Your SlideShare is downloading. ×
0
Abnormal Pap Test
Abnormal Pap Test
Abnormal Pap Test
Abnormal Pap Test
Abnormal Pap Test
Abnormal Pap Test
Abnormal Pap Test
Abnormal Pap Test
Abnormal Pap Test
Abnormal Pap Test
Abnormal Pap Test
Abnormal Pap Test
Abnormal Pap Test
Abnormal Pap Test
Abnormal Pap Test
Abnormal Pap Test
Abnormal Pap Test
Abnormal Pap Test
Abnormal Pap Test
Abnormal Pap Test
Abnormal Pap Test
Abnormal Pap Test
Abnormal Pap Test
Abnormal Pap Test
Abnormal Pap Test
Abnormal Pap Test
Abnormal Pap Test
Abnormal Pap Test
Abnormal Pap Test
Abnormal Pap Test
Abnormal Pap Test
Abnormal Pap Test
Abnormal Pap Test
Abnormal Pap Test
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Abnormal Pap Test

6,218

Published on

Published in: Technology, Business
0 Comments
6 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
6,218
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
321
Comments
0
Likes
6
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. Management of Women with Abnormal Pap Test
  • 2. Bethesda System 2001 <ul><li>Squamous cell Atypical squamous cells (ASC) of undetermined significance (ASC-US) cannot exclude HSIL (ASC-H) </li></ul><ul><li>Low-grade squamous intraepithelial lesion (LSIL) </li></ul><ul><li>High-grade squamous intraepithelial lesion (HSIL) </li></ul><ul><li>Squamous cell carcinoma </li></ul>
  • 3. Bethesda System 2001 <ul><li>Glandular cell </li></ul><ul><ul><li>Atypical glandular cells (AGC) </li></ul></ul><ul><ul><li>Atypical glandular cells, favor neoplastic </li></ul></ul><ul><ul><li>Endocervical adenocarcinoma in situ (AIS) </li></ul></ul><ul><ul><li>Adenocarcinoma </li></ul></ul>
  • 4. Comparison of Terminology Bethesda System CIN system Dysplasia ASCUS Cellular Atypia Unspecified Cellular changes LSIL CIN I Mild Dysplasia HSIL CIN II Moderate dysplasia CIN III Severe Dysplasia/ CIS
  • 5. Management strategy depends <ul><li>Availability of resources for diagnosis like Colposcope, HPV testing </li></ul><ul><li>Availability of resources for treatment like LEEP, Cryotherapy, LASER </li></ul><ul><li>Age of the woman </li></ul><ul><li>Need of reproductive life </li></ul><ul><li>Grade & extent of the lesion </li></ul><ul><li>Motivation for follow up </li></ul><ul><li>Expertise </li></ul>
  • 6. Abnormal Pap test ASCUS LSIL HSIL HPV –ve HPV +ve Rpt Pap Negative Colposcopy LEEP ECC +ve -ve Treat & Follow up Diagnostic cone Treat & Follow up
  • 7. ATYPICAL SQUAMOUS CELLS
  • 8. ATYPICAL SQUAMOUS CELLS <ul><li>Abnormal cells are seen due to an infection or irritation or may be precancerous </li></ul><ul><li>Least reproducible of cytological categories </li></ul><ul><li>Low risk of invasive ca (0.1-0.2%) </li></ul><ul><li>CIN 2,3 prevalence higher with ASC-H </li></ul><ul><li>ASC-H should be considered to represent equivocal HSIL </li></ul>
  • 9. ASC-US <ul><li>Initial evaluation may be by 3 Approaches: </li></ul><ul><ul><li>2 repeat cytological exams performed at 6 month intervals </li></ul></ul><ul><ul><li>Testing for High-Risk HPV </li></ul></ul><ul><ul><li>Single colposcopic exam </li></ul></ul><ul><li>REFLEX TESTING: refers to testing for high risk HPV at the time of initial screening. This spares 40-60% of women from undergoing colposcopy. </li></ul><ul><li>Prevalence of HPV DNA positivity changes with age among women with ASC-US </li></ul><ul><ul><li>HPV testing only if 21years or over. </li></ul></ul><ul><ul><li>HPV testing more efficient in older women with ASC-US because it refers a lower proportion to colposcopy </li></ul></ul>
  • 10. Recommended Management of Women with ASC-US <ul><li>ASC-US, HPV “-”: Repeat cytology 12 months </li></ul><ul><li>ASC-US, HPV “+”: Colposcopy </li></ul><ul><ul><li>Negative colpo: do ECC </li></ul></ul><ul><ul><li>Unsatisfactory colpo do ECC </li></ul></ul><ul><ul><li>Satisfactory colpo, with lesion present in TZ ECC (Acceptable) </li></ul></ul><ul><ul><li>POST COLPOSCOPY: </li></ul></ul><ul><ul><li>ASC-US, HPV “+”, No CIN do HPV* @ 12 months </li></ul></ul><ul><ul><li>-or- repeat cytology @6,12 months </li></ul></ul><ul><ul><li>Note: It is not recommended to perform HPV testing at intervals of < 12 months. </li></ul></ul>
