PAP TEST 2023 ALEXANDRIA FINAL.pdf

PAPANICOLAOU TEST
CERVICO-VAGINAL SMEAR CYTOLOGY

AHMED EL-HABASHI, MD, PH.D, FIAC
PROFESSOR OF PATHOLOGY, NCI, CAIRO UNIVERSITY
Fellow Of International Academy Of Cytology
PAPANICOLAOU TEST
CERVICO-VAGINAL SMEAR CYTOLOGY

Superficial squamous cells
Intermediate squamous cells
Parabasal cells
Basal cells
Reserve cells
Endocervical cells
Squamous metaplasia
Endometrial cells
Repair cells
IUD effect
Granulocytes
Lymphocytes
Histiocytes
Plasma cells
Stromal cells
Tubal metaplasia
Parakeratotic cells
Histiocytic giant cells
NON-NEOPLASTIC CELLS IN PAP. TEST

Lectures Outline
DAY 1/PART I
The Pap-Test Background/Rationale
Cytopreparatory methodology
Conventional smearing
Liquid-based technology
Normal cytology and infectious agents
The Bethesda System (TBS)
Squamous Neoplasia Cytomorphology
DAY2/PART II
Glandular Neoplasia Cytomorphology
HPV testing/Screening
Reactive and reparative changes/Diagnostic pitfalls

BACKGROUND
 Although cervical cancer is the fourth most
common cancer among women worldwide,
mortality rates are decreasing, mainly in
high-income countries.
 Improvements in screening, diagnosis and
treatment are probably the reason for this
decline.
Rev Bras Ginecol Obstet 2022

CUMULATIVE RISK OF CEVICAL CANCER

INCIDENCE AND MORTALITY OF CERVICAL CANCER

The Papanicolaou Method
Dr. George N.
Papanicolaou (1883-1962)
developed a method
whereby cellular material
removed directly from the
uterine cervix, processed,
stained and examined
microscopically.
To indirectly classify and
infer likely cervical
neoplasia.

Papanicolaou and Traut : A Most
Fruitful Collaboration, 1941

Papanicolaou
and Traut : A
Most Fruitful
Collaboration
1943
Monograph: Diagnosis of Uterine Cancer by the Vaginal Smear

Gynecologic cytology
 It is a screening tool
 It is designed to detect squamous
lesions

Goals of gynecologic
cytology
 To decrease the incidence of cervical
cancer by detecting pre-malignant
lesions
 To reduce mortality of cervical cancer
by early detection and treatment
 To detect some clinically relevant
infections

Normal Cevix, Colposcopy
original
squamous
epithelium
Columnar
epithelium
SCJ
SCJ
original
squamous
epithelium
Columnar
epithelium

Squamo-columnar Junction
Mature Metaplasia

THEORY
 Cervical cancer proceeds in a predictable fashion over a long
period, allowing ample opportunity for intervention at a
precancerous stage.
Low-grade ---high-grade dysplasia ( average of 9 years)
High-grade ---- invasive cancer ( 3 months to 2 years).
 Up to 70% of (CIN 1) lesions resolve spontaneously within1 to 2
years
 More than 99% of cervical cancers have detectable HPV DNA
sequences. Infection with high-risk oncogenic human
papillomavirus (HPV) types(16, 18,…) is the most significant
risk factor in the development of cervical cancer.

Pap-Test Impact
It has reduced the incidence of cervical
cancer from second among cancers in
women to 11th, and mortality from
second to 13th.
It is the most cost-effective cancer
reduction program ever devised.

The biggest problem is using Pap smear on
symptomatic patients.
It is not sensitive with invasive lesions so
when the result comes back normal, a
clinician may be mislead and misses a serious
lesion.
It was the doctor’s mistake in the first place
to perform a Pap smear on a bleeding
woman.

Pap-Test Advantages
 Non-Invasive
 Simple
 Reproducible
 Inexpensive
 Screening test
 T-Zone and Adjacent Epithelia Sampling
 Conveys a degree of risk-status of carcinogenesis

Instruments For Collection of
Cervical Cell Sample
Ayre spatula
Cotton-tip
applicator
Cervix brush
Cytobrush

Technique of Uterine Cervix
Cytology Sampling

Conventional Smear Limitation
 Excessive inadequate sampling
 Limited sensitivity (51%)
 Up to 60% false negative rate
 Compromised material by:
Mucous, blood, inflammatory
cells and air-drying artefact

Liquid Based Cytology (LBC)
 Revolution in Gynecologic Cytopathology
 Problem Solving:
Removal of blood, mucous,
Randomization
Standardized cell concentration on slides
Thin, monolayers
Adequate fixation/No air dryness
Excellent staining

ADVANTAGES OF LBC
 Improved method of sampling the cervix
 Detects more dyskaryosis
 Fewer unsatisfactory smears
 Improves laboratory efficiency
 Compatible with HPV testing and scanning
technologies

Liquid Based Cytology (LBC)
 In 1996, the FDA approved the first
liquid-based Pap test known as the
ThinPrep® Pap test.
 Surepath®, a second liquid-based Pap
test, was FDA approved in 1999.

THINPREP SYSTEM SUREPATH SYSTEM

Liquid Based Pap-Test
Platforms
􀂾 ThinPrep Method 􀂾 SurePath Method
Imprint/Filtration
Sedimentation

Problem Solving
 Removal of RBC
 Removal of mucus
 Randomization
 Excellent staining

Removal of Blood
Major advantage: removal of
RBC
Reduce the number
Unsatisfactory
interpretations

CONVENTIONAL Liquid-Based Cytology

Improved sampling & Processing
 Conventional smear
– Never get all sample on slide
– >80% of cells discarded
– Non-random sample
– Technique determines quality
of smear
 Fixation, spreading artefacts
etc
 LBC
– Virtually all cells
transferred to vial
– Random sample
transferred to slide
– Uniform quality of
slide preparation (lab)

Meta-analysis
 Sensitivity up to 80% for
Thin-Prep cytology
 Sensitivity 51-58% for
Conventional Smear

Technical Differences Between LBP and Conventional Smear
Features LBP Conventional
Cost Expensive < expensive
Sample collection Uniform Variable
Sample transfer Entire <80%
Fixation Immediate Varies
Transport Easy Easy to difficult
Slide preparation Automated Manual
Number of cells 50,000 >300,000
Slide evaluation Easy Tedious
Cells in a well-defined Cells Diffusely smeared in
20 mm and 13 mm 25 X 75 mm area
diameter area for TP
and SP respectively
Cell preservation Good Insufficient
Obscuring factors None Usually present
Air drying None Usually present
Screening time Reduced Long
Reproducibility Yes No
Ancillary studies Possible +/-

General Cytologic Features on LBP and Conventional Smear
Feature LBP Conventional smear
Quantity Enhanced Variable
Background
Clean Yes No
RBCs Reduced Present/usually obscure
Neutrophils Reduced Present/usually obscure
Necrosis Clumped Diffuse/usually obscure
Cellularity Lower Higher
Cell distribution Uniform Uneven, thick
Cell size Smaller Larger
Architecture Less Preserved Preserved
Cytomorphology Preserved Preserved
Extracellular material **** ****
Quantiity Reduced Preserved
Mitosis Preserved Preserved

Superficial cells
Intermediate cells
Parabasal cells
Basal cells

ENDOMETRIAL
SUPERFICIAL
RESERVE ENDOCERVICAL
PARABASAL
INTERMEDIATE
20
35
50
50
30
50
um2

Normal cervical cytology
Normal ectocervix:
Structure of the ectocx
CT=connective tissue,
BM=basement memb.
L1=basal cells (1 layer),
L2=parabasal cells (2
layers),
L3=intermediate cells
(around 8 layers),
L4=superficial cells (5 or
6 layers) and
L5=exfoliating cells.

