Management of abnormal pap test

763 views

Published on

Published in: Health & Medicine, Technology
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
763
On SlideShare
0
From Embeds
0
Number of Embeds
63
Actions
Shares
0
Downloads
0
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

Management of abnormal pap test

  1. 1. Management of Abnormal PAP smear Emad R. Sagr, MBBS, FRCSC
  2. 2. Impact of Cervical Cancer •  Morbidity –  Global prevalence: ~2.3 million –  Global incidence: ~500,000 –  Globally, cervical cancer is second to breast cancer as the leading cause of cancer in women. •  Mortality –  3rd most common cause of overall female cancer- related mortality worldwide 1. World Health Organization. Geneva, Switzerland: World Health Organization; 2003:1–74. 2. Ferlay J, Bray F, Pisani P, Parkin DM. Lyon, France: IARC Press; 2004.
  3. 3. Facts and Figures •  The incidence has dramatically decreased from –  32 cases per 100,000 in the 1940s to –  8 cases per 100,000 in the 1990s. •  Mortality declined 45 % between 1970s and 1990s, while incidence declined 43.3 %
  4. 4. 59,929 29,814 Europe 78,896 61,670 Africa 48,328 21,402 South America 14,670 5796 United States/ Canada 1,063 330 Australia/ New Zealand 42,538 22,594 Southeast Asia 61,132 31,314 Eastern Asia 17,165 8124 Central America 157,759 86,708 Southcentral Asia Cervical Cancer Incidence and Mortality Estimates by Region 1. Ferlay J, Bray F, Pisani P, Parkin DM. Lyon, France: IARC Press; 2004.
  5. 5. PAP TEST •  What is a Pap Smear ? •  The cervical transformation zone. •  All cervical intraepithelial neoplasias (CIN) arise within the transformation zone of the cervix.
  6. 6. PATIENT INSTRUCTION •  No intercourse during the 24 hours prior to the test •  No douching during the 24 hours prior to the test
  7. 7. Technique
  8. 8. Technique •  Visualize entire cervix if possible •  Carefully remove any obscuring discharge •  Sample ectocervix first with spatula •  Sample endocervix with gentle cytobrush rotation •  Apply material uniformly to slide •  Fix rapidly with spray or liquid fixative
  9. 9. Technique •  Hold spray fixative 10 inches away from slide •  Collect cells before bimanual exam •  Avoid contamination with lubricant •  Test for GC and Chlamydia after pap smear
  10. 10. INFORMATION REQUIRED •  Patient name •  Patient age •  Last menstrual period •  History of hormone use •  IUD •  Previous abnormal Pap smears •  Relevant clinical information- e.g., abnormal bleeding, discharge, pelvic pain, etc.
  11. 11. Specimen Interpretation •  Requires a well-trained and experienced cytotechnologist •  Steps to reduce laboratory errors –  10 % Rescreening. –  Limits in workload.
  12. 12. Advances in Specimen Collection and Interpretation •  Fluid-Based (Monolayer) Technology (ThinPrep and Autocyte PREP) •  Neural Networks ( PAPNET and the AutoPap 300 QC) •  HPV Genotyping ( Digene Hybrid Capture® HPV DNA Test ) •  Optoelectronic screening (Polarprobe)
  13. 13. Techniques of Cervical Cytology •  Liquid-based •  Conventional
  14. 14. Questions •  When should screening begin? •  What is the optimal frequency of cervical cytology screening? •  At what age is it appropriate to recommend discontinuing screening?
  15. 15. The 2001 Bethesda System •  More than 400 cytopathologists, cytotechnologists, histopathologists, family practitioners, gynecologists, public health physicians, epidemiologists, and attorneys participated in the workshop, which was convened by the NCI. •  Cosponsored by 44 professional societies. •  More than 20 countries were represented.
  16. 16. THE 2001 BETHESDA SYSTEM Terminology for Reporting Results of Cervical Cytology •  Specimen Adequacy •  General Categorization (Optional) •  Interpretation/Result •  Automated Review and Ancillary Testing •  Educational Notes and Suggestions (Optional)
  17. 17. SPECIMEN ADEQUACY •  Satisfactory for evaluation –  describe presence or absence of transformation zone component and any other quality indicators, e.g., partially obscuring blood, inflammation, etc.) •  Unsatisfactory for evaluation . . . (specify reason) –  Specimen rejected/not processed (specify reason) –  Specimen processed and examined, but unsatisfactory for evaluation of epithelial abnormality because of (specify reason……)
  18. 18. •  GENERAL CATEGORIZATION (optional) –  Negative for Intraepithelial Lesion or Malignancy –  Epithelial Cell Abnormality: See Interpretation/Result (specify squamous or glandular as appropriate) –  Other: See Interpretation/Result •  AUTOMATED REVIEW –  If case examined by automated device, specify device and result. •  ANCILLARY TESTING –  Provide a brief description of the test methods and report the result so that it is easily understood by the clinician.
  19. 19. INTERPRETATION/RESULT •  Negative for Intraepithelial Lesion or Malignancy –  Organisms •  Trichomonas vaginalis •  Fungal organisms morphologically consistent with Candida species •  Shift in flora suggestive of bacterial vaginosis •  Bacteria morphologically consistent with Actinomyces species •  Cellular changes consistent with herpes simplex virus
