Management of abnormal pap smear Done by: Noor Al- khawaja

What is pap smear?

• The papanicolaou Test Is the mainstay of cervical cancer Screening.

• It involves exofilating cells from The transformation zone of the cervix to enable examination of these Cells Microscopicaly For detection of precancerous and cancerous lesions

What is abnormal smear?

• Abnormal due to Inadequacy/unsatisfactory

• Abnormal due to inflammation

• Abnormal due to infection

• Abnormal due to dysplastic changes

Unsatisfactory Pap test result :

means that the laboratory staff could not review the cells well enough to give a report. There may be a number of reasons why this occurs including: 1) not enough cells able to be examined 2) inflammation as result of infection; this results in difficulties in being able to see the cells of the cervix on the test slide adequately 3) changes to the cells as women ge

What is the management of inadequate smear?

Inflammation on Pap smear results, does not indicate any particular pathology. Therefore, does not necessitate routine treatment.

What is the management of inflammatory smear?

•Possible causes of inflammatory smear :

• 1. Infection

• 2. Chronic cervicitis

• 3. Atrophic cervicitis

• 4. Chemical or mechanical irritation to cervix (tampon, douching)

•COMMON INFECTIONS…

• Tricomonas vaginalis

• Fungal ie candidiasis

• Bacterial Vaginosis

• Actinomyces

• Herpes Simplex

• Managed by treating the organism.

Squamous cell Changes:

What is the recommended management for dysplastic changes?

ATYPICAL SQUAMOUS CELL : • Undetermined Significance (ASC-US) :

abnormal cytologic changes that are suggestive of squamous intraepithelial lesion (SIL) but are qualitatively and quantitatively less than those of a definitive SIL diagnosis.

• Cannot Exclude High Grade Lesion (ASC-H) Cells that likely consist of a mixture of true high-grade squamous intraepithelial lesion and other findings that mimic such lesion But lack criteria for defenitive interpretation

Low-grade squamous intraepithelial lesions (LSIL. CIN 1

• Lesions associated with human papillomavirus (HPV) infection. These tend to be associated with transient changes that regress over time

Preceded by LSIL or less : Patients with CIN 1 preceded (LSIL), (ASC-US), or cytology that is negative for intraepithelial lesion or malignancy (NILM) but positive for human papillomavirus (HPV) are at low risk for the development of cervical cancer, and observation is therefore recommended

• 2_When preceded by HSIL cytology an immediate diagnostic excisional procedure or observation (HPV testing and colposcopy at one year) is acceptable.

• 3_When preceded by ASC-H cytology Observation is recommended • A diagnostic excisional procedure is not recommended:

HIGH GRADE INTRAEPITHELIAL LESSION (HGSIL)/ CIN 2-3

• CIN 2-3 is a cervical cancer precursor

• CIN 2 and 3 are discussed together because histologic distinction between the two grades of CIN is poorly reproducible and both grades have an increased risk for progression to cancer.

1_If histologic HSIL is unspecified (reported as histologic HSIL or HSIL [CIN 2,3] without distinction

• Treatment is preferred

. Observation (with colposcopy and HPV testing at 6 and 12 months) is acceptable.

2_If CIN 2 is specified:

•Treatment is recommended. •Observation (with colposcopy and HPV testing at 6 and 12 months for up to two years) is acceptable

3_If CIN 3 is specified Observation is unacceptable.

Treatment is recommended.

• When treatment is planned, a diagnostic excisional procedure is performed; ablation is an acceptable alternative.

• observation is the preferred approach for CIN 1 because these lesions are likely to regress. Because some CIN 2 lesions will regress, observation is an option for some patients, such as those who plan future childbearing and are concerned about the potential adverse obstetric outcomes (eg, preterm delivery) after an excisional procedure.

• CIN 3, however, is a direct precursor to cervical cancer, and treatment, not observation, is always recommended.

• Excisional treatments _cold knife conization, _ loop electrosurgical excision procedure (LEEP; also called large loop excision of the transformation zone [LLETZ]). _ laser conization.

• Ablative treatments include cryotherapy, CO2 laser ablation, and thermal ablation (eg, diathermy, cold coagulation).

. Hysterectomy is unacceptable as a primary treatment for CIN but is an option for patients who are incompletely treated with excision or ablation or who have recurrent CIN.

• Methods of local ablation 1) Cryotherapy acts on the principle of crystallizing the intracellular water at temperature of –90°C. It uses either nitrous oxide or carbon dioxide. Depth of tissue destruction is 5 mm. This method is ideal for minor degree and localized CIN lesions. 2) Cold coagulation destroys cervical tissue at a temperature of 100–120°C. It does not need any anesthesia. Depth of tissue destruction is about 4 mm. 3) Electro diathermy destroys cervical tissue up to a depth of 8–10 mm using a unipolar needle electrode. It is done under general anesthesia. 4) carbon dioxide laser through colposcopic guidance—can destroy the epithelium by vaporization up to a depth of 7 mm. The method is of choice when CIN extends onto the vaginal fornices