Superficial squamous cell
-Large polygonal cells
-Have a centrally located small, round, pyknotic nucleus.
-The cytoplasm is bright, sharply demarcated and stains red
20

- Large polygonal
- Have a centrally located
- vesicular nucleus
-The cytoplasm is transparent light
blue/blue-green
35

Intermediate squamous cell
- Large polygonal
- Have a centrally located vesicular nucleus
-The cytoplasm is transparent light blue/blue-green

Parabasal cells
Round or oval & have variably sized nucleus.
-High N:C ratio.
- Typically have dense cytoplasm.
„
50

Columnar
Epithelium
Columnar
epithelium

SQUAMOUS METAPLASIA
Flat sheets of immature sq. cells
- Round to oval nuclei & bland chromatin pattern
- Abundant finely vacuolated cytoplasm
- Cells arranged in an interlocking fashion like paving stones, and usually are contiguous with
clusters of endocervical cells.

Pregnancy Changes
Navicular “ Boat like” cells

HYPERKERATOSIS
Anucleate, mature, polygonal squamous cells may be
numerous and appear as single cells or plaques of
tightly adherent cells

Parakeratosis
Heavily keratinized sq. cells with orangeophilic
cytoplasm and small, pyknotic nuclei

Normal Endometrial cells
SMALL 3D TIGHT CLUSTER
SMALL ROUND CELLS
MONOTONY
KNOBBY BORDER
SCANT VACUOLATED
CYTOPLASM
HYPERCHROMATIC
NUCLEI
30

Endocervical cells Endometrial cells
50 30

SMEAR NOMENCLATURE
1
2
3
4
5
Negative for malignant cells
Inflammatory atypia
Squamos atypia
Koilocytotic atypia
Mild dysplasia
Moderate dysplasia
Severe dysplasia
Carcinoma in situ
Invasive Carcinoma
Negative
CIN 1
CIN 2
CIN 3
CIN 3
Inv Ca
Descriptive
(WHO)
(1968)
Pap
(1954)
CIN
(1978)
Interobserver and
intraobserver
variability:
Lack of
reproducibility
No relevant clear
cut data for clinical
management
It does not reflect
the most current
understanding of
cervical
neoplasia.

The Bethesda System (1988)
Why?
• To establish terminology that
would provide clear-cut thresholds
for management and decrease
interobserver variability.

TBS CONFERENCE
• This terminology and the process that created it have had
a profound impact on the practice of cervical cytology for
laboratorians and clinicians alike.
• TBS has also set the stage for standardization of
terminology across multiple organs systems, (THYROID,
URINE, BILIARY, SALIVARY).
• TBS has initiated significant research in the biology and
cost-effective management for human papillomavirus
(HPV)- associated anogenital lesions.
• TBS has fostered worldwide unification of clinical
management for these lesions.

Nomenclature
Cervical Intraepithelial Neoplasia Is a Continuous
Spectrum of Disease
Mild Dysplasia
Moderate
Dysplasia
Severe
Dysplasia
Carcinoma in
situ
CIN I CIN II CIN III
LSIL
LOW GRADE
SQUAMOUS INTRA-
EPITHELIAL LESION
HPV
HSIL
HIGH GRADE SQUAMOUS
INTREEPITHELIAL LESION
SCC
SCC
SCC

THE BETHESDA SYSTEM
Was developed to provide a uniform
diagnostic terminology that would
facilitate communication between the
laboratory and the clinician and
management decisions for cervical
neoplasia (1988, 1991, 2001, 2014/15)

Revision Bethesda
ASCUS
 Bethesda 1991:
– ASCUS-FR: favoring a reactive process
– ASCUS-FN: favoring a dsyplastic/neoplastic process
– ASCUS-NOS: not other specified
 Bethesda 2001:
– ASC-US: undetermined significance
– ASC-H: suggestive of HSIL
ASC IS NOT A WASTEBASKET

BETHESDA 2014/15: WHY?
1- Increase use of LBC.
2- The addition of co-testing (Pap and
hrHPV testing) and, more recently,
primary hrHPV testing as additional
screening options.
 3- Approval and implementation of
prophylactic HPV vaccines; and updated
guidelines for cervical cancer screening
and clinical management.

BETHESDA 2014:
WHAT HAS CHANGED?
 There were minimal changes relating to the
terminology itself
 Reporting of benign-appearing endometrial cells is
now recommended for women aged 45 years
 No new category was created for squamous
lesions with LSIL and few cells suggestive of
concurrent HSIL (add note or LSIL with ASC-H)
 More images to refine cytologic criteria

BETHESDA 2014
 Chapter 1: Adequacy
 Chapter 2: Non-neoplastic changes
 Chapter 3: Endometrial cells
 Chapter 4: Atypical squamous cells
 Chapter 5: Squamous epithelial cell abnormalities
 Chapter 6: Glandular epithelial cell abnormalities
 Chapter 7: Other malignant neoplasms
 Chapter 8: Anal cytology
 Chapter 9: Adjunctive testing (HPV/P16)
 Chapter 10: Computer-assisted interpretation
 Chapter 11: Educational notes and comments
 Chapter 12: Risk assessment in cervical cancer

The Bethesda Reporting System
 Specific components
Specimen type (CC/LBC)
Specimen adequacy
General categorization
Automated review
Ancillary testing
Interpretation/result
Educational notes and recommendation

General Categorization
 A: Negative for Intraepithelial Lesion or
Malignancy (NILM)
 B: Epithelial Cell Abnormality (specify
squamous or glandular as appropriate)
 C: Others

Interpretation/Result
 A-NEGATIVE FOR INTRAEPITHELIAL LESION
OR MALIGNANCY (NILM):
ORGANISMS:
Trichomonas vaginalis
Fungal organisms consistent with Candida spp
Shift of flora suggestive of bacterial vaginosis
Actinomyces spp
Herpes simplex virus
OTHER NON NEOPLASTIC FINDINGS
 Reactive changes : inflammation/repair, radiation, IUD
 Glandular cells status post-hysterectomy, Atrophy

 B- EPITHELIAL CELL ABNORMALITIES
 Squamous cell
ASC-US (Atypical Squamous Cells of Undetermined Significance)
ASC-H (Atypical Squamous Cells, cannot exclude HSIL)
LSIL (Low Grade Squamous Intraepithelial Lesion/HPV)
HSIL ( High Grade Squamous Intraepithelial Lesion)
SCC ( Squamous Cell carcinoma)
Glandular cell
AGC (endcerv., endometrial, NOS)
AGC (ENDOCERV FAVOR NEOPLASIA)
AGC (FAVOR NEOPLASIA)
AIS
ADENOCA (ENDOCE, ENDOMET, EXTRAUET, NOS)
Other malignant Neoplasm
 C- OTHER (eg, endometrial cells in a woman ≥ 45 years)

Adequacy Description:
NILM: Squamous metaplasia
Normal polygonal squamous
metaplastic cells with round to oval
nuclei and bland chromatin pattern. On
liquid based preparations cells may
appear more rounded, and nuclei may
appear smaller. This would be
interpreted as "NILM".
The presence of squamous
metaplastic cells indicates
that the transformation
zone has been sampled
(a minimum of 10 well-
preserved endocervical or
metaplastic cells is required
for this quality indictor).

