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Pap smear (2)
1.
2. PAP smear: named after
Dr. George Papanicolaou (1883-1962)
ď‚—Vaginal smears from guinea pigs (1917)
ď‚—Women (1920)
ď‚—Hormonal
cycles
ď‚—Pathological conditions (1928)
3. Cytologic screening for cervical cancer
ď‚—Usefulness of pap smear in the screening programme
for cancer cervix is shown by the following:
ď‚—Long latent period of 10-15 years between CIN and
invasive cancer allows adequate treatment of CIN
and prevention of invasive cancer
ď‚—Proved successful in reducing the incidence of
invasive cancer by 80% and the mortality by 70%
4. When to screen
ď‚—Start within 3 years of onset of sexual activity or by age
of 21, whichever is first.
ď‚—High risk factors for cervical dysplasia:
ď‚—Early onset of sexual activity
ď‚—Multiple sexual partners
ď‚—Smoking habits
ď‚—Oral contraceptives
ď‚—HPV and HIV positive women
5. Screening frequency
ď‚—Yearly until three consecutive normal pap smears, then
may decrease frequency to every 2-3 years
ď‚—Annual screening for high-risk women is highly
recommend.
6. When to stop routine screening
Age 70 and “adequate recent screening”
ď‚—Three consecutive negative pap smears
ď‚—No abnormal pap smears in last 10 years
ď‚—Hysterectomy for benign lesion
9. Columnar Epithelium
ď‚—Upper and middle endo-cervical canal
ď‚—Single layer of columnar cells arranged in
folds
ď‚—Mucin producing (not true glands)
10. Squamous Metaplasia
ď‚—Central ectocervix and lower endocervical canal
ď‚—Replacement of columnar cells by squamous epithelium
ď‚—Progressive and stimulated by
ď‚—Acidic environment with onset of puberty
ď‚—Estrogen causing eversion of endocervix
11. Original Squamo-columnar Junction
ď‚—Placement determined between 18-20 weeks gestation
ď‚—Most often found on ectocervix
ď‚—Can be found in vagina or vaginal fornices
ď‚—Less apparent over time with maturation of
epithelium
12. “New” Squamo-columnar Junction
ď‚—Border between squamous epithelium and columnar
epithelium
ď‚—Found on ecto-cervix or in endo-cervical canal
ď‚—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
ď‚—Zone between original squamo-columnar junction and
the “new” squamo-columnar junction
ď‚—Nabothian cysts visually identify the transformation
zone if present
20. Technique
ď‚—Visualize entire cervix if possible
ď‚—Carefully remove any obscuring discharge
ď‚—Sample ectocervix first with spatula
ď‚—Sample endocervix with gentle cytobrush
rotation
ď‚—Apply material uniformly to slide
ď‚—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
ď‚—Negative for intraepithelial lesion or malignancy
ď‚—Other non-neoplastic findings
ď‚—Reactive cellular changes
ď‚—Glandular cells status post hysterectomy
ď‚—Atrophy
ď‚—Other
Endometrial cells (women ≥ 40 yrs)
33. Various types of cervical lesions as seen on Pap smears:
adenocarcinoma
34. Accuracy
ď‚—Single pap smear-diagnostic sensitivity 60%
ď‚—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
ď‚—Abnormal cytology is an indication of colposcopic
evaluation and directed biopsy