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Pap maneg

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Pap maneg

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Pap maneg

  1. 1. Management Of Abnormal Pap Test, When To Refer For Colposcopy Ahmed Mousa MBBS, M.Sc, FRCSC, FACOG Assistance Professor and Consultant of Gynecology Oncology King Abdulaziz University
  2. 2. ∗ The importance of cervical cancer screening ∗ The modality of screening ∗ The advantages and the disadvantages of each modality. ∗ The interpretation of cytological abnormalities. ∗ The management of of abnormal result. Objectives
  3. 3. ∗ Is the fourth most common cancer affecting women worldwide ∗ 528,000 cases estimated in 2012 ∗ 85% occur in developing countries ∗ 266,000 estimated death from cervical cancer ∗ account for 7.5% of all female cancer related death ∗ 87% of cervical cancer death occur in developing countries. GLOBOCAN 2012 (IARC) Cervical Cancer
  4. 4. ∗ Human Papillomavirus is the etiological risk factor ∗ Is the most common sexually transmitted disease with a 79% estimated life time risk of cervical infection. (CDC Fact sheet 2013) ∗ HPV DNA detected in 99.7% cervical carcinoma. (Walboomers, J.M., et al.) Cervical Cancer Etiology
  5. 5. ∗ HPV are classified based on their oncogenic characteristics into ∗ High risk type (oncogenic) ∗ HVP 16 & 18 account for 73% of cervical cancer cases. ∗ HPV 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66 and 68 account for the remaining cases ∗ Low risk type Cervical Cancer Etiology
  6. 6. Woodman et al. Nature Reviews Cancer 7, 11–22 (January 2007) | doi:10.1038/nrc2050 HPV-mediated progression of cervical cancer 10 -13years90% clear the infection within 2 years
  7. 7. ∗ Pap test ∗ Conventional ∗ Liquid based cytology ∗ HPV ∗ Primary ∗ Reflex ∗ Co-testing Screening for cervical cancer
  8. 8. ∗ Since the introduction of Pap test as screening method, there has been 70% decreased in the incidence and mortality from cervical cancer Pap test
  9. 9. ∗ Conventional vs liquid based cytology ∗ Both have similar sensitivity and specificity for detection high grade and low grade intraepithelial lesion ∗ conventional pap smear is more specific than LBC for ASCUS ∗ LBC reduces unsatisfactory pap test in subgroup of patients with obscured blood and inflammatory cells. ∗ LBC cytology offer the advantage of performing HPV test Pap test Whitlock EP et al, Arbyn M et al, Davey E et all
  10. 10. ∗ Overall the sensitivity of Pap test range between 50- 70% ∗ Reasons for failure ∗ Failure to screen ∗ Failure to detect abnormality in the first Pap test ∗ Failure to follow up abnormal Pap test Pap test Leyden et all, 2005
  11. 11. Solomon et al 2001
  12. 12. ∗ hrHPV vs Pap test ∗ Primary hrHPV or in combination with cytology is more sensitive than pap test in the detection of HSIL and cancer. ∗ Use of hrHPV alone or in combination with cytology reduce the incidence of HSIL (RR:0.34 for primary and RR: 0.30 for cotetsting) and invasive cervical cancer (RR:0.44) compared to Pap test. ∗ Improved detection of ADK HPV
  13. 13. ∗ Role of genotyping ∗ HVP 16 and 18 ∗ Cumulative incidence of HSIL over 3 years 21-26% ∗ Other types ∗ Cumulative incidence of HSIL over 3 years 5-6.5 % HPV
