MANAGEMENT OF ABNORMAL - PowerPoint Presentation

Slide1

MANAGEMENT OF ABNORMAL PAP SMEAR

DR ALIFAH BT MOHD ZIZIO&G SPECIALISTSGHSlide2

BETHESDA SYSTEM 2001

It was designed to provide uniform diagnostic language to facilitate

communication between cytologists

and clinician

3 general categories

Within Normal LimitsBenign Cellular ChangesEpithelial Cell Abnormality Slide3

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 sample

Presence of endocervical cells (at least 10) is recommended (not required for women < 40 y.o

) Slide4

WHAT IS ABNORMAL PAP SMEAR?

Abnormal due to inadequacy

Abnormal due to inflammation

Abnormal due to

infection

Abnormal due to dysplastic changesSlide5

1. INADEQUATE OR UNSATISFACTORY SMEARSlide6

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 smearSlide7

INADEQUATE/UNSATISFACTORY SMEAR

A smear that is

unreliable for the detection of cervical epithelial cell abnormalitiesSlide8

INADEQUATE/ UNSATISFACTORY SMEAR

1. Sampling

Scanty cells

Blood

, mucous,

pus2.PreparationToo thick due to poor spreadingAir drying artifact

Broken slide

3

.Mainly

endocervical

cellSlide9

HOW TO DEAL WITH INADEQUATE/

UNSATISFACTORY SMEAR ??

Correct timing of smear

Correct timing of smear

Do not use cream or gel

Cleaning of excessive mucusChoice of sampling devicesCorrect spreadingRapid fixation (< 10 second)Correct timing of smearDo use cream or gelSlide10

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

3

RD

SMEAR UNSATISFACTORY

NEGATIVE FOR INTRAEPITHELIAL

LESSION COLPOSCOPYROUTINE SCREENINGSlide11

2. INFLAMMATORY SMEARSlide12

Inflammation on Pap smear results,

does not indicate any particular pathology Therefore, does not necessitate routine treatment. Slide13

POSSIBLE CAUSES……

InfectionChronic cervicitis

Atrophic

cervicitis

Chemical or mechanical irritation to cervix-

tampoon, douchingSlide14

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 INFLAMMATORYNORMALCOLPOSCOPYROUTINE SCREENINGSlide15

3. ABNORMAL SMEAR DUE TO INFECTION Slide16

COMMON INFECTIONS….

Tricomonas vaginalis

Fungal

ie

candidiasisBacterial VaginosisActinomycesHerpes Simplex

ORGANISM

TREATMENT

TRICHOMONAS

VAGINALIS

T. METRONIDAZOLE 400MG TDSFUNGAL INFECTION (CANDIDA)CANNESTAN PESSARY 200MG ONBACTERIA VAGINOSIST. METRONIDAZOLE 400MG TDSSlide17

PAP SMEAR

NEGATIVE FOR MALIGNANT CELL

SPECIFIC MICROORGANISM

TREAT ANY INFECTION

NORMAL

ROUTINE SCREENING

REPEAT PAP SMEAR 6/12 Slide18

4. ABNORMAL SMEAR DUE TO DYSPLASTIC CHANGESSlide19

DYSPLASTIC CHANGES

SQUAMOUS

CELL ABNORMALITY

GLANDULAR ABNORMALITY

ASCUS ASC-HLGSILHGSIL

INVASIVE

SQUAMOUS

CELL CARCINOMA

AGS

AISINVASIVE ADENOCARCINOMASlide20

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

–15

64. Normal Cervix

HPV

Infection/

CIN

* 1

CIN

2 / CIN 3 /Cervical CancerSlide21

%

Regress

Persist

Progress to CIS

Progress to Invasion

CIN 1

60

30

10

1

CIN 2

40

35

20

5CIN 3

30<56-18 (5y), 36(10y

)NATURAL HISTORY……..Slide22

SQUAMOUS CELL ABNORMALITY…Slide23

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 CarcinomaSlide24

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)Slide25

PAP SMEAR

ATYPICAL

SQUAMOUS CELL (ASC

)

ASCUS

REPEAT 6/12NEGATIVE FOR INTRAEPITHELIAL

LESSION

RESUME NORMAL SCREENING

HPV

DNA TESTING

POSITIVE

NEGATIVECOLPOSCOPYSlide26

PAP SMEAR

ASC

-H

COLPOSCOPYSlide27

2. LOW GRADE INTRAEPITHELIAL LESSION

(LGSIL) / CIN 1CIN

I being the morphologic manifestation of a self-limited sexually transmitted HPV infection

60% 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. Slide28

Assessment of client

yes

No

Presence of at least 1 criteria:

-Age > 30 yrs

Poor complianceImmunocompromised

Sx

Hx

of

pre-invasive

lesion +ve for high risk HPV (16,18,31,33,45,52,58)Immediate colposcopyRepeat smear in 6/12

NILMLSILResume routine screening scheduleColposcopy=60%Slide29

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 routineSlide30

3.HIGH GRADE INTRAEPITHELIAL

LESSION (HGSIL)/ CIN 2-3CIN 2-3 is a cervical cancer precursor1.CIN

240% of CIN II regress

30

% 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 years

36% of

CIN

III

progress to invasive disease over a 20 yearsSlide31

PAP SMEAR

HGSIL

COLPOSCOPY

AND BIOPSY

Subsequent management depends on:

Whether lesion identifiedWhether colposcopy satisfactory

Annual smear following treatmentSlide32

MANAGEMENT APPROACH

EXCISION METHOD

LLETZ

Cold

knife cone biopsy

HysterectomySlide33

ABLATIVE METHODS

Cryocautery

Electrodiathermy

Cold

coagulationSlide34

PAP SMEAR

INVASIVE

SQUAMOUS CANCER

COLPOSCOPY

AND BIOPSY

Subsequent management depends on: Stage of the disease

4. INVASIVE SQUAMOUS CELL CANCERSlide35

GLANDULAR ABNORMALITYSlide36

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

AdenocarcinomaSlide37

GLANDULAR ABNORMALITIES

The most common significant lesions associated

with AGC (Atypical Glandular Cells) are

actually

squamous

Management should include colposcopy and endocervical samplingSlide38

ATYPICAL ENDOMETRIAL CELLS

Always

perform endometrial sampling

If endometrial sampling is negative

:

colposcopy with endocervical samplingSlide39

GLANDULAR ABNORMALITIESSlide40

OTHERS…Slide41

PAP SMEAR

ATROPHY

LOCAL ESTROGEN CREAM

1G

ON FOR 2 WEEKS THEN TWICE WEEKLY FOR 6 WEEKS

ATROPHY SMEAR

REPEAT IN 6 MONTHS Slide42

PAP SMEAR

REACTIVE CELLULAR CHANGES DUE TO RADIATION, REPAIR OR

IUCD

REACTIVE CELLULAR CHANGES

REPEAT IN 1 YEAR Slide43

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

excissionSlide44

THANK YOU…….