Pap Smear

Cervicovaginal smear
a cytological screening test first suggested by Dr. George Papanicolaou in 1947 and adopted for use since the 1960's. Used to reveal exfoliated cells collected from cervix that may be pre-cancerous or cancerous allowing for prevention of cervical cancer.

Cheap and easy test Reliable test It has helped drastically lower the number of women who die of cervical cancer.

Indication

Recommended yearly starting at age 18 years or when sexually active, if younger than 18. Less frequent screening if have negative Pap test 3 years in a row, or if not sexually active. Multiparity No upper age limit exists even after menopause. National Cancer Institute encourages women age 65 years and older to get Pap tests at least every 2 years even not sexually active and every year if at higher risk History of STD Abnormal pv bleeding Past history or family history of cervical malignancy Multiple sexual partners

Screening initiation Within 3 years of first vaginal sexual activity Screening interval Low risk once in every 3 years High risk annually until 3 consecutive -ve pap smear test continue every 2-3 years Woman that have not been screened > 5 years screen annually until 3 consecutive ve pap smear All woman who have had CIN f/u with annual smears for the first 5 years or longer

Preparation

Best time is when pt is not menstruating. Advice patient to avoid the following for 2 days before the test, because these might hide any abnormal cells.

Intercourse Douches Vaginal medications Vaginal contraceptives such as birth control foams, creams, or jellies

Procedure

Done as outpatient Lithotomy position Area is clean & drape A Cusco speculum is passed up the vagina & cervix is displayed Should be painless procedure

A sample of cells will be scraped from the cervix and endocervix using a wooden spatula or a cervical brush

The sample of cells is applied evenly to a glass slide and sprayed with a fixative and is sent for examination under microscope.

Limitation

Even the best collection procedure, false negative rate of at least 4% still happen. Up to 2/3 of false negative Pap smear result from the collection procedure. However, development from cervical dysplasia to invasive carcinoma takes years. If yearly screening is performed, then the chance of a lesion being missed is very low.

Causes of abnormal Pap smear

Invasive CA CIN Atrophic changes Flat condyloma Inflammation especially trichomoniasis and chronic cervicitis

Regeneration after injury (metaplasia) Vaginal CA Vulvar CA Upper genital tract CA (Endomet,fallop tube,ovary) Previous radiation therapy

Epithelial Cell Abnormalities

According to Dyskaryotic findings (hyperchromasia / large nuclear to cytoplasmic ratio)
1)

Squamous cells
Atypical Squamous cell of Uncertain Significance (ASCUS) Low grade squamous intraepithelial lesion (LSIL) High grade squamous intraepithelial lesion (HSIL) Squamous Cell Carcinoma

2)

Glandular cells
Atypical Glandular Cell of Uncertain Significance (AGUS) Endometrial cells that are cytologically benign in post menopausal patients Adenocarcinoma

Bethesda Classification
Alternative classification mainly used in USA Smear showing abnormal cell are placed in 3 categories: 1.ASCUS (atypical sq. cell of uncertain significant) 2.Low grade SIL (sq. intraepithelial lesion),which include HPV infection as shown by koilicytosis(a halo around the nucleus of some cells) and mild dyskariosis. 3. High grade SIL includes moderate dyskariosis predictive of CIN2,severe dyskariosis,predictive of CIN3 and Ca in situ.

Description

Bethesda System

CIN Grading

Normal

Normal
ASCUS LGSIL LGSIL

Normal
Atypia HPV Atypia condylomatous atypia and koilocytic atypia CIN 1 CIN 2

Classification of Squamus Cell Abnormalities

Atypical Reactive or Neoplastic HPV Atypia with HPV

Mild Dysplasia Moderate Dysplasia

LGSIL HGSIL

Severe Dysplasia
CIS Invasive Cancer

HGSIL
HGSIL Invasive Cancer

CIN 3
CIS Invasive Cancer

Mx of an AbN Pap smear

Lesion
Normal

LGSIL
HPV Infection
Rpt PS every 6/12 3x,if HPV persist > colposcopy

HGSIL
Mild dyskariosis Moderate dyskariosis Severe dyskariosis
Refer for colposcopy & biopsy

If 1st pap smear repeat within 1 year, otherwise every 2 years

Either rpt PS 3x Refer for every 6/12 and colposcopy & if persist refer biopsy OR refer at once for colposcopy

Colposcopy

Colposcopy is the diagnostic test to evaluate patients with an abnormal cervical cytological smear or abnormal appearing cervix.

Indications

Pap smear consistent with dysplasia or cancer. Pap smear with evidence of HPV infection Pap smear with ASCUS or repeated ASCUS. Pap smear with repeated inflammation. Abnormal-appearing cervix. Patients with a history of intrauterine diethylstilbestrol (DES) exposure.

COLPOSCOPY

Binocular operating microscope, magnification btwn 5-20X Technique : 1) Inspect cervix any abnormal vessels pattern (wash with NS or view through green filter will highlight the blood vessels as black lines.

2) 5% acetic acid identify dysplastic area - dysplastic area : white - squamous epit : pink 3) Schillers test (Lugols solution) identify normal sq epit - Normal sq epit : stain dark brown - AbN sq epit,columnar epit : not stain 4) Colposcopic-directed biopsy

Histology

Mild dysplasia nuclear abN in the basal 3rd of epithelium, the upper layer are not affected Moderate dysplasia some dyskariotic nuclei are found in the upper layer of epithelium & abN nuclei are more common Severe abN nuclei occupied all the epithelial layers & high nuclei cytoplasmic ratio. Carcinoma in situ no differentiation as the surface layer are reached, the nuclei vary in size and stain deeply, the cells are crowded and the cytoplasm are scanty.