  14. 14. ∗ <21 ∗ No screening ∗ 21-29 ∗ Cytology alone every 3 years ∗ 30-65 ∗ HPV co-testing every 5 years ∗ Or cytology every 3 years ∗ >65 ∗ No screening unless ∗ Inadequate screening ∗ History of CIN 2/3, cervical ca ∗ Following Hysterectomy ∗ No screening following benign disease ∗ Screen if history of CIN 2/3, cervical cancer Screening Per ASCCP 2012
  15. 15. Recently updated guideline for cervical cancer Warner K. Huh , Kevin A. Ault , David Chelmow , Diane D. Davey , Robert A. Goulart , Francisco A.R. Garcia , Walte... Use of primary high-risk human papillomavirus testing for cervical cancer screening: Interim clinical guidance Gynecologic Oncology, Volume 136, Issue 2, 2015, 178 - 182 http://dx.doi.org/10.1016/j.ygyno.2014.12.022
  16. 16. ∗ Defined as ∗ Scanty cellularity ∗ Obscured by blood or inflammatory cells ∗ Or could not be processed for any reasons Pap test should be repeated in 2-4 months ∗ OR ∗ HPV negative  repeat pap or HPV in 3 years ∗ HPV positive ∗ Colposcopy ∗ Or genotyping ∗ HPV 16/18  colpo ∗ Other types ∗ Pap test ∗ Abnormal colop ∗ Normal routine screen Unsatisfactory
  17. 17. ∗ HPV status ∗ Unknown ∗ Offer HPV test ∗ Positive ∗ Cytology and HPV at 1 year ∗ Negative routine screening NILM but absent EC/TZ
  18. 18. ∗ The most common abnormality (2.8%) ∗ Risk ∗ 7 % underlying CIN II ∗ 3% underlying CIN III ∗ 0.1% underlying invasive cancer ∗ 25% associated with HPV ∗ HPV + ∗ 18% underlying CIN II ∗ 7% underlying CIN III ∗ 0.4% underlying invasive cancer ∗ HPV – ∗ 1.5% underlying HSIL ∗ Options ∗ Repeat Pap test in one year ∗ ASCUS or more  colpo ∗ Normal  routine screen ∗ Preform HPV (Reflex test) ∗ Positive  colpo ∗ Negative  routine screen ASCUS
  19. 19. ∗ Incidence 0.17% ∗ Risk ∗ CIN II: 35% ∗ CIN III: 18% ∗ Invasive cancer: 2.6 % ∗ Patient must be referred to colposcopy ∗ Do not perform HPV ( 67% of patients are positive) ASC-H
  20. 20. ∗ Incidence 1 % ∗ Risk ∗ CIN II:16% ∗ CIN III: 5.2% ∗ Invasive cancer :0.16% ∗ HPV + in 88% ∗ HPV + ∗ CIN II: 19% ∗ CIN III: 6% ∗ HPV negative ∗ CIN II: 5% ∗ CIN III : 2% ∗ Two options ∗ Colposcopy ∗ HPV ∗ Positive  colposcopy ∗ Negative ∗ Repeat both test in one year ∗ If any abnormal colposcopy ∗ Normal routine screening LSIL
  21. 21. ∗ Incidence 0.21% ∗ Risk ∗ CIN II: 70% ∗ CIN III: 47% ∗ Invasive cancer: 7% ∗ HPV positivity: 75% ∗ Even those with negative test the risk of CIN II/III >30% and invasive cancer 6% ∗ Refer to colposcopy HSIL
  22. 22. ∗ Incidence 0.1-2% ∗ AGC ∗ Endocervical ∗ Endometrial ∗ NOS ∗ 10% endometrial ca ∗ AGC-favor neoplasia ∗ Endocervical ∗ ADK 5% ∗ AIS 2.5 ∗ Endometrial ∗ Endometrial ca: 27% ∗ CAH: 22% ∗ NOS ∗ AIS ∗ Adenocarcinoma ∗ Finding is benign in 60-70% ∗ Approximately 50% associated with squamous abnormality AGC
  23. 23. ∗ AGC-endometrial ∗ Perform endometrial biopsy and ECC ∗ If negative refer to colposcopy ∗ AGC- other category ∗ Colposcopy ∗ ECC ∗ And endometrial biopsy if age > 35 and at risk of endometrial ca ∗ AIS ∗ Colposcopy ∗ If no lesion identified cold knife biopsy AGC
  24. 24. Thank you

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