ENI ELINA FADZLIYANTI MOHD PODZI MUHD. NIZAMUDDIN ABU BAKAR

TAN LIN LING

PRESENTER:THE ONE WHO IS IN FRONT OF EVERYBODY,

SHAKING

Story: Pap Smear

Goal for today

Understand Pap smear and its history.Gain familiarity with its classification

Bethesda classification Papanicolaou classification

Familiarized with Pap smear

What is Pap smear?

A simple test used to detect uterine and cervical abnormality by taking a tissue sample at cervix.

Application of Cytohormonal evaluation Monitor hormonal therapy Screening for cervical ca.

It is not a diagnostic, more to screen asymptomatic patient.

A bit history of Pap smear

Based on work of Dr George Papanicolaou (1893-1962) and Dr Herbert Traut in 1928 on cytologic screening (published 1948)

Papanicolaou smear is too LONG.. So we called it Pap’s in short

How it is done?

How it is done?

1. Speculum is introduced in to the vagina this allows the cervix to be clearly seen.

2. Small sample of Cells are taken by passing a brush over its surface. It can be either using wooden spatula ( Ayle’s spatula) as well

3. These cells are smeared on tho the slide and sprayed to dry.

How it is done

Endocervical brushAylesbury spatulaGlass slidePreservative (95%

ethyl alcohol, ether)Papanicolaou stainMicroscope

Investigation done by pathologist

Preparation for Pap smear

Avoid1. Douches2. Vaginal medication3. Vaginal contraception (foam, creams, jellies)4. Sex

At least 2-3 days before Pap smear Avoid pap smear during menstruation. But it can be

done with liquid-based Pap kit

Pap smear and pregnancy

Controversialif had abnormal smears prior to pregnancy,

Pap test should be taken No further than 15 weeks gestation and only

with a spatulaColposcopy and Biopsy indicated if suspicious

looking cervix.Remember pregnant cervix are highly

vascularised and can bleed heavily

Target group for Pap smear

All women aged 18-70 years who have ever had sex

Women who still have a cervix after subtotal hysterectomy

35-70 age group have a higher risk of developing cervix ca.

Women who had hysterectomy for CIN

Who to screen? guidelines

organization When to start Frequency of test

When to stop

American Cancer Society

2004

3 years after intercourse, no later than 21

Yearly with exceptions: every 2 years if liquid-based kit

every 2-3 years if three normal tests in a row in women >30 years old

Total hysterectomy for benign disease OR> 70 years old with at least three normal Pap smear results and no abnormal Pap results in the last 10 years

organization When to start Frequency of test

When to stop

US preventive Service 2003

Within 3 years of first intercourse OR 21 years old, whichever comes first

At least every 3 years (no evidence that every year is better than every 3 years)

Recommend test for women older than 65 years of age, if adequate screening with normal results and otherwise not at risk for cervical cancer.

Recommend against women who have had a total hysterectomy for benign disease

organization When to start Frequency of test

When to stop

American College of Obstetric and Gynecology

Within 3 years of first intercourse OR 21 years old, whichever comes first

Yearly until age 30 years. Beginning at age 30, if three normal annual Pap results, can do a Pap alone every 2-3 years

Difficult to set an upper age limit

postmenopausal women screened within the prior 2-3 years have a very low risk of developing abnormal Pap smears.

Risk factors

Regardless of age, do the test annual if the person had Early sexual activity (teens) Multiple sexual partners Past history of STD, warts Family history of cervical ca HIV, HPV/HSV type II infection OCP more than 5 years Weakened immune system Smoking habits

Classification of Pap’s result

Pap’s classes Description Bethesda classification 2001

I normal Normal, variant

II Reactive changes Reactive changes

atypia ASC, AGC

koilocytosis Low grade SIL

III CIN I Mild dysplasia Low grade SIL

III CIN II Moderate dysplasia High grade SIL

III CIN III Severe dysplasia High grade SIL

IV Ca in situ, suspicious High grade SIL

V invasive Microinvasion(<3mm)

Frankly invasive(3>mm)