Unsatisfactory squamous cellularity. Endocervical cells are
seen in a honeycomb arrangement.

An adequate conventional
smear
An adequate conventional
smear has an estimated
minimum of approximately
8,000-12,000 well visualized
and preserved squamous.
About 7 or more fields with
this level of cellularity are
needed for adequate
squamous cellularity.
This image was composed to depict the
appearance of a 4X field with
approximately 1400 cells. It is to be used
as a guide in assessing squamous cellularity
of conventional specimens.

Squamous cellularity~1000 cells in this
4X field
This image was composed to
depict the appearance of a 4X
field with approximately 1000
cells. It is to be used as a guide in
assessing squamous cellularity of
conventional specimens.
A minimum of 8 4X
fields with similar (or
greater) cellularity are
needed to call the
specimen adequate

4X field
This image was composed to depict the
appearance of a 4X field with
approximately 500 cells. It is to
be used as a guide in assessing squamous
cellularity of conventional specimens.
A minimum of 16 4X
fields with similar (or
greater) cellularity are
needed to call the
specimen adequate
according to Bethesda
2001 criteria.

4X field
This image was composed to depict
the appearance of a 4X field with
approximately 150 squamous cells. It
is to be used as a guide in assessing
squamous cellularity of conventional
specimens
If all fields have this level of
cellularity the specimen will
meet the minimum
cellularity criterion, but by
only a small margin. This
image illustrates the
minimum average 4X field
cellularity for conventional
smears (assuming all fields
are similar.).

Squamous cellularity:~75 cells in this 4X
field/Unsatisfactroy
This image was composed to depict
the appearance of a 4X field with
approximately 75 cells. It is to be
used as a guide in assessing
squamous cellularity of
conventional specimens.
The specimen is
unsatisfactory if all
fields have this
level, or less, of
squamous
cellularity.

Air Drying Artifact/Unsat
Cytomorphologic Criteria:
Enlarged pale nuclei with loss of
nuclear detail. Air dried nuclei flatten
out (as opposed to well-fixed cells,
which maintain a more 3-dimensional
shape), and do not take up stain very
well. This leads to enlarged pale
appearance. Cytoplasm is also
degenerated, and evaluation of cells
is difficult.
Explanatory Notes:
Extensive air drying may mean that a
specimen is unsatisfactory (if >75%
of cells show air drying). If less
extensive, air drying may be
mentioned as a quality indicator.
if >75%

Unsatisfactory- obscuring RBCs and WBCs
Unsatisfactory for evaluation of epithelial
abnormality due to obscuring blood and
inflammation.
Unsatisfactory due to obscuring
inflammation. Greater than 75%
obscuring is considered
unsatisfactory if no abnormal
cells are identified.
If 50 - 75% of the slide has this
appearance, obscuring
inflammation should be
mentioned in the quality
indicators section of the report if >75%

Unsatisfactory: Obscuring RBCs and
WBCs
Over 75% of cells are
obscured by inflammation
and blood
Unsatisfactory due to obscuring
inflammatory cells. Greater than 75%
obscuring is considered unsatisfactory if no
abnormal cells are identified. If 50 ? 75% of
the slide has this appearance, obscuring
inflammation should be mentioned in the
quality indicators section of the report.
Follow-up:
This patient should have a repeat cervical
cytology specimen or other clinical
evaluation

SPECIMEN ADEQUACY
Satisfactory for evaluation
1. The pt. and the specimen are prominently identified;
2. Pertinent cl. history is available,
3. Technically interpretable specimen and of proper cellular
composition (Obscuring elements may be mentioned if 50–
75% of epithelial cells are obscured
4. Note the presence or absence of endocervical /trans-
formation zone component (EC/TZ)
The absence of endocervical cells does not affect specimen
adequacy. Clinicians are expected to use their judgment,
and to consider repeating the Pap if the patient is at high
risk for cervical cancer.

General Categorization
 A: Negative for Intraepithelial Lesion or
Malignancy (NILM)
 B: Epithelial Cell Abnormality (specify
squamous or glandular as appropriate
 C: Others

A-NEGATIVE FOR INTRAEPITHELIAL
LESION OR MALIGNANCY (NILM):
ORGANISMS:
Trichomonas vaginalis
Fungal organisms consistent with Candida spp
Shift of flora suggestive of bacterial vaginosis
Actinomyces spp
Herpes simplex virus
OTHER NON NEOPLASTIC FINDINGS
Reactive changes : inflammation/repair, radiation, IUD
Glandular cells status post-hysterectomy, Atrophy

INFECTIONS
 BACTERIAL
 VIRAL
 FUNGAL
 PROTOZOAL
 CONTAMINANT

Shift in normal flora
Bacterial Vaginosis
Cytology:
Short bacilli (coccobacilli), curved bacilli, or mixed bacteria
No lactobacilli
“filmy” appearance

HSV
Multinucleation
Molding of nuclei
Margination of chromatin
Ground-glass nuclei
Eosinophilic intranuclear inclusions
3M

15 to 30 μm long
Pear shaped
Pale, eccentrically placed nucleus
Red cytoplasmic granules
Polyballs
Leptothrix
Trich change
Trichomoniasis

Leptothrix suggests Trich. Vaginalis

Candidiasis
Long pseudohyphae tangles and skewers of
squamous cells around pseudohyphae
(―spaghetti and meatballs,‖ ―shish kebabs‖

Actinomycosis
Tangled clumps of bacteria (―cotton
balls,‖ ―dust bunnies‖)
Long, filamentous organisms

Pap. Test
PART I
Cytomorphology of Abnormal
Squamous Epithelium

 Squamous cell
 Glandular cell
 AGC (NOS)
 AGC (ENDOCERV FAVOR NEOPLASIA)
 AGC (FAVOR NEOPLASIA)
 AIS
 ADENOCA (ENDOCE, ENDOMET, EXTRAUET, NOS)
 Other malignant Neoplasm

CTRITRIA OF DYSPLASIA
DEGREE OF MATURATION
CELL SHAPE AND SIZE
NUCLEAR ATYPIA
NUCLEAR SIZE AND N/C RATIO
CHROMATIN PATTERN AND NUCLEAR
MEMBRANE IRREGULARITY
MITOTIC ACTIVITY
LOCATION AND CONFIGURATION
CIN3
CIN2
CIN1

CIN1/LSIL CIN1/HPV/LSIL
CIN3/HSIL
CIN2/HSIL
NORMAL SQUAMOUS LININING

CIN 1 & HPV CIN 2 &3
Histology

 Squamous cell
 Glandular cell
 AGC (NOS)
 AIS

Cytomorphology
Intermediate or superficial -sized cells
Nuclear enlargement ( ≥3 times the size of normal intermediate cell nucleus)
with mod. variation in nuclear size .

