1.
Taking a PAP SMEAR

2.
Cervical Cancer : Pap smear <ul><li>George N Papanicolaou introduced cervical cytology in clinical practice in 1940 </li></ul><ul><li>In 1945, PAP smear was endorsed by American cancer society as an effective method for prevention of cervical cancer </li></ul><ul><li>Many countries now have National cervical screening programs </li></ul>

3.
Indian scenario <ul><li>Commonest cancer in women in India </li></ul><ul><li>Major cause of deaths in women due to cancer </li></ul><ul><li>Usually diagnosed at advanced stage </li></ul><ul><li>No National program </li></ul><ul><li>Uniformly low incidence of cervical screening in India (6% in rich & 4% in poor) </li></ul>

4.
Histological Types 30 <ul><li>Squamous Cell Carcinoma : 80-95% </li></ul><ul><li>Adenocarcinoma : 5-20% </li></ul><ul><li>Other : Clear cell, sarcomas </li></ul>

5.
Transformation zone <ul><li>Cervix develops from 2 embryonic sites </li></ul><ul><li>* from Mullerian duct - lined by columnar epithelium </li></ul><ul><li>* from urogenital plate - lined by stratified squamous epithelium </li></ul><ul><li>Point at which columnar and squamous epithelium meet is called as original squamo-columnar junction </li></ul>

6.
Transformation zone <ul><li>Under influence of estrogen, original SCJ moves onto the portio. </li></ul><ul><li>Exposure of delicate columnar cells to vaginal environment leads to squamous metaplasia. </li></ul><ul><li>Transformation zone - </li></ul><ul><li>- Area of squamous metaplasia </li></ul><ul><li>- Area between original and new SCJ </li></ul>

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Transformation zone

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Transformation Zone -TZ <ul><li>Exposure of TZ to carcinogens begins the process of intraepithelial neoplasia </li></ul><ul><li>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 </li></ul><ul><li>95% of cervical cancers develop in TZ </li></ul><ul><li>Important to take sample from TZ </li></ul>

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Transformation Zone <ul><li>Transformation zone may not be viewed during routine speculum examination </li></ul>

10.
Why cervical screening is a feasible and useful strategy? <ul><li>Relative accessibility of cervix to take the smear </li></ul><ul><li>Long natural history of cervical carcinogenesis </li></ul><ul><li>Relative conservative treatment for premalignant lesions </li></ul><ul><li>Cost effectiveness3 </li></ul>

11.
PAP Smear <ul><li>PAP smear sampling of cervix involves scraping of cervical surface and a portion of non visualised cervical canal using various sampling devices </li></ul>

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Significance of Pap smear <ul><li>Detect precancerous & invasive cancer cervix cases in early stages </li></ul><ul><li>Positive screeners can be selected for selective tests and management </li></ul><ul><li>With treatment, progression of disease is halted. Thus morbidity associated with advanced cancer decreases </li></ul><ul><li>Mortality reduces by 20-60 %. </li></ul><ul><li>Helps us to study natural history of disease. </li></ul>

13.
Cervical Cancer : Pap smear <ul><li>Early detection of pre-malignant lesions by Pap smears prevent at least 70% of potential cervical cancers. </li></ul>

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Of the 30% who actually develop cervical cancer: <ul><li>8% elude cytological detection </li></ul><ul><ul><li>- imperfections in cytological technology </li></ul></ul><ul><ul><li>- biologic behavior of malignant lesions </li></ul></ul><ul><li>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. </li></ul>

15.
How to take a Pap Smear ? <ul><li>Proper technique is very important </li></ul><ul><li>More problems are due to improper sampling than screening </li></ul><ul><li>Not to be collected during menses </li></ul><ul><li>Avoid vaginal contraceptives, vaginal medications for at least 48 hrs before taking smear </li></ul><ul><li>Abstinence for 24 hrs </li></ul><ul><li>Postpartum smear should be taken only after 6 - 8 weeks of delivery </li></ul>

16.
<ul><li>Patient in dorsal position </li></ul><ul><li>Good illumination is necessary </li></ul><ul><li>Cusco’s speculum is inserted to visualise & fix the cervix </li></ul><ul><li>Inspection of cervix done & findings are noted </li></ul><ul><li>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 </li></ul>How to take a Pap Smear ?

