplasm.

This sounds obvious,

but I want to break them up into those two compartments in the 

nuclei.

We run into what papa nickel out called disk keratosis 

and which so many people associate that if you see that 

you must have cancer and he never meant that it's 

associated with cancer.

It,

however,

is associated with the early 

lesions of cancer with the early pre cancerous 

lesions and with the early early lesions which aren't 

even cancer at the present time but are very,

very active.

And we noticed even in them very 

minor,

a tip is in the healing a tip.

Use of the service.

We'll find these types of 

changes that the nuclei become large.

This is something that that 

occurs even by looking at the cell,

crosswise cross eyed.

The nuclei tend to become a little large 

cytomegalovirus occurs with the minimal 

uh part of,

of irritation.

The minimal uhh types of a chip to 

have seen Ahmed ali.

Now,

if we have an epithelium that in addition to 

being uh being somewhat 

atypical is a minor a tibia.

And so the cells as they reach the surface or are 

are all able to become carry a pick.

Not IQ.

We then add to the huge nuclei,

we add to it.

We had the features of the area.

Pick no sis namely darkness.

In other words hyper from asia.

But we also have blurry.

Now this is the hyper chrome asia of a blurring 

degenerated nucleus,

which is not a type of 

hypericum asia that is valuable to us.

And so we must discount that as far as the 

severity of the lesion.

And so we end up really with only one thing,

we have large nuclei carrie omega lee 

and the other thing that we have in this lesion 

in the minor lesion is the ability of the 

cells to mature.

Which we see in the sight of pleasant mature squamous type 

cells.

Another thing we note in this particular minor 

lesion is that there's this very peculiar of 

perry nuclear clearing which 

leo costs referred to as coil oh 

psychosis.

Which one season the cells which has no 

significance at all as far as cancer but is found much 

more frequently in the minor and in the 

moderate platypus than in any of the others.

And these are features going along with 

a minor inflammatory tapia showing 

kylo psychosis.

Now if if we move to the utopias that are 

more severe that we see that the 

more that the moderate Petipa's 

shed cells much the same as the 

previous ones.

But they also shed cells whose nuclei 

a party whose cytoplasm is less mature 

and is not able to flatten out.

Yeah.

This is a flat screen of cytoplasm as is that 

one.

But this is a less mature cytoplasm not flattening 

out.

And this is not only not flattening out but it's not making 

much cytoplasm and we get 

more of what we refer to as a moderate 

it's a moderately mature disk idiotic cell 

with the moderate a tip is but we yet get 

some whose cytoplasm is able to 

mature.

And and we're just picking up 

more of the less mature ones.

Now when we have the very grave a 

tapia's we then get more of these 

unable to mature.

We get more of these very very immature 

ones and we'll note the nuclear changes 

are now getting worse too.

We're now getting hyper chrome asia.

But this is hyper cremation,

a well preserved nucleus which is not blurry.

Which is not degenerative for this.

Hyper chrome asia means something.

This isn't the hyper chrome asia curio 

prognosis or cell degeneration and this 

means that we have increased activity and we're 

very worried about it.

So we're getting to major changes in nuclei with 

the more severe lesions tend to be more severely 

disc erotic and the cytoplasm with the 

more severe lesions,

a higher percentage of them are not able to mature.

Now when we get insight to carcinoma,

we can still have shed from insight to 

carcinoma.

Many cells with moderately abundant 

cytoplasm.

But we also have some 

and in certain side of in certain lesions,

very few of them with a very scanty side of 

pleasant.

Sometimes it's just just enough to make a 

diagnosis.

Other times,

practically every cell shed from inside a carcinoma 

has.

This very scanty cytoplasm is completely unable 

to mature and is more typical of 

the classical,

non characterizing insight.

A carcinoma in service.

Now I want to go to case for which I know you 

don't have but you will have And this 

is the section of tissue of a 38,

year old army wife 

with who had a slight vaginal 

discharge.

And the cervix had a ridden area At 

about 12:00 which bled very easily.