Nuclear features of LSIL without cytoplasmic HPV changes.
Nuclear enlargement and hyperchromasia of sufficient degree for the
interpretation of LSIL.
Demonstration of HPV cytopathic effect is not necessary for an interpretation of
LSIL, if required nuclear changes are present.


Intermediate or superficial -sized cells
Nuclear enlargement ( >3 times the size of normal intermediate cell
nucleus) with mod. variation in nuclear size .

Classic koilocytes have large, sharply defined perinuclear cytoplasmic
cavities surrounded by dense rims of cytoplasm (wire- loop periphery). Their
nuclei are usually enlarged and atypical, but not always, Binucleation is noted

PSEUDOKOILOCYTOSIS
GLYCOGEN
INFLAMMATORY

LSIL
Hyperchromasia (uniformly granular increase in chromatin or irregular
chromatin distribution).

3- High-grade squamous intraepithelial lesion (HSIL)
Encompassing : moderate and severe dysplasia, carcinoma in situ;
CIN 2 and CIN3
Age: mid- to late reproductive years (ages 26 to 48 years), although they may
be seen at any age after the onset of sexual activity.
20 % will progress to invasive cancer if left untreated

Cytomorphology
-Usually parabasal-
sized cells smaller,
less mature
squamous cells
-Nuclear
enlargement, the
same range as in
LSILs,(N/C ratio is ½
2/3, higher because
the cells are smaller

HSIL:
IRREGULAR NUCLEAR MEMBRANE
UNEVEN COARSE CHROMATIN
N/C 1/2-2/3
IREGULAR CONTOUR
PARABASAL SIZE

HSIL
Usually marked hyperchromasia and marked chromatin coarseness. The
nucleoli are absent.

VARIABLE CHROMATIN
HIGH N/C RATIO, VARIABLE CHROMATIN AND
PLEOMORPHISM IN HSIL

Architecturally, the cells of HSILs are arranged in two main
patterns:
as distinct individual cells or

as cohesive groups of cells with indistinct cell borders
( syncytial –like groups’).

The participants at TBS 2001 supported the concept of adding the phrase
“invasion cannot be ruled out” to cases of HSIL in which there is non
diagnostic cytologic evidence of invasion.
Cytomorphology
Small abnormal sq.
cells. There is some
necrotic cellular
debris in the back
ground, (?? invasion)
Necrotic cellular
debris may be seen
as focal aggregates of
debris (usually
associated with
abnormal epithelial
cells) in an otherwise
clean background

HSIL, r/o invasion
Keratinized dysplastic cells with nucleoli, and angulated or ?carrot? shaped
nuclei. ?? Invasion. A clinician must understand that no diagnosis of HSIL
on cytologic material excludes the possibility of invasive cancer, and that
colposcopy and biopsy are necessary for confirmation.

WASHED OUT CHROMATIN
PALE DYSKARYOSIS

 Squamous cell
ASC (Atypical Squamous Cells)
 Glandular cell
 AGC (NOS)
 AIS

EPITHELIAL CELL ABNORMALITIES
*SQUAMOUS CELL :
Atypical squamous cells (ASC): subdivided into two types:
1-ASC-US (undetermined significance)
2- ASC-H (cannot exclude high-grade SIL)
• ASC of undetermined significance (ASC-US)
- ASCUS is defined as " squamous cell abnormalities
that are more marked than those attributable to reactive
changes but that quantitatively and qualitatively fall
short of a definitive diagnosis of SIL
- SUGGESTIVE OF LSIL
- A woman with ASC-US has a 5% to 17% chance of having CIN 2 or 3.

Cytomorphology
ASCUS defined by a number of criteria. The principal one was nuclear size
(2.5 to 3 times) intermediate squamous cell nucleus

Atypical squamous cells of undetermined significance
- Other cellular changes include some hyperchromasia and/or mild nuclear
membrane irregularity .

ATYPICAL PARAKERATOSIS TYPICAL PARAKERATOSIS
ASCUS VS LSIL

(ASC-H) cannot exclude HSIL
Denote cases that demonstrate some but not all features of HSIL.

ASC-H resemble metaplastic sq. cells and have an increased N/C ratio.

Other features: mild irregularity in nuclear contour and mild hyperchromasia

The cells of ASC-H were more likely to present as isolated single cells

ASC-H
Metaplastic cells with enlarged nuclei and nuclear contour irregularities
showing variation in size, shape, and ++ ratio of nuclear to cytoplasmic area.
SQUAMOUS METAPLASIA
ASC-H
ASC-H

Type of Preparation:
ThinPrep/ LBP
Clinical History:
32 year old female, LMP- 2 weeks ago

DIAGNOSIS
• LSIL
• HSIL
• ASC-US

Interpretation:
LSIL
Large, multinucleated
dysplastic cells with "mature"
cytoplasm and distinct cell
borders. Nucleus shows
enlargement which is > 3X
intermediate nuclei,
hyperchromasia,
pleomorphism of size and
shape. No nucleoli seen.
Explanatory Notes:
Note the overall large cell
size, well-defined cytoplasm
and multinucleation. .

Conventional
Magnification:
Medium

DIAGNOSIS
• Squmous Cell Carcinoma
• Atypical parakeratosis
• LSIL

•
INTERPRETATION
LSIL
Cells with keratinized cytoplasm, slight
nuclear enlargement and hyperchromasia
("atypical parakeratosis") interpretation as
LSIL is based on nuclear features.
Explanatory Notes:
"Parakeratosis" is a descriptive term used
for abnormal keratinization of the
cytoplasm but it is not an interpretation
and is not part of the Bethesda
terminology. "Parakeratotic" changes may
be seen in cells without nuclear
abnormalities and in SIL.

Conventional

Conventional
HSIL (SYNCYTIAL PATTERN)

ThinPrep/ LBC
Clinical History:
29 year old, from "high-risk" clinic

DIAGNOSIS
• PARABASAL CELLS
• HSIL
• ASC-H

Interpretation:
HSIL
•
In liquid-based preparations, cells
from HSIL are often isolated, small
in size and have nuclei that are
slightly larger than an intermediate
cell nucleus. Dense cytoplasm and
centrally placed nuclei are consistent
with a squamous origin.
Explanatory Notes:
Close attention to isolated cells is
required when screening liquid based
preparations since the abnormal cells
tend to be isolated and may not be as
apparent as clusters of HSIL cells.
Additionally, these isolated cells may lie
between benign cell clusters or in ?empty
spaces? on the preparation. When the
criteria for HSIL are met, such cells should
be interpreted as HSIL and not ASC-H.

