Departement of Anatomical Pathology

Materi Praktikum Patologi Anatomi Modul Repoduksi

Pap smear dan Biopsi

dr. Susilorini

Departement of Anatomical Pathology

Medical Faculty of Sultan Agung Islamic University

Risk factors and causes of Risk factors and causes of cervical cancercervical cancer

Doctors cannot always explain why one woman develops Doctors cannot always explain why one woman develops cervical cancer and another does not. However, we do cervical cancer and another does not. However, we do know that a woman with certain risk factors may be more know that a woman with certain risk factors may be more likely than others to develop cervical cancer. A risk factor is likely than others to develop cervical cancer. A risk factor is something that may increase the chance of developing a something that may increase the chance of developing a disease.disease.

Women who think they may be at risk for cancer of the Women who think they may be at risk for cancer of the cervix should discuss this concern with their doctor. They cervix should discuss this concern with their doctor. They may want to ask about a schedule for checkups. If a woman may want to ask about a schedule for checkups. If a woman has an HPV infection, her doctor can discuss ways to avoid has an HPV infection, her doctor can discuss ways to avoid infecting other people. infecting other people.

The Pap test can detect cell changes in the cervix caused The Pap test can detect cell changes in the cervix caused by HPV. Treatment of these cell changes can prevent by HPV. Treatment of these cell changes can prevent cervical cancer. There are several treatment methods, cervical cancer. There are several treatment methods, including freezing or burning the infected tissue. including freezing or burning the infected tissue. Sometimes medicine also helpsSometimes medicine also helps

Studies have found a number of factors that may increase Studies have found a number of factors that may increase the risk of cervical cancer. These factors may act together the risk of cervical cancer. These factors may act together

to increase the risk even more:to increase the risk even more:

Human papillomaviruses (HPVs):Human papillomaviruses (HPVs): HPV infection is the main risk HPV infection is the main risk factor for cervical cancer. HPV is a group of viruses that can infect factor for cervical cancer. HPV is a group of viruses that can infect the cervix. HPV infections are very common. These viruses can be the cervix. HPV infections are very common. These viruses can be passed from person to person through sexual contact. Most adults passed from person to person through sexual contact. Most adults have been infected with HPV at some time in their lives. Some have been infected with HPV at some time in their lives. Some types of HPV can cause changes to cells in the cervix. These types of HPV can cause changes to cells in the cervix. These changes can lead to genital warts, cancer, and other problems. changes can lead to genital warts, cancer, and other problems. Doctors may check for HPV even if there are no warts or other Doctors may check for HPV even if there are no warts or other symptoms.symptoms.

Lack of regular Pap tests:Lack of regular Pap tests: Cervical cancer is more common Cervical cancer is more common among women who do not have regular Pap tests. The Pap test among women who do not have regular Pap tests. The Pap test helps doctors find precancerous cells. Treating precancerous helps doctors find precancerous cells. Treating precancerous cervical changes often prevents cancer.cervical changes often prevents cancer.

Weakened immune systemWeakened immune system (the body's natural defense (the body's natural defense system): Women with HIV (the virus that causes AIDS) infection or system): Women with HIV (the virus that causes AIDS) infection or who take drugs that suppress the immune system have a higher-who take drugs that suppress the immune system have a higher-than-average risk of developing cervical cancer. For these women, than-average risk of developing cervical cancer. For these women, doctors suggest regular screening for cervical cancer.doctors suggest regular screening for cervical cancer.

Age:Age: Cancer of the cervix occurs most often in women over the Cancer of the cervix occurs most often in women over the age of 40.age of 40.

Sexual history:Sexual history: Women who have had many sexual partners have a Women who have had many sexual partners have a higher-than-average risk of developing cervical cancer. Also, a woman higher-than-average risk of developing cervical cancer. Also, a woman who has had sexual intercourse with a man who has had many sexual who has had sexual intercourse with a man who has had many sexual partners may be at higher risk of developing cervical cancer. In both partners may be at higher risk of developing cervical cancer. In both cases, the risk of developing cervical cancer is higher because these cases, the risk of developing cervical cancer is higher because these women have a higher-than-average risk of HPV infection.women have a higher-than-average risk of HPV infection.

Smoking cigarettes:Smoking cigarettes: Women with an HPV infection who smoke Women with an HPV infection who smoke cigarettes have a higher risk of cervical cancer than women with HPV cigarettes have a higher risk of cervical cancer than women with HPV infection who do not smoke.infection who do not smoke.

Using birth control pills for a long time:Using birth control pills for a long time: Using birth control pills Using birth control pills for a long time (5 or more years) may increase the risk of cervical for a long time (5 or more years) may increase the risk of cervical cancer among women with HPV infection.cancer among women with HPV infection.

