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Taking A Pap Smear
Taking A Pap Smear
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Pap smear (2)

  1. 1. PAP smear: named after Dr. George Papanicolaou (1883-1962) Vaginal smears from guinea pigs (1917) Women (1920) Hormonal cycles Pathological conditions (1928)
  2. 2. Cytologic screening for cervical cancer Usefulness of pap smear in the screening programme for cancer cervix is shown by the following: Long latent period of 10-15 years between CIN and invasive cancer allows adequate treatment of CIN and prevention of invasive cancer Proved successful in reducing the incidence of invasive cancer by 80% and the mortality by 70%
  3. 3. When to screen Start within 3 years of onset of sexual activity or by age of 21, whichever is first. High risk factors for cervical dysplasia: Early onset of sexual activity Multiple sexual partners Smoking habits Oral contraceptives HPV and HIV positive women
  4. 4. Screening frequency Yearly until three consecutive normal pap smears, then may decrease frequency to every 2-3 years Annual screening for high-risk women is highly recommend.
  5. 5. When to stop routine screening Age 70 and “adequate recent screening” Three consecutive negative pap smears No abnormal pap smears in last 10 years Hysterectomy for benign lesion
  6. 6. Original Squamous Epithelium Vagina and outer ectocervix 4 cell layers Well-glycogenated (pink) unless atrophic
  7. 7. Columnar Epithelium Upper and middle endo-cervical canal Single layer of columnar cells arranged in folds Mucin producing (not true glands)
  8. 8. Squamous Metaplasia Central ectocervix and lower endocervical canal Replacement of columnar cells by squamous epithelium Progressive and stimulated by Acidic environment with onset of puberty Estrogen causing eversion of endocervix
  9. 9. Original Squamo-columnar Junction Placement determined between 18-20 weeks gestation Most often found on ectocervix Can be found in vagina or vaginal fornices Less apparent over time with maturation of epithelium
  10. 10. “New” Squamo-columnar Junction Border between squamous epithelium and columnar epithelium Found on ecto-cervix or in endo-cervical canal Majority of cervical cancers and precursor lesions arise in immature squamous metaplasia, i.e. the leading edge of the squamo-columnar junction
  11. 11. Transformation Zone Zone between original squamo-columnar junction and the “new” squamo-columnar junction Nabothian cysts visually identify the transformation zone if present
  12. 12. Squamous Epithelium
  13. 13. Parabasal Cells
  14. 14. Intermediate Cells
  15. 15. Superficial Cells
  16. 16. Endocervix
  17. 17. Endocervical Cells
  18. 18. 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
  19. 19. Classification of Pap smear Class Reagen(WHO) Ruchart Bethesda Class 1 negative negative Within normal Class 2 inflammation Class 3 Mild dysplasia CIN-l (HPV) LSIL (HPV) Class 4 Mod dysplasia Seve dysplasia Carcinoma in situ CIN-ll CIN-lll HSIL Class 5 Invasive cancer Invasive cancer Invasive cancer ------ ASCUS
  20. 20. “Normal” Pap Smear Negative for intraepithelial lesion or malignancy Other non-neoplastic findings Reactive cellular changes Glandular cells status post hysterectomy Atrophy Other Endometrial cells (women ≥ 40 yrs)
  21. 21. Normal smear
  22. 22. Epithelial Cell Abnormalities: Squamous Atypical squamous cells ASC-US: undetermined significance ASC-H: cannot exclude HSIL LSIL: low grade (CIN 1) HSIL: high grade (CIN 2 - 3) Squamous cell carcinoma
  23. 23. SIL and CIN
  24. 24. Various types of cervical lesions as seen on Pap smears: CIN I.
  25. 25. Various types of cervical lesions as seen on Pap smears: CIN Il
  26. 26. Various types of cervical lesions as seen on Pap smears: CIN lll
  27. 27. Various types of cervical lesions as seen on Pap smears: invasive squamous cell carcinoma.
  28. 28. Epithelial Cell Abnormalities: Glandular Atypical glandular cells,specify site of origin,if possible Atypical glandular cells - favor neoplastia Endocervical adenocarcinoma in situ Adenocarcinoma
  29. 29. Various types of cervical lesions as seen on Pap smears: adenocarcinoma
  30. 30. Accuracy Single pap smear-diagnostic sensitivity 60% False negative results upto25% due to: too scanty,too thick,too bloody,poorly stained smear misinterpretation by the cytologist • In the presence of infection repeat cytology has to be done after the infection is controlled Abnormal cytology is an indication of colposcopic evaluation and directed biopsy