quick revise

1. DR.VAISHALI SEC DNB OBS &GYNE
SGM,NEWDELHI
7/8/16

2.  Squamocolumnar junction ?

3.  zone where columnar Endocervical
epithelium meets Squamous epithelium
of ectocervix .

4. What is transformation zone ?

5.  Zone between the original
squmocolumnar junction which is
squamosquamous due to metaplasia & is
outside to the newly developed SCJ
which is inside .
 Metaplastic process is very active at the
time of menarche ,during or after first
pregnancy.
 This metaplastic cells have potential to
undergo atypical transformation by
trauma or infection.

8.  Metaplasia ?
 Dysplasia ?
 CIN ?

9.  Metaplasia –reserve cells beneath columnar
epithelium sometimes transforms in to
mature squamous cells
 They are normal cells without nuclear
atypia & do not become malignant.
 Abnormal nuclear changes is atypical
metaplasia is precursor of dysplasia

10.  Dysplasia - cell resembling cancer cells
 Cell morphology is altered
 Disorderly arrangement of cells
 cell vary in size shape & polarity
 alteraration in nuclear cytoplasmic ratio.
 large irregular hyperchromatic nuclei
mitotic figure .
 lesion progress with time end up as frank
cancer

11. CIN
 Richart introduced the concept .
 Part or the full thickness of the stratified
squamous epithelium is replaced by cells
showing varying degrees of dysplasia .
 Lesions progress with time.
 30 % of lesion by 10 yr may end up as
frank invasive cancer .

12. CIN I ,II, III ?

13. CIN I -
Represents atypical cells with
increased nuclear to cytoplasmic ratio
and hyperchromatic nuclei present in
the lower 1/3 of the epithelial layer
from the basement membrane .
May revert to normal, persist or
progress

14. CIN I
Cytology

15. CIN II
Shows further progression of
nuclear abnormalities with greater
involvement of the epithelial
thickness. In CIN II, immature
basaloid cells occupy the lower 2/3
of the epithelium

16. CIN II
Cytology

17. CIN III
Represents almost total
involvement of the epithelium with
only one or two layers of mature
cells remaining at the surface.
When the entire epithelium is
involved, the term carcinoma in situ
(CIS) is applied.

18. CIN III
Cytology Histology



21.  What is Bethesda system of cytological
abnormality ?

22. Table 17.2 Bethesda System 2001
 Specimen Type: Indicate conventional smear (Pap smear) vs.
liquid based vs. other
 Specimen Adequacy
 Satisfactory for evaluation (describe presence or absence of
endocervical/transformation zone component and any other
quality indicators, eg, 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)

23.  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 (eg, endometrial cells
in a woman 40 years of age)

24.  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

25. Interpretation/Result
 Negative for Intraepithelial Lesion or Malignancy
(when there is no cellular evidence of neoplasia, state this in
the General Categorization above and/or in the
Interpretation/Result section of the report, whether or not
there are organisms or other nonneoplastic findings)
 Organisms
 Trichomonas vaginalis
 Fungal organisms morphologically consistent with Candida
spp.
 Shift in flora suggestive of bacterial vaginosis
 Bacteria morphologically consistent with Actinomyces spp.
 Cellular changes consistent with herpes simplex virus

26.  Other Nonneoplastic Findings (optional to report;
list not inclusive):
 Reactive cellular changes associated with:
 inflammation (includes typical repair)
 radiation
 intrauterine contraceptive device (IUD)
 Glandular cells status posthysterectomy
 Atrophy

27.  Other
 Endometrial cells (in a woman 40 years of age)
(specify if negative for squamous intraepithelial lesion•)
 Epithelial Cell Abnormalities
 Squamous Cell
 Atypical squamous cells
 of undetermined significance (ASC-US)
 cannot exclude HSIL (ASC-H)
 Low-grade squamous intraepithelial lesion (LSIL) encompassing:
HPV/mild dysplasia/CIN 1
 High-grade squamous intraepithelial lesion (HSIL) encompassing:
moderate and severe dysplasia, CIS/CIN 2 and CIN 3
 with features suspicious for invasion (if invasion is suspected)
 Squamous cell carcinoma

28.  Glandular Cell
 Atypical
 endocervical cells (not otherwise specified [NOS] or specify in
comments)
 endometrial cells (NOS or specify in comments)
 glandular cells (NOS or specify in comments)
 Atypical
 endocervical cells, favor neoplastic
 glandular cells, favor neoplastic
 Endocervical adenocarcinoma in situ
 Adenocarcinoma
 endocervical
 endometrial
 extrauterine
 NOS

29.  Other Malignant Neoplasms (specify)
 Educational Notes and Suggestions (optional)

30.  what is pap test ?