A cervical smear in a biopsy was taken.

This is the cervical smear.

This is the biopsy and this is the cervical 

smear.

That's your number three and # four.

Mhm.

Now this was seen by a board certified 

pathologist at an army hospital and he felt this was 

carcinoma inside too and 

sent her to a larger hospital 

to walter reed actually for a therapy.

But the biopsy was sent through 

channels and at the 

area laboratory.

The not only the biopsy was looked at but also the cervical 

smear was looked at and one can see that 

we do have carrier meagley large nuclei but it's 

pale and it's able to mature 

and we also have quite a bit of nuclear is 

tippy a here of perhaps this curiosity type 

and it's moderately hyper chromatic,

but it's a little blurry and one doesn't know how much of that 

is due to degeneration or how much of that hyper from asIA is 

actually due to the increased activity of these cells.

Uh all in all,

it was not felt to represent a 

cancer either on cells or on 

tissue.

It's a very severe borderline gravy 

tapia.

And if one looked at the smear a little farther,

one ran into this.

Now this of course,

is typical of herpes.

Herpes,

Simplex,

genitals,

type two herpes 

multi multiple nuclei 

packed in there like the seeds in the pomegranate or the 

stones in the gallbladder Moulay,

not just lying there loose but molding 

around each other,

yet having a fairly 

intact and compact cytoplasm.

Not a lot of it,

but it's intact and it tends to 

be very criminal.

Filic,

got a lot of protein.

It's a very criminal Felix cytoplasm 

and the nuclei show a certain amount of 

degeneration.

Well,

first we see the multi new creation which 

is which is self 

stimulation and this happens first,

that's the reason that we've had this.

This is epithelial stimulation.

There have been quite a few articles in the literature,

a sighting lesions that have been called insight to 

carcinoma tissue 

and others citing lesions that have been 

called carcinoma in sight to on 

cells in the early 

days.

The early stages of of herpes.

Now the early stages are a proliferated stage and many 

times we'll see nuclei still retaining 

a a granular chromosome 

pattern of paps,

disc neurosis.

However,

now they begin to degenerate in the second 

phase is out of a nondescript degeneration plus 

a very specific type of degeneration.

And one looks around in herpes for nuclear 

inclusions.

This is about the best that one had,

but one doesn't need nuclear inclusion and herpes.

If you have what I refer to as a gelatin,

what I feel.

The word gelatinous tends to 

describe it better than ground glass because it's not 

finally divided Granules.

It's more of a uniform gelatinous 

appearance just like the nucleus was was pumped up 

with a syringe of jell O.

And this very gelatinous 

appearances as diagnostic to me as is a 

nuclear inclusion.

Well,

this is herpes.

This is this is a herpetic lesion which 

when one took the biopsy,

what you recall was this biopsy 

and one was to cut the block down farther.

one then got uhh ran 

into an ulcer which was not present on the 

original section of the block.

and in the edge of that Ulcer one ran into 

cells like this which are right 

down here,

the multi new created cells right on the edge of the ulcer.

These not only the 

herpetic viral infection usually affects the 

cells of the screams epithelium,

but it doesn't have to,

it can also affect the endo cervical Colombia ourselves.

Now this is another lesion and this 

is our classical non 

characterizing insight to carcinoma 

from the basement membrane.

The cells remain the same basically all the way up to 

the surface.

There's a little bit of serum on the surface,

but there's no maturation on the surface.

A very,

very high nuclear cytoplasmic 

ratio is present,

giving when we get the cells exfoliated a very high 

nuclear cytoplasmic ratio.

Once again with the nuclei that 

Papanikolaou characterizes,

disc periodic very hyper chromatic.

The nuclear membranes wavy 

chrome button,

coarsely granular perico martin somewhat 

cleared but uniformly distributed 

amongst the chromosome Granules and 

this extremely high nuclear cytoplasmic 

ratio.

But the cytoplasm is intact and must be 

intact for our diagnosis.

I now note that there are no nuclear ally,

rarely under one of 

pure non characterizing insight.

