management of abnormal pap smear dr alifah bt mohd zizi o&g specialist sgh
TRANSCRIPT
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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 TREATMENT
TRICHOMONAS VAGINALIS T. METRONIDAZOLE 400MG TDS
FUNGAL 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 ABNORMALITIES
1.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…….