Basics Screening. Pap Smear

1. Screening in
Gynaecology
Dr RK Saxena
Professor (O&G)
MVJ MC & RH

2. Screening
• To detect disease among healthy
population
• Without symptoms of disease
• Purpose: decrease mortality due to
the disease screened

3. Disease appropriate for screening
• High prevalence of disease
• Known natural history, precursor lesion and
course of progression
• Detection of early stage disease, amenable
to cure
• Method used is simple, cheap, specific and
sensitive, acceptable, risk-free and
accessible

4. Screening
• Cervical cancer
• Ovarian cancer
• Endometrial cancer
• Breast cancer

5. Cervical Carcinoma

6. Carcinoma of the cervix
• Commonest lower genital tract
cancer
• Current age-standardized rate is
22 per 100 000 per annum
• Median age: 50 years

7. Natural history of low-grade
HPV cervical lesion
• Cervical HPV is very common, related
to sexual behaviour
• High spontaneous remission rate
• LSIL progress to HSIL in 70% in 10 yrs

8. Cervical cytology
Sensitivity and Specificity
• Overall sensitivity: 61-64%,
• Overall specificity : 60-70%
New technology
• Automation for cervical cancer screening
• Liquid-based cytology(LBC) - thin layer
preparation (Eliminate air-dried artifact,
Inflammatory cells, Blood, mucus)
• HPV testing combined with PAP smear
improves screening

9. How to take a cervical smear?
Procedure

10. When not to take a cervical
smear
• Blood in vagina, on the cervix - usually
because of menstruation
• Obvious or gross growth on the cervix -
a biopsy is more appropriate
• Cervix cannot be seen

11. How to interpret a cytology
report?

12. PAPANICOLAOU SMEAR REPORTING
– BETHESDA SYSTEM
n Satisfactory / Unsatisfactory for reporting
n Negative for Intraepithelial Lesion - Normal
n Infection ( Organism to be specified)
n Benign (Reactive /Reparative) cellular changes
n ASCUS ( Atypical squamous cells of undetermined
significance)
n LSIL ( Low grade sq intra-epithelial lesion)
n HSIL (High grade sq intra-epithelial lesion)
n Squamous cell carcinoma

13. How to manage abnormal smear?

14. Inflammatory changes with
atypia
–could be due to vaginitis or infection
such as monilia, trichomonas, herpes
or condyloma.
–Treat the cause and repeat the smear
4 to 6 months later to ensure that
dysplastic cells were not masked by
the previous inflammatory cells.

15. Management of LSIL
Management of LSIL
•Only about 1% of LSIL associated with
cancer
•Options:
–repeat smear 4-6 months interval
Management of HSIL / ASCUS
•Colposcopy
•Biopsy of abnormal area

16. Colposcope

17. COLPOSCOPY PROCEDURE
• Dorsal lithotomy position
• Clean and drape
• Cusco’s speculum
• Focus Colposcope
– Clean with saline
– 3-5% acetic acid
(Abnormal areas seen as acetowhite areas)
– Lugol’s Iodine
(Abnormal areas seen as Iodine negative areas)
– Take biopsy from edge of abnormal areas (include small part
of normal areas in biopsy specimen)
Biopsy
Area

18. Colposcopy
nAcetic acid
–coagulation of nuclear
protein preventing
light to pass through
the epithelium
–Higher nuclear density
and higher
concentration of
protein => white
intensity increase

19. n Schiller / Lugol’s Iodine
– Normal, mature
squamous epithelium
contains abundant
glycogen
– Produce dark brown
stain
– Abnormal epithelium
contains relatively little
or no glycogen
– Remain relative
unstained

20. Colposcopy Findings

21. Treatment of high grade CIN
• Ablative therapy
–cryotherapy
–cold coagulation
–diathermy
–laser evaporisation
• Excision therapy
–cone (knife, laser, loop excision)
• Hysterectomy is rarely indicated

22. LEEP Procedure

23. Cone Biopsy Procedure

24. Ovarian Carcinoma

25. Ovarian Cancer - Importance
§ 4th common cause of cancer mortality
§ Most (70%) diagnosed at advanced stage
where cure is uncommon.
§ Ranks 3rd among gynecologic cancers
§ Ranks 5th among women cancers.
0
5
10
15
20
25
Breast
Cancer
Cervical
Cancer
Ovarian
Cancer
Per lac
women
30 Incidence of
Gynecolgical
Cancers in
India

26. Family History
Family history Risk
None 1.5 %
First degree relative 5 %
Two 1st degree relative 35-40 %
Hereditary ovarian cancer
syndrome
40 %
Mutation in BRCA 1 & 2 35-65 %
Breast ca & BRCA1 & 2 56-87 %