DIAGNOSIS
• HSIL
• ASC-H
• HISTIOCYTES

Interpretation:
NILM: Histiocytes
PITFALL WITL HSIL
Streaming pattern of single cells with
round, ovoid, and bean-shaped nuclei.
These cells are histiocytes with
eccentric round to oval nuclei and
foamy cytoplasm.
Explanatory Notes:
These cells possess fine cytoplasmic
vacuoles that may resemble degenerative
vacuoles sometimes found in normal
metaplasia, ASC-H, and HSIL. Typically,
cells of squamous lineage are polygonal
in shape and possess dense cytoplasm.
(Compare with ASC-H and HSIL in
mucus).

Interpretation:
HSIL in Mucus Strand
•
Isolated HSIL cells in a stream of
mucus (lower power in upper right
inset). The pattern of HSIL cells
streaming within mucus can mimic
histiocytes and endocervical/
metaplastic cells. At high power,
HSIL can be readily distinguished
from benign cellular elements.
Explanatory Notes:
This is a pattern that is important to be
aware of to avoid false negatives.

SurePath/ LBP

DIAGNOSIS
• HSIL
• LSIL
• SQUAMOUS METAPLASIA

Interpretation:
HSIL
•
Severely dysplastic cells on
the left display a high
nuclear to cytoplasmic ratio
and irregular nuclear
membranes. Moderately
dysplastic cells on the
right have similar nuclei
and more cytoplasm.
Explanatory Notes:
Note the nuclear membrane
irregularities and abnormally
distributed chromatin. In
liquid based preparations,
hyperchromasia may not be
as prominent as in
conventional smears.

DIAGNOSIS
• HSIL
• LSIL
• LSIL/HSIL

I
Interpretation:
LSIL/HSIL (Borderline)
•
Clinical History:
28 year old woman, LMP 3 weeks, routine
exam
Borderline LSIL/ HSIL. The abnormal cells
characterizing moderate dysplasia have a fair
amount of cytoplasm compared to severe
dysplasia/ CIN3, but less than that in LSIL
cells. These cells are at the borderline of what
may be interpreted as LSIL by some and HSIL
by others.
Explanatory Notes:
While the majority of SIL cases can be
classified as HSIL or LSIL, in occasional
cases, the distinction between LSIL and HSIL
may not be possible. However note that mildly
dysplastic cells are often seen in slide
preparations diagnostic of more severe
lesions. Histologic follow-up of such cases is
LSIL or if HSIL, it tends to be CIN 2 (moderate
dysplasia).
LSIL AND ASC-H (2014/15)

Interpretation:
Squamous cell carcinoma
Cytomorphologic
Criteria:
Dysplastic squamous
cells with anisocytosis
and anisonucleosis
including keratinization
and tadpole cells are
diagnostic of invasive
squamous cell
carcinoma.

Interpretation:
Squamous cell carcinoma
•
Cells on the left with scant
cytoplasm display nuclei with
irregularly distributed, coarsely
granular chromatin and prominent
nucleoli. On the right, lysed blood
and a stripped nucleus, tumor
diathesis, is evident.
Explanatory Notes:
Invasive carcinoma with prominent
nucleoli may suggest
adenocarcinoma; however, in this
case centrally located nuclei and flat
arrangement of cells is consistent
with squamous cell carcinoma.

Nuclear features of LSIL without cytoplasmic HPV changes.
Nuclear enlargement and hyperchromasia is of sufficient degree for the
interpretation of LSIL.
Demonstration of HPV cytopathic effect is not necessary for an interpretation of
LSIL, if required nuclear changes are present.

HSIL:
IRREGULAR NUCLEAR MEMBRANE
N/C ½-2/3
IREGULAR CONTOUR
PARABASAL SIZE

Pap. Test: PART II
Glandular Lesions

Squamous cell
Glandular cell
AGC (NOS)
AGC (FAVOR NEOPLASIA)
AIS

Glandular cell Abnormalities

Limitations with glandular lesions
(technical)
• Not readily visualized by
colposcopy
• Could be multifocal
and/or high
• Histopathology has its
own problems
– Criteria for dysplasia not
well defined
– Invasive versus in situ
– Microinvasive versus
invasive
• The brush has its own
problems
• Neoplastic change could
be deep

AGC Survey
 AGC (FN) and AGC (NOS) was
separated by TBS 2001, because they
represent women at different risk for
neoplasia

Endocervical cells Endometrial cells

Endocervical adenocarcinoma in situ
(AIS)
Intact endocervical gland
lined by pseudostratified
glandular cells with
enlarged, elongated,
hyperchromatic nuclei.
"gland-in-gland
arrangement.
Apoptosis & Mitotic figures
are numerous.

Adenocarcinoma in situ (AIS)
• TBS 2001concluded that the
criteria for adenocarcinoma in
situ have been shown to be
predictive and reproducible
that a separate category be
established
• AIS (cytol) is associated
with AIS (histopath) in 48 % -
69 % or invasive cervical
adenoca in 38 %
• 50 % have coexisting
squamous abnormality

Adenocarcinoma in situ:
Diagnostic criteria
• Nuclear enlargement, elongation & stratification
• Variation in nuclear size & shape
• Hyperchromasia, finely to moderately granular chromatin
• Nucleoli are small or inconspicuous
• Mitotic figures may be seen

EC Adenocarcinomain Situ
• 1) Hyperchromatic crowded groups
Rosettes
Feathering
Strips with Pseudostratification
• 2) Increased nucleus to
cytoplasmicratio
• 3) Nuclei large (75 um2)
• 4) Even chromatin with coarse
granularity
• 5) Micronucleoli
• 6) Mitoses, apoptotic bodies
• 7) Amphophilic granular cytoplasm
• 8) Clean or inflammatory background

AIS
Rosetting and tissue pattern shift in nuclear stratification, maintaining a picket-
fence formation. “Feathering” with nuclei falling outside of the grouping.

AIS
More tissue pattern shift in nuclear stratification, maintaining a picket-fence
formation. “Feathering” with nuclei falling outside of the grouping.

AIS
This group of glandular cells exhibits the nuclear crowding as well as
hyperchromatic chromatin pattern. Cell dyshesion is also evident along the
edges.

Endocervical adenocarcinoma in situ
(AIS) IN LBC
• Aggregate of abnormal cells with
elongated hyperchromatic nuclei
arranged in glandular strips that have
nuclear pseudostratification and
suggestion of a gland lumen. There is
some suggestion of feathering at the
periphery.
Cells with elongated nuclei and
nuclear pseudostratification are
classic features of endocervical AIS.
Feathering at the periphery of cells
sheets may be more subtle in liquid-
based preparations.
• Numerous abnormal glandular cells
arranged singly, in small aggregates and
pseudostratified strips. Nuclei are round,
oval or elongated with irregular nuclear
membranes and small nucleoli. Note the
mitotic figure.
•
In liquid-based preparations, AIS often
presents with pseudostratified strips
of cells having short "bird-tail"
arrangements.

