cervical cancer screening module 2

Cervical Cancer Screening

Module II

Terminology

Cytology

Pathology

Module II

Cervical Cancer Screening

TerminologyEquivalent terminologies

Squamous intraepithelial lesion (SIL)

Dysplasia

Intraepithelial lesion, specify location

Cervix : CIN

Vagina : VAIN

Vulva : VIN

Anus : AIN

Penis : PIN

Carcinoma–in–situ (CIS)Module II

Cervical Cancer Screening

Terminology

Bethesda System (2001) has been used to describe Pap Smear Findings

Terminology for Pap smear interpretation is discrete from terminology for biopsies (histology) of the lower genital tract

Cytology: LSIL, HSIL

Histology: CIN 1, CIN 2, CIN 3, CIS

Cytological LSIL is not equivalent to histopathologicalCIN I and cytological HSIL is not equivalent to histopathological CIN 2 or 3

Module II

Terminology (CYTOLOGY)

Bethesda System

Specimen Type

Conventional, ThinPrep, Other

Specimen Adequacy

Satisfactory for evaluation

Unsatisfactory due to (specify reason)

General Category

Negative for malignancy

Epithelial cell abnormality (squamous or glandular)

Other (see interpretation)

Module II

Terminology - Bethesda System:

Interpretation: Negative

Absence of malignancy needs to be stated

Describe infection if present

Trichomonas, Candida, Actinomyces

Other Nonneoplastic findings

Reactive cellular changes

Glandular cells post hysterectomy

Atrophy

Module II

Terminology - Bethesda System:

Interpretation: Other

Endometrial cells

In a woman over 40 years

Specify whether negative for squamous intraepithelial

lesion

Module II

Terminology - Bethesda System: Epithelial Cell Abnormalities: Squamous

Atypical Squamous Cells (ASC)

Of undetermined significance (ASC -US)

Cannot exclude High Grade Squamous

Intraepithelial Lesion (ASC -H)

Module II

Terminology - Bethesda System: Epithelial Cell Abnormalities: Squamous

Low Grade Squamous Intraepithelial Lesion (LSIL)

Cellular changes consistent with HPV, CIN 1, mild

dysplasia

High Grade Squamous Intraepithelial Lesion (HSIL)

Moderate to severe dysplasia, CIN 2, CIN 3, CIS

Indicate if features suspicious for invasion

Squamous Cell Carcinoma

Module II

Terminology - Bethesda System: Epithelial Cell Abnormalities: Glandular

AtypicalEndocervical cells

Endometrial cells

Not otherwise specified

Atypical, favor neoplasticEndocervical cells

Not otherwise specified

Endocervical Adenocarcinoma-in-situ (AIS)

AdenocarcinomaModule II

Terminology - Bethesda System: Epithelial Cell Abnormalities

Other malignant neoplasms (specify)

Module II

Terminology - PATHOLOGY

Lower Anogenital Squamous Terminology LAST

Project

Designed to comprehensively evaluate the terminology

of HPV associated lesions

Module II

Terminology - PATHOLOGY

LAST Project Recommendations

Squamous Intraepithelial lesions

Superficially invasive squamous cell carcinoma

Biomarkers in HPV-associated lower anogenital

squamous lesions

Module II

Terminology - PATHOLOGY

LAST Project Recommendations

Squamous Intraepithelial lesions

A unified histopathological nomenclature with a single

set of diagnostic terms for all HPV associated

preinvasive lesions

A two tiered nomenclature for noninvasive HPV-

associated squamous proliferations

The terminology for HPV associated squamous lesions

of the lower anogenital tract is LSIL and HSIL (just as it

is for cytology)

Module II

Terminology - PATHOLOGY

LAST Project Recommendations

Superficially invasive squamous cell carcinoma

(SISCCA)

SISCCA should be used for minimally invasive cancer is

defined as an invasive cancer that is

1) not visible

2) depth of invasion of <3 mm

3) horizontal spread < 7 mm

4) has been completely excised

Module II

Terminology - PATHOLOGY

LAST Project Recommendations

Biomarkers in HPV-associated lower anogenital

squamous lesions

P16 immunohistochemistry staining is recommended

when unclear if CIN 2 or 3 versus nonmalignant

process such as reparative, squamous metaplasia

Module II

Cervical Cancer Screening

Cytology

Module II

Cytology

The Atypical Pap Smear

DefinitionAbnormality in squamous or columnar cells in which the cells show mild to moderate alterations in nuclear size and morphology

CausesTrauma

Infection

Intraepithelial neoplaisia

Cancer

Radiation

Chemotherapy

CytologyAtypical Squamous Cells Uncertain Significance

3 to 10% of all screening Pap smears

10 to 40% risk of underlying intraepithelial lesion

Decreased estrogen results in increase ASCUS in

menopause

Atypical Squamous CellsPap Smear Diagnosis

ASC-US 50% will be positive for high risk HPV5-7% presence of CIN 2-3

ASC-H24-94% presence of CIN 2-3

Cytology: ASCUSSingle cell shows increased nuclear to cytoplasmic ratio but otherwise

bland features

Cytology : ASCUSAtypical cells with surrounding inflammatory cells

Cytology : Atypical Glandular CellsClumps of Glandular cells with surrounding inflammatory and

atypical squamous cells

Cytology: Atypical Glandular CellsClumps of atypical glandular cells concerning for malignancy

Cytology: Atypical Glandular CellsAdenocarcinoma

Cytology

Glandular Lesions

LESIONS NUMBER (% of 268 AGUS Pap Smears )

Premalignant squamous cervix 28 (10.4%)

Premalignant glandular cervix 13 (4.9%)

Adenocarcinoma of the cervix 7 (2%)

Endometrial hyperplasia 6 (2.2%)

Uterine cancer 12 (4.5%)

Metastatic adenocarcinoma 1 (0.4%)

TOTAL 67 (25%)

Kim et al; Gyn Oncol vol 73 p 292 (1999)

Cervical Cancer Screening

Pathology

Module II

Cervical BiopsyOverlying benign stratified squamous epithelium. Underlying normal

endocervical glands

Cervical BiopsySquamous metaplasia and benign squamous metaplasia in

endocervical gland crypts

Cervical Biopsycondyloma

Cervical BiopsyCIN 2 with keratinization

Cervical BiopsyCarcinoma in situ with gland crypt involvement

Cervical BiopsyMicroinvasive squamous cell carcinoma : disruption of the basement

membrane (arrow)

Cervical BiopsyInvasive squamous cell carcinoma

Cervical BiopsyBenign endocervical glands

Cervical BiopsyAdenocarcinoma-in-situ: note full thickness atypical change within

endocervical gland

Cervical biopsyInvasive endocervical adenocarcinoma

CERVICAL CANCER

SCREENING MODULE II

CONCLUSIONS-The Bethesda system for pap smear reporting is reviewed.

-Lower Anogenital Squamous Terminology LAST Project is

discussed.

-Terminology for cytology and pathology are reviewed.