Download - Management of abnormal cervical smear
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MANAGEMENT OF ABNORMAL PAP SMEAR
DR ALIFAH BT MOHD ZIZIO&G SPECIALIST
SGH
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BETHESDA SYSTEM 2001•It was designed to provide uniform diagnostic language to facilitate communication between cytologists and clinician
• 3 general categories• Within Normal Limits• Benign Cellular Changes• Epithelial Cell Abnormality
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BETHESDA SYSTEM 2001
• Adequacy of the sample is paramount
• 8000 – 12,000 squamous cells for conventional PS/10 HPF
• 5000 cells/10 HFP for liquid-based sample
• Presence of endocervical cells (at least 10) is recommended (not required for women < 40 y.o)
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WHAT IS ABNORMAL PAP SMEAR?1. Abnormal due to inadequacy
2. Abnormal due to inflammation
3. Abnormal due to infection
4. Abnormal due to dysplastic changes
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1. INADEQUATE OR UNSATISFACTORY SMEAR
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SATISFACTORY SPECIMEN..• Appropriate labeling and identifying information
• Relevant clinical information
• Adequate numbers of well preserved and well visualized squamous epithelial cells.
• An adequate endocervical / transformation zone component (from a patient with a cervix).
• Quality of the Pap smear will still be noted when: 1. More than 10 well preserved endocervical or metaplatic cells
are seen2. No blood or inflammation obscuring the Pap smear
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INADEQUATE/UNSATISFACTORY SMEAR
•A smear that is unreliable for the detection of cervical epithelial cell abnormalities
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INADEQUATE/ UNSATISFACTORY SMEAR
1. SamplingScanty cellsBlood, mucous, pus2.PreparationToo thick due to poor spreadingAir drying artifactBroken slide3.Mainly endocervical cell
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HOW TO DEAL WITH INADEQUATE/UNSATISFACTORY SMEAR ??•Correct timing of smear
•Correct timing of smear•Do not use cream or gel•Cleaning of excessive mucus•Choice of sampling devices•Correct spreading•Rapid fixation (< 10 second)•Correct timing of smear•Do use cream or gel
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PAP SMEAR
UNSATISFACTORY
• TX ANY INFECTION • GIVE A COURSE OF ESTROGEN IF POST MENOPAUSE WITH ATROPHY
REPEAT 6/12
2ND SMEAR UNSATISFACTORY
REPEAT 6/12
3RD SMEAR UNSATISFACTORY
NEGATIVE FOR INTRAEPITHELIAL
LESSION
COLPOSCOPY
ROUTINE SCREENING
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2. INFLAMMATORY SMEAR
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•Inflammation on Pap smear results, does not indicate any particular pathology
•Therefore, does not necessitate routine treatment.
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POSSIBLE CAUSES……
•Infection
•Chronic cervicitis
•Atrophic cervicitis
•Chemical or mechanical irritation to cervix- tampoon, douching
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PAP SMEAR
NEGATIVE FOR MALIGNANT CELL
INFLAMMATORY
TX ANY INFECTION OR ATROPHY
REPEAT 6/12
2ND SMEAR INFLAMMATORY
REPEAT 6/12
3RD SMEAR INFLAMMATORY
NORMAL
COLPOSCOPY
ROUTINE SCREENING
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3. ABNORMAL SMEAR DUE TO INFECTION
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COMMON INFECTIONS….
• Tricomonas vaginalis• Fungal ie candidiasis• Bacterial Vaginosis• Actinomyces• Herpes Simplex
ORGANISM TREATMENTTRICHOMONAS VAGINALIS T. METRONIDAZOLE 400MG
TDSFUNGAL INFECTION (CANDIDA)
CANNESTAN PESSARY 200MG ON
BACTERIA VAGINOSIS T. METRONIDAZOLE 400MG TDS
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PAP SMEAR
NEGATIVE FOR MALIGNANT CELL
SPECIFIC MICROORGANISM
TREAT ANY INFECTION
NORMAL
ROUTINE SCREENING
REPEAT PAP SMEAR 6/12
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4. ABNORMAL SMEAR DUE TO DYSPLASTIC CHANGES
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DYSPLASTIC CHANGES
SQUAMOUS CELL ABNORMALITY
GLANDULAR ABNORMALITY
• ASCUS• ASC-H•LGSIL•HGSIL•INVASIVE SQUAMOUS CELL CARCINOMA
• AGS• AIS•INVASIVE ADENOCARCINOMA
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Spectrum of Changes in Cervical Squamous Epithelium Caused by HPV Infection
*CIN = cervical intraepithelial neoplasia
Adapted from Goodman A, Wilbur DC. N Engl J Med. 2003;349:1555–1564.
Normal Cervix
HPV Infection/CIN* 1
CIN 2 / CIN 3 /Cervical Cancer
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% Regress Persist Progress to CIS
Progress to Invasion
CIN 1 60 30 10 1
CIN 2 40 35 20 5
CIN 3 30 <56 - 18 (5y), 36(10y)
NATURAL HISTORY……..
