Case overview on Management of Pap Smear result.pptx

Its a case presentation on the management of pap smear results.

1. HOUSE OFFICERS PRESENTATION DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY ABUTH, SHIKA PRESENTER: DR. M JIBO MODERATOR: DR. AYUBA D DATE: 8/10/24 10/7/2024 1

2. Case Overview A 40 year old multipara presents to the clinic with the result of her pap smear. What are the likely reports and how will you manage them? 10/7/2024 2

3. Outline Introduction Pap Smear Process Screening Guidelines Bethesda Classification Management of Abnormal Results Treatment Options Preventive Strategies Conclusion Reference 10/7/2024 3

4. Introduction A Pap smear (Papanicolaou test) is a screening procedure used to detect potentially precancerous and cancerous processes in the cervix. Proper management of Pap smear results is essential to prevent the progression of cervical abnormalities to cervical cancer. 10/7/2024 4

5. Pap Smear Process Speculum insertion: for visualization and accessibility Sample collection: Cyto brush or spatula Laboratory Analysis: For detection of cellular changes 10/7/2024 5

6. Screening Guidelines(ACOG, 2021) AGE GROUP SCREENING METHOD FREQUENCY <21 No screening N/A 21-29 Pap smear alone Every 3 years 30-65 -pap smear alone -hrHPV Testing alone -Co-testing Every 3years Every 5 years Every 5 years >65 No screening if there is adequate negative previous screenings HPV Vaccinated individuals Follow age-specific guidelines After Hysterectomy No screening if the cervix has been removed and no history of high grade precancerous lesions or cancer 10/7/2024 6

7. Screening Guideline(SOGON and RCOG) Age Group Type of Test Frequency <25 years - - 25-49 years HPV DNA Test 5-10 years 50-65 years HPV DNA Test 5-10 years >65 years - - After Total Hysterectomy - - 10/7/2024 7

8. HPV Co-Testing Co-testing for HPV and Pap smear improves risk assessmen t 10/7/2024 8

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12. The Bethesda Classification The Bethesda System is a widely used system for reporting cervical and vaginal cytological diagnoses, particularly for Pap smear results. 1. Specimen Adequacy Satisfactory for evaluation - Endocervical/transformation zone component present Unsatisfactory for evaluation - Specimen quality is insufficient (e.g., too few squamous cells, obscured by blood, inflammation) 10/7/2024 12

13. 2 . General Categorization Negative for intraepithelial lesion or malignancy (NILM) - No evidence of cancer or precancerous changes Epithelial Cell Abnormality - Further classification needed if abnormal cells are detected 10/7/2024 13

14. 3 . Other Non-neoplastic Findings Organisms : Trichomonas vaginalis, Candida spp., bacterial vaginosis, herpes simplex virus, etc. Non-neoplastic cellular variations(squamous metaplasia, keratotic changes), reactive cellular changes associated with; inflammation(lymphocytic cervicitis),radiation 10/7/2024 14

15. 4 . Epithelial Cell Abnormalities Atypical Squamous Cells (ASC ) ASC-US: Atypical squamous cells of undetermined significance ASC-H: Atypical squamous cells, cannot exclude HSIL (High-grade squamous intraepithelial lesion) 10/7/2024 15

16. Low-Grade Squamous Intraepithelial Lesion (LSIL) Mild abnormalities, often associated with HPV infection High-Grade Squamous Intraepithelial Lesion (HSIL) More severe abnormalities, with a higher risk of progression to cancer Squamous Cell Carcinoma Malignant cells indicative of invasive cancer 10/7/2024 16

17. 5 . Glandular Cell Abnormalities Atypical Glandular Cells (AGC ) Abnormalities in glandular cells Endocervical Adenocarcinoma in situ (AIS) Precancerous lesions confined to the glandular epithelium Adenocarcinoma Malignant glandular cells, indicative of cancer 10/7/2024 17