  20. 20. INTERPRETATION/RESULT (Cont.) •  Negative for Intraepithelial Lesion or Malignancy –  Other non-neoplastic findings (Optional to report; list not comprehensive) •  Reactive cellular changes associated with – Inflammation – Radiation – Intrauterine contraceptive device •  Glandular cells status post hysterectomy •  Atrophy
  21. 21. INTERPRETATION/RESULT (Cont.) •  Epithelial Cell Abnormalities –  Squamous cell •  Atypical squamous cells (ASC) –  ASC-US –  ASC-H •  Low-grade squamous intraepithelial lesion (LSIL) –  Encompassing: human papillomavirus/mild dysplasia/cervical intraepithelial neoplasia (CIN) 1 •  High-grade squamous intraepithelial lesion (HSIL) –  Encompassing: moderate and severe dysplasia, carcinoma in situ; CIN 2 and CIN 3 •  Squamous cell carcinoma
  22. 22. INTERPRETATION/RESULT (Cont.) –  Glandular cell •  Atypical glandular cells (AGC) (specify endocervical, endometrial, or not otherwise specified) •  Atypical glandular cells, favor neoplastic (specify endocervical or not otherwise specified) •  Endocervical adenocarcinoma in situ (AIS) •  Adenocarcinoma –  Endocervical –  Endometrial –  Extrauterine –  Not otherwise specified (NOS)
  23. 23. THE WHO AND BETHESDA SYSTEM TERMINOLOGY WHO histological terms Bethesda Cytological Terms CIN 1/ Mild Dysplasia LSIL CIN 2 / Moderate Dysplasia HSIL CIN 3 / Severe Dysplasia HSIL CIN 3 / Carcinoma in Situ HSIL
  24. 24. Abnormal Pap test – How common is it? 12,200 cancers 300,000 HSIL 1.25 million LSIL 2-3 million ASC 50-60 million women screened
  25. 25. ASC frequency and association with CIN §  Least reproducible of cytological categories §  Average frequency of ASC 4.4 % §  ASC associated with CIN 2/3 5 - 17 % §  ASC-H associated with CIN 2/3 24 - 94 % §  ASC associated with cervical ca 0.1 - 0.2 %
  26. 26. Repeat Cytology @ 6 mos X 2 HPV DNA Testing Colposcopy “When liquid-based cytology is used, or when co-collection for HPV DNA testing can be done, "reflex" HPV DNA testing is the preferred approach” ASCCP Management Guidelines ASC-US Wright TC Jr, Cox JT, Massad LS, Twiggs LB, Wilkinson EJ, for 2001 ASCCP-Sponsored Consensus Conference. 2001 Consensus Guidelines for the management of women with cervical cytological abnormalities. JAMA. 2002;287:2120-2129.
  27. 27. Patient Management Using HPV Triage ASCUS HPV TEST Low Risk + or HPV– HPV + Repeat Pap and/or HPV Test in 12 mo. or return to routine screening at discretion of clinician COLPOSCOPY
  28. 28. Recommended Management of Women with ASC-US SPECIAL POPULATIONS •  Postmenopausal women with ASC-US should be managed in the same manner as women in the general population. •  Immunosuppressed women with ASC-US should be managed in the same manner as women in the general population.
  29. 29. Recommended Management of Women with ASC-US SPECIAL POPULATIONS •  Adolescent women (20 years and younger) –  Should not be screened unless they have been sexually active for 3 years –  With ASC-US, follow-up with annual cytological testing is recommended. –  At the 24 month follow-up, those with an ASC-US or greater result should be referred to colposcopy.
  30. 30. Recommended Management of Women with ASC-US SPECIAL POPULATIONS •  Pregnancy Ø Mgt options (over age 20) same as nonpregnant, with the exception that it is acceptable to defer colposcopy until at least 6 weeks postpartum.
  31. 31. Recommended Management of Women with ASC-H (CANNOT EXCLUDE HSIL) All should have Colposcopy
  32. 32. Low-grade Squamous Intraepithelial Lesion (LSIL) •  Cytological diagnosis of LSIL, 2% of women •  2nd most common abnormal cytology report (ASC-US is most common) •  85% with LSIL, have biopsy-confirmed CIN –  18% CIN II-III –  .03% invasive cervical cancer •  LSIL is highly predictive of HPV infection
  33. 33. Recommended Management of Women with LSIL All should have Colposcopy
  34. 34. High-grade Squamous Intraepithelial Lesion (HSIL) •  0.7 % of cytology reports •  75% will have biopsy-confirmed CIN II-III •  1-2 % invasive Cervical Ca •  An immediate Leep or Colposcopy/ECC is acceptable (except in pregnancy or adolescents)
  35. 35. Recommended Management of Women with HSIL All should have Colposcopy
  36. 36. Managing Women with HSIL UNACCEPTABLE STRATEGIES •  Ablation is unacceptable in the following circumstances: Ø Colposcopy has not been performed Ø CIN II-III is not identified histologically Ø ECC identifies CIN of any grade •  Triage utilizing either of the following is unacceptable Ø Repeat cytology Ø HPV DNA testing
  37. 37. AGC frequency and association with CIN •  Mean frequency of AGC 0.4 % •  Associated CIN 1, 2, or 3 9 - 54 % •  AGC assoc. with AIS 8 % •  AGC assoc. with carcinoma 3 - 17 % Jones and Davey Arch Pathol lab Med 2000,124:672 Jones and Novis. Arch Pathol Lab Med 2000;124:665 Ronnett et al, Hum Pathol 1999;30:816 Veljovich et al, Am J Obstet Gynceol 1998;179:382 Soofer and Sidaway Cancer 2000;90:207
  38. 38. Recommended Management of Women with AGC All should have •  Colposcopy •  ECC •  EMB
  39. 39. Conclusion ASC-US Repeat Cytology HPV test Colposcopy ASC-H LGSIL HGSIL AGC AIS SCC
  40. 40. And that s the end of What do You need To know

×