Pathology (Laboratory)

Papanicolaou Smear (PART I)

28 January 2008

PAPANICOLAOU SMEAR
PAP SMEAR TERMINOLOGY
A. Previous Systems and the Bethesda System

Pap Classes Description Bethesda 2001

I Normal Normal and
variants
II Reactive Changes Reactive Changes
Atypia ASC, ASG
Koilocytosis Low Grade SIL
III CIN I Mild dysplasia Low Grade SIL
III CIN II Moderate dysplasia High Grade SIL
III CIN III Severe dysplasia High Grade SIL
IV Ca in situ, High Grade SIL
suspicious
V Invasive Microinvasion
(<3mm)
Frankly invasive
(>3mm)
CIN = cervical intraepithelial neoplasia, SIL = squamous
intraepithelial lesion

B. Pap Classes Are Out Because:

1. Do not reflect current understanding of pathology
2. Classes not transferrable to histology terms
3. No classes for non-cancerous entities A. Important Changes Over Older Systems:
4. No longer uniform 1. Pap considered a Medical Consult
5. Years of experience have demonstrated a lack of 2. Pathologist responsible for diagnosis
reproducibility 3. Referring physician provides history
4. Must have a statement of adequacy
C. To put it another way... One man's dysplasia is another 5. Recommendations regarding follow-up should be made
man's carcinoma-in-situ. by pathologist

THE BETHESDA SYSTEM (2001) B. The Bethesda System Report Includes:

1. Whether the pap is an adequate sample
2. Incidental findings such as evidence of infection
3. Evidence of lesions: low-grade SIL, high-grade SIL, or
cancer

C. New Bethesda System Classification Terms:

1. Low-grade squamous lntraepithelial lesion (low-grade
SIL)
a. Cellular changes associated with HPV
b. Mild (slight) dysplasia/CIN 1
2. High-grade squamous intraepithelial lesion (high-grade
SIL)"
a. Moderate dysplasia/CIN II
b. Severe dysplasia/CIN III
c. carcinoma in situ/CIN III
3. Atypical Squamous Cells (ASC)
a. Unspecified (ASC-US) - includes uspecified and
favor benign/inflammation
b. Cannot exclude HSIL (ASC-H)
4. Atypical Glandular Cells of Uncertian Significance (AGC)
AGC is broken down into favoring endocervical,
endometrial, or not otherwise specified origin or
endocervical adenocarcinoma in situ (AIS)
a. Unspecified (AGC-US)
b. Atypical glandular cells, favor neoplastic (AGC-H)

D. Endocervical cells - Used to determine the adequacy of a

pap smear.
1. Statistically significant relationship between patient
age/fertility state and yield of endocervical cells.

E. Miscellaneous
1. "Atypia" is used only if undetermined significance and
should include a recommendation for follow-up. (ASC
and ASG)
2. Descriptive diagnosis should be given to common
problems (changes due to trich, yeast, etc.) Do not trust
Pap smear to diagnose or exclude infections!!

virns, u & brim 1 of 4

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3. Metaplasia - The physiologic conversion of columnar sexual activity or than age 21