Having many children:Having many children: Studies suggest that giving birth to many Studies suggest that giving birth to many children may increase the risk of cervical cancer among women with children may increase the risk of cervical cancer among women with HPV infection. HPV infection.

Diethylstilbestrol (DES) may increase the risk of a rare form of cervical Diethylstilbestrol (DES) may increase the risk of a rare form of cervical cancer and certain other cancers of the reproductive system in cancer and certain other cancers of the reproductive system in daughters exposed to this drug before birth. DES was given to some daughters exposed to this drug before birth. DES was given to some pregnant women in the United States between about 1940 and 1971. pregnant women in the United States between about 1940 and 1971. (It is no longer given to pregnant women.)(It is no longer given to pregnant women.)

Symptoms of cervical cancerSymptoms of cervical cancer

Precancerous changes and early cancers of the cervix generally do Precancerous changes and early cancers of the cervix generally do not cause pain or other symptoms. It is important not to wait to not cause pain or other symptoms. It is important not to wait to feel pain before seeing a doctor.feel pain before seeing a doctor.

When the disease gets worse, women may notice one or more of When the disease gets worse, women may notice one or more of these symptoms:these symptoms:

Abnormal vaginal bleedingAbnormal vaginal bleeding Bleeding that occurs between regular menstrual periodsBleeding that occurs between regular menstrual periods Bleeding after sexual intercourse, douching, or a pelvic examBleeding after sexual intercourse, douching, or a pelvic exam Menstrual periods that last longer and are heavier than beforeMenstrual periods that last longer and are heavier than before Bleeding after menopauseBleeding after menopause

Increased vaginal dischargeIncreased vaginal discharge Pelvic painPelvic pain Pain during sexual intercourse Pain during sexual intercourse Infections or other health problems may also cause these Infections or other health problems may also cause these

symptoms. Only a doctor can tell for sure. A woman with any of symptoms. Only a doctor can tell for sure. A woman with any of these symptoms should tell her doctor so that problems can be these symptoms should tell her doctor so that problems can be diagnosed and treated as early as possible.diagnosed and treated as early as possible.

In In gynecologygynecology, the , the Papanikolaou testPapanikolaou test or or Papanicolaou testPapanicolaou test (also called (also called Pap smearPap smear, , Pap testPap test, , cervical smearcervical smear, or , or smear testsmear test) is a medical ) is a medical screeningscreening method, invented independently by method, invented independently by Aurel BabeşAurel Babeş[1][1] and and Georgios PapanikolaouGeorgios Papanikolaou. .

Primarily designed to detect premalignant and Primarily designed to detect premalignant and malignant processes in the malignant processes in the ectocervixectocervix. It may also . It may also detect infections and abnormalities in the endocervix detect infections and abnormalities in the endocervix and endometrium.and endometrium.

The test aims to detect and prevent the The test aims to detect and prevent the progression of HPV-induced progression of HPV-induced cervical cancercervical cancer and other abnormalities in the female and other abnormalities in the female genitalgenital tract by sampling tract by sampling cellscells from the outer opening from the outer opening of the of the cervixcervix (Latin for "neck") of the (Latin for "neck") of the uterusuterus and the endocervix. and the endocervix.

The endocervix may be partially sampled with the The endocervix may be partially sampled with the device used to obtain the ectocervical sample, but due device used to obtain the ectocervical sample, but due to the anatomy of this area, consistent and reliable to the anatomy of this area, consistent and reliable sampling cannot be guaranteed. As abnormal sampling cannot be guaranteed. As abnormal endocervical cells may be sampled, those examining endocervical cells may be sampled, those examining them are taught to recognize them.them are taught to recognize them.

The endometrium is not directly sampled with the The endometrium is not directly sampled with the device used to sample the ectocervix. Cells may device used to sample the ectocervix. Cells may exfoliate onto the cervix and be collected from there, exfoliate onto the cervix and be collected from there, so as with endocervical cells, abnormal cells can be so as with endocervical cells, abnormal cells can be recognised if present but the Pap Test should not be recognised if present but the Pap Test should not be used as a screening tool for endometrial malignancy.used as a screening tool for endometrial malignancy.

It is generally recommended that females who have It is generally recommended that females who have had sex seek regular Pap smear testing. Guidelines on had sex seek regular Pap smear testing. Guidelines on frequency vary, from annually to every five years. If frequency vary, from annually to every five years. If results are abnormal, and depending on the nature of results are abnormal, and depending on the nature of the abnormality, the test may need to be repeated in the abnormality, the test may need to be repeated in three to twelve months.three to twelve months.