A carcinoma does one get nuclear line and the nuclear 

I tend to be perfectly round.

They don't tend to elongate and the nuclear 

outline is that of of away 

venous of an undulation,

not that of the nuclear regularity of 

of invasive cancer.

And these cells don't functionally differentiate.

The one thing that could possibly be said to be a functioning 

differentiation is a very 

harsh cytoplasm,

the very crisp cytoplasmic border at times one 

gets in these cells,

but not always When one does begin to 

get functional differentiation,

one then worries about invasion.

And here we get here we 

have a characterizing Granules in the 

cytoplasm and the lady in granule or granule that 

looks like a lady in,

we'll get tadpoles.

We have cytoplasmic differentiation now it's 

become invasive.

It can differentiate the insight who 

sell finds it very difficult to uh to 

uh to differentiate with the 

exception of those inciting carcinomas which occur out 

near the ecto cervix.

And they tend to differentiate more.

But the major mostly insightful carcinomas 

of the cervix are of the more,

more classical type that we've discussed.

Note also were beginning to develop nuclear ally 

were beginning to develop large areas of pair of Cormack and 

clearing.

Which you're not university 

are not uniformly dispersed here we have Peric Roma 

and clearing,

but it's uniformly dispersed throughout the cytoplasm.

Throughout the nucleus.

Here it is not.

There are large areas of clearing here.

It's not clear over here.

The nuclear membrane tends to be wavy,

just like the disk periodic cells.

And all of a sudden there's a sharp point,

a sharp point up there,

a sharp point out there.

And for no reason at all,

we get the nuclear membrane irregularities that we 

associate with cancer.

And so thus with the with the micro 

invasive tumor which we have here,

we have going from bottom to top many of the 

same type cells we had with the insight who carcinoma,

namely perhaps disc periodic cells.

But we do also in addition have cells in 

tissue,

in tissue with the same nuclear characteristics we've 

talked about.

The pere chromosome begins to clear,

the chromosome begins to clump.

The nuclei become very irregular and also 

in tissue.

Now we we again pick up 

the ability for the cells to functionally differentiate 

but very atypically 

and it's usual for the history pathologist to look at 

the tongues of these little things for these little pearls 

down at the base of the tongue.

Here's one that hasn't gotten done quite so far,

but it's a long way from the surface and it's 

a typical functional differentiation.

Now the type of cells that we've 

shed will show the same thing as the 

cells and the tissues certainly,

and one doesn't need any more evidence in this day and 

age that the cells were looking at in 

cytology are identical with the cells 

we have in tissue.

And an appreciation of what we see exfoliated 

gives us a better appreciation 

of what lies in the tissue.

And when we get invasive carcinoma,

we then pick up,

we pick up the nuclear changes of nuclear ally of 

massive chromosome clumping of pere chroma and 

clearing and of a typical lengthening abnormal 

shapes.

And then in the cytoplasm we now 

see a cell that can begin to differentiate.

The insight of carcinoma is not able to differentiate 

and the less than inside to differentiates.

Normally typically like the dysplasia 

but the invasive more than inside to then 

differentiates.

But it differentiates a typically it can also 

differentiate typically,

but it begins to pick up more more 

of the atypical differentiations.

Tadpoles,

many atypical ecto endo plas.

Ums this elongated nucleus.

It's a so called fiber type cell spindle 

cell and this one looks like a typical fiber cell.

But this one has made a large bowl showing 

us the ecto plasm very typical characterization.

The large amount of ectoplasm here and then a little thin room 

of ectoplasm,

the end of plasm going between the nucleus and the 

tail.

the nucleus and the tail thrown into 

of curls and spirals gave me the 

typical herk heimer spiral,

so called february apparatus.

These are all types of functional 

differentiation which are not typical 

and which one finds with with 

invasive carcinoma.

Now with micro invasive carcinoma,

we begin to pick these changes up and 

so the major difference between insight to micro 

invasion is we begin to pick up on nuclear 

ally,

we begin to pick up chromosome clumping.

