Management of abnormal cervical smear

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

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
• 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
2ND SMEAR UNSATISFACTORY
REPEAT 6/12
3RD SMEAR UNSATISFACTORY
NEGATIVE FOR
INTRAEPITHELIAL LESSION
COLPOSCOPY
ROUTINE SCREENING

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
2ND SMEAR INFLAMMATORY
REPEAT 6/12
3RD SMEAR INFLAMMATORY
NORMAL
COLPOSCOPY
ROUTINE SCREENING

16. COMMON INFECTIONS….
• Tricomonas vaginalis
• Fungal ie candidiasis
• Bacterial Vaginosis
• Actinomyces
• Herpes Simplex
ORGANISM TREATMENT
TRICHOMONAS VAGINALIS T. METRONIDAZOLE 400MG TDS
FUNGAL INFECTION (CANDIDA) CANNESTAN PESSARY 200MG ON
BACTERIA VAGINOSIS T. METRONIDAZOLE 400MG TDS

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

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. •
% Regress Persist Progress to
CIS
Progress to
Invasion
CIN 1 60 30 10 1
CIN 2 40 35 20 5
CIN 3 30 <56 - 18 (5y), 36(10y)
NATURAL HISTORY……..

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
POSITIVE NEGATIVE
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

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

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…….