AIS
NUCLEAR
ENLARGEMENT
CROWDING,
OVERLAPPING
HYPERCHROMASIA
FEATHERING
ROSETTES

INDIVIDUAL TUMOR CELLS IN AIS
LBC

Adenocarcinoma in situ:
Diagnostic criteria
• Sheets, strips, rosettes with nuclear crowding
• Loss of honeycomb pattern (increase NC ratio,
diminish cytoplasm & ill-defined cell borders)
• Palisading nuclear arrangement with feathering
• Nuclear enlargement, elongation & stratification
• Variation in nuclear size & shape
• Hyperchromasia, finely to moderately granular
evenly distributed chromatin pattern.
• Nucleoli are small or inconspicuous
• Mitotic figures may be seen
• Clean background . Abnormal squamous cells
Anything less is classified as atypical endocervical cells,
favor neoplastic

Glandular cell
AGC ( Endocer/endomet NOS)
AGC (ENDOMETR FAVOR NEOPLASIA)
AIS

Invasive endocervical adenocarcinoma

Epithelial Cell Abnormalities – Glandular:
Adenocarcinoma
Endocervical
Adenocarcinoma:
– 3D Cell Clusters
– Well Preserved
Nuclear Features
– Irregular nuclei,
abnormal chromatin,
tumor diathesis.
– Macronucleoli.

Invasive Endocervical
Adenocarcinoma
1) Abundant Cellularity
2) 3D Clusters, 2D SHEETS, SYNCYTIAL, SINGLE
3) Features of AIS
4) Discohesion
5) Macronucleoli
6) Increasing N:C
7) Increasing Nuclear Size
8) Increasing Chromatin Abnormality –chromatin
clearing
9) Tumor Diathesis Present

Endocervical Adenocarcinoma
•
• Cluster of glandular cells with scalloping, polys engulfment and nucleoli.

ENDOCERVICAL ADENOCARCINOMA
DIATHESIS IN LBC

ENDOMETRIAL CELLS IN PAP. TEST

C- OTHER (eg, endometrial cells in a woman ≥ 45 years)

Endometrial Adenocarcinoma
• 3D ball-like arrangements and tight
clusters with common group border.
• Generally small cells in small groups
favors endometrial origin.
• Scant cytoplasm, hyerchromatic nuclei
• Cell in cell engulfment, and phagocytotic
features are more commonly associated
with endometrial adenocarcinoma.
•Note the background of single cell
apoptosis characteristic of endometrial
origin.
• The isolated group appears somewhat out
of context with the benign and mature
ectocervical component. Patient was post
menopausal and not atrophic.
60x
WATERY (FINELY GRANULR) DIATHESIS

• 60x
60x
Classic endometrioid differentiation
Cluster of small cells with minimal cytoplasm
.

60x
Degenerated small 3D cluster. A spectrum of degenerated and well
preserved malignant cells suggests cells have been shed at
various times and therefore support endometrial origin.
Note background of watery exudate
harboring single abnormal cells, apoptotic
debris and mature hormonal pattern

Watery Diathesis Tumor
ENDOCER ,ADECARCINOAMA
ENDOMET. ADENOCARCINOMA

Endomet Ca Vs Endocer Ca
Endocer ca
Endocer ca
Endocer ca Endomet ca

Endocervical Adenocarcinoma vs.
• Endocervical Adenocarcinoma
– Abundant abnormal material
• Directly scraped
• Well preserved material
• Cells and cell groupings
generally larger in size
• Abundant, foamy cytoplasm,
occasionally columnar shaped
• AIS precursor with
endocervical architecture
may be seen
• Endometrial Adenocarcinoma
– Isolated abnormal groups
• Cell shedding
• Variable preservation of cells
• Cells and cell groupings
generally smaller in size
• Scant, cyanophilic cytoplasm
with occasional conspicuous
vacuoles
• Mature hormonal pattern,
watery transudate may be
see

Papillary grouping
Depth-of-focus, high N/C ratio and prominent nucleoli.

Isolated 3D cluster with scalloped edges and mucinous vacuolization.

Cluster of malignant cells with vacuolated cytoplasm, nucleoli and engulfed
polys. Lesion metastatic to the vagina (vaginal smear). Note clean
background.

Adenocarcinoma
Papillary Serous Uterine Adenocarcinoma :
papillary groups and stripped nuclei with prominent nucleoli.

Papillary Serous Uterine Adenocarcinoma :
papillary group
Large cells

Glandular cell
AIS

Glandular cell

More common in LBC: but generally rare 0.2% of all Pap. Test.

ENDOCERVICAL CELLS
SHORT OF AIS

Atypical endocervical cells, NOS
SHEETS, STRIPS
CELL CROWDING , OVERLAP AND
PSEUDOSTRATIFICATION
NUCLEAR ENLARGEMENT 3-TIMES
MILD PLEOMORPHISM
MILD HYPERCHROMASIA
MILD CHROMATIN IRREGULARITY
MILD INCREASE N/C RATIO
MITOSIS IS RARE
OCCASIONAL NUCLEOLI
DISTINCT CELL BORDERS

Atypical endocervical cells,
NOS
Sheet of cells with enlarged round or oval
nuclei with prominent nucleoli. Chromatin is
finely granular and evenly distributed but
occasional chromocenters are seen. Cell
borders are well-defined. Mitotic figures are
noted.
Explanatory Notes:
In some cases, atypical glandular cells
associated with benign processes may be
difficult to differentiate from neoplastic
processes, especially when mitotic activity is
prominent.
Follow-up:
ECC and multiple follow-up Pap smears over
three years were negative and the patient
have no other gynecologic findings. In view of
the benign follow-up, the cytologic atypia and
mitotic activity are thought to represent
endocervical repair

Atypical endocervical cells
NOS
Clinical History:
54 year old woman 4 months s/p radiation
therapy for Stage I cervical cancer
Sheet of abnormal cells with markedly
pleomorphic nuclei (vary widely in size and
shape) and prominent nucleoli. Chromatin is
finely granular and cell borders are fairly
distinct. Occasional cytoplasmic vacuoles
are noted.
Explanatory Notes:
Ionizing radiation therapy may produce
striking atypias in the endocervical
epithelium that can mimic residual
carcinoma. This degree of atypia usually
resolves within 18 months after completion
of therapy.
Follow-up:
Changes became less severe over time on
follow-up Pap smears. Findings are
compatible with post radiation atypia

Interpretation:
Atypical endocervical cells, NOS
• Type of Preparation:
Conventional
Clinical History:
34 year old female
Cells are characterized by
disordered arrangement and
enlarged round or oval nuclei with
occasional nucleoli.
Explanatory Notes:
Atypical endocervical cells typically
show features that exceed those of
obvious reactive/reparative
changes but do not fulfill the criteria
for endocervical adenocarcinoma in
situ.
Follow-up:
Adenocarcinoma in situ (AIS)

AGC : Endocervical, FN
Abnormal cells in sheets and strips
with nuclear crowding and
pseudostratification
Rare rosettes or feathering
Enlarged elongated hyperchromatic
nuclei
Coarse irregular chromatin
Occasional mitosis and apoptosis
High N/C ratio
Ill-defined cell borders
SUGGESTIVE FOR AIS

ATYPICAL ENDOCER. CELLS NORMAL ENDOCER. CELLS

ATYPICAL ENDOMETRIAL CELLS
• Atypical endometrial cells may be
associated with the presence of a wide
variety of processes, including polyps,
chronic endometritis, hyperplasia, and
carcinoma.