We begin to pick up irregular perico McCann clearing.

We begin to pick up a typical functional 

differentiation,

lengthening,

very macabre shapes etcetera.

And as you know,

Alan Ng has in a very,

very fine study,

has been able to actually in a very high degree of 

accuracy predict from psychology the 

length of micro invasion that he will run 

into in tissue.

Now this is not to say and 

please don't misinterpret what I'm saying.

This is not to say that we rule out invasion 

from psychology.

No more than to say we rule out invasion 

from histology.

Neither of them are perfect.

But it is to say that if that if the 

histology fails to show invasion,

we should get very adequate psychologic 

um material psychologic specimens 

to be sure there is no evidence for invasion.

So one needs to use both histology and 

cytology to rule out invasion in 

the times when it's very important,

such as the lady who's pregnant.

I'd like to just show in addition to this,

which is a large cell characterizing cancer.

This is a large cell non characterizing the bud,

Wentz and Jim Regan and this 

one has a better prognosis.

And then the one with the poorest prognosis,

of course is the is a small sound non 

characterizing.

I want to say a fast word about the location of these lesions.

The earliest lesions,

which is the ones were mainly interested in because these when we 

catch them are Are able to be almost 

100% curable.

And the early lesions of the cervix.

If we go back about 20 years ago from a series by 

Marsh,

she took cervical lesions about 300 

cases and and he pulled out what,

according to his definition were so called early 

cervical cancer.

His definition was they were confined to 

either above the external loss 

or below the external loss.

And if they involve both of them,

he threw them out.

So it's very,

very early and that they're very restricting.

He got 44 out of that group.

And it's amazing that when one looks at his group of that,

44,

were combined,

were confined above the external loss.

This tells us something.

This tells us that if we have a perfectly 

normal appearing cervix and if if it's 

not spatulas were not able to get up even in Capasa 

copy to see very high.

If it's spatulas,

one can with with proper cervical speculate,

get up and look up the wall,

but but not very high.

Sometimes it's hard to see the anterior wall even in good 

Capasa copy with the spatula cervix.

And while Capasa copy is the best tool the clinician 

has now for these early lesions,

is it a grave a tip here?

Is it an early cancer?

It is not perfect And one can 

have very normal exhaust cervix.

And yet on opening that Uterus one will 

see a 

Luca plastic sarah pigeon.

This area going up that canal which 

had a higher power will reveal 

that this is the lesion,

a very irregular syrup.

Indigenous lesion,

virtually nothing on on the outside.

And this brings to mind one of arthur heard IX 

and Don Mackay's pictures of about 20 years 

ago.

This of course is using the boston terminology of anna 

pleasure rather than dysplasia and it 

matches it very very nicely A 

lesion that is not one lesion.

In other words if we took a biopsy in this in this particular 

lesion this would be in sight to this was mainly incited 

carcinoma with quite a bit of dysplasia.

But there was an area of invasive 

cancer which which lay around there somewhere.

And of course if one doesn't take the proper tissue,

he's not gonna miss,

he's gonna miss it.

If one doesn't take the proper cytology,

he's gonna miss it too.

And this is one of the big reasons we don't like the word 

cervical scraping.

We prefer the word pen,

cervical scraping because pan cervical 

scraping to us means not only the 

ecto cervix,

the wage earners,

their first described cervical scraping.

And he said,

you put the point of the cervical spatula in the 

oss and using that as a fulcrum.

You then rotated 360°. of course.

That's an ecto cervical scraping.

And this unfortunately is what so many of our clinicians are 

giving us now and they're calling it a cervical scraping 

and it's only an extra cervical scraping,

but to get as high up the end a cervical canal as 

possible.

Is is of the utmost importance to get 

these very earliest lesions.

There are other ways,

of course,

rather than this,

there's the cotton swab.

The cotton swab causes the cells to draw.

And more so in the more disease cervix,

a higher percentage of the cells will show 

so called drying artifact,

even though one works real fast on it and gets it into 

fixative right away.

