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  • 1. Body Mass Index and Outcome of ASC-H-Interpreted Cervical Smears in Postmenopausal Women Ahn S., Lee Y., Sung J., Lee J., Oh Y., Sung C., Song S. Presented by Phetnamnueng Yimthet 53080092
  • 2. Introduction Pap Smear or Cervical pap smear is a method to investigate a disorder of the cervical cells lining in the precancerous stage and the early stages of cervical cancer. , , PAP SMEAR.
  • 3. Introduction (cont.) General Categorization Negative for intraepithelial lesion or malignancy Epithelial Cells Abnormality Squamous cell lesion Other Malignant Neoplasms Glandular cell lesion
  • 4. General Categorization of Squamous cell lesion Atypical squamous : ASC-US, ASC-H ASC-US ASC-H LSIL (Low-grade squamous intraepithelial lesion) CIN 1 CIN 1; HPV CIN 2-3 Keratinizing HSIL (High-grade squamous intraepithelial lesion) Squamous cell carcinoma (ASC-US : atypical squamous cells of undetermined significance ; ASC-H : atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion)
  • 5. Background of Study Cytryn et al (2009), Selvaggi et al (2003) • ASC-H is associated with a significantly higher incidence of HSIL during the follow-up compared with ASC-US. • The reporting of ASC-H does lead to the detection of HSIL in average of 68% of the ASC-H positive patients.
  • 6. Background of study (Cont.) Louro et al (2003), Sung et al (2011) • Patient age is an important factor to be considered when evaluating the risk of ASC-H smears. • A follow-up study of the ASC-H positive has been reported that patients younger than 40 years has a higher rate of HSIL than the age 40 or older. • The study suggests the positive ASC-H in older patients may be associated with secondary changes (atrophy or metaplastic changes).
  • 7. Background of study (Cont.) Repse- Fokter et al (2008) Postmenopausal vaginal atrophy is correlated with decreased estradiol and body mass index (BMI)
  • 8. • ASC-H can be difficult to distinguish from secondary changes which occur more frequently at older ages. Secondary atrophic changes hypoestrogenic status • Body fat tissue is an important source of estrogen in postmenopausal women. Body fat body mass index (BMI)
  • 9. Body mass index (BMI) could affect ASC-H interpretation and the outcome of ASC-H smears in postmenopausal women.
  • 10. Study design • Cross-sectional study of retrospective data between July 2002 and August 2008 ( The Samsung Seoul Hospital, Korea ) • 154 postmenopausal women with ASC-H positive , age ≥ 55 years, without hormonal contraceptive or Hormonal therapy
  • 11. Patients and Methods (Cont.) 154 patients Colposcopy Normal colposcopy ( 79 patients ) Follow-up Pap test for 6-12 months Colposcopic abnormalities ( 75 patients ) Follow-up tissue sampling
  • 12. Patients and Methods (Cont.) Classification of the follow-up results Negative LSIL : CIN 1 HSIL : CIN 2 , CIN 3 Carcinoma
  • 13. Patients and Methods (Cont.) 154 smears Conventional Pap smear (107) ThinPrep test Smear (47)
  • 14. Patients and Methods (Cont.) Patient data collection Body weight and height were obtained from medical chart BMI was calculated BW BMI = ---------------(height)2 Serum estradiol levels were measured in 46 patients using a Coat-A-Count estradiol kit. HPV DNA testing were performed in 41 patients (Hybrid Capture II or the HPV DNA microchip)
  • 15. Characteristics of the 154 postmenopausal women Characteristics Median age, years Range Preparation Conventional ThinPrep HPV test (n= 41) Negative Positive Outcome (n=154) Negative LSIL HSIL Carcinoma Patients, n (%) 62 55-85 107 (69.5) 47 (30.5) 19 (46.3) 22 (53.7) 103 (66.9) 13 (8.4) 28 (18.2) 10 (6.5)
  • 16. Patients and Methods (Cont.) Pearson’s 2 : test correlation between SIL and BMI, SIL and HPV Mann-Whitney U test : test correlation between serum estradiol and BMI *P < 0.05 was considered as statistic significance
  • 17. Results
  • 18. Classification of patient BMI BMI (n = 154) Patients, n (%) < 18.5 (underweight) 6 (3.9) 18.5-22.9 (normal) 64 (41.6) 23-24.9 (overweight) 34 (22.1) 25-29.9 (obese 1) 47 (30.5) ≥30 (obese 2) 3 (1.9)
  • 19. Outcome of the postmenopausal women with ASC-H smears stratified by BMI BMI with cutoffs of 23 % BMI with cutoffs of 25 42% 29.8% 30% % *P = 0.014 vs BMI < 23 % 28.8% 22.1%
  • 20. Representative figures of ASC-H BMI  23 BMI  23 BMI < 23 CIN3 Carcinoma NILM CIN3 Carcinoma NILM ( NILM : Negative for intraepithelial lesion or malignancy )
  • 21. Conventional vs. Liquid-based preparation BMI with cutoffs of 25 BMI with cutoffs of 23 Prevalence (%) LSIL or LSIL+ HSIL or HSIL+ Prevalence (%) LSIL or LSIL+ HSIL or HSIL+ BMI<23 BMI≥23 BMI<23 Conventional P < vs BMI 23 BMI≥23 LBP BMI<25 BMI≥25 Conventional BMI<25 BMI≥25 LBP
  • 22. Correlation of BMI and serum estradiol levels Serum estradiol (pg /ml) BMI<23 P BMI with cutoffs of 25 Serum estradiol (pg /ml) BMI with cutoffs of 23 BMI≥23 vs BMI<25 BMI<25 BMI≥25
  • 23. *P 80 70 60 50 72.7% 40 30 20 36.8% 10 0 HPVvs HPV- HPV+ Prevalence of HSIL or HSIL+ (%) Prevalence of LSIL or LSIL+ (%) Association of HPV and the presence of SIL 70 60 50 59.1% 40 30 20 10 15.8% 0 HPV- HPV+
  • 24. Discussion The present findings In patients with higher BMI, an underlying squamous intraepithelial lesion (SIL) was more frequent than in patients with lower BMI, and a higher BMI was also associated with increased serum estradiol levels and HPV positive.
  • 25. Discussion (cont.) Hormonal alteration and ASC-H interpretation Patton et al (2008) The diagnosis of ASC-H in postmenopausal Pap smears has a low predictive value in the subsequent diagnosis of HSIL in contrast to the pregnant, postpartum, and contraceptive-use categories. The finding supports the idea that hormonal alterations are associated with the risk level of ASC-H smear.
  • 26. Discussion (cont.) Vaginal atrophic changes associated with estradiol and BMI Repse-Fokter A. et al (2008) • Estradiol and BMI are associated with vaginal cell maturation and atrophy in postmenopausal women. • Increased BMI was associated with increased serum estradiol levels.
  • 27. Discussion (cont.)
  • 28. Conclusions • Postmenopausal women with an ASC-H smear who are higher BMI are more likely to have underlying SIL on follow-up • Therefore, patient BMI should be considered when evaluating the risk level of ASC-H smears in postmenopausal women
  • 29. Acknowledgements • • • • • Asst. Prof. Petcharat Trongtorsak Atchareeya Nudchawong (Hu-So, English major) Hattaya Chanasit (Education, English major) Isara Techakijwaroros (Medical) Tippawan Kasaratikool (Allied Health Science)
  • 30. Thank you

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