If the abnormality requires closer scrutiny, the If the abnormality requires closer scrutiny, the patient may be referred for detailed inspection of the patient may be referred for detailed inspection of the cervix by cervix by colposcopycolposcopy. The patient may also be . The patient may also be referred for referred for HPV DNA testingHPV DNA testing, which can serve as an , which can serve as an adjunct to Pap testingadjunct to Pap testing

Diagnosis of cervical cancer

If a woman has a symptom or Pap test results that suggest precancerous cells or cancer of the cervix, her doctor will suggest other procedures to make a diagnosis.

These may include: Colposcopy: The doctor uses a colposcope to look at

the cervix. The colposcope combines a bright light with a magnifying lens to make tissue easier to see. It is not inserted into the vagina. A colposcopy is usually done in the doctor's office or clinic.

Biopsy: The doctor removes tissue to look for precancerous cells or cancer cells. Most women have their biopsy in the doctor's office with local anesthesia.

A pathologist checks the tissue with A pathologist checks the tissue with a microscopea microscope

• Punch biopsy: The doctor uses a sharp, hollow device to Punch biopsy: The doctor uses a sharp, hollow device to pinch off small samples of cervical tissue.pinch off small samples of cervical tissue.

• LEEP: The doctor uses an electric wire loop to slice off a LEEP: The doctor uses an electric wire loop to slice off a thin, round piece of tissue.thin, round piece of tissue.

• Endocervical curettage: The doctor uses a curette (a Endocervical curettage: The doctor uses a curette (a small, spoon-shaped instrument) to scrape a small small, spoon-shaped instrument) to scrape a small sample of tissue from the cervical canal. Some doctors sample of tissue from the cervical canal. Some doctors may use a thin, soft brush instead of a curette.may use a thin, soft brush instead of a curette.

• Conization: The doctor removes a cone-shaped sample Conization: The doctor removes a cone-shaped sample of tissue. A conization, or cone biopsy, lets the of tissue. A conization, or cone biopsy, lets the pathologist see if abnormal cells are in the tissue pathologist see if abnormal cells are in the tissue beneath the surface of the cervix. The doctor may do beneath the surface of the cervix. The doctor may do this test in the hospital under general anesthesia. this test in the hospital under general anesthesia. Conization also may be used to remove a precancerous Conization also may be used to remove a precancerous area.area.

It is not a perfect test. "A nurse performing It is not a perfect test. "A nurse performing 200 tests each year would prevent a death 200 tests each year would prevent a death

once in 38 years. once in 38 years. During this time she or he would care for During this time she or he would care for over 152 women with abnormal results, over 152 women with abnormal results, over 79 women would be referred for over 79 women would be referred for

investigation, over 53 would have investigation, over 53 would have abnormal biopsy results, and over 17 abnormal biopsy results, and over 17

would have persisting abnormalities for would have persisting abnormalities for more than two years. more than two years.

At least one woman during the 38 years At least one woman during the 38 years would die from cervical cancer despite would die from cervical cancer despite

being screened."being screened."[2][2]

Slide PreparationSlide Preparation::

The Traditional Method:The Traditional Method: the conventional method of preparation for the conventional method of preparation for the laboratory is to spread the collected material on a glass slide and to the laboratory is to spread the collected material on a glass slide and to fix it immediately either by spraying the slide or by immersing it in vial of fix it immediately either by spraying the slide or by immersing it in vial of preservative. To avoid air-drying errors in the interpretation the slide preservative. To avoid air-drying errors in the interpretation the slide should be fixed right away. Sometimes the smears placed on the glass should be fixed right away. Sometimes the smears placed on the glass slide are thick and difficult to analyze. slide are thick and difficult to analyze.

The ThinPrep:The ThinPrep: the liquid-based system uses a proprietary fixative into the liquid-based system uses a proprietary fixative into which the clinician places the collection devices. The devices are which the clinician places the collection devices. The devices are agitated for a prescribed period, and the vial containing the fixative is agitated for a prescribed period, and the vial containing the fixative is sealed, labeled, and forwarded to the laboratory where the slide actually sealed, labeled, and forwarded to the laboratory where the slide actually is prepared. The U.S. Food and Drug Administration (FDA) allows the is prepared. The U.S. Food and Drug Administration (FDA) allows the ThinPrep technique to be marketed as better able to detect both low-ThinPrep technique to be marketed as better able to detect both low-grade and high-grade squamous intraepithelial lesions (LSIL and HSIL, grade and high-grade squamous intraepithelial lesions (LSIL and HSIL, respectively) than the conventional method of preparation (3). respectively) than the conventional method of preparation (3).

The SurePath System:The SurePath System: it also uses a proprietary preservative solution it also uses a proprietary preservative solution into which a supplied collection device is placed. The liquid and the into which a supplied collection device is placed. The liquid and the collection device are sent to the laboratory. The FDA has approved this collection device are sent to the laboratory. The FDA has approved this technique for use and allows it to be marketed as equivalent to the technique for use and allows it to be marketed as equivalent to the conventional Pap test. Several other methods of cell collection and conventional Pap test. Several other methods of cell collection and preparation currently are in development. None of these had yet received preparation currently are in development. None of these had yet received FDA approval. FDA approval.

