MANAGEMENT OF ABNORMAL PAP SMEAR

DR ALIFAH BT MOHD ZIZIO&G SPECIALIST

SGH

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

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)

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

1. INADEQUATE OR UNSATISFACTORY SMEAR

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

INADEQUATE/UNSATISFACTORY SMEAR

•A smear that is unreliable for the detection of cervical epithelial cell abnormalities

INADEQUATE/ UNSATISFACTORY SMEAR

1. SamplingScanty cellsBlood, mucous, pus2.PreparationToo thick due to poor spreadingAir drying artifactBroken slide3.Mainly endocervical cell

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

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

2. INFLAMMATORY SMEAR

•Inflammation on Pap smear results, does not indicate any particular pathology

•Therefore, does not necessitate routine treatment.

POSSIBLE CAUSES……

•Infection

•Chronic cervicitis

•Atrophic cervicitis

•Chemical or mechanical irritation to cervix- tampoon, douching

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

3. ABNORMAL SMEAR DUE TO INFECTION

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

PAP SMEAR

NEGATIVE FOR MALIGNANT CELL

SPECIFIC MICROORGANISM

TREAT ANY INFECTION

NORMAL

ROUTINE SCREENING

REPEAT PAP SMEAR 6/12

4. ABNORMAL SMEAR DUE TO DYSPLASTIC CHANGES

DYSPLASTIC CHANGES

SQUAMOUS CELL ABNORMALITY

GLANDULAR ABNORMALITY

• ASCUS• ASC-H•LGSIL•HGSIL•INVASIVE SQUAMOUS CELL CARCINOMA

• AGS• AIS•INVASIVE ADENOCARCINOMA

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

% 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……..

SQUAMOUS CELL ABNORMALITY…

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

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)

PAP SMEAR

ATYPICAL SQUAMOUS CELL (ASC)

ASCUS

REPEAT 6/12

NEGATIVE FOR INTRAEPITHELIAL LESSION

RESUME NORMAL SCREENING

HPV DNA TESTING

POSITIVE NEGATIVE

COLPOSCOPY

PAP SMEAR

ASC-H

COLPOSCOPY

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.

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%

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

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

PAP SMEAR

HGSIL

COLPOSCOPY AND BIOPSY

•Subsequent management depends on:• Whether lesion identified• Whether colposcopy satisfactory

•Annual smear following treatment

MANAGEMENT APPROACH

EXCISION METHOD•LLETZ•Cold knife cone biopsy•Hysterectomy

ABLATIVE METHODS

•Cryocautery

•Electrodiathermy

•Cold coagulation

PAP SMEAR

INVASIVE SQUAMOUS CANCER

COLPOSCOPY AND BIOPSY

•Subsequent management depends on:• Stage of the disease

4. INVASIVE SQUAMOUS CELL CANCER

GLANDULAR ABNORMALITY

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

GLANDULAR ABNORMALITIES

•The most common significant lesions associatedwith AGC (Atypical Glandular Cells) are actually squamous

•Management should include colposcopy and endocervical sampling

ATYPICAL ENDOMETRIAL CELLS• Always perform endometrial sampling

• If endometrial sampling is negative : colposcopy with endocervical sampling

GLANDULAR ABNORMALITIES

OTHERS…

PAP SMEAR

ATROPHY

LOCAL ESTROGEN CREAM 1G ON FOR 2 WEEKS THEN TWICE WEEKLY FOR 6 WEEKS

ATROPHY SMEAR

REPEAT IN 6 MONTHS

PAP SMEAR

REACTIVE CELLULAR CHANGES DUE TO RADIATION, REPAIR OR IUCD

REACTIVE CELLULAR CHANGES

REPEAT IN 1 YEAR

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

THANK YOU…….