Management of Abnormal Pap Smear .pptx

Abnormal Pap Smear Management

1. Abnormal Pap Smear: Management

2. Introduction: Importance of screening for cervical cancer Cervical cancer is the second most common cancer in Indian women In India around 1.23 lakh new women are diagnosed with cervical cancer every year 67,500 of these die of the disease Almost all cervical cancers are associated with oncogenic HPV. Up to 80% of women harbour oncogenic HPV during their reproductive life, only < 1 in 10,000 will develop cervical cancer

3. Screening test for cancer cervix Various screening tests for cancer cervix Pap smear; Conventional/ liquid based Visual inspection with acetic acid Visual inspection with Lugol’s iodine High risk HPV DNA testing Colposcopy

4. Conventional vs Liquid based Cytology

5. Transformation Zone

6. Natural History CIN1 CIN2 CIN3 Regress 57% 43% 32% Persist 32% 35% 56% Progress 11% 22% Invasive carcinoma 1% 5% >12%

7. Objectives Know the spectrum of results of pap smear Identify the those at higher risk of preinvasive lesions Counsel the women with abnormal pap smear on additional tests Advice appropriate follow up

8. Interpretation / Results of Pap Smear Bethesda 2014 Negative for intraepithelial lesion or Malignancy Non neoplastic findings (optional to report) Nonneoplastic cellular variations: squamous metaplasia, atrophy Reactive cellular changes: inflammation, radiation Organisms Trichomonas vaginalis Fungal candida Shift in flora as in Bacterial vaginosis Bacteria consistent with Actinomyces Spp Cellular changes consistent with Herpes simplex or Cytomegalovirus

9. Interpretation / Results of Pap Smear Bethesda 2014 Other Endometrial cells ( ≥ 45 yrs ) Epithelial cell abnormalities Squamous cell : Atypical cells (US, H); LSIL; HSIL; Squamous cell Carcinoma Glandular cell : Atypical (endocervical, endometrial, glandular) NOS Atypical (endocervical, glandular) favours neoplasia Endocervical adenocarcinoma insitu (AIS) Adenocarcinoma ( endocervical, endometrial, extrauterine, NOS) Other Malignant Neoplasms (Specify)

10. Implications of Abnormal Pap findings Epithelial cell abnormalities: SQUAMOUS CELLS ASC-US LSIL : HPV/ mild dysplasia/CIN 1 ASC-H HSIL: Moderate and severe dysplasia, CIS ;CIN2 and CIN3 Epithelial cell abnormalities: GLANDULAR CELLS AGC AGC favours neoplasia AIS Lesser abnormalities Higher abnormalities Lesser abnormality Higher abnormalities

11. Unsatisfactory Cytology Unsatisfactory cytology LBC /Treat inflammation/ atrophy Repeat cytology after 2-4 mths Abnormal Normal Unsatisfactory Routine testing Cytology/ Cotesting @ 1 yr Manage as per ASCCP guidelines Colposcopy if ≥ 30 yrs HPV DNA Positive Negative Triage with HPV DNA not recommended if Co-testing is not done Manage as per ASCCP 2012 guidelines

12. Benign appearing endometrial cells in women ≥ 45 yrs Exfoliated Endometrial cells is a normal finding during menses and proliferative phase of cycle In postmenopausal women in is abnormal and raises possibility of endometrial neoplasia Intervention : Endometrial Biopsy in postmenopausal women ASCCP 2012

13. Atypical cells of undetermined significance (ASCUS) ASCUS Triage with HPV DNA if ≥ 30 yrs Negative Positive Repeat cotesting @ 1 yr Colposcopy + Endocervical sampling if no lesion/ inadequate Manage as per ASCCP guidelines 2012 If < 30 yrs repeat cytology @1 yr ≥ ASCUS Normal Routine screening @ 3 yrs Both negative If >ASCUS or HPV+ Repeat co testing @ 3 yrs

14. Low grade squamous intraepithelial lesion (LSIL) LSIL Triage with HPV DNA if ≥ 30 yrs Negative Positive Repeat co-testing @ 1 yr Colposcopy + Endocervical sampling if no lesion/inadequate Manage as per ASCCP guidelines 2012 If < 30 yrs Both negative If ≥ASCUS or HPV + ve Repeat co testing @ 3 yrs

15. Pregnant women with LSIL

16. Atypical squamous cells: cannot exclude high grade SIL (ASC-H)

17. Follow of women with no lesion/biopsy proven CIN:(preceding lesser lesions ASCUS/LSIL)

18. Follow of women with no lesion/biopsy proven CIN:(preceding higher lesions ASCUS-H/HSIL)

19. Follow of women with biopsy confirmed CIN2/3

20. Atypical glandular cells

21. Follow up of patients with AGC

22. Adenocarcinoma In Situ

23. Take home messages Cervical cancer screening is recommended from 25-65 yrs Cytology alone every 3 yrs, cytology+ HPV DNA every 5 yrs >30 yrs, VIA every 5 yrs No HPV DNA < 30 yrs. HPV DNA normally clears in 2 yrs Inadequate cytology should be repeated after treatment for atrophy/inflammation after 2-4 mths . Colposcopy if 2 consecutive reports ASCUS/LSIL are lesser abnormalities hence triaging with HPV DNA indicated if age > 30 yrs. If < repeat cytology @ 1 yr indicated. Colposcopy if HPV DNA + or ≥ ASCUS on cytology

24. Take home messages Higher lesions ASC-H/ HSIL no triaging with HPV DNA. Colposcopy for all AGC no triaging with HPV DNA. Colposcopy + ECC± EB if AGC ( endocervical /glandular cells). AGC (endometrial) ECC+EB AGC favour neoplasia /AIS ECC+EB followed by hysterectomy or if no invasive disease excisional biopsy Lesser lesions: No lesion/CIN 1 on colposcopy Cotesting @ 1yr :if negative for both, cotesting @3 yrs then every 5 yrs. If either positive (≥ ASCUS or HPV DNA +): colposcopy Higher lesions: No lesion/CIN 1 on colposcopy Cotesting @ 1yr and 2 yrs/ excisional diagnostic procedure. If negative for both : cotesting @3 yrs then every 5 yrs. If either positive (≥ ASCUS or HPV DNA + ve ): colposcopy

25. Thanks