And if one uses a cotton swab,

I feel it should be a non observant cotton and it 

should be dipped into normal saline beforehand.

But even then,

there's a much higher percentage of unsatisfactory.

And of course,

the,

the Western Reserve technique of walter scott 

to put in a 

a an aspirating cannula into the end of 

cervix and aspirate.

That material is very fine,

wonderful material in the hands of the Western Reserve group.

But I don't know why other people just cannot do it so 

well.

We get a very high unsatisfactory 

percentage in our material.

And uh and even stand patent 

when he went up to buffalo gave up the under cervical 

aspiration because his clinician 

just couldn't do it right.

It's a superb technique when one gets people like the 

Western Reserve group who are so interested that they 

get a very,

very fine,

simple uhh 

The average clinician is able to take a 

very refined pan cervical scraping as long 

as he knows he should get up as high as he can.

Now the vaginal pool material we feel is very 

important.

Also,

we feel it's important.

From two major points with 

the vaginal pool mature,

we can find the portion that 

is the vaginal wall portion,

the vaginal wall component of the vaginal pool material.

And we can therefore do a hormonal evaluation on it 

which at times will detect cancer.

At times it'll detect hormonal abnormalities.

One cannot do,

one cannot do an accurate hormonal evaluation 

on surgical material.

This will lead you down the primrose path and won't even tell 

you that it's misleading you.

On the other hand,

when there's something wrong with vaginal 

pool material,

namely when it's inflammatory and it's not accurate,

it'll tell you,

but that's not true of cervical material.

One can make an evaluation,

but its value is in question.

You don't know whether it's good or not.

And the other thing about vaginal pool is you get material from the 

endometrium,

you get material from the tubes,

material from the ovaries And it 

does pick up endometrial,

it picks up cells in 75-80% 

and then it picks up a typical cells and atypical 

hormonal patterns in another 15-20% 

and one can get over 80%,

about 83% in our series of,

of endometrial carcinoma detections,

you find the cells in about 75%.

Then I'll go through that and the ovarian tumors 

utilizing vaginal pool.

One can find the sales and about a third of the cases,

Not only a third,

but a third is better than nothing.

And you don't find them in India cervical 

aspirants only very rarely or with cervical 

scrapings.

You do find them with endometrial aspirations.

But in in vaginal pool you 

find about a third and you also get another 

third In women over the age of 

65 who have an atypical hormonal pattern that will 

help you pick up or help you detect that you have ovarian.

So we prefer a vaginal pool and we prefer 

putting them together on a single slide.

Getting first the vaginal pool because this has mucus 

and when you have service site,

a cervical material does not protect the 

cells well.

And of course when we have disease in the cervix,

we have serum and it doesn't protect the cells well.

So we like to get the vaginal pool first,

we put it on the slide as a puddle and don't spread it 

and then get the pan cervical scraping,

getting as high as we can all the way around,

mixing it with that vaginal pool and then 

moving over to the bottle of fixative,

making the cell spread and dropping it in.

And this is very critical,

immediate wet fixation.

If one is going to use this an aerosol spray,

that's fine too.

As long as it's poised and ready to go,

it's an immediate fixation.

One man can't do it,

make the cells spread and then pick up 

and adjust the aerosol spray.

By that time many of the cells have dried 

and the pathologists are scratching their head wondering why they're 

not able to make diagnoses.

They wish they could like to say 

one fast word about this lesion.

This lesion is obviously cancer.

There's a huge nuclear list.

There is a nucleus with no nuclear lie and here's a 

nucleus that has about 10 nuclear lie 

multiple nuclear ally varying in a 

tissue fragment the number of varying tissue fragment.

Another thing.

Note how round in the secular these nuclei are.

I think of a physical like a florentine 

flask.

It's under pressure.

It's sort of a bloated nucleus.

It's under pressure.

And note the amount of cytoplasm here with the 

nuclei down at one side.

So it's calumnies are oriented.

It's got abundant cytoplasm,

it's got particular nuclei and it makes a Luminal 

border and it has moderately prominent nuclear life.

