sample taker training cervical cytology & management of abnormalities

Sample Taker Sample Taker TrainingTraining

Cervical CytologyCervical Cytology

&&

Management of Management of AbnormalitiesAbnormalities

Cervical Cytology ResultsCervical Cytology Results

•Negative•Negative with infection•Unsatisfactory•Abnormal

Types of Cells SeenTypes of Cells Seen

Mature Cell PatternMature Cell Pattern

• Pre-menopause• HRT• Oestrogen cream• Tamoxifen• Obese women

Immature Cell Pattern – Immature Cell Pattern – Oestrogen DeficientOestrogen Deficient

• Post menopausal• Post-natal• Depoprovera

Evidence of Transformation Evidence of Transformation Zone SamplingZone Sampling

Endocervical Cells

and/or

Metaplastic Cells

Background Blood CellsBackground Blood Cells

Polymorphs Red Blood Cells

A lot of the blood is removed during processing but occasionally may be noticeable in the background of the sample

Endometrial CellsEndometrial Cells

These come from the womb lining

May be shed during menstruation together with blood

Late Menstrual CycleLate Menstrual Cycle

Cells break up & some detail is lost

Best time to take a smear?Best time to take a smear?

• Menstruation – no (Days 1-5)• Proliferative phase – OK• Ovulation – OK• Avoid the later days of the cycle

if possible

InfectionsInfections

• Candida

• Trichomonas (TV)

• Herpes

Rarely worm eggs maybe seen = contaminant

Unsatisfactory SamplesUnsatisfactory Samples• Reason for unsatisfactory given in

report– May help when taking repeat sample

e.g. treatment of infection or topical oestrogen treatment

• Repeat in 3 months (minimum)

• After 3 unsatisfactory samples – refer to colposcopy

Abnormal Abnormal ResultsResults

Cervical AbnormalitiesCervical Abnormalities• May be squamous or glandular in

origin

• Non-cervical abnormalities including metastatic cancer may be seen (rare)

Abnormalities That May Be Abnormalities That May Be Seen On Cervical SamplesSeen On Cervical Samples

Squamous Abnormalities - CIN (Cervical Intraepithelial Neoplasia)

Endocervical Abnormalities (Glandular Neoplasia)

Glandular Neoplasia (non-cervical) – cells may shed but NOT directly sampled

Squamous DyskaryosisSquamous Dyskaryosis• Cytological term

meaning abnormal nucleus

Progression of CINProgression of CIN

Normal Cells

Low grade dyskaryosis

Borderline changes

Moderate dyskaryosis

Severe dyskaryosis

Cancer

Treatment

Normal

If left untreated (36%)

HPV / Smoking etc.

Squamous AbnormalitiesSquamous Abnormalities• Borderline Changes• Mild dyskaryosis

• Moderate dyskaryosis• Severe Dyskaryosis

• Severe/?invasive carcinoma

Low Grade

High Grade

Borderline ChangesBorderline Changes

Minor changes seen but not dyskaryotic

CIN 1 CIN 2 CIN 3

mild moderate severenormal

CIN1 CIN2 CIN3 (in a crypt) CANCER

MILD DYSK MODERATE SEVERE SEV/?INV

Basement membrane

Cervical Cancer - SquamousCervical Cancer - Squamous

ManagementManagement• Low grade

• High grade

• Severe dyskaryosis / ?invasion

HPV test to decidemanagement

Colposcopy referral

URGENT colposcopyreferral

Glandular Abnormalities That May Be Glandular Abnormalities That May Be Seen On Cervical SamplesSeen On Cervical Samples

Endocervical Abnormalities (Glandular Neoplasia)

Glandular Neoplasia (non-cervical) – cells may shed but NOT directly sampled

Glandular AbnormalitiesGlandular AbnormalitiesBorderline Changes

?Glandular Neoplasia(Cervix)

?Glandular Neoplasia(Other)

HPV Test to decide management

Urgent referral to colposcopy

Urgent referral to gynae

Do not delay referrals if Do not delay referrals if clinical symptomsclinical symptoms

• A negative cervical sample does NOT exclude a non-cervical abnormality e.g. womb cancer, ovarian cancer

• Post menopausal bleeding – refer to gynae

• If cervix looks suspicious refer to colposcopy

• Don’t wait for cytology result

Malignant looking cervixMalignant looking cervix

Summary of ManagementSummary of Management

Low grade abnormalities

HPV test

High grade dyskaryosis

Colposcopy

Glandular abnormalities

Cervical

Non-cervical

+ve

-ve Routine Recall

Gynae

Early Repeat TestsEarly Repeat Tests• If HPV testing is not performed early

repeat tests may be requested.– Repeat interval indicated on report– Patient recalled by letter

Early Repeat SamplesEarly Repeat Samples- HPV Test - HPV Test NOTNOT Performed Performed

• Low grade abnormalities– 6 or 12 month repeat samples

• (3 negative results before return to routine recall)

• High grade abnormalities after treatment – 12 month repeat samples

• (10 annual repeats before return to routine recall)

Management after Management after HysterectomyHysterectomy

• NOT followed up by the CERVICAL screening programme – cease recall

– Follow up is the responsibility of the Gynaecologist