HISTORY Papanicolaou first reported in 1923 that cervical cancer or precancer could be detected by pap smear. But it was only in 1943 that Pap test became accepted and widely used. Many terminologies were used. Mostly numbers and term dysplasia. There were multiple poorly defined gradations which were poorly reproducible. In 1988 the first Bethesda System workshop was convened to address the issue and to standardize the reporting of pap smear. In 2001 a consensus was achieved and a terminology was recommended The 2001 Bethesda System (TBS) Revision agreed upon in 2014

1. A.B.C. of Paps Smear
Update (2016)
DR. SUDHIR JAIN
Consultant Pathologist
…Caring hearts, healing hands

2. Dr. Sudhir Jain
MBBS,. MD Pathology PAIMER
Taught for 2 decades at PGIMER ,Chandigarh
AIIMS ,Delhi
MAMC , Delhi
Maduguri University,Nigeria
Sharda Medical Collage
Considered Guru of HPE / Cytology in, Northern India
Passionate teacher

3. Georgios Papanikolaou 1883 - 1962
PAP SMEAR – BETHESDA 2014

4. HISTORY
•Papanicolaou first reported in 1923 that cervical cancer
or precancer could be detected by pap smear.
• But it was only in 1943 that Pap test became accepted
and widely used.
•Many terminologies were used. Mostly numbers and
term dysplasia. There were multiple poorly defined
gradations which were poorly reproducible.
•In 1988 the first Bethesda System workshop was
convened to address the issue and to standardize the
reporting of pap smear.
•In 2001 a consensus was achieved and a terminology
was recommended The 2001 Bethesda System (TBS)
•Revision agreed upon in 2014

6. Normal histology

7. Histological classification of Cervical neoplasia

8. Current Cytologic Classification

9. CYTOLOGY HPV COTESTING
Sensitivity Lowest Higher Highest
Repeat interval for
negative screen
Shortest Longer Longest
Triage test required For equivocal
cytology
For all positive
results
For all HPV positive
and cytology negative
results
Triage test options HPV, repeat
cytology,
biomarkers
Cytology, HPV
genotyping,
Biomarkers
Repeat cotest, HPV
genotyping,
Biomarkers
Diagnostic test Colposcopic biopsy
CURRENT OPTIONS FOR CERVICAL CANCER
SCREENING

10. Recently there is concern about the demise of
Papanicolaou test since it is gradually yields its place
to primary cervical cancer screening by HPV and other
bio-marker testing. One big factor was that almost
50% of the epithelial abnormities were reported at
ASCUS which failed to give clear-cut guidelines for
management.
It appears that the Pap smear is going to stay because
of two reasons:
1. Its high specificity and
2. Limitation of resources for HPV and bio-marker
testing.

11. When to do a pap test and
exclusions ?
•Screening guidelines vary from
country to country
•ASCCP recommends screening of
women between 21 to 65 years
of age

12. SAMPLE COLLECTION

13. At least one half to two thirds of
false negatives are the result of
patient conditions present at the
time of sample collection and
submission and the skill and
knowledge of the individual who
obtains the specimen

14. This proper procedures must be
followed for collection of pap
smears and their transport to the
laboratory

15. Guidelines for collection
• PATIENT PREPARATION
– No douche 48 hours prior to test
– Not use tampons, birth control foam, jellies or
other vaginal creams for 48 hours prior to test
– Refrain from intercourse 48 hours prior to test
• DEVICES TO COLLECT PAP SMEARS
– A Spatula, spatula and brush or a broom like brush
can be used.

16. Devices

18. Devices
• Plastic spatulas are preferred since wooden retain
cellular material
• Analysis of different methods has shows that
overall, cytobrush and spatula together provide
the best specimen.
• However the choice of device is dependent upon
the size and shape of cervix
– Transformation zone may or may not be visualized
since its location varies from patient to patient
– It is important to sample the endocervix in patients
when the transformation zone is not visualized.

22. Technique for Sample Collection
• USING SPATULA AND ENDOCERVICAL BRUSH
– Vaginal fornix and ectocervix should be sampled
before the ectocervix/transformation zone
– First, a sample of ectocervix is taken using a spatula.
The notched end is rotated 360o around the
circumference of cervical os.
– The spatula is held with specimen face up while the
endocervical sample is collected.
– Insert the endocervical brush into the endocervial
canal until the bristles closest to hand are visible.
Rotate 45 tp 90o and remove

23. Technique 2
– Sample on the spatula is spread evenly on one
half of the labeled glass side , using a single
uniform motion.
– Endocervical brush is then rolled over along the
remaining half of the slide. Brush should not be
smeared.
– Rapidly immerse the slide in fixative or use the
spray.
– For liquid based test, spatula and endocervicval
brush is rinsed in the specimen vial

27. Fixation of the Sample
• Immediate fixation of the cellular sample
within seconds is necessary.
– Immerse the smear in alcohol for 30 minutes,
remove and let it dry before it is sent to the
laboratory.
Or
– Spray fix the slide. Spray over the slide from a
distance of 6 to 10 inches. Let it dry and then send
to the laboratory.

