Abnormal Paps: DR Vidhi Chaudhary

ABNORMAL PAPS
DR VIDHI CHAUDHARY
ASSOCIATE PROFESSOR .DNB.,MRCOG(UK). DIP.
LAPROSCOPY(KIEL,GERMANY)
OBSTETRICS AND GYNAECOLOGY
LADY HARDINGE MEDICAL COLLEGE, DELHI
Cease of screening
 Women should be ceased from the programme where they do not have a cervix due to:
 • having undergone total hysterectomy (women with a subtotal hysterectomy remain at
risk and should remain in the programme)
• congenital absence of the cervix
• being a male-to-female transsexual
• having undergone a radical trachelectomy for cervical cancer
ABNORMALPAPS SMEAR
HPV triage and test of cure
 High negative predictive value of HR-HPV testing.

 Cervical samples - borderline changes (of squamous or endocervical type) or low-grade
dyskaryosis are given a reflex HR-HPV test.
 Those who are HPV positive are referred to colposcopy; those who are HR-HPV negative
are returned to routine recall.
 High-grade dyskaryosis or worse are referred straight to colposcopy without a HR-HPV
test
 ?Invasive squamous cell carcinoma – colposcopy
HR-HPV ‘test of cure’ protocol,
 After treatment for all grades of CIN- repeat cervical screening six months after
treatment.
 Negative, borderline change (of squamous or endocervical type), or low-grade
dyskaryosis is given an HR-HPV test. If the HPV test is negative, the woman is recalled
for a screening test in three years.
 IF NEGATIVE- ROURINE RECALL
 HR-HPV positive-colposcopy.
 High-grade dyskaryosis or worse are referred straight to colposcopy
?Glandular neoplasia
 originated from the endocervix, or the source -refer for colposcopy.

 If endometrium or another gynaecological site, the woman should be referred to a
gynaecology clinic.
Benign endometrial cells in cervical samples
 under the age of 40 do not indicate significant endometrial pathology

 n women aged over 40, who are beyond the twelfth day of the menstrual cycle except
- oral contraceptives,
-hormone replacement therapy, or tamoxifen,
-where an IUCD has been fitted
Evaluation required
Colposcopic examination
 The following data should be recorded at the colposcopic examination:

 Reason For Referral (100%)
 Grade Of Cytological Abnormality (100%)
 Whether The Examination Was Adequate Or Inadequate - For The Examination To Be
Adequate The Entire Cervix Must Be Seen (100%).
 The Presence Or Absence Of Vaginal And/Or Endocervical Extension
 The Colposcopic Features Of Any Lesion
 The Colposcopic Impression Of Lesion Grade
 The Type Of Transformation Zone, Ie Type 1,2 Or 3
 The Site Of Any Colposcopically Directed Biopsies
Colposcopically directed punch biopsy
 Unless an excisional treatment is planned, biopsy should be carried out when the cytology
indicates high-grade dyskaryosis (moderate) or worse, and always when a recognisably
atypical transformation zone is present (100%).
Invasive disease
 AN EXCISIONAL FORM OF BIOPSY is recommended (95%) in the following

circumstances:
• when most of the ectocervix is replaced with high-grade abnormality
• when low-grade colposcopic change is associated with high-grade dyskaryosis (severe) or
worse
• when a lesion extends into the endocervical canal, sufficient cervical tissue should be
excised to remove the entire endocervical lesion
 In the situations mentioned above, punch biopsies are not considered to be reliably
informative.
Treatment of CIN: Observation(CIN 1)
 Over 50% of CIN1 lesions will regress over 22 months

 Follow up of women with histologically confirmed CIN1 can either be by colposcopy or
community based cytology.
 The follow up interval should not be less than 12 months.
 Persistence beyond 24 mths- treatment
Treatment of CIN:Surgical
 Surgical techniques
 ABLATIVE Techniques are only suitable when:
 • the entire transformation zone is visualised (100%)
 • there is no evidence of glandular abnormality (100%)
 • there is no evidence of invasive disease (100%) • there is no major discrepancy between
cytology and histology.
 Only in exceptional circumstances should ablative treatment be considered for women
over 50 years of age.
Ablative techniques –low grade CIN
 Local destruction
 All women must have an established histological diagnosis before undergoing destructive
therapy (100%). Laser ablation
 Cryocautery- liquid nitrogen. a double freeze-thaw-freeze technique
Treatment of CIN :High grade : Excision
 The goal of excision is to remove all the abnormal epithelium.