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SQUAMOUS CELL ABNORMALITY…
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ABNORMAL PAP SMEAR DUE TO DYSPLASTIC CHANGES – SQUAMOUS CELL ABNORMALITIES
1. Atypical Squamous Cells (ASC)- Atypical Squamous Cells-Undetermined Significance (ASC-US)- Atypical Squamous Cells, Cannot Exclude High Grade Lesion
(ASC-H)
2. Low-grade Squamous Intraepithelial Lesion (LSIL) (Mild Dyskaryosis / HPV/CIN 1)
3. High-grade Squamous Intraepithelial Lesion (HSIL)(Mod or Severe Dyskaryosis / CIN 2,3)
4. Invasive Squamous Cell Carcinoma
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1. Undetermined Significance (ASC-US)•Cytologic changes suggestive of a low grade squamous lesion but lack criteria for definitive interpretation.
2. Cannot Exclude High Grade Lesion (ASC-H)•Cytologic changes suggestive of a high grade squamous lesion but lack criteria for definitive interpretation.
1.ATYPICAL SQUAMOUS CELL (ACS)
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PAP SMEAR
ATYPICAL SQUAMOUS CELL (ASC)
ASCUS
REPEAT 6/12
NEGATIVE FOR INTRAEPITHELIAL LESSION
RESUME NORMAL SCREENING
HPV DNA TESTING
POSITIVE NEGATIVE
COLPOSCOPY
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PAP SMEAR
ASC-H
COLPOSCOPY
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2. LOW GRADE INTRAEPITHELIAL LESSION (LGSIL) / CIN 1
•CIN I being the morphologic manifestation of a self-limited sexually transmitted HPV infection
•60% of CIN I regress spontaneously•30% of CIN I persists. •10% of CIN I lesions progress to CIN III,•1% may ultimately progress to invasive
cancer.
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Assessment of client
yes No
Presence of at least 1 criteria:-Age > 30 yrs-Poor compliance-Immunocompromised- Sx- Hx of pre-invasive lesion- +ve for high risk HPV (16,18,31,33,45,52,58)Immediate
colposcopy
Repeat smear in 6/12
NILM LSIL
Resume routine screening schedule
Colposcopy
=
60%
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MANAGEMENT APPROACH-A lesion that persist after 1-2 years or any progression during follow up suggest need of treatment
-If HPV testing is available, +ve HPV: indication for treatment
- Treatment- local ablative/ excission
-Follow up after treatment for CIN1-repeat smear in 6/12-repeat smear and colposcopy in 12/12-If normal, yearly pap smear x 2 years then back
to normal routine
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3.HIGH GRADE INTRAEPITHELIAL LESSION (HGSIL)/ CIN 2-3
• CIN 2-3 is a cervical cancer precursor
1.CIN 2• 40% of CIN II regress• 30% of CIN II persist• 20% of CIN II progress to CIN III• 5% of CIN II progress to CIN III
2. CIN 3• 33% of CIN III regress• 18% of CIN III progress to invasive disease over a 10
years• 36% of CIN III progress to invasive disease over a 20
years
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PAP SMEAR
HGSIL
COLPOSCOPY AND BIOPSY
•Subsequent management depends on:• Whether lesion identified• Whether colposcopy satisfactory
•Annual smear following treatment
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MANAGEMENT APPROACH
EXCISION METHOD•LLETZ•Cold knife cone biopsy•Hysterectomy
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ABLATIVE METHODS
•Cryocautery
•Electrodiathermy
•Cold coagulation
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PAP SMEAR
INVASIVE SQUAMOUS CANCER
COLPOSCOPY AND BIOPSY
•Subsequent management depends on:• Stage of the disease
4. INVASIVE SQUAMOUS CELL CANCER
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GLANDULAR ABNORMALITY
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ABNORMAL PAP SMEAR DUE TO DYSPLASTIC CHANGES- GLANDULAR CELL ABNORMALITIES1.Atypical Glandular Cells (AGS) (undetermined
or favour neoplastic)
2.Adenocarcinoma in Situ (AIS)
3. Invasive Adenocarcinoma
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GLANDULAR ABNORMALITIES
•The most common significant lesions associatedwith AGC (Atypical Glandular Cells) are actually squamous
•Management should include colposcopy and endocervical sampling
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ATYPICAL ENDOMETRIAL CELLS• Always perform endometrial sampling
• If endometrial sampling is negative : colposcopy with endocervical sampling
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GLANDULAR ABNORMALITIES
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OTHERS…
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PAP SMEAR
ATROPHY
LOCAL ESTROGEN CREAM 1G ON FOR 2 WEEKS THEN TWICE WEEKLY FOR 6 WEEKS
ATROPHY SMEAR
REPEAT IN 6 MONTHS
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PAP SMEAR
REACTIVE CELLULAR CHANGES DUE TO RADIATION, REPAIR OR IUCD
REACTIVE CELLULAR CHANGES
REPEAT IN 1 YEAR
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ABNORMAL PAP SMEAR IN PREGNANCY
• Reported abnormal smear during pregnancy 1%- 8%• Follow-up should be similar to non pregnant state-every trimester• Regardless of gestation, suspicious lesion shouldbe biopsied. •Cervical biopsy does not increase the risk of miscarriage• If evidence of invasive cancer- require excission
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THANK YOU…….