28. One Slide or Two Slides
No consensus has been reached on the clinical
benefit of one slide versus two slides for cervical
cytology. Several comparative studies have been
performed and concluded that the single slide
method is an acceptable alternative to the double
slide method. The single slide method decreases
the number of slides screened in the laboratory,
reduces costs for glass slides, and requires less
space for storage
USE TWO SLIDES IF THERE IS ANY VISIBLE LESION
ON CERVIX.

29. Information to be Provided to Lab
• Name and identification
• Age or date of birth
• Menstrual status (LMP, hysterectomy,
postpartum, hormone therapy)
• Previous abnormal result if any
• Previous biopsy or surgical procedure

30. Pap Smear Report

32. TBS 2001
Major changes that were introduced in TBS 2001
are:
1. Squamous intraepithelial lesion with only two
gradations – Low and high ( L-SIL & H-SIL)
2. Introduced the concept of “Statement of
adequacy”
3. Introduced the terms “ Atypical
squamous/Glandular cells of undetermined
significance (ASC-US, AGC-US)

33. The term ASC-US became highly controversial as it led to
frustrations for clinicians as it failed to enable them to
make clear cut management decisions
In US 50% of the reported abnormalities are ASC-US
In response to this ASCUS-LSIL TRIAGE STUDY was
undertaken. The results of this study established
molecular testing for HPV as the most effective tool to
resolve the issue.

34. • Use of Liquid based cytology
• Co-testing (Pap and hrHPV)
• Primary hrHPV screening
• Changes in histopathology terminology
• Advent of prophylactic vaccines.
WHY TBS 2014

35. TBS 2014 – What Has Changes
• Bethesda terminology changes
– Minimal changes
• Reporting of Benign Appearing Endometrial
cells in Now Recommended for Women > 45
(presence of endometrial cells in postmenopausal
women is considered abnormal)
• No new Category was Created for ASC-US

36. TBS 2014 SYSTEM FOR REPORTING
CERVICAL CYTOLOGY
SPECIMEN TYPE – CONVENTIONAL OR LIQUID BASED
SPECIMEN ADEQUACY :
Satisfactory for evaluation (describe
presence/absence of endocervical / TZ cells
Unsatisfactory for evaluation (Specify reasons)
GENERAL CATEGORIZATION (OPTIONAL)
Negative for intraepithelial lesion or malignancy
Others ( Endometrial cells in woman > 45 years of
age)
Epithelial cell abnormality

37. TBS 2014 System of Reporting 2
INTERPRETATION/RESULT
NEGATIVE FOR INTRAEPITHELIAL LESION OR
MALIGNANCY
Non Neoplastic Cellular variations
oSquamous metaplasia
oKeratotic changes
oTubal metaplasia
oAtrophy
oPregnancy associated changes

38. TBS 2014 ….. 3
Reactive cellular changes associated with
o Inflammation and repair
o Lymphocytic cervicitis
o Radiation
o Intrauterine contraceptive device
Gladular cell status post hysterectomy
Organisms
o Trichomonas vaginalis

39. oFungal organisms consistent with Candida
oShift in flora suggestive of bacterial vaginosis
oBacteria consistent with morphology of Actinomyces
spp
oCellular changes associated with herpes simplex virus
oCellular
o changes associated with cytomegalovirus
OTHER
Endometrial cells in woman > 45 years

40. TBS 2014 .. Cont.
EPITHELIAL CELL ABNORMALITIES
SQUAMOUS CELLS
 Atypical squamous cells
 Of undermined significance (ASC-US)
 Can not exclude HSIL (ASC_H)
 Low-grade squamous intraepithelial lesion
(Encompassing HPV/mild dysplasia/CIN1)
High-grade squamous intraepithelial lesion
(encompassing moderate and severe dysplasia, CIS, CIN2,CIN3)
 With features suggestive of invasion
Squamous cell carcinoma

41. TBS 2014 …. cont
GLANDULAR CELLS
 Atypical
 Endocervical cells
 Endometrial cells
 Glandular cells
 Atypical
 Endocervical cells , favor neoplastic
 Endometrial cells, favor neoplastic
 Endocervical carcinoma in situ
 Adenocarcinoma (Endocervical, endometrial ,
extrauterine, NOS)

42. Summery
Technique of taking pap smear has to be learnt
by every gynaecologist interpretation of
abnormal pap smear. Has to be learnt by every
gynaecologist practicing medicine.

43. ISO 14001:2004 (EMS)
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ISO 9001:2008
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