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MANAGEMENT OF ABNORMAL PAP SMEAR DR ALIFAH BT MOHD ZIZI O&G SPECIALIST SGH.

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Presentation on theme: "MANAGEMENT OF ABNORMAL PAP SMEAR DR ALIFAH BT MOHD ZIZI O&G SPECIALIST SGH."— Presentation transcript:

1 MANAGEMENT OF ABNORMAL PAP SMEAR DR ALIFAH BT MOHD ZIZI O&G SPECIALIST SGH

2 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

3 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)

4 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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6 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 seen 2. No blood or inflammation obscuring the Pap smear

7 INADEQUATE/UNSATISFACTORY SMEAR A smear that is unreliable for the detection of cervical epithelial cell abnormalities

8 INADEQUATE/ UNSATISFACTORY SMEAR 1. Sampling Scanty cells Blood, mucous, pus 2.Preparation Too thick due to poor spreading Air drying artifact Broken slide 3.Mainly endocervical cell

9 HOW TO DEAL WITH INADEQUATE/ UNSATISFACTORY 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

10 PAP SMEAR UNSATISFACTORY TX ANY INFECTION GIVE A COURSE OF ESTROGEN IF POST MENOPAUSE WITH ATROPHY REPEAT 6/12 2 ND SMEAR UNSATISFACTORY REPEAT 6/12 3 RD SMEAR UNSATISFACTORY NEGATIVE FOR INTRAEPITHELIAL LESSION COLPOSCOPY ROUTINE SCREENING

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

13 POSSIBLE CAUSES…… Infection Chronic cervicitis Atrophic cervicitis Chemical or mechanical irritation to cervix- tampoon, douching

14 PAP SMEAR NEGATIVE FOR MALIGNANT CELL INFLAMMATORY TX ANY INFECTION OR ATROPHY REPEAT 6/12 2 ND SMEAR INFLAMMATORY REPEAT 6/12 3 RD SMEAR INFLAMMATORY NORMAL COLPOSCOPY ROUTINE SCREENING

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16 COMMON INFECTIONS…. Tricomonas vaginalis Fungal ie candidiasis Bacterial Vaginosis Actinomyces Herpes Simplex ORGANISMTREATMENT TRICHOMONAS VAGINALIST. METRONIDAZOLE 400MG TDS FUNGAL INFECTION (CANDIDA)CANNESTAN PESSARY 200MG ON BACTERIA VAGINOSIST. METRONIDAZOLE 400MG TDS

17 PAP SMEAR NEGATIVE FOR MALIGNANT CELL SPECIFIC MICROORGANISM TREAT ANY INFECTION NORMAL ROUTINE SCREENING REPEAT PAP SMEAR 6/12

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19 DYSPLASTIC CHANGES SQUAMOUS CELL ABNORMALITY GLANDULAR ABNORMALITY ASCUS ASC-H LGSIL HGSIL INVASIVE SQUAMOUS CELL CARCINOMA AGS AIS INVASIVE ADENOCARCINOMA

20 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

21 %RegressPersistProgress to CIS Progress to Invasion CIN CIN CIN 330<56-18 (5y), 36(10y) NATURAL HISTORY……..

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23 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

24 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)

25 PAP SMEAR ATYPICAL SQUAMOUS CELL (ASC) ASCUS REPEAT 6/12 NEGATIVE FOR INTRAEPITHELIAL LESSION RESUME NORMAL SCREENING HPV DNA TESTING POSITIVENEGATIVE COLPOSCOPY

26 PAP SMEAR ASC-H COLPOSCOPY

27 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.

28 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%

29 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

30 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

31 PAP SMEAR HGSIL COLPOSCOPY AND BIOPSY Subsequent management depends on: Whether lesion identified Whether colposcopy satisfactory Annual smear following treatment

32 MANAGEMENT APPROACH EXCISION METHOD LLETZ Cold knife cone biopsy Hysterectomy

33 ABLATIVE METHODS Cryocautery Electrodiathermy Cold coagulation

34 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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36 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

37 GLANDULAR ABNORMALITIES The most common significant lesions associated with AGC (Atypical Glandular Cells) are actually squamous Management should include colposcopy and endocervical sampling

38 ATYPICAL ENDOMETRIAL CELLS Always perform endometrial sampling If endometrial sampling is negative : colposcopy with endocervical sampling

39 GLANDULAR ABNORMALITIES

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41 PAP SMEAR ATROPHY LOCAL ESTROGEN CREAM 1G ON FOR 2 WEEKS THEN TWICE WEEKLY FOR 6 WEEKS ATROPHY SMEAR REPEAT IN 6 MONTHS

42 PAP SMEAR REACTIVE CELLULAR CHANGES DUE TO RADIATION, REPAIR OR IUCD REACTIVE CELLULAR CHANGES REPEAT IN 1 YEAR

43 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 should be biopsied. Cervical biopsy does not increase the risk of miscarriage If evidence of invasive cancer- require excission

44 THANK YOU…….


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