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Pap smear (2)
1.
2. PAP smear: named after
Dr. George Papanicolaou (1883-1962)
Vaginal smears from guinea pigs (1917)
Women (1920)
Hormonal
cycles
Pathological conditions (1928)
3. 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%
4. 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
5. 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.
6. 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
9. Columnar Epithelium
Upper and middle endo-cervical canal
Single layer of columnar cells arranged in
folds
Mucin producing (not true glands)
10. 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
11. 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
12. “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
13. Transformation Zone
Zone between original squamo-columnar junction and
the “new” squamo-columnar junction
Nabothian cysts visually identify the transformation
zone if present
20. 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
21.
22.
23. 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
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ASCUS
24. “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)
33. Various types of cervical lesions as seen on Pap smears:
adenocarcinoma
34. 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