  • 11. Rpt Cytology @ 6 & 12 Months HPV –ve HPV +ve Rpt Cytology @ 12 months Colposcopy ECC if no lesions or unsatisfactory colpo No CIN CIN Repeat Cytology @ 6, 12 months Or HPV DNA test @12 months Treat & follow up ASCUS
  • 12. Recommended Management of ASC-US <ul><li>Excisional procedures unacceptable for ASC-US unless CIN II-III proven on histology </li></ul><ul><li>Follow up – with REPEAT 6 monthly CYTOLOGICAL TESTING is recommended, until two consecutive negative results for CIN or malignancy are obtained. Then annual Follow up is recommended. </li></ul><ul><li>On a Repeat test if ASC-US or greater cytological abnormality is found Colposcopy is recommended </li></ul>
  • 13. Recommended Management of Women with ASC-H (CANNOT EXCLUDE HSIL) <ul><li>All should undergo Colposcopy </li></ul><ul><ul><li>In women in whom CIN 2,3 is not identified at coloposcopy,follow up: </li></ul></ul><ul><ul><ul><li>with HPV testing at 12 months </li></ul></ul></ul><ul><ul><ul><li>Or </li></ul></ul></ul><ul><ul><ul><li>Cytological testing at 6&12 months is acceptable </li></ul></ul></ul><ul><li>On repeat Cytological testing, refer to Colposcopy, if </li></ul><ul><ul><li>Subsequently test ‘+’ for HPV </li></ul></ul><ul><ul><li>Subsequently have ASC-US or greater </li></ul></ul>
  • 14. ASC-H Colposcopy ECC if no lesions or unsatisfactory colpo CIN 2,3 > ASC or HPV+ Treat & Follow up Rpt Cytology @ 6, 12 months OR HPV DNA Test @ 12 mths No CIN 2,3 Colposcopy Negative Routine screening
  • 15. Low Grade SIL
  • 16. LSIL <ul><li>Cytological diagnosis of LSIL, 2% of women </li></ul><ul><li>2nd most common abnormal cytology report (ASC-US is most common) </li></ul><ul><li>85% with LSIL, have biopsy-confirmed CIN </li></ul><ul><ul><li>18% CIN II-III </li></ul></ul><ul><ul><li>.03% invasive cervical cancer </li></ul></ul><ul><li>LSIL is highly predictive of HPV infection </li></ul><ul><li>COLPOSCOPY: recommended with LSIL </li></ul>
  • 17. LSIL <ul><li>ECC is preferred for </li></ul><ul><ul><li>Non-pregnant women in whom no lesions are identified </li></ul></ul><ul><ul><li>Women with an ‘unsatisfactory colposcopy’ </li></ul></ul><ul><li>ECC is acceptable for </li></ul><ul><ul><li>‘ Satisfactory colposcopy’ & a Lesion identified in the transformation zone </li></ul></ul>
  • 18. LSIL Colposcopy Negative Unsatisfactory colpo No lesion Satisfactory Colpo Lesion in TZ ECC No CIN CIN 2,3 Cytology @ 6, 12 mths OR HPV testing Treat & Follow up
  • 19. LSIL – Post Colposcopy Management <ul><li>In the absence of histologically identified CIN, diagnostic excisional or ablative procedures are unacceptable for the initial management of patients with LSIL </li></ul>
  • 20. HIGH GRADE SIL HSIL
  • 21. High-grade Squamous Intraepithelial Lesion (HSIL) <ul><li>0.45% OF cytology reports </li></ul><ul><li>75% will have biopsy-confirmed CIN II-III </li></ul><ul><li>1-2 % invasive Cervical Ca </li></ul><ul><li>An immediate Leep or Colposcopy/ECC is acceptable (except in pregnancy or adolescents) </li></ul>
  • 22. HSIL Colposcopy ECC Unsatisfactory colpo Satisfactory Colpo No CIN 2,3 Diagnostic Excisional procedure Observe with Cytology / Colposcopy Treat & Follow up LEEP CIN 2,3
  • 23. Managing Women with HSIL UNACCEPTABLE STRATEGIES <ul><li>Ablation is unacceptable in the following circumstances: </li></ul><ul><ul><li>Colposcopy has not been performed </li></ul></ul><ul><ul><li>CIN II-III is not identified histologically </li></ul></ul><ul><ul><li>ECC identifies CIN of any grade </li></ul></ul><ul><li>Triage utilizing either of the following is unacceptable </li></ul><ul><ul><li>Repeat cytology </li></ul></ul><ul><ul><li>HPV DNA testing </li></ul></ul>