27. Neoplastic Ovarian Tumors
Surface epithelial – 65-70%
Germ cell tumors – 15-20%
Sex cord Stromal Tu – 10-15%
Metastatic tumors – 5%
4 basic categories of ovarian neoplasms:

28. Ovarian Cancer
Vague non-specific symptoms responsible
for late diagnosis & poor survival rates
Symptoms of ovarian cancer :
•Asymptomatic
•Lower abdominal pain / pressure
•Mass abdomen / Abdominal enlargement
•Vaginal bleeding
•Urinary / bowel symptoms

29. Why screening for ovarian cancer
is difficult?
• Anatomic location of the ovary, not easily
accesible
• Lack well defined precursor lesion and
has poorly defined natural history
• Low prevalence, need exquisite specificity
to avoid unnecessary intervention
• Lack of a good method

30. Ovarian cancer screening
• Recommended only for high risk patients
– Serum CA125
– Transvaginal ultrasonogram
• Serum CA125
• Elevated in 82% of epithelial ovarian cancer
and <1% of healthy women
• Limitations: lack of sensitivity in Stage I
disease, poor specificity (elevated in benign
and other malignant conditions)

31. TVS: Features suggestive of malignancy
• Bilateral
• Fixed
• Variegated
consistency
• Solid
• Nodules in pouch of
Douglas
• Ascites -
Haemorrhagic

32. Solid Ovarian Tu

33. Bilateral: Cyst and mass in each ovary

34. Ultrasound for
Detection of Ascites

35. Ovarian malignancy containing two papillary
excrescences (arrows)

36. Ovarian screening
• Not cost-effective
• May be considered in high risk population
• No place for population screening yet

37. Endometrial Carcinoma

38. Should endometrial cancer be
screened?
• Precursor lesion, atypical endometrial
hyperplasia
• Accessibility of endometrium to
sampling
• High cure rate for early disease
Majority detected at early stage because
of abnormal bleeding esp PMB

39. Endometrial Cancer Screening
• Tools explored
–Pelvic ultrasound (>8mm endometrial
thickness in postmenopausal women)
–Endometrial aspirate (inadequate
sampling in menopausal women)

40. Pipplle Aspiration

41. Dilatation & Curettage

42. Hysteroscopy

43. Endometrial cancer screening
• Not justified in population screening
• excellent prognosis of majority of Ca
endometrium unlikely will result in
decreased mortality rates

44. Breast Carcinoma

45. Breast Ca : India
• Current age-standardized rate is 19.1
per 100 000 per annum
• Incidence rate peaks below age 50.
• Cases presenting for treatment are
locally advanced
• Availability and level of facilities for
treatment are variable
• Survival rates are consequently low

46. Screening Tests
• Mammography
• Clinical breast exam
(CBE)
• Breast self-exam
(BSE)
• The two cornerstones of early detection are
– awareness of the disease &
– opportunistic and population-based screening.

47. Screening: Mammography
Mammography
Mammography reduces the
rate of death from breast
cancer by 7%–23%, with a
median of 15%.1
•Current Recommendation:
Mammography
•(CBE & BSE widely used as
tools to increase breast
awareness) 1. Berry DA, et al. N Eng J Med. 2005;353:1784-1792.

48. Clinical Breast Examination
• May identify 4.5%–10.7% of breast cancers
that mammography misses
• Clinician proficiency impacts effectiveness
• Recommendations vary:
– American Cancer Society
• Every 3 years for average-risk women in 20s
and 30s
• Annually for women aged 40
– U.S. Preventive Services Task Force
• No recommendation/Not enough evidence

49. • IARC Working Group concluded in 2002 that
there is inadequate evidence that breast
screening by CBE, either alone or together with
mammography, can reduce mortality from
breast cancer
• However, cancers detected by CBE tend to be
diagnosed at an earlier stage than those not
detected by screening
• A greater potential for effectiveness in a setting
where stage at diagnosis is generally poor
Clinical Breast Exam

50. Reasons for Screening Disparities
• Inadequate access to facilities and equipment
• Financial restraints, including a lack of
adequate health insurance
• Lack of patient knowledge of breast cancer
risk and the need for screening
• Any mass in the breast is regarded as
carcinoma until proven otherwise
• Patient Education is the key to early detection
of breast cancer

51. Breast Self Examination

52. Clinical Breast Examination

53. THANK YOU

54. Speculum

55. Ayres’ spatula, endocervical
brush

56. Broom type sampler