And this has a lot to recall with regard to 

endo cervical cells.

They are vesicular nuclei.

They have abundant cytoplasm that's calumnies are in 

form and has Luminal borders.

Mhm.

Mhm.

And the only problem is these frequently in the cervical 

adenocarcinoma frequently looks like a very 

reactive and a cervical cell.

Now the big difference that helps me there is that the 

very reactive endo cervical cells have a 

background of service itis.

In the end of cervical adenocarcinoma can very frequently be 

found the void of the cervical mucus and 

avoid of any real service itis no real evidence 

why those reactive cells should be there.

And then one really gets interested and looks at the nuclear lion 

by golly rather than all of them having one or two or 

three nuclear lie.

One has no nuclear lion.

One has nine to clear line.

Now that is another major malignant criteria.

That is a good malignant criteria.

Many times when it occurs 

solution how a point about endo cervical 

adenocarcinoma is that it is 

found higher up the cervical 

canal.

It's able to go up as high as the internal loss 

or it can go as low as the external loss in 

origin.

And so the early in the,

early in the cervical canal tumors 

are able to hide above even a good cervical 

scraping.

But the important thing is they hide above the office 

biopsy of the physician.

And when he takes a biopsy of the cervix and he thinks the 

cervical cancer,

he's going to take the usual cervical cancer biopsy 

and he'll miss the end of cervical 

adenocarcinoma as that is unless you point out that 

this is an indo cervical adam.

Of course,

no mind of course,

a cone or some people like DNC,

I'm sorry.

And a cervical cure ratings uh 

of Mhm.

Is the way to detect that you do have the tumor.

Now,

this is your case # two.

And you see these are 

somewhat irregular nuclei on some of them,

but there are many that are large and pouched out 

bloated,

so called vesicular type.

And we have an epithelial Luminal border 

along here with abundant cytoplasm in the 

nuclei oriented towards the base.

We have a columnar type cell 

which is malignant.

It is not in a very inflammatory background.

It's not a real 

massively massively inflamed 

chronic service side us.

It's it's a background that makes us worried 

with regard to the APL asia.

But it doesn't give us an excuse that it is an 

inflamed cervix that's shedding very reactive in the 

cervical cells.

There is a section of the indo cervical adenocarcinoma from that 

case.

Now let's go briefly to the endometrium 

and remember this,

we pick up mainly by the pool material.

Now the classical endometrial cells show a lot of good 

malignant criteria.

This is grade four,

grade three Regan ending,

showed that beautifully in there fast.

Ical that the later grade show 

beautiful malignant criteria.

The earlier grades,

however,

show many other uh many minor 

criteria and a lot of features of other type 

cells.

Take this beautiful little history site for instance,

it actually is not a history site.

When you look carefully,

you see there's a biophysics cytoplasm.

The outside of the cytoplasm tends to be a little pale 

and history sites tend to do that.

And then the nuclear I have irregularities and they have 

irregularities opposite where history site should.

And these anti Hoff irregularities can be a key 

that you're not dealing with.

Just a very active history site.

And note also the background is that it has superficial 

cells in the background.

It has a shift to the right.

These ladies past the age of 

65 should have only 10% superficial or 

thereabouts.

Now,

this is a history side looking sell.

But look at that the outside side of 

Plasm and this one is a very,

very dark reactive cell.

And once again with the outside type side of 

plaza.

But the nuclear regularities over here and over here 

just don't go along with those of history site.

Very early adenocarcinoma.

Grade one or so called grade one half.

Depending on who's Terminology 

one uses.

This is another very early grade one 

adenocarcinoma.

These look like little folded over history 

sites.

A very active history sites are to be a 

very concerning to us.

This is case number six of yours.

And this is a higher power of that 

cell.

Way down at the bottom.

Now on on her whole material,

on her whole material.

This is all we had on her whole material.

And this is a lady who was 

78 years of age and she had about 

18% superficial cells.

And she had very early,

very early great one adenocarcinoma.