Microglandular Hyperplasia
Tubal Metaplasia
Vacuolated IUD Cells
Menstrual EMC
Flat
Fresh
Columnar/
Low N/C
EC like

ASSCP GUIDELINES FOR AGC
£
£
£
€
£ Loop Electrical Excision Procedure


Glandular cell



EXTRA-UTERINE CA
• Although most
commonly associated
with ovarian carcinoma,
psammoma bodies may
also be seen in fallopian
tube carcinoma and
papillary serous
carcinomas of the
endometrium.
• Note clean background,
generally typical of
tumors not originating in
the cervix.

MOLECULAR TESTING IN
CERVICAL CYTOLOGY (PAP. TEST)
HPV TESTING
BIGGEST THREAT TO
PAP.TEST

CA CANCER J CLIN 2015;65:87–108

HPV oncoprotein E7 impairs function of pRB,
disrupting its ability to bind E2F
This leads to deregulated cell proliferation,
genetic instability and p16 over-expression

Role of HPV Testing in
Cervical Cytology
 Triage of low grade abnormalities: LSIL/ASCUS
 Test of “cure”
 Co-testing
 PRIMARY SCREENING

PAP. TEST RETIREMENT
POST-PAP ERA
HPV
SCREENING &
GENOTYPING

Primary HPV screening
Refers to screening with an HPV
test and performing cytology only
as part of the triage of a positive
result.

PRIMARY SCREENING
FOR CERVICAL CACINOMA
WHY?
 More Sensitive than Pap. Test.
 Cost Saving
 Easier
 More reliable
 Less subjective

HPV PRIMARY SCREENING
The WHO AND ACS recommend screening based on HPV
testing instead of cytology, when resources are available
For primary HPV screening, the improvement in sensitivity
reduces the rate of false-negative results.
It detects more than 60% to 70% of cases of invasive cervical
carcinoma compared to cytology-based screening.
Cytology alone is acceptable if there is no access to
Primary HPV testing.

HPV TESTING METHODOLOGY
HC II
CERVISTA
ABBOTT
COBAS (ROCHE)
APTIMA
ONCOLARITY (BD, 2018)

Applications of High-Risk Human
Papillomavirus Testing
(hrHPV) with or Without Genotyping
 Triage of an abnormal cytology result by a hrHPV
test effectively improves the balance of sensitivity
vs. specificity for colposcopic referral and prevalent
disease detection.
 Co-testing refers to the performance of both an
HPV test and a cervical cytology at the time of
screening. Thus, combinations of HPV and
cytology test results lead to algorithmic referral to
colposcopy, with short-term follow-up or routine
long interval screening being based on the risk of
precancer or cancer.

Many Developed Countries
HPV CERVICAL CA SCREENING
 Netherlands
 Australia
 Italy
 Austria
 UK
 Others

Control of Low Specificity
of HPV Testing
 Cytology triage
 Repeat testing
 Genotyping (hrHPV: 16,18,45)
 CINtec ICC

BIOMARKERS
 With HPV-associated neoplasia, a variety of
related biomarkers have utility in the identifi
cation of high-grade squamous intraepithelial
lesions.
 The best-studied biomarkers are p16 and
ProExC (aberrant cell cycle due to
oncogenic effects of HPV), and Ki67 (cell
proliferation)

BIOMARKERS
 p16/ki67 is more sensitive with non- inferior
specificity, for the detection of HSIL, as compared to
cervical cytology, when used in a screening role.
 It has been suggested that dual-stained cytology
screening may play a role in younger women where
hrHPV testing has limitations.
 ProExC has shown utility in the triage of atypical
glandular cells and ASC-H and as a follow-up
immunocytochemical/cytology test after primary
HPV screening

Dual p16 and ki67
DIAGNOSIS: HSIL

Dual staining of cell for p16 and Ki-67 (CINtec
PLUS) for traige HPV +ve Women

Sample Report for Adjunctive
Immunocytochemical Result
Adequacy :
 Satisfactory for interpretation
General categorization :
 Epithelial cell abnormality, squamous cell
Interpretation :
 Atypical squamous cells – undetermined significance (ASCUS)
Note : Immunocytochemical stains for p16 and Ki67 (performed
in combination) show dual-stained positive cells.
Comment : The combination of p16 and Ki67 dual staining has
been shown to correlate to the presence of HSIL in subsequent
biopsy specimens

ProxC
Immunocytoexpression profiles of a novel assay ProEx C for
topoisomerase II alpha (TOP2A) and minichromosome maintenance
protein 2 (MCM2) in abnormal interpreted smears

American Cancer Society Recommendations for
Cervical Cancer Screening, 2020

The most important thing to remember
is to get screened regularly, no matter
which test you get.

 American Cancer Society
Recommendations for Cervical
Cancer Screening, 2020

CONCLUSION
 The Bethesda System neither
promotes nor discourages the use of
any specific brand of HPV test.
 But current practice guidelines
recognize that clinically valid HPV
testing is an integral part of
contemporary practice
 In locales where HPV testing is not
available, regular Pap testing will
remain the screening method of choice.

HPV TESTING IMPACT
FROM CRISIS TO OPPORTUNITY
 Cytotechnology labor market—an impending crisis
For cytotechnologists, molecular training a must
 Cytotechnology schools under threat
Mid-level staff School of Medicine
 Pap. Test Should continue in countries with
limited resources

HPV 16/18 vaccine
HPV 6/11/16/18 vaccine

GLOBAL PROGRESS IN HPV
VACCINATION FROM 2010-2015

WHO RECOMMENDATIONS
 Cervical cancer is the fourth most common type of
cancer in women, and more than 95% of cervical cancer is
caused by sexually transmitted HPV.
 Averting the development of cervical cancer by increasing
access to effective vaccines is a highly significant step in
alleviating unnecessary illness and death.
 The primary target of vaccination is girls aged 9-14, prior to
the start of sexual activity. The vaccination of secondary
targets such as boys and older females is recommended
where feasible and affordable.

WHO updates recommendations on HPV
vaccination schedule
20 December 2022
 A one or two-dose schedule for girls
aged 9-14 years/TARGET
 A one or two-dose schedule for girls
and women aged 15-20 years
 Two doses with a 6-month interval for
women older than 21 years

From 6 February 2023 the human papillomavirus
(HPV) vaccine schedule will become a single dose
schedule in Australia
Gardasil®9 vaccine.
 Human papillomavirus (HPV) vaccines are a safe and
reliable way to protect young people from a range of HPV-
related cancers and diseases.
 HPV vaccines are critical to eliminating cervical cancer.
Almost all cervical cancer relates to HPV infection.
 Vaccination also protects against genital warts and HPV
related genital, anal and oropharyngeal cancers.
 From 6 February 2023, the routine 2-dose HPV vaccine
schedule provided to young people aged 12 to 13 years will
become a single dose schedule.