 LLETZ, LEEP, CONE.
 CIN3 extending to margins after excision
- Reexcion if women is above 50 yrs or glandular abnormality or suspicion of invasion
 Type 1 cervical TZ -remove tissue to a depth/length of more than 7mm (<10MM)
 Type 2 cervical TZ -remove tissue to depth/length of 10mm to 15mm,
 Type 3 cervical TZ-f 15mm to 25mm
CIN :Follow up after treatment: TOC
Management of glandular abnormalities
 Colposcopic punch biopsy is of low sensitivity for diagnosis of

intraepithelial glandular lesions.
 An excisional biopsy including the endocervical canal is required.
 A cylindrically-shaped cervical excisional biopsy, including the whole
transformation zone (TZ) and at least 1cm of endocervix above the SCJ is
appropriate.
 OLD women- TZ not visible-, a cylindrical biopsy should be taken that
includes all of the visible TZ and 20mm to 25mm of the endocervical canal
Conservative management of confirmed HG-
CGIN
 High-grade cervical glandular intraepithelial neoplasia (HG-CGIN)

often occurs in young women.
 Conservative management is recommended for those wishing to
retain fertility, if the margins of the excisional specimen are
negative and invasion is excluded
Hysterectomy for cervical glandular neoplasia
 Fertility Is Not Required

 There Are Positive Margins After An Adequate Excisional Procedure
 Treatment By Cone Biopsy Is Followed By Further High Grade Cytological
Abnormality
 The Patient Is Unwilling To Undergo Conservative Management
 Adequate Cytological Follow Up Has Not Been Possible, Eg Because Of Cervical
Stenosis
 The Patient Has Other Clinical Indications For The Procedure
 Invasive disease has been confidently excluded.
Previous treatment for CGIN: Follow up
 Women who undergo excision for CGIN are at risk of recurrence.

 CGIN has been completely excised, at the time of first excision or subsequent re-excision, a test of
cure (TOC) sample should be taken six months after treatment.
 If negative for cytology (endocervical cells must be present) and negative for HR-HPV a second
TOC sample is taken 12 months later (ie 18 months after treatment)
 if both negative for cytology and HR-HPV the woman can be discharged to recall in three
years.
 If either cytology or HR-HPV, at six or 18 months after treatment, is positive the woman should
be referred to colposcopy.
Previous treatment for CGIN : Failed TOC
 HRHPV
If the woman fails TOC at six months only because of a positive HR-HPV test and NORMAL colposcopic
examination-
-second TOC sample 12 months later, if this sample is negative for cytology and HR-HPV the woman - recall
in three years.
 CYTOLOGY
 If a positive cytology result is reported in either of the six or 18 months ‘TOC’ samples Refer to
colposcopy.
 If no colposcopic abnormality is present and re-excision is not appropriate orthere is incompletely
excised CGIN and have declined re-excision the women should revert to ten years of cytology follow up.
Follow-up after a hysterectomy with CIN
 Risk of VaIN
 Completely excised CIN should have vaginal vault cytology at six and 18 months
 Incompletely excised CIN (or uncertain excision), follow up should be as if their cervix
remained in situ –
 CIN 1: vault cytology at six, 12 and 24 months
 CIN 2/3: vault cytology at six and 12 months, followed by nine annual vault cytology
samples – follow up continues to 65 years or until ten years after surgery (whichever is
later) •
Follow up of stage Ia1
 If conservative treatment for cervical cancer has been performed, leaving a residual
cervix, cytological follow up is recommended.
 Cervical cytology should be taken six and 12 months after treatment,
 Followed by annual cytology for the next nine years before return to routine recall to 65
years
Pregnancy: screening
 Abnormal cytology should undergo colposcopy in late first or early second trimester
 Low-grade changes triaged to colposcopy on the basis of a positive HPV test, -assessment
may be delayed until after delivery
 ‘Test Of Cure’ appointment should not be delayed after treatment for CIN2 or CIN3 with
involved or uncertain margin status or cGIN
Colposcopic evaluation of the pregnant
woman
:
 CIN1 or less is suspected, repeat the examination three months following delivery
 CIN2 or CIN3 is suspected, repeat colposcopy at the end of the second trimester. If the
pregnancy has already advanced beyond that point, repeat three months following
delivery
 Invasive disease is suspected clinically or colposcopically, a biopsy adequate to make the
diagnosis is essential (Cone, wedge, and diathermy loop )

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ABNORMAL PAPS

 High negative predictive value of HR-HPV testing.

 originated from the endocervix, or the source -refer for colposcopy.

 under the age of 40 do not indicate significant endometrial pathology

 The following data should be recorded at the colposcopic examination:

 AN EXCISIONAL FORM OF BIOPSY is recommended (95%) in the following

 Over 50% of CIN1 lesions will regress over 22 months

 The goal of excision is to remove all the abnormal epithelium.

 Colposcopic punch biopsy is of low sensitivity for diagnosis of

 High-grade cervical glandular intraepithelial neoplasia (HG-CGIN)

 Fertility Is Not Required

 Women who undergo excision for CGIN are at risk of recurrence.

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