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Taking A Pap Smear
Taking A Pap Smear
Taking A Pap Smear
Taking A Pap Smear
Taking A Pap Smear
Taking A Pap Smear
Taking A Pap Smear
Taking A Pap Smear
Taking A Pap Smear
Taking A Pap Smear
Taking A Pap Smear
Taking A Pap Smear
Taking A Pap Smear
Taking A Pap Smear
Taking A Pap Smear
Taking A Pap Smear
Taking A Pap Smear
Taking A Pap Smear
Taking A Pap Smear
Taking A Pap Smear
Taking A Pap Smear
Taking A Pap Smear
Taking A Pap Smear
Taking A Pap Smear
Taking A Pap Smear
Taking A Pap Smear
Taking A Pap Smear
Taking A Pap Smear
Taking A Pap Smear
Taking A Pap Smear
Taking A Pap Smear
Taking A Pap Smear
Taking A Pap Smear
Taking A Pap Smear
Taking A Pap Smear
Taking A Pap Smear
Taking A Pap Smear
Taking A Pap Smear
Taking A Pap Smear
Taking A Pap Smear
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Taking A Pap Smear


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  • 1. Taking a PAP SMEAR
  • 2. Cervical Cancer : Pap smear
    • George N Papanicolaou introduced cervical cytology in clinical practice in 1940
    • In 1945, PAP smear was endorsed by American cancer society as an effective method for prevention of cervical cancer
    • Many countries now have National cervical screening programs
  • 3. Indian scenario
    • Commonest cancer in women in India
    • Major cause of deaths in women due to cancer
    • Usually diagnosed at advanced stage
    • No National program
    • Uniformly low incidence of cervical screening in India (6% in rich & 4% in poor)
  • 4. Histological Types 30
    • Squamous Cell Carcinoma : 80-95%
    • Adenocarcinoma : 5-20%
    • Other : Clear cell, sarcomas
  • 5. Transformation zone
    • Cervix develops from 2 embryonic sites
    • * from Mullerian duct - lined by columnar epithelium
    • * from urogenital plate - lined by stratified squamous epithelium
    • Point at which columnar and squamous epithelium meet is called as original squamo-columnar junction
  • 6. Transformation zone
    • Under influence of estrogen, original SCJ moves onto the portio.
    • Exposure of delicate columnar cells to vaginal environment leads to squamous metaplasia.
    • Transformation zone -
    • - Area of squamous metaplasia
    • - Area between original and new SCJ
  • 7. Transformation zone
  • 8. Transformation Zone -TZ
    • Exposure of TZ to carcinogens begins the process of intraepithelial neoplasia
    • While exact role of carcinogens in this process remains poorly understood, it is clear that HPV and cigarette smoking can cause dysplasia at the TZ
    • 95% of cervical cancers develop in TZ
    • Important to take sample from TZ
  • 9. Transformation Zone
    • Transformation zone may not be viewed during routine speculum examination
  • 10. Why cervical screening is a feasible and useful strategy?
    • Relative accessibility of cervix to take the smear
    • Long natural history of cervical carcinogenesis
    • Relative conservative treatment for premalignant lesions
    • Cost effectiveness3
  • 11. PAP Smear
    • PAP smear sampling of cervix involves scraping of cervical surface and a portion of non visualised cervical canal using various sampling devices
  • 12. Significance of Pap smear
    • Detect precancerous & invasive cancer cervix cases in early stages
    • Positive screeners can be selected for selective tests and management
    • With treatment, progression of disease is halted. Thus morbidity associated with advanced cancer decreases
    • Mortality reduces by 20-60 %.
    • Helps us to study natural history of disease.
  • 13. Cervical Cancer : Pap smear
    • Early detection of pre-malignant lesions by Pap smears prevent at least 70% of potential cervical cancers.
  • 14. Of the 30% who actually develop cervical cancer:
    • 8% elude cytological detection
      • - imperfections in cytological technology
      • - biologic behavior of malignant lesions
    • 22% represent women who develop cervical cancer because of failure to regularly seek Pap smears => women whose cancers could have been prevented with early detection and treatment.
  • 15. How to take a Pap Smear ?
    • Proper technique is very important
    • More problems are due to improper sampling than screening
    • Not to be collected during menses
    • Avoid vaginal contraceptives, vaginal medications for at least 48 hrs before taking smear
    • Abstinence for 24 hrs
    • Postpartum smear should be taken only after 6 - 8 weeks of delivery
  • 16.
    • Patient in dorsal position
    • Good illumination is necessary
    • Cusco’s speculum is inserted to visualise & fix the cervix
    • Inspection of cervix done & findings are noted
    • Ayres spatula is inserted first. It is placed at cervical os so that longer end goes into cervical canal and smaller end rests on ectocervix
    How to take a Pap Smear ?
  • 17. How to take a Pap Smear ?
    • Spatula is rotated through 360 degrees maintaining contact with ectocervix
    • Do not use too much force [bleeding /pain]
    • Do not use too less force [inadequate sample]
    • Sample is smeared evenly on the slide and fixed immediately
    • Both sides of spatula are to be smeared
  • 18. How to take a Pap Smear ?
    • Endocervical sample is collected using an endocervical brush
    • Insert the cytobrush into canal, so that last bristles of brush are visible
    • Rotate the brush through 180 degrees. [more rotations increase the chance of bleeding]
    • Sample is rolled on the slide and fixed.
