Pap Smear

PAP SMEAR INDICATIONS PROCEDURE DEMONSTRATION OF A SLIDE REPORTING OF A SLIDE

INTRODUCTION • Initiated BY DR. GEORGE PAPANICULOAU • ONLY A SCREENING TEST • ANY ABNORMAL PATHOLOGY NEEDS FURTHER INVESTIGATIONS • FORMS ONE OF THE ROUTINE GYNAECOLOGICAL EXAMINATION IN A WOMEN • DETECTS ABOUT 98% OF CA CERVIX AND 80 % OF ENDOMETRIAL MALIGNANCIES

INDICATIONS • Screening purpose • Women at higher risk Young intercourse smoking use of OCPs Multiparity HPV Low socio economic status

– HIV infections – High life time number of male sexual partner – Who do not receive regular PAP testing

INDICATIONS Women who have had a hysterectomy • Cervix left behind at surgery No screening post hysterectomy if : Hysterectomy was done for a benign condition • There was pathological documentation that the cervical epithelium had been completely removed • Smears before surgery were normal

PROCEDURE • AIM To obtain adequate representative sample from the squamo columnar junction also known as Transformation Zone or Transitional Zone

CERVICAL ANATOMY • Cervix is composed of columnar epithelium which lines the endocervical canal and the squamous epithelium which lines the exocervix. The point at which they meet is the squamo columnar junction • It is a dynamic point • In neonates -- at exocervix • At menarche – oestrogen stimulates the subcolumnar reserve cells to undergo metaplasia

• Hence metaplasia advances from the original SCJ inward, towards the external os. This process establishes an area called the Transformational Zone - extends from original SCJ to physiologically active SCJ.

NORMAL TRANSFORMATIONAL ZONE • Described as having four layers - The basal layer or germinal cells is a single row of immature cell with large nuclei and a small amount of cytoplasm. - The parabasal layer or prickle cell layer includes 2 to 4 rows of immature cells that have normal mitotic figures and provide the replacement cells for the overlying epithelium.

• The intermediate layer or navicular cells includes 4 to 6 rows of cells with large amount of cytoplasm in a polyhedral shape • Superficial layer or stratum corneum includes 5 to 8 rows of flattened cells with pyknotic nucleus and cytoplasm filled with glycogen.

PROCEDURE • Patient is put in dorsal position, labia parted, cusco’s speculum is gently introduced without lubricants or jelly. • A circumferential sample is obtained by turning the Ayre’s through 360 degrees. • As women advances at about 40 years the SCJ migrates into endocervix – cytobrush or cotton tipped applicator is used

• Not to take during active menstruation • Not to apply jelly • If excessive discharge wipe with cotton swab • Once the sample is obtained, a mono layer slide is made • After the sample is spread it is fixed immediately. Avoid air drying . • If aerosol fixative is used, it is directed at a distance of 25 cm

• Cells are fixed using 95 % ethyl alcohol for 15 minutes • After fixation slide is sent to cytology lab with complete requisition.

REPORTING OF A SLIDE – Normal cells:

• -Superficial cells – • Large mature polygonal cells with pyknotic nucleus • Intermediate cells – basophilic squamous cells with vesicular nuclei • Parabasal or basal cells – small, round or oval basophilic squamous cells

•

• Metaplastic cells • Small or large parabasal cells with prominent cell border eccentric nucleus and a large intracellular vacuole. • Malignant cells – hyperchromatic with great increase in chromatin content. Nuclear/cytoplasmic ratio is increased

BETHESDA SYSTEM • • • •

• • •

Within normal limits Infection (organism should be specified) Reactive and reparative changes Squamous cell abnormalities - Atypical squamous cells - of undetermined significance (ASC-US) - Exclude high grade lesions (ASC-H) Low grade squamous intraepithelial lesion (LSIL) High grade intraepithelial lesion (HSIL) Squamous cell carcinoma

WHO RECOMMENDATION • Unsatisfactory (reason to be stated) • No abnormal cells - Metaplasia • Abnormal cells consistent with benign atypia (non dysplastic) - Inflammatory effect - Trichomonas effect - Viral or yeast effect - Irradiation effect - Keratinization effect - Atypical metaplasia - Condyloma effect - Others

WHO RECOMMENDATION • Abnormal cells consistent with dysplasia - Mild dysplasia (CIN 1) - Moderate dysplasia (CIN 2) - Severe dysplasia (CIN 3) • Abnormal cells consistent with Malignancy - Consistent with insitu squamous carcinoma (CIN 3) - Consistent with invasive sq. ca

-Consistent with adeno ca. - Type unspecified • Abnormal cells not specifically classified - Comments

REFERENCES • Colposcopy Principles and practice – Barbara S. Apgar • Comprehensive cytopathology – sounders Bibbo • Nowarks Text book of Gynaecology

THANX