18. Cytology Test Result Categories Acronym Description NILM Negative for Intraepithelial Lesion or Malignancy ASC-US Atypical Squamous Cells of undetermined significance ASC-H Atypical Squamous Cells-cannot exclude HSIL LSIL Low-grade squamous intraepithelial lesion includes mild dysplasia/CIN 1 HSIL High-grade Squamous Intraepithelial Lesion Includes moderate to severe dysplasia,CIN 2/3 AGC-NOS Atypical Glandular cells, not otherwise specified AGC-FN Atypical Glandular Cells, favor neoplasia AIS Endocervical Adenocarcinoma In Situ AdenoCA Adenocarcinoma SCC Squamous Cell Carcinoma 10/7/2024 18

19. Cytological Classification of Cervical Smear Results BETHESDA CLASSIFICATION HISTOLOGICAL EQUIVALENT NILM (Negative for Intraepithelial Lesion or Malignancy) Normal cervical epithelium or benign findings (e.g., cervicitis, reactive changes) ASC-US (Atypical Squamous Cells of Undetermined Significance) Benign/reactive changes or sometimes CIN 1 (LSIL) ASC-H (Atypical Squamous Cells – cannot exclude HSIL) CIN 2 or CIN 3 (HSIL) LSIL (Low-grade Squamous Intraepithelial Lesion) Cervical intraepithelial neoplasia grade 1 (CIN 1) HSIL (High-grade Squamous Intraepithelial Lesion) Cervical intraepithelial neoplasia grade 2 or 3 (CIN 2/3) Squamous Cell Carcinoma Invasive squamous cell carcinoma AGC (Atypical Glandular Cells) Benign glandular processes, CIN 2/3, AIS, or invasive adenocarcinoma Adenocarcinoma Invasive adenocarcinoma 10/7/2024 19

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22. Results Inadequate Negative Positive 10/7/2024 22

23. NILM No abnormal cells detected Non-neoplastic cellular findings; inflammatory changes Management : Routine screening as per age-appropriate guidelines if there is no abnormal cells HPV negative: Repeat Pap in 1 year HPV positive: Colposcopy Inflammatory : HVS±ECS → Treat →Persistent inflammatory changes → Colposcopy 10/7/2024 23

24. ASC-US Atypical Squamous Cells of undetermined significance ( ASC-US) Mildly abnormal cells but not clearly precancerous . Management : hr HPV testing If HPV-positive: Colposcopy If HPV-negative: Repeat cytology in 12 months Alternative: Repeat Pap smear at 6 months interval. If both are negative continue routine screening. If either is abnormal (ASC-US), do colposcopy 10/7/2024 24

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26. ASC-H Atypical Squamous Cells, Cannot Exclude High-Grade Squamous Intraepithelial Lesions (ASC-H) Cells that may indicate a high-grade lesion but require further investigation . Management: Colposcopy to confirm or exclude HSIL 10/7/2024 26

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28. LSIL (Low-grade Lesions) Mild cellular changes, often linked to HPV infection. Management: I mmediate colposcopy for women 25-29 years HPV testing for women ≥ 30 years HPV Negative: Repeat Pap in 12 months HPV Positive: Colposcopy 10/7/2024 28

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30. HSIL (High-grade Lesions) Severe abnormal cells suggesting moderate to severe dysplasia with high cancer risk. Management : Colposcopy and biopsy. Treatment 10/7/2024 30

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32. AGC (Atypical Glandular Cells) Glandular cell abnormalities that may signal pre - cancer ous changes in the endocervical canal Management : Colposcopy E ndocervical curettage Possible endometrial biopsy (>35 years or has risk factors of endometrial pathology) Treatment 10/7/2024 32

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34. Adenocarcinoma In Situ (AIS) Precancerous cells found in the glandular tissue of the cervix . Management: Immediate colposcopy Diagnostic excisional procedure Endocervical sampling to check margin: If positive: consider repeat excision or hysterectomy(simple) If negative: Desires fertility: Pap smear + HPV test every 6 months for 2 years. Repeat excision in case of recurrence Not desirous of fertility: Hysterectomy 10/7/2024 34

35. Squamous Cell Carcinoma or Adenocarcinoma Presence of cancerous cells Management: Immediate referral to a gynecologic oncologist for further diagnostic testing and treatment planning. 10/7/2024 35

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37. Treatment Options Conservative : Low-grade lesions may resolve. Excisional : LEEP Cold knife conization Ablative: Cryotherapy Laser ablation Hysterectomy for severe dysplasia or AIS. 10/7/2024 37