CAVEAT
 HPV vaccines do not protect against the all HPV
types.
 Cervical screening remains essential to protect
against cancers arising from other HPV types.
 Cervical screening and HPV vaccination will provide
the best protection against cervical cancer/high
prevention.
 HPV vaccination + organized screening would be the
best economic model.

HPV VACCINATION AND SCREENING
ARE COMPLEMENTARY

Sample Report for Adjunctive
Immunocytochemical Result
Adequacy :
 Satisfactory for interpretation
General categorization :
 Epithelial cell abnormality, squamous cell
Interpretation :
 Atypical squamous cells – undetermined signifi cance
Note : Immunocytochemical stains for p16 and Ki67
(performed in combination) show dual-stained positive cells.
Comment : The combination of p16 and Ki67 dual staining
has been shown to correlate
 to the presence of HSIL in subsequent biopsy specimens

Conclusions
 Given all the recent press about new methods of cervical
cancer screening and the lack of sensitivity of the Pap test,
some may question the significance of a new edition of the
Bethesda atlas.
 Before exaggerating the demise of the Pap test, it must be
remembered that it still has significant utility worldwide.
 Because of its greater specificity compared with HPV
testing, the Pap test will have importance as a diagnostic
triage tool after a positive HPV screening test.
 In locales where HPV testing is not available, regular
Pap testing will remain the screening method of choice.

 The best way to find cervical cancer early is to have regular
screening tests. The tests for cervical cancer screening are the
HPV test and the Pap test. These tests can be done alone or at
the same time (called a co-test). Regular screening has been
shown to prevent cervical cancers and save lives.
 The most important thing to remember is to get screened
regularly, no matter which test you get.
 People who have had a total hysterectomy (removal of the
uterus and cervix) should stop screening (such as Pap tests
and HPV tests), unless the hysterectomy was done as a
treatment for cervical cancer or serious pre-cancer. People
who have had a hysterectomy without removal of the cervix
(called a supra-cervical hysterectomy) should continue cervical
cancer screening according to the guidelines above. ● People
who have been vaccinated against HPV should still follow
these guidelines for their age groups

BENEFITS OF CERVICALCANCER
SCREENING
 Screening tests offer the best chance
to have cervical cancer found early
when treatment can be most
successful. Screening can also actually
prevent most cervical cancers by
finding abnormal cervical cell changes
(pre-cancers) so that they can be
treated before they have a chance to
turn into a cervical cancer.

 The ACS recommends the primary HPV test* as the preferred test for cervical
cancer screening for people 25-65 years of age. (*A primary HPV test is an
HPV test that is done by itself for screening. The US Food and Drug
Administration has approved certain tests to be primary HPV tests.) ● Some
HPV tests are approved only as part of a co-test, when the HPV test and the
Pap test are done at the same time to screen for cervical cancer. Because a
primary HPV test may not be an option everywhere, a co-test every 5 years or
a Pap test every 3 years are still good options. ● All the screening tests
(primary HPV test, co-test, and Pap test) are good at finding cancer and pre-
cancer. The primary HPV test is better at preventing cervical cancers than a
Pap test done alone and does not add more unnecessary tests, which can
happen with a co-test. The most important thing to remember is to get
screened regularly, no matter which test you get. The result of the HPV test,
along with your past test results, determines your risk of developing cervical
cancer. If the test is positive, this could mean more follow-up visits, more tests
to look for a pre-cancer or cancer, and sometimes a procedure to treat any
pre-cancers that might be found. Because there are many different follow-up
or treatment options depending on your specific risk of developing cervical
cancer, it is best to talk to your healthcare provider about your screening
results in more detail, to fully understand your risk of cervical cancer and what
follow-up plan is best for you. For more information, see the American Cancer
Society document HPV and HPV Testing2 .

Loop electrosurgical procedure (LEEP or LLETZ): In this
method, the tissue is removed with a thin wire loop that is
heated by electricity and acts as a small knife. For this
procedure, a local anesthetic is used, and it can be done in
your doctor's office. ● Cold knife cone biopsy: This method
uses a surgical scalpel or a laser instead of a heated wire to
remove tissue. You will receive anesthesia during the
operation (either a general anesthesia, where you are asleep,
or a spinal or epidural anesthesia, where an injection into the
area around the spinal cord makes you numb below the
waist) and it is done in a hospital. ● Possible complications of
cone biopsies include bleeding, infection and narrowing of
the cervix. Having any type of cone biopsy will not prevent
most women from getting pregnant, but if a large amount of
tissue has been removed, women may have a higher risk of
giving birth prematurely. References Eifel P, Klopp AH, Bere

HPV TESTING
CONCLUSIONS
 1. Should HPV testing alone replace cytology for women
older than 30 years? The WHO AND ACS recommend
screening based on HPV testing instead of cytology, when
resources are available, since 2014.16 For primary
screening, the improvement in sensitivity reduces the rate
of false-negative results. Human papillomavirus testing is
recommended due to its higher sensitivity compared to
cytology in the first screening; it detects more than 60%
to 70% of cases of invasive cervical carcinoma compared
to cytology-based screening.6 Cytology alone is
acceptable if there is no access to primary HPV testing

 Testing for HPV is more likely to detect
adenocarcinoma precursor lesions than cytology-
based screening. With it, there is an increase in
the proportion of adenocarcinomas detected,
achieving a more efficient screening.18,19 In
high-income countries, HPV testing is cost-
effective because of its higher negative predictive
value combined with extended testing intervals.
 In low and middle income countries, cost-
effectiveness must be addressed. The success of
the screening programs in those countries is
affected by factors not usually considered in high-
income ones: the access of women to screening
and further assessment and the lack of control in
testing intervals.

 Recommendation For women older
than 30 years in Brazil, HPV testing
alone should replace cytology.
Cytology should be used as a triage
test for cases of positive result on the
HPV test ¼

 Suggestions regarding the management of HPV-
based screening in women older than 25 years of
age, when genotyping is not available or if types
other than 16 or18 are detected. Abbreviations:
Hr-HPV, high-risk HPV test; cyto, cytology; HSIL þ
, atypical squamous cells, cannot exclude a high-
grade lesion (ASC-H); high-grade squamous
intraepithelial lesion (HSIL); atypical glandular
cells (AGCs); or adenocarcinoma in situ (AIS)

The United States Preventive Services Task Force
(USPSTF) has released new recommendations on
screening for cervical cancer: 2018

1- Repeat cytology in 2-4 months.
2- Colposcopy in case of two successive unsatisfactory cytology tests.
3- Colposcopy in case of positive HPV16 or 18 genotyping as well as in
≥30 y-o female with positive hrHPV results

PAP TEST 2023 ALEXANDRIA FINAL.pdf

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to PAP TEST 2023 ALEXANDRIA FINAL.pdf

Similar to PAP TEST 2023 ALEXANDRIA FINAL.pdf (20)

Recently uploaded

Recently uploaded (20)

PAP TEST 2023 ALEXANDRIA FINAL.pdf