  • 19. Fixation of smear
    • Fixation is done immediately with fixative like 95% alcohol or cytofix spray to avoid air drying
    • Spray should be kept at 10 inches, to avoid destruction of cells by propellent in the spray
    • Smear should monolayer for proper penetration of cell surface by fixative
  • 20. How to take a Pap Smear ?
    • Slide should be labeled properly with patients name, identification no. and details
    • Detailed history and clinical examination findings are to be mentioned
    • Patient details and clinical findings are to be maintained in a register
    • Advice is given regarding further follow up and treatment
  • 21. Systems for cervical cytology reporting
    • George N Papanicolaou (1954)
    • 5 classifications based on certainty of finding malignant cells
    • Descriptive system – WHO - (1968)
    • based on morphologic criteria – included mild, moderate,
    • severe dysplasia and Ca In Situ
    • Richart – CIN –based on histologic diagnosis
  • 22. Systems for cervical cytology reporting
    • Bethesda system – TBS (1988)
    • National cancer institute revised in 1991 and 2001
    • Adequacy of smear must be determined before reporting
    • Smear is adequate when
    • - Patient identification
    • - adequate clinical history
  • 23. Bethesda system
    • Interpretable cellular cytology
    • not obscured by inflammation, debris, blood, drying
    • not scanty smear
    • Adequate sampling from transformation zone
    • presence of at least 2 clusters of well preserved endocervical cells or metaplastic cells
  • 24. Bethesda system
    • Results :
    • Within normal limits ( WNL )
    • Benign cellular changes - this term was removed and group was included in WNL in 2001
      • Reactive or Reparative changes – seen with atrophy, inflammation, surgery, radiation, IUCD, tampoons
      • Infections – trichomoniasis, fungal, bacterial, HSV.
  • 25. Bethesda system - results
    • Epithelial cells abnormalities
      • Squamous cells
        • ASCUS
        • ASCUS-H - suggestive of high grade lesion
        • LSIL - changes associated with HPV, atypical changes, mild dysplasia/ CIN1
        • HSIL – moderate to severe dysplasia / CIN2, 3 and Ca In Situ
        • HSIL – where invasion cannot be ruled out
        • Squamous cell carcinoma
  • 26. Bethesda system
    • Results :
    • Glandular cells – AGUS (Endocervical, endometrial)
    • Adenocarcinoma
    • (endocervical, endometrial, extrauterine)
    • Other malignant neoplasms
  • 27. Normal cervix-cytology
    • Squamous cells
    • Exfoliated indivisual cells
    • Navicular in shape with abundant cytoplasm and small, dark, round /oval, pyknotic nuclei
    • Glandular cells
      • Many times seen in clumps - linear or honeycombed pattern.
      • Slightly larger and basal nuclei
  • 28. Cervical cytology - Inflammation
    • Interpretation difficult due to inflammatory background
    • Lot of neutrophils and blood can obscure cellular details
  • 29. Low grade lesions
  • 30. High grade lesions High grade squamous lesion High grade glandular lesion
  • 31. Abnormal Pap smear- HPV
    • Peripherial condensation of cytoplasm - wire looping effect
    • Koilocyte
  • 32. Invasive Invasive Invasive Class 5 HSIL CIN3 Ca In Situ Class 4 LSIL(HPV) HSIL HSIL CIN1 CIN2 CIN3 Mild dysplasia Moderate dysplasia Severe dysplasia Class 3 Reactive, reparatative changes, ASCUS, LSIL(HPV) Inflammatory, squamous, koilocytic atypia Class 2 WNL negative negative Class-1 Bethesda CIN Descriptive PAP
  • 33.
    • Single test will not detect cervical abnormality but with 3 negative tests there is less than 1% chance of cervical abnormality
    • Conventional cytology has specificity of 98% and sensitivity of 51%.
    PAP smear
  • 34. PAP Smears - Limitations
    • Low sensitivity 51%
    • False negative rates are due to faulty sampling, improper fixation or interpretation problems
    • Large group population & high risk group screening not possible
    • No consensus regarding testing
  • 35. Pap smear as screening method
    • New guidelines
      • Target group - All women aged 18-70 yrs who have ever had sex
      • Timing of Initial Screening -
        • I nitial screening at age of 21 years or within 3 years of sexual activity
        • ACOG Guidelines-(Aug2003 ), American Cancer Society (Nov 2002) and U.S. Preventative Services Task Force (Jan 2003)
  • 36. Pap smear - guidelines
        • Screening interval - yearly till the age of 30 then 3 yearly
        • When to End Screening
        • - After 70 yrs
        • - Post Hysterectomy
        • - done for benign lesions
        • - previous 3 normal PAP reports
        • - confirmed complete removal of cervical epithelium
  • 37. Pap smear - guidelines
    • In high risk group after treatment for CIN
    • every 3 monthly for 2 years
      • every 6 monthly for 3yrs
      • Yearly thereafter
      • Women who had hysterectomy for CIN, it is necessary to do vault smears
      • In women who received vaccination against HPV, it is necessary to continue screening
  • 38. Liquid Based Cytology
    • To improve results of PAP newer techniques like liquid based cytology are recommended
    • Cells are obtained with a broom, then the head is broken off in to a vial containing preservative fluid
    • In the laboratory the sample is spun to remove obscuring material
    • It gives clearer image, no cell clumps
    • It will assist in future automated reading
  • 39.
    • Several slides can be prepared from one smear
    • Chlamydia, HPV testing can be done at later date
    • Reduces the incidence of inadequate and repeat smears
    Liquid Based Cytology
  • 40. Cancer Cervix IS PREVENTABLE , IF Detected EARLY!!!!!!!!! Thank You