17.
How to take a Pap Smear ? <ul><li>Spatula is rotated through 360 degrees maintaining contact with ectocervix </li></ul><ul><li>Do not use too much force [bleeding /pain] </li></ul><ul><li>Do not use too less force [inadequate sample] </li></ul><ul><li>Sample is smeared evenly on the slide and fixed immediately </li></ul><ul><li>Both sides of spatula are to be smeared </li></ul>

18.
How to take a Pap Smear ? <ul><li>Endocervical sample is collected using an endocervical brush </li></ul><ul><li>Insert the cytobrush into canal, so that last bristles of brush are visible </li></ul><ul><li>Rotate the brush through 180 degrees. [more rotations increase the chance of bleeding] </li></ul><ul><li>Sample is rolled on the slide and fixed. </li></ul>

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Fixation of smear <ul><li>Fixation is done immediately with fixative like 95% alcohol or cytofix spray to avoid air drying </li></ul><ul><li>Spray should be kept at 10 inches, to avoid destruction of cells by propellent in the spray </li></ul><ul><li>Smear should monolayer for proper penetration of cell surface by fixative </li></ul>

20.
How to take a Pap Smear ? <ul><li>Slide should be labeled properly with patients name, identification no. and details </li></ul><ul><li>Detailed history and clinical examination findings are to be mentioned </li></ul><ul><li>Patient details and clinical findings are to be maintained in a register </li></ul><ul><li>Advice is given regarding further follow up and treatment </li></ul>

21.
Systems for cervical cytology reporting <ul><li>George N Papanicolaou (1954) </li></ul><ul><li>5 classifications based on certainty of finding malignant cells </li></ul><ul><li>Descriptive system – WHO - (1968) </li></ul><ul><li>based on morphologic criteria – included mild, moderate, </li></ul><ul><li> severe dysplasia and Ca In Situ </li></ul><ul><li>Richart – CIN –based on histologic diagnosis </li></ul>

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Systems for cervical cytology reporting <ul><li>Bethesda system – TBS (1988) </li></ul><ul><li>National cancer institute revised in 1991 and 2001 </li></ul><ul><li>Adequacy of smear must be determined before reporting </li></ul><ul><li>Smear is adequate when </li></ul><ul><li>- Patient identification </li></ul><ul><li>- adequate clinical history </li></ul>

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Bethesda system <ul><li>Interpretable cellular cytology </li></ul><ul><li>not obscured by inflammation, debris, blood, drying </li></ul><ul><li>not scanty smear </li></ul><ul><li>Adequate sampling from transformation zone </li></ul><ul><li>presence of at least 2 clusters of well preserved endocervical cells or metaplastic cells </li></ul>

24.
Bethesda system <ul><li>Results : </li></ul><ul><li>Within normal limits ( WNL ) </li></ul><ul><li>Benign cellular changes - this term was removed and group was included in WNL in 2001 </li></ul><ul><ul><li>Reactive or Reparative changes – seen with atrophy, inflammation, surgery, radiation, IUCD, tampoons </li></ul></ul><ul><ul><li>Infections – trichomoniasis, fungal, bacterial, HSV. </li></ul></ul>

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Bethesda system - results <ul><li>Epithelial cells abnormalities </li></ul><ul><ul><li>Squamous cells </li></ul></ul><ul><ul><ul><li>ASCUS </li></ul></ul></ul><ul><ul><ul><li>ASCUS-H - suggestive of high grade lesion </li></ul></ul></ul><ul><ul><ul><li>LSIL - changes associated with HPV, atypical changes, mild dysplasia/ CIN1 </li></ul></ul></ul><ul><ul><ul><li>HSIL – moderate to severe dysplasia / CIN2, 3 and Ca In Situ </li></ul></ul></ul><ul><ul><ul><li>HSIL – where invasion cannot be ruled out </li></ul></ul></ul><ul><ul><ul><li>Squamous cell carcinoma </li></ul></ul></ul>

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Bethesda system <ul><li>Results : </li></ul><ul><li>Glandular cells – AGUS (Endocervical, endometrial) </li></ul><ul><li>Adenocarcinoma </li></ul><ul><li>(endocervical, endometrial, extrauterine) </li></ul><ul><li>Other malignant neoplasms </li></ul>