endocervical cells to flat exocervical squamous cells. age 21
Norman finding - no special follow-up needed. Screening At least every 3 Annually with
4. "Parakeratosis" is a term for the persistence of the frequency years conventional
nuclei of the keratinocytes into the stratum corneum cytology or every 2
(horny layer) of the skin. Parakeratosis is normal in the years with liquid-
epithelium of true mucus membranes of the mouth and based cytology.
vagina. After age 30,
5. "Dyskeratosis" is a term for abnormal, premature, or women with 3
imperfect characterization of the keratinocytes. consecutive normal
6. Hyperkeratosis implies increased keratin in the sample tests may be
and should be followed-up closely since there may be screened every 2-3
an increased risk of cancer. years.
Screening after No cytologic testing No cytologic testing
POINTS ABOUT THE PAP hysterectomy after total after total
A. Highly effective for screening only. It is not diagnostic. It hysterectomy for hysterectomy for
only identifies those at risk for dysplasia or cancer. benign condition benign condition
After age 65 (see After age 70 (see
B. False Negative Pap Smears: Rate = 5 - 50% -- 10 - 29% Discontinuation
below) below)
usually quoted. 80% are true false negatives, 20% are lab Routine screening Insufficient Not yet FDA
errors for HPV infection evidence approved. If
approved,
C. Repeating cervical smears. conventional or
1. LSUHSC Study: "Using follow-up cervical smears to liquid-based
monitor patients who have low-grade SILs carries cytology combined
unacceptable risks, and a diagnostic test such as with test for DNA
colposcopy is indicated." from high-risk HPV
2. ASCCP Consensus Guidelines recommend routine subtypes should be
colposcopy instead of repeated Paps since follow-up performed not more
cytological studies have usually had high rates of loss often than every 3
to follow-up, a 53% to 76% likelihood of abnormal years
follow-up cytology results requiring eventual
colposcopy, and a small but real risk of delaying the B. Cervical cancer screening should begin three years after the
identification of invasive cancers. onset of vaginal intercourse or by age 21. Data suggest that
there is little risk of missing an important cervical lesion
D. Inadequacies in Pap Smear Screening until three to five years after initial exposure to human
1. False negative Paps papillomavirus (HPV). Screening before the three-year
2. Failure to identify high risk patient at entry. period may result in overdiagnosis of cervical lesions that
3. Inaccurate or incomplete reports from the lab to clinic would regress spontaneously. An upper age limit is
to patient necessary for health care professionals who do not ask
4. Lack of adequate tracking and follow-up. patients about their sexual history and for adolescents who
5. Poor patient compliance. are unable or unwilling to disclose prior consensual or
nonconsensual intercourse. The need for cervical cancer
E. Summary of lesions missed by Pap: screening should not be the basis for the onset of
1. Occur outside of a large eversion. gynecologic care.
2. Small lesions.
3. Advanced invasive lesions since they have infection and C. Screening should be performed annually with conventional
necrotic tissue, which can obscure the true cytology. cervical cytology smears or every two years using liquid-
4. Rapidly progressive lesions. based cytology. After age 30, women who have had three
5. Lesions deep in the cervical canal. consecutive normal tests can be screened every two to
F. Factors That Diminish the Accuracy of Pap Smears - Clinician three years unless they have a history of in utero exposure
Factors to diethylstilbestrol (DES), are infected with human
1. Contamination with blood or oil-based lubricants immunodeficiency virus (HIV), or are immunocompromised
2. Mislabeled or unlabeled slides by organ transplantation, chemotherapy, or chronic
3. Inadequate clinical history corticosteroid treatment.
4. Inadequate sampling of the transformation zone
5. Slide material too thick or insufficient D. Cervical cancer screening can be discontinued at age 70 in
6. Performing pap in spite of obvious infection women with an intact cervix who have had at least three
documented, consecutive, normal cervical cytology tests
G. Factors That Diminish the Accuracy of Pap Smears - and no abnormal tests within the previous 10 years. Women
Laboratory Factors who have a history of cervical cancer or in utero exposure to
1. Confusing smears or names DES and women who are immunocompromised (including
2. Failure to identify dysplastic cells those infected with HIV) should continue cervical cancer
3. Misinterpretation of diagnostic cells screening as long as they are in good health.
4. Poorly controlled technical process
Guidelines for Obtaining a Pap Smear
Screening Intervals: 2002 ACS Recommendations for A. Visual inspection of the lower genital tract and cervix
Detection of Cervical Cancer through the speculum is a prerequisite to optimal sample
A. The guidelines are based on a literature review combined collection.
with expert opinion when sufficient evidence was not
available. B. The location and appearance of the transformation zone is
variable depending on such factors as vaginal pH,
Comparison of ACS guidelines with the USPSTF pregnancy, hormonal mileu (age), prior therapy, and
Guidelines on Screening for Cervical Cancer individual anatomy.
Criteria USPSTF guideline ACS 2002
guideline C. An optimal cervical specimen includes sampling of the
Age to initiate Optimum age Three years after squamous and columnar epithelium, encompassing in
screening unknown; within 3 the onset of sexual particular the transformation zone, where the majority of
years of onset of activity; no later cervical neoplasias arise.
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c. Immediately fix slide.