  • 24. SIL in Pregnancy <ul><li>Aim of Colposcopy is to Identify invasive Ca </li></ul><ul><ul><li>Lesser lesions never treated </li></ul></ul><ul><ul><li>Colposcopy is preferred for pregnant, non-adolescent with LSIL, HSIL </li></ul></ul><ul><ul><li>In LSIL Deferring Colpo until at least 6 wks PostPartum is acceptable </li></ul></ul><ul><ul><li>In HSIL Colposcopy is recommended Performed by experienced clinician </li></ul></ul>
  • 25. SIL in Pregnancy <ul><li>Biopsy of lesions suspicious for CIN II-III or cancer is preferred </li></ul><ul><li>Biopsy of other lesions is acceptable </li></ul><ul><li>ECC is unacceptable in pregnancy </li></ul><ul><li>Re-evaluation with cytology / colposcopy is recommended no sooner than 6 weeks PP </li></ul>
  • 26. ASCUS & LSIL in ADOLESCENTS <ul><li>Adolescent women Should not be screened unless they have been sexually active for 3 years </li></ul><ul><li>HPV testing is unacceptable for adolescent with ASCUS or LSIL </li></ul><ul><ul><li>>80% of sexually active adolescents test + for HPV over a 2 year obsv. period </li></ul></ul><ul><li>If HPV testing was performed, the results should not influence management </li></ul><ul><li>With LSIL, follow-up with annual cytological testing is recommended </li></ul><ul><ul><li>91% show regression at 36 months </li></ul></ul><ul><ul><li>CIN III before age 20, RARE </li></ul></ul>
  • 27. LSIL in POSTMENOPAUSAL WOMEN <ul><li>Prevalence of HPV, CIN II-III decline with age in women with LSIL </li></ul><ul><li>Manage less aggressively, triage using HPV may be attractive </li></ul><ul><li>Postmenopause with LSIL, should be managed the same as premenopausal women with ASC-US </li></ul><ul><li>Postmenopausal & immunosuppressed women with ASC-US should be managed in the same manner as women in the general population. </li></ul>
  • 28. ATYPICAL Glandular Cells
  • 29. ATYPICAL GLANDULAR CELLS <ul><li>0.2% of Pap results </li></ul><ul><li>High incidence of underlying neoplasia (9-38% AGC have associated neoplasia CIN 2 or 3, AIS, Cancer) </li></ul><ul><li>Both Cytology or HPV lack sensitivity to be used alone as a triage test. </li></ul>
  • 30. ATYPICAL GLANDULAR CELLS <ul><li>3 Categories: </li></ul><ul><ul><li>AGC, NOS </li></ul></ul><ul><ul><li>AGC, FAVOR NEOPLASIA </li></ul></ul><ul><ul><li>AIS (adenocarcinoma in situ) </li></ul></ul>
  • 31. ATYPICAL GLANDULAR CELLS <ul><li>INITIAL EVALUATION includes multiple tests </li></ul><ul><ul><li>Colposcopy & ECC for all AGC </li></ul></ul><ul><ul><li>HPV testing </li></ul></ul><ul><ul><li>Endometrial evaluation ( if Age >35 yrs) </li></ul></ul><ul><ul><li>Diagnostic excisional procedure necessary inspite of initial negative testing (if AGC favor neoplasia or AIS) </li></ul></ul>
  • 32. AIS Hysterectomy preferred Margins involved ECC +ve Reexcision recommended Long term Follow up Diagnostic excisional procedure If future fertility desired Conservative Management Margins negative
  • 33. Management of CIN <ul><li>Observation </li></ul><ul><li>Conservative </li></ul><ul><li>A. Local Ablation </li></ul><ul><ul><li>Cryocautery </li></ul></ul><ul><ul><li>Cold Coagulation </li></ul></ul><ul><ul><li>Laser Vaporization </li></ul></ul><ul><ul><li>Electrocoagulation diathermy </li></ul></ul><ul><ul><li>B. Excisional Method </li></ul></ul><ul><ul><li>Excisional Biopsy </li></ul></ul><ul><ul><li>Cold Knife conization </li></ul></ul><ul><ul><li>Laser conization </li></ul></ul><ul><ul><li>LEEP or LLETZ </li></ul></ul><ul><li>3. Hysterectomy </li></ul>
  • 34. TOP 10 KEY POINTS <ul><li>Initiate Pap smears at age 21, or 3 years after onset of sexual intercourse </li></ul><ul><li>Excisional procedures unacceptable for ASC-US unless CIN II-III (histology) </li></ul><ul><li>REFLEX testing with ASC-US spares 40-60 % colposcopy </li></ul><ul><li>ASC-H should be considered to represent equivocal HGSIL </li></ul><ul><li>HPV Screening used only for women >30 yrs. </li></ul><ul><li>For CIN I: cytological follow-up is the only recommended management option, regardless of whether the colposcopic exam is satisfactory. (LGSIL pap; CIN-1 histology) </li></ul>

×