31. Pap Test
The Pap test was introduced as a
cervical screening test in 1943 by
George Papanicolaou . It is a way to
examine cells collected from the cervix
and vagina. This test can show the
presence of infection, inflammation,
abnormal cells, or cancer.

32.  George Papanicolaou
 The first observation of cancer
cells in the smear of the uterine
cervix was one of the most
thrilling experiences of my
scientific career

33. When should the screening
start ?

35. How is the pap test done ?

36.  A Pap test is simple, quick, painless.
 While a woman lies on an examination table, the
clinician inserts a speculum into her vagina to
open it. To do the test, a sample of cells is taken
from in and around the cervix with a wooden
scraper and placed on a glass slide and rinsed in
liquid fixative and sent to a laboratory for
examination.

37. Ayers Spatula
 Concave end to fit the
cervix
 Convex end for
vaginal wall and
vaginal pool scrapings

38. Sample Cervix
 Use concave end
 Rotate 360 degrees
 Don’t use too much
force (bleeding, pain)
 Don’t use too little force
(inadequate sample)

39. Cytobrush
 Insert ~ 2 cm (until
brush is fully inside
canal)
 Rotate only 180
degrees (otherwise
will cause bleeding)

41. When should the pap test be done ?

42. Pap test
 A woman should have this test when she is not
menstruating;
 the best time is between 10 & 20 days after the first
day of the menstrual period.
 For about 2 days before a Pap test, she should
avoid intercourse douching, or using vaginal
medicines or spermicidal foams, creams or jellies.

43. Methods to Improve Accuracy of
Pap smear
1. Perform a Pap smear when the patient is in the
proliferative phase.
2. The patient should avoid intercourse or
intravaginal products/douches for 24-48 hours
before examination
3. Use no lubricant prior to the test
4. Have cytobrush, spatula, slide and other supplies
on hand before exam.

44. Methods to Improve Accuracy of
Pap smear(cont.)
1. Rotate the Ayers spatula through a 360-
degree arc over the SCJ and avoid excessive
pressure
2. Collect the endocervical specimen using
cytobrush or saline-moistened cotton swab
and apply it to the same slide .
3. Rapidly apply fixative to the slide, if spray
is used hold it 10 inches from the slide

45. Liquid - based cytology
 Specimen is placed in a liquid fixative
 Removes blood ,mucus
 Suspended cells are placed over slide to
form thin monolayer
 Can be employed to test HPV infection .

47. What is HPV triage strategy ?

48. HPV triage strategy
Pap smear
HPV testing by PCR
coloposcopy

49. HPV vaccine

50. Role of vaccination
• Claimed to induce higher antibodies in blood & site of
infection
• Antibodies neutralize the virus & prevent entry into cells

51. Routine HPV Vaccination
Recommendations
 The vaccination series can be started as young as 9
years of age
 “Catch-up” vaccination recommended for females 13
through 26 years of age

52. Vaccines available in India

53.  Treatment options in preinvasive
lesion of cervix

54. CIN Management

61. Treatment options in preinvasive
lesion
 Local destructive by cauterisation, cryosurgery,
laser
 Local excision by conisation with knife , LLETZ
 Radical excision by trachelectomy
,hysterectomy .

62.  MANAGE MENT OF LSIL ?

63. MANAGEMENT OF MILD DYSPLASIA ,LSIL
 Treat the infection ,
 Follow –up cytology every 6-12 months .
 If persistent over 1 year follow up with
colposcopy & treat by ablation by coagulation
,cryosurgery ,laser.
 Life long follow up .

64.  Criteria for conservative methods in
preinvsive lesions

65. Criteria for conservative methods in preinvasive
lesions
 Young woman desirous of childbearing .
 Entire lesion is within squamocolumnar junction
 No micro or macroinvasion proved by biopsy .
 No endocervical involvment .

66.  MANAGEMENT OF HSIL ?

67.  LOCAL EXCISION BY CONISATION
 LLETZ , LEEP-LOOP ELECTRO SURGICAL
EXCISION PROCEDURE .
 RADICAL EXCISION BY TRACHELECTOMY
,HYSTERECTOMY WITH REMOVAL OF CUFF
 FOLLOW UP.

68.  CONE BIOPSY?

69.  IS BOTH DIAGNOSTIC & THERAPEUTIC
 WHEN ABNORMAL AREA IS LARGE
 DONE WHEN SQUAMOCOLUMNAR JUNCTION
HAS RECEDED IN THE ENDOCERVICAL CANAL
 DESCREPANCY BETWEEN CYTOLOGY &
COLPOSCOPY
 DONE UNDER G.A
 BY LASER BLEEDING IS LESS

70.  ROLE OF HYSTERECTOMY ?

71. It is indicated when patient is not
compliance with follow-up and has
completed her family.
Associated fibroids ,DUB , prolapse
 Microinvasion exists .
Recurrent high -grade CIN