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Normal cervix-cytology <ul><li>Squamous cells </li></ul><ul><li>Exfoliated indivisual cells </li></ul><ul><li>Navicular in shape with abundant cytoplasm and small, dark, round /oval, pyknotic nuclei </li></ul><ul><li>Glandular cells </li></ul><ul><ul><li>Many times seen in clumps - linear or honeycombed pattern. </li></ul></ul><ul><ul><li>Slightly larger and basal nuclei </li></ul></ul>

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Cervical cytology - Inflammation <ul><li>Interpretation difficult due to inflammatory background </li></ul><ul><li>Lot of neutrophils and blood can obscure cellular details </li></ul>

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Low grade lesions

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High grade lesions High grade squamous lesion High grade glandular lesion

31.
Abnormal Pap smear- HPV <ul><li>Peripherial condensation of cytoplasm - wire looping effect </li></ul><ul><li>Koilocyte </li></ul>

32.
Invasive Invasive Invasive Class 5 HSIL CIN3 Ca In Situ Class 4 LSIL(HPV) HSIL HSIL CIN1 CIN2 CIN3 Mild dysplasia Moderate dysplasia Severe dysplasia Class 3 Reactive, reparatative changes, ASCUS, LSIL(HPV) Inflammatory, squamous, koilocytic atypia Class 2 WNL negative negative Class-1 Bethesda CIN Descriptive PAP

33.
<ul><li>Single test will not detect cervical abnormality but with 3 negative tests there is less than 1% chance of cervical abnormality </li></ul><ul><li>Conventional cytology has specificity of 98% and sensitivity of 51%. </li></ul>PAP smear

34.
PAP Smears - Limitations <ul><li>Low sensitivity 51% </li></ul><ul><li>False negative rates are due to faulty sampling, improper fixation or interpretation problems </li></ul><ul><li>Large group population & high risk group screening not possible </li></ul><ul><li>No consensus regarding testing </li></ul>

35.
Pap smear as screening method <ul><li>New guidelines </li></ul><ul><ul><li>Target group - All women aged 18-70 yrs who have ever had sex </li></ul></ul><ul><ul><li>Timing of Initial Screening - </li></ul></ul><ul><ul><ul><li>I nitial screening at age of 21 years or within 3 years of sexual activity </li></ul></ul></ul><ul><ul><ul><li>ACOG Guidelines-(Aug2003 ), American Cancer Society (Nov 2002) and U.S. Preventative Services Task Force (Jan 2003) </li></ul></ul></ul>

36.
Pap smear - guidelines <ul><ul><ul><li>Screening interval - yearly till the age of 30 then 3 yearly </li></ul></ul></ul><ul><ul><ul><li>When to End Screening </li></ul></ul></ul><ul><ul><ul><li>- After 70 yrs </li></ul></ul></ul><ul><ul><ul><li>- Post Hysterectomy </li></ul></ul></ul><ul><ul><ul><li>- done for benign lesions </li></ul></ul></ul><ul><ul><ul><li>- previous 3 normal PAP reports </li></ul></ul></ul><ul><ul><ul><li>- confirmed complete removal of cervical epithelium </li></ul></ul></ul>

37.
Pap smear - guidelines <ul><li>In high risk group after treatment for CIN </li></ul><ul><li>every 3 monthly for 2 years </li></ul><ul><ul><li>every 6 monthly for 3yrs </li></ul></ul><ul><ul><li>Yearly thereafter </li></ul></ul><ul><ul><li>Women who had hysterectomy for CIN, it is necessary to do vault smears </li></ul></ul><ul><ul><li>In women who received vaccination against HPV, it is necessary to continue screening </li></ul></ul>

38.
Liquid Based Cytology <ul><li>To improve results of PAP newer techniques like liquid based cytology are recommended </li></ul><ul><li>Cells are obtained with a broom, then the head is broken off in to a vial containing preservative fluid </li></ul><ul><li>In the laboratory the sample is spun to remove obscuring material </li></ul><ul><li>It gives clearer image, no cell clumps </li></ul><ul><li>It will assist in future automated reading </li></ul>

39.
<ul><li>Several slides can be prepared from one smear </li></ul><ul><li>Chlamydia, HPV testing can be done at later date </li></ul><ul><li>Reduces the incidence of inadequate and repeat smears </li></ul>Liquid Based Cytology

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Cancer Cervix IS PREVENTABLE , IF Detected EARLY!!!!!!!!! Thank You