D. Collecting the Pap Smear
1. Label the frosted end of the glass slide with the
patient's name prior to collection.
2. Insert the speculum, which may be moistened with
water or saline if necessary. Traditionally, no other
lubricants are recommended. However, a recient
blinded study in 182 patients randomly assigned to
have either only warm water or a water soluble 2. Option #2
lubricant to assist speculum insertion, only 2 a. Smear the spatula sample across the slide; roll the
unsatisfactory smears were found among 93 patients brush material directly over the previously spread
with the lubricant and two were found among 89 using sample.
only warm water. They concluded that use of a water b. Immediately fix slide.
soluble lubricant on the vaginal introitus and external
speculum facilitates examination with no adverse effect
on Pap smear interpretation. However, do not use any
lubricants other than water or saline on Thin-prep slides
since they plug the filter and may produce an
unsatisfactory smear.
3. Visually inspect the cervix for abnormalities.
4. Identify the transformation zone and direct sampling 3. Option #3
efforts to encompass this area. a. Smear the spatula sample over the left-hand side
a. The endocervical limit of the transformation zone is of the slide, cover the right-hand side with
dynamic, defined by the leading edge of the cardboard and immediately spray fix.
migrating squamo-columnar junction. b. Roll the brush material onto the right-hand side of
b. In post menopausal women, it is often high in the the slide and spray fix.
endocervical canal and not visible.

E. Collecting the Pap Smear - Spatula

1. Choose the contoured end of the spatula which best
conforms to the cervix and the transformation zone.
2. Rotate the spatula 360o about the circumference of the
cervix, while maintaining firm contact with the epithelial
surface.
3. With a clockwise rotation beginning and ending at 9
o'clock (or counter-clockwise rotation from 3 o'clock to
3 o'clock), the collected material is retained on the
upper horizontal surface as the instrument is removed.
4. Do not smear the sample at this time unless you
immediately fix the specimen. Hold the spatula
between the fingers of the non-sampling hand (or rest it
on the glass slide with the specimen face-up), while the
cervical brush material is collected.
5. Spread the material collected on the spatula evenly
over the slide with a single smooth stroke motion.
I. Collecting the Pap Smear - Plastic "Broom"
1. Another collection instrument, a plastic "broom-like"
brush (Cervex-brush or Papette), simultaneously
samples the endocervix and ectocervix.
2. To use the "broom," insert the long central bristles into
the os until the lateral bristles bend against the
ectocervix. Rotate 3-5 times in both directions.
3. To transfer material, stroke both sides of the "broom"
across the glass slide. Place second stroke exactly over
the first stroke.

F. Collecting the Pap Smear - Cervix Brush

1. These brushes have circumferential bristles that come

into contact with the entire os surface on insertion.
2. The brush need only be turned 1/4 turn.
3. Roll the brush across the slide by twirling the handle.
4. Not currently recommended for pregnancy.

G. Collecting the Pap Smear

1. The object is to quickly but evenly spread the cellular
material in a monolayer on the slide.
2. Thin out large clumps of material as much as possible,
while avoiding excessive manipulation which can
damage cells.
3. Transfer material from both sampling instruments to the
slide within a few seconds and fix immediately in order
to avoid air-drying artifact.
4. Immediately fix the specimen by either immersing the
slide in 95% ethanol or coating the slide with a surface
fixative.
H. Spatula & Brush - 3 Options for Transferring Material:
1. Option #1
a. Smear the spatula on the upper half of the slide.
b. Roll the brush across the lower half of the slide.
J. Collecting the Pap Smear - Cotton Swab
1. The use of a cotton tip applicator is not recommended.
It usually provides less cellular samples, possibly
because of trapping of material in the cotton fibers.
2. "...one third of the cases with false negative cytologies
were limited by lack of an endocervical component; all
but one were obtained with the cotton swab"
NOTE:
Guys.. walang nakalagay na notes s powerpoint.. but nahanap ko
un site n pinagkunan ni doc.. nand2 n rin un mga notes ko. ;o)
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