Story: Pap Smear

ENI ELINA FADZLIYANTI MOHD PODZI

MUHD. NIZAMUDDIN ABU BAKAR
TAN LIN LING

PRESENTER:
THE ONE WHO IS IN FRONT OF EVERYBODY, SHAKING
 Goal for today

Understand Pap smear and its history.

Gain familiarity with its classification
 Bethesda classification
 Papanicolaou classification
Familiarized with Pap smear
 What is Pap smear?

A simple test used to detect uterine and cervical

abnormality by taking a tissue sample at cervix.
Application of
 Cytohormonal evaluation
 Monitor hormonal therapy
 Screening for cervical ca.

It is not a diagnostic, more to screen asymptomatic

patient.
A bit history of Pap smear
Based on work of Dr
George Papanicolaou
(1893-1962) and Dr
Herbert Traut in 1928 on
cytologic screening
(published 1948)

Papanicolaou smear is
too LONG.. So we called
it Pap’s in short
How it is done?
 How it is done?

1. Speculum is introduced in to the vagina this allows

the cervix to be clearly seen.
2. Small sample of Cells are taken by passing a brush
over its surface. It can be either using wooden
spatula ( Ayle’s spatula) as well
3. These cells are smeared on tho the slide and
sprayed to dry.
How it is done
Endocervical brush
Aylesbury spatula
Glass slide
Preservative (95% ethyl
alcohol, ether)
Papanicolaou stain
Microscope

 Investigation done by
pathologist
 Preparation for Pap smear

Avoid
1. Douches
2. Vaginal medication
3. Vaginal contraception (foam, creams, jellies)
4. Sex

 At least 2-3 days before Pap smear

 Avoid pap smear during menstruation. But it can be done with
liquid-based Pap kit
 Pap smear and pregnancy

Controversial
if had abnormal smears prior to pregnancy, Pap test
should be taken
No further than 15 weeks gestation and only with a
spatula
Colposcopy and Biopsy indicated if suspicious
looking cervix.
Remember pregnant cervix are highly vascularised
and can bleed heavily
 Target group for Pap smear

All women aged 18-70 years who have ever had sex
Women who still have a cervix after subtotal
hysterectomy
35-70 age group have a higher risk of developing
cervix ca.
Women who had hysterectomy for CIN
 Who to screen? guidelines

organization When to start Frequency of When to stop

test
American Cancer 3 years after Yearly with Total hysterectomy
Society 2004 intercourse, no exceptions: every 2 for benign disease
later than 21 years if liquid-based OR
kit > 70 years old with at
least three normal
every 2-3 years if Pap smear results
three normal tests in and no abnormal Pap
a row in women >30 results in the last 10
years old years
organization When to start Frequency of When to stop
test
US preventive Within 3 years of At least every 3 Recommend test for
Service 2003 first intercourse OR years (no evidence women older than 65
21 years old, that every year is years of age, if
adequate screening
whichever comes better than every 3
with normal results
first years) and otherwise not at
risk for cervical
cancer.

Recommend against
women who have had
a total hysterectomy
for benign disease
organization When to start Frequency of When to stop
test
American College of Within 3 years of Yearly until age 30 Difficult to set an
Obstetric and first intercourse OR years. Beginning at upper age limit
Gynecology 21 years old, age 30, if three
whichever comes normal annual Pap postmenopausal
first results, can do a Pap women screened
alone every 2-3 within the prior 2-3
years have a very low
years
risk of developing
abnormal Pap smears.
 Risk factors

Regardless of age, do the test annual if the person

had
 Early sexual activity (teens)
 Multiple sexual partners

 Past history of STD, warts

 Family history of cervical ca

 HIV, HPV/HSV type II infection

 OCP more than 5 years

 Weakened immune system

 Smoking habits
 Classification of Pap’s result

Pap’s classes Description Bethesda classification

2001
I normal Normal, variant
II Reactive changes Reactive changes
atypia ASC, AGC
koilocytosis Low grade SIL
III CIN I Mild dysplasia Low grade SIL
III CIN II Moderate dysplasia High grade SIL
III CIN III Severe dysplasia High grade SIL
IV Ca in situ, suspicious High grade SIL
V invasive Microinvasion
(<3mm)
Frankly invasive
(3>mm)
Classification of Pap’s result
On speculum examination
Pap Classes Are Out Because:
 Do not reflect current understanding of pathology
 Classes not transferrable to histology terms
 No classes for non-cancerous entities
 No longer uniform
 Years of experience have demonstrated a lack of
reproducibility
Important Changes Over Older Systems:
 Pap considered a Medical Consult
 Pathologist responsible for diagnosis
 Referring physician provides history
 Must have a statement of adequacy
 Recommendations regarding follow-up should be made by
pathologist
The Bethesda System Report Includes:
 Whether the pap is an adequate sample
 Incidental findings such as evidence of infection
 Evidence of lesions: low-grade SIL, high-grade SIL, or cancer
 Bethesda System Classification Terms:

