Presentation on theme: "MANAGEMENT OF ABNORMAL PAP SMEAR"— Presentation transcript:
1 MANAGEMENT OF ABNORMAL PAP SMEAR DR ALIFAH BT MOHD ZIZIO&G SPECIALISTSGH
2 BETHESDA SYSTEM 2001It was designed to provide uniform diagnostic language to facilitate communication between cytologists and clinician3 general categoriesWithin Normal LimitsBenign Cellular ChangesEpithelial Cell Abnormality
3 BETHESDA SYSTEM 2001 Adequacy of the sample is paramount 8000 – 12,000 squamous cells for conventional PS/10 HPF5000 cells/10 HFP for liquid-based samplePresence of endocervical cells (at least 10) is recommended (not required for women < 40 y.o)
4 WHAT IS ABNORMAL PAP SMEAR? Abnormal due to inadequacyAbnormal due to inflammationAbnormal due to infectionAbnormal due to dysplastic changes
6 SATISFACTORY SPECIMEN.. Appropriate labeling and identifying informationRelevant clinical informationAdequate 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
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 smearDo not use cream or gelCleaning of excessive mucusChoice of sampling devicesCorrect spreadingRapid fixation (< 10 second)Do use cream or gel
10 GIVE A COURSE OF ESTROGEN IF POST MENOPAUSE WITH ATROPHY PAP SMEARUNSATISFACTORYTX ANY INFECTIONGIVE A COURSE OF ESTROGEN IF POST MENOPAUSE WITH ATROPHYREPEAT 6/12NEGATIVE FOR INTRAEPITHELIAL LESSION2ND SMEAR UNSATISFACTORYREPEAT 6/123RD SMEAR UNSATISFACTORYROUTINE SCREENINGCOLPOSCOPY
12 Inflammation on Pap smear results, does not indicate any particular pathology Therefore, does not necessitate routine treatment.
13 POSSIBLE CAUSES……InfectionChronic cervicitisAtrophic cervicitisChemical or mechanical irritation to cervix- tampoon, douching
14 NEGATIVE FOR MALIGNANT CELL PAP SMEARNEGATIVE FOR MALIGNANT CELLINFLAMMATORYTX ANY INFECTION OR ATROPHYREPEAT 6/12NORMAL2ND SMEAR INFLAMMATORYREPEAT 6/12ROUTINE SCREENING3RD SMEAR INFLAMMATORYCOLPOSCOPY
20 Spectrum of Changes in Cervical Squamous Epithelium Caused by HPV Infection CIN* 1CIN 2 / CIN 3 /Cervical CancerNormal CervixKey PointIntegration of HPV into the DNA of the infected host cell is commonly associated with high-risk oncogenic HPV types1 and is linked to the activity of E6 and E7 proteins.2BackgroundIn benign HPV-associated skin lesions, the HPV virus maintains its genome as episomes at low copy numbers (10–200 copies/cell) in the basal cells of the epithelium separate from the host cell DNA. To maintain its viral DNA as an episome, viral E1 and E2 proteins are expressed. Failure to express E1 leads to the integration of the HPV genome into the host cell chromosome.3Integration of HPV into the DNA of the infected host cell is commonly associated with high-risk oncogenic HPV types1 and is considered an important step in tumor progression.2 In malignant HPV-associated skin lesions, HPV DNA integration into the host cell’s chromosome regularly occurs through a break in the viral genome around the E1/E2 region. Integration-mediated disruption of E2 may trigger uncontrolled expression of E6 and E7, resulting in cellular transformation.2The E6 protein associates with the tumor suppressor protein p53 and promotes proteolytic destruction of the protein. This leads to malignant transformation and loss of regulated cell growth. The E7 protein associates with the retinoblastoma protein (pRB), which inactivates the cell cycle restriction function of this protein.2References1. Gallo G, Bibbo M, Bagella L, et al. Study of viral integration of HPV-16 in young patients with LSIL. J Clin Pathol. 2003;56:532–536.2. Syrjänen KJ, Syrjänen SM. Molecular biology of papillomaviruses. In: Papillomavirus Infections in Human Pathology. Chichester, United Kingdom: John Wiley & Sons, Inc.; 2000:11–51.3. Doorbar J. The papillomavirus life cycle. J Clin Virol. 2005;32(suppl):S7–S15.*CIN = cervical intraepithelial neoplasiaAdapted from Goodman A, Wilbur DC. N Engl J Med. 2003;349:1555–1564.
21 NATURAL HISTORY…….. % Regress Persist Progress to CIS Progress to InvasionCIN 16030101CIN 24035205CIN 3<56-18 (5y), 36(10y)
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.ATYPICAL SQUAMOUS CELL (ACS) 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.
25 ATYPICAL SQUAMOUS CELL (ASC) PAP SMEARATYPICAL SQUAMOUS CELL (ASC)ASCUSHPV DNA TESTINGPOSITIVENEGATIVEREPEAT 6/12COLPOSCOPYNEGATIVE FOR INTRAEPITHELIAL LESSIONRESUME NORMAL SCREENING
27 2. LOW GRADE INTRAEPITHELIAL LESSION (LGSIL) / CIN 1 CIN I being the morphologic manifestation of a self-limited sexually transmitted HPV infection60% of CIN I regress spontaneously30% of CIN I persists.10% of CIN I lesions progress to CIN III,1% may ultimately progress to invasive cancer.
28 NILM LSIL Immediate colposcopy Colposcopy No yes Assessment of client =NoyesAssessment of clientPresence of at least 1 criteria:-Age > 30 yrsPoor complianceImmunocompromisedSxHx of pre-invasive lesion+ve for high risk HPV(16,18,31,33,45,52,58)Repeat smear in 6/1260%NILMLSILImmediate colposcopyResume routine screening scheduleColposcopy
29 MANAGEMENT APPROACHA lesion that persist after 1-2 years or any progression during follow up suggest need of treatmentIf 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 precursor1.CIN 240% of CIN II regress30% of CIN II persist20% of CIN II progress to CIN III5% of CIN II progress to CIN III2. CIN 333% of CIN III regress18% of CIN III progress to invasive disease over a 10 years36% of CIN III progress to invasive disease over a 20 years
31 Subsequent management depends on: Whether lesion identified PAP SMEARHGSILCOLPOSCOPY AND BIOPSYSubsequent management depends on:Whether lesion identifiedWhether colposcopy satisfactoryAnnual smear following treatment
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 associatedwith AGC (Atypical Glandular Cells) are actually squamousManagement should include colposcopy and endocervical sampling
38 ATYPICAL ENDOMETRIAL CELLS Always perform endometrial samplingIf endometrial sampling is negative : colposcopy with endocervical sampling
41 LOCAL ESTROGEN CREAM 1G ON FOR 2 WEEKS THEN TWICE WEEKLY FOR 6 WEEKS ATROPHY SMEARPAP SMEARATROPHYLOCAL ESTROGEN CREAM 1G ON FOR 2 WEEKS THEN TWICE WEEKLY FOR 6 WEEKSREPEAT IN 6 MONTHS
42 REACTIVE CELLULAR CHANGES PAP SMEARREACTIVE CELLULAR CHANGES DUE TO RADIATION, REPAIR OR IUCDREPEAT 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 trimesterRegardless of gestation, suspicious lesion shouldbe biopsied.Cervical biopsy does not increase the risk of miscarriageIf evidence of invasive cancer- require excission