This is the time to find the adenocarcinoma for 

cure.

One should not hesitate to go up into the endometrial 

cavity by either aspiration or 

by brushing.

And and there are 

other techniques.

Also.

The elaborate technique is a very fine one.

And the so called jet washing is a good one.

But uh keep your criteria high.

If it's unsatisfactory or less than satisfactory,

tell the clinician that don't make him think that he's 

doing a good job.

Now the the I.

U.

D.

Is a subject I want to just touch on briefly.

And here is your number eight a 

vaginal smear that we've noted in the last 2.5 

years and patients who have I.

E.

Ds.

Having in their material 

little sulfur type Granules.

You go down on them.

They may or may not have neutral files around them.

Typical of what we like to call sulfur Granules.

But you can see this is a pap Nicholaus staying.

You can see parallel rods.

Put your branching and put your granular 

And this is action.

Oh my sees,

this is a gram stain of it.

We never saw it before.

Now we began to see it about as I say 

234 years ago We now have 

140 cases everyone associated with i.

e.

DS.

And this is this 

is a fluorescent down the body.

Uhh this is for acting to my season pass 

qalandia.

It was negative for acting like action of mrs.

Israeli.

We do not have one traction to mice is bogus,

but this is the organism of acting to 

mrs and surrounding of this group.

It's interesting that now we found it in 

12 cases in tissue one on the 

DNC.

Seven on tubo.

Ovarian abscess is one of 

following a hysterectomy with the I.

U.

D.

In place in which you're not able to see the organisms only.

But we could also see them on 

section.

And we we're also able to do a fluorescent antibody work 

on it.

And it and on one case who 

died of pneumonia following a DNC.

A laparotomy um um 

with bilateral tubal abscesses 

and had the organism in there.

Uhh this is from a 

a paper coming out of 

our lab Gupta 

And of 140.

That's the way they went.

We are not able to pin any particular type of an I.

u.

d.

and and after the missus has been found 

as little as three months after the insertion of the I.

U.

D.

Or as long as seven years after the insertion of the I.

U.

D.

Now one fast thing about ovarian cancer that these 

cells can go down the tubes.

They will drop off even before 

uh the host is able to accept them.

So you don't have to have implants in order to have these 

things go down the tubes in order to then see 

them in the vaginal pool.

Now note that the that the background is 

very clear and this is the background of two things of 

ovarian tumor.

In the background of metastatic tumor.

This is a primary and the breast 

metastatic to the vaginal smear.

This is primary ovarian with this bubble 

gum type of pouched out back.

You'll hear it is with papillary.

Another feature of Bulgarian.

Uh huh.

Papillary can be endometrial also.

But it's very common with ovarian.

And of course the finding of Sanoma bodies.

It can be endometrium but it's very common with 

ovarian and at 

times one gets a very peculiar perry nuclear 

clearing the house and halo,

which is much more common with ovarian than it is 

with the endometrium and others.

And as I mentioned a third of them,

one gets cells that are shed Able to be 

diagnosed.

Another third one gets in a typical hormonal pattern of 

women over the age of 45,

which you can only pick up on the vaginal component and 

then another third we missed completely and one has to think in 

terms of a cola synthesis.

Now this is your last case number seven And 

this is not a very clean background.

But this was a lady who was in her 70s and she has about an 

18% superficial cells which is much higher than one 

should have.

And I blow up of this,

it did have a perry nuclear clearing and 

was a primary ovarian adenocarcinoma.

Well I'm afraid Don that I I 

run awfully fast and I've left many many things and 

said,

but it's been a real pleasure to be with you today.

Okay.

Yeah.

Thank you,

Jeff,

ladies and gentlemen,

is are there any questions from the audience?

We neglected to say that there is one microphone in the 

audience.

We had two but one of them is not working.

However,

Miss Dues right there has a microphone and if 

there's a question we'd be glad to hear it.

No questions for dr Frost.

If there aren't then I have a few announcements to make 

one.

There are restrooms available 

immediately to the right.

Their room 102 for the ladies.