Low-grade squamous lntraepithelial lesion (low-

grade SIL)
 Cellular changes associated with HPV
 Mild (slight) dysplasia/CIN 1
High-grade squamous intraepithelial lesion (high-
grade SIL)"
 Moderate dysplasia/CIN II
 Severe dysplasia/CIN III
 carcinoma in situ/CIN III
 Cont:

Atypical Squamous Cells (ASC)

 Unspecified (ASC-US) - includes unspecified and favor
benign/inflammation
 Cannot exclude HSIL (ASC-H)
Atypical Glandular Cells of Uncertian Significance
(AGC) AGC is broken down into favoring
endocervical, endometrial, or not otherwise specified
origin or endocervical adenocarcinoma in situ (AIS)
 Unspecified (AGC-US)
 Atypical glandular cells, favor neoplastic (AGC-H)
 Miscellaneous

 "Atypia" is used only if undetermined significance and should

include a recommendation for follow-up. (ASC and ASG)
 Descriptive diagnosis should be given to common problems
(changes due to trich, yeast, etc.)
 Do not trust Pap smear to diagnose or exclude infections!!
 Metaplasia - The physiologic conversion of columnar
endocervical cells to flat exocervical squamous cells.
 Normal finding - no special follow-up needed.
 Cont:

 "Parakeratosis" is a term for the persistence of the nuclei of

the keratinocytes into the stratum corneum (horny layer) of
the skin. Parakeratosis is normal in the epithelium of true
mucus membranes of the mouth and vagina.
 "Dyskeratosis" is a term for abnormal, premature, or
imperfect characterization of the keratinocytes.
 Hyperkeratosis implies increased keratin in the sample and
should be followed-up closely since there may be an increased
risk of cancer.
 Why we do it? Pap smear

 Epidemiologic Proof for Cervical Ca Screening - Why we do it...

 MacGregor (1976):
 Screened women - invasive cancer rate = 30-50/100,000
 Unscreened women - invasive cancer rate = 310/100,000
 Fidler (1968):
 Screened women - invasive cancer rate = 5/100,000
 Unscreened women - invasive cancer rate = 29/100,000
 Walton (1976):
 Strong correlation between screening intensity and cervical cancer
mortality (R=0.72)
 Adami (1994):
 "Cytologic screening reduces mortality from cervical cancer by earlier
diagnosis of invasive disease" Cancer 1994; 73:140-7.
"... a majority of women diagnosed with invasive
carcinoma of the uterine cervix do not receive
routine pap smears..." NY State J of Med
 Inadequacies of Pap smear

False negative Paps

 False Negative Pap Smears: Rate = 5 - 50% -- 10 - 29% usually
quoted. 80% are true false negatives, 20% are lab errors
Failure to identify high risk patient at entry.
Inaccurate or incomplete reports from the lab to
clinic to patient
Lack of adequate tracking and follow-up.
Poor patient compliance.
 Some lesion missed by Pap smear

Occur outside of a large eversion.

Small lesions.
Advanced invasive lesions since they have infection
and necrotic tissue, which can obscure the true
cytology. Koss, JAMA. 1989:737.
Rapidly progressive lesions.
Lesions deep in the cervical canal.
 Factors That Diminish the Accuracy of Pap Smears
by clinicians

Contamination with blood or oil-based lubricants

Mislabeled or unlabeled slides
Inadequate clinical history
Inadequate sampling of the transformation zone
Slide material too thick or insufficient
Performing pap in spite of obvious infection
 Factors That Diminish the Accuracy of Pap Smears
by laboratory

Confusing smears or names

Failure to identify dysplastic cells
Misinterpretation of diagnostic cells
Poorly controlled technical process
 Summary of Pap Smear

Highly effective for screening only. It is not

diagnostic. It only identifies those at risk for
dysplasia or cancer.
All women who have had sex and who still have a
cervix –need to have a pap smear
one may cease having the pap after 70 yrs of age if
all other paps were normal
Pap smear can prevent about 90% of cervix
dysplasia
Recommendation ACOG 2010
Reminder for my classmates

Do pap smear every 2 years

any question? Please keep to yourself and read about
it.
Thank you