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41. Preventive Strategies Health Education : H ealth education and counseling for parents, young girls/boys and women/men to practice safe sex and delayed sexual debut and benefits of HPV vaccination HPV vaccination: It significantly lowers risk of cervical cancer Lifestyle Modifications: Adopting a healthy lifestyle like exercise and diet enhances immune system and decreases cancer risk Regular health check up: Routine gynaecological exams and screening guarantee early detection of abnormalities fostering timely intervention and treatment 10/7/2024 41

42. Conclusion Effective management of Pap smear results is critical in preventing cervical cancer Patient education and engagement are key for successful outcomes 10/7/2024 42

43. References 1. American College of Obstetricians and Gynecologists (ACOG). (2021). Cervical cancer screening and prevention . Retrieved from http://www.acog.org 2. Centers for Disease Control and Prevention (CDC). (2020). Cervical cancer screening guidelines . Retrieved from https://www.cdc.gov/cancer/cervical/basic_info/screening.htm 3. Mayer, C., & Mahdy , H. (2023). Abnormal Papanicolaou smear . In StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560850/ 4. National Cancer Institute (NCI). (2021). Pap and HPV testing . Retrieved from https://www.cancer.gov/types/cervical/pap-hpv-testing-fact-sheet 10/7/2024 43

44. 5. Saslow , D., Solomon, D., Lawson, H. W., et al. (2012). American Cancer Society, ASCCP, and ASCP guidelines for the prevention and early detection of cervical cancer. Journal of Lower Genital Tract Disease, 16 (3), 175-204. https://doi.org/10.1097/LGT.0b013e31825f8b1d 6. World Health Organization (WHO). (2021). Human papillomavirus (HPV) and cervical cancer . Retrieved from https://www.who.int/news-room/fact-sheets/detail/human-papillomavirus-(hpv)-and-cervical-cancer 7. Barbara, S., Apgar, M., & Anne. (2009). Update on ASCCP consensus guidelines for abnormal cervical screening tests and histology. American Academy of Family Physicians . 10/7/2024 44

45. 8. Kattoor , J., & Kamal, M. M. (2022). The gray zone squamous lesions: ASC-US / ASC-H. CytoJournal , 19, 30. https:// doi.org/10.4103/cytojournal.cytojournal_107_22 9. L.Chesney Thompson(2005) Evaluation of abnormal Pap smear result Volume 25, No 16 Post Graduate Obstetrics and Gynaecology 10. Akinola , O. I., Aimakhu , C. O., Ezechi , O. C., & Fasubaa , O. B. (2018). Society of Obstetrics and Gynecology of Nigeria – Clinical practice guidelines: Guidelines for the prevention of cervical cancer. Tropical Journal of Obstetrics and Gynaecology , 35, 371-376. 11. World Health Organization (WHO). (2021). WHO guideline for screening and treatment of cervical pre-cancer lesions for cervical cancer prevention (2nd ed.). Geneva: World Health Organization. Licence : CC BY-NC-SA 3.0 IGO. 10/7/2024 45

46. 12. Perkins RB, Guido RS, Castle PE, Chelmow D, Einstein MH, Garcia F, Huh WK, Kim JJ, Moscicki AB, Nayar R, Saraiya M, Sawaya GF, Wentzensen N, Schiffman M; 2019 ASCCP Risk-Based Management Consensus Guidelines Committee. 2019 ASCCP Risk-Based Management Consensus Guidelines for Abnormal Cervical Cancer Screening Tests and Cancer Precursors. J Low Genit Tract Dis. 2020 Apr;24(2):102-131. doi : 10.1097/LGT.0000000000000525. Erratum in: J Low Genit Tract Dis. 2020 Oct;24(4):427. doi : 10.1097/LGT.0000000000000563. PMID: 32243307; PMCID: PMC7147428 . 13 . Yahya , Anisah , Zubairu , Ismail & Bawa , Umma . (2020). Awareness and utilization of cervical cancer screening services among primary health care providers in Zaria. Annals of African Medical Research. 2. 10.4081/aamr.2019.68. 10/7/2024 46