This document discusses Pap smear testing for cervical cancer screening. It begins by outlining the history of Pap smears and their endorsement as an effective screening method. It then discusses cervical cancer as the most common cancer in Indian women. The document covers the histological types of cervical cancer, the transformation zone of the cervix, and why screening is an important strategy. It provides details on taking a Pap smear, including sampling techniques and fixation. The document also discusses reporting systems, screening guidelines, limitations of Pap smears, and liquid-based cytology as an improved method. Throughout, it emphasizes that early detection of pre-cancerous lesions through regular Pap smear screening can prevent the majority of cervical cancers.

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. PAP Descriptive CIN Bethesda
Class-1 negative negative WNL
Class 2
Inflammatory,
squamous, koilocytic
atypia
Reactive, reparatative
changes, ASCUS,
LSIL(HPV)
Class 3
Mild dysplasia
Moderate dysplasia
Severe dysplasia
CIN1
CIN2
CIN3
LSIL(HPV)
HSIL
HSIL
Class 4 Ca In Situ CIN3 HSIL
Class 5 Invasive Invasive Invasive

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 -
Initial 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