CIN = cervical intraepithelial neoplasia, SIL = squamous intraepithelial lesion

Classification of Pap’s result

On speculum examination

Pap Classes Are Out Because: Do not reflect current understanding of pathology Classes not transferrable to histology terms No classes for non-cancerous entities No longer uniform Years of experience have demonstrated a lack of

reproducibility

Important Changes Over Older Systems: Pap considered a Medical Consult Pathologist responsible for diagnosis Referring physician provides history Must have a statement of adequacy Recommendations regarding follow-up should be

made by pathologist

The Bethesda System Report Includes: Whether the pap is an adequate sample Incidental findings such as evidence of infection Evidence of lesions: low-grade SIL, high-grade SIL, or

cancer

Bethesda System Classification Terms:

Low-grade squamous lntraepithelial lesion (low-grade SIL) Cellular changes associated with HPV Mild (slight) dysplasia/CIN 1

High-grade squamous intraepithelial lesion (high-grade SIL)" Moderate dysplasia/CIN II Severe dysplasia/CIN III carcinoma in situ/CIN III

Cont:

Atypical Squamous Cells (ASC) Unspecified (ASC-US) - includes unspecified and favor

benign/inflammation Cannot exclude HSIL (ASC-H)

Atypical Glandular Cells of Uncertian Significance (AGC) AGC is broken down into favoring endocervical, endometrial, or not otherwise specified origin or endocervical adenocarcinoma in situ (AIS) Unspecified (AGC-US) Atypical glandular cells, favor neoplastic (AGC-H)

Miscellaneous

"Atypia" is used only if undetermined significance and should include a recommendation for follow-up. (ASC and ASG)

Descriptive diagnosis should be given to common problems (changes due to trich, yeast, etc.)

Do not trust Pap smear to diagnose or exclude infections!!

Metaplasia - The physiologic conversion of columnar endocervical cells to flat exocervical squamous cells.

Normal finding - no special follow-up needed.

Cont:

"Parakeratosis" is a term for the persistence of the nuclei of the keratinocytes into the stratum corneum (horny layer) of the skin. Parakeratosis is normal in the epithelium of true mucus membranes of the mouth and vagina.

"Dyskeratosis" is a term for abnormal, premature, or imperfect characterization of the keratinocytes.

Hyperkeratosis implies increased keratin in the sample and should be followed-up closely since there may be an increased risk of cancer.

Why we do it? Pap smear

Epidemiologic Proof for Cervical Ca Screening - Why we do it... MacGregor (1976):

Screened women - invasive cancer rate = 30-50/100,000 Unscreened women - invasive cancer rate = 310/100,000

Fidler (1968): Screened women - invasive cancer rate = 5/100,000 Unscreened women - invasive cancer rate = 29/100,000

Walton (1976): Strong correlation between screening intensity and cervical

cancer mortality (R=0.72) Adami (1994):

"Cytologic screening reduces mortality from cervical cancer by earlier diagnosis of invasive disease" Cancer 1994; 73:140-7.

"... a majority of women diagnosed with invasive carcinoma of the uterine cervix do not receive routine pap smears..." NY State J of Med

Inadequacies of Pap smear

False negative Paps False Negative Pap Smears: Rate = 5 - 50% -- 10 -

29% usually quoted. 80% are true false negatives, 20% are lab errors

Failure to identify high risk patient at entry. Inaccurate or incomplete reports from the lab

to clinic to patient Lack of adequate tracking and follow-up. Poor patient compliance.

Some lesion missed by Pap smear

Occur outside of a large eversion. Small lesions. Advanced invasive lesions since they have

infection and necrotic tissue, which can obscure the true cytology. Koss, JAMA. 1989:737.

Rapidly progressive lesions. Lesions deep in the cervical canal.

Factors That Diminish the Accuracy of Pap Smears

by clinicians

Contamination with blood or oil-based lubricants

Mislabeled or unlabeled slides Inadequate clinical history Inadequate sampling of the transformation

zone Slide material too thick or insufficient Performing pap in spite of obvious

infection

Factors That Diminish the Accuracy of Pap Smears

by laboratory

Confusing smears or names Failure to identify dysplastic cells Misinterpretation of diagnostic cells Poorly controlled technical process

Summary of Pap Smear

Highly effective for screening only. It is not diagnostic. It only identifies those at risk for dysplasia or cancer.

All women who have had sex and who still have a cervix –need to have a pap smear

one may cease having the pap after 70 yrs of age if all other paps were normal

Pap smear can prevent about 90% of cervix dysplasia

Recommendation ACOG 2010

Reminder for my classmates

Do pap smear every 2 years

any question? Please keep to yourself and read about it.

Thank you