Methods of CollectionMethods of Collection

In the recent past, adaptation in the collection and preparation In the recent past, adaptation in the collection and preparation methods, new methods of interpretation, and the introduction methods, new methods of interpretation, and the introduction of adjunctive tests have been shown to improve the sensitivity of adjunctive tests have been shown to improve the sensitivity of the Pap test without markedly decreasing its specificity. of the Pap test without markedly decreasing its specificity.

Originally, cervical cells samples were obtained from the Originally, cervical cells samples were obtained from the posterior vaginal pool. It has been shown repeatedly that this posterior vaginal pool. It has been shown repeatedly that this is a poor source of cells and that the sample should be is a poor source of cells and that the sample should be collected only from the portio and endocervix. collected only from the portio and endocervix.

Cervical cytology samples should be obtained using either a Cervical cytology samples should be obtained using either a spatula and endocervical brush or an instrument that can spatula and endocervical brush or an instrument that can collect cells from both the ectocervix and endocervix. collect cells from both the ectocervix and endocervix.

Technical aspectsTechnical aspects Samples are collected from the outer Samples are collected from the outer

opening or opening or osos of the cervix using an of the cervix using an Aylesbury spatulaAylesbury spatula and an endocervical and an endocervical brush, or (more frequently with the advent brush, or (more frequently with the advent of of liquid-based cytologyliquid-based cytology) a plastic-fronded ) a plastic-fronded broom. The broom is not as good a broom. The broom is not as good a collection device, since it is much less collection device, since it is much less effective at collecting endocervical effective at collecting endocervical material as the spatula and brush.material as the spatula and brush.[3][3]

The cells are placed on a glass slide and The cells are placed on a glass slide and checked for abnormalities in the checked for abnormalities in the laboratorylaboratory..

1.Micro anatomy of the uterine cervix: 1= Nulliparous, 2= Multiparous (A: external os, pink area = non keratinized squamous epithelium, purple area = glandular epithelium composed of one layer of mucin secreting and ciliated cells).

2. Micro anatomy of the uterine cervix: 1 = Nulliparous, 3 = Menopausal (A: External os, violet area = non-keratinized squamous epithelium, purple area = glandular epithelium composed of one layer of mucin secreting and ciliated cells).

Practical aspectsPractical aspects

The physician or operator collecting a sample for the test inserts a The physician or operator collecting a sample for the test inserts a speculumspeculum into the patient's vagina, to obtain a cell sample from the into the patient's vagina, to obtain a cell sample from the cervixcervix. .

A pap smear appointment is normally not scheduled during menstruation.A pap smear appointment is normally not scheduled during menstruation. The procedure is usually painful, because of the neuroanatomy of the The procedure is usually painful, because of the neuroanatomy of the

cervix. However, this can depend on the patient's cervix. However, this can depend on the patient's anatomyanatomy, the skill of the , the skill of the practitioner, psychological factors, and other conditions. Results usually practitioner, psychological factors, and other conditions. Results usually take about 3 weeks.take about 3 weeks.

Slight bleeding, cramps, and other discomfort can occur afterwards.Slight bleeding, cramps, and other discomfort can occur afterwards. Other tests, including the TruTest, an Other tests, including the TruTest, an endometrial biopsyendometrial biopsy used for early used for early

detection of uterine cancer, can be performed during the same visit.detection of uterine cancer, can be performed during the same visit.

Smear sampling/slide preparation for conventional cytologySmearing of the exocervical sample with a wooden spatula (Ayre's spatula). Some may have a longer bifid extremity for a better endocervical sampling

Smearing of the endocervical sample taken with the thinner

extremity of the wooden spatula.

Spray fixation: immediate, during a few seconds, with a spray/slide distance around 20 cm.

1Scanning electron 1Scanning electron microscopy: superficial cells microscopy: superficial cells

and Döderlein bacilliand Döderlein bacilli

superficial cell, scanning electron microscopy: flat cell with a small nucleus (arrow).

superficial cell, scanning electron microscopy: Flat cell with traces of other cells and several Döderlein bacilli.

The sample is stained using the The sample is stained using the Papanicolaou technique, in which Papanicolaou technique, in which tinctorialtinctorial dyes and acids are selectively retained by dyes and acids are selectively retained by cells. cells.

Unstained cells can not be visualized with Unstained cells can not be visualized with light microscopy. The stains chosen by light microscopy. The stains chosen by Papanicolau were selected to highlight Papanicolau were selected to highlight cytoplasmic keratinization, which actually cytoplasmic keratinization, which actually has almost nothing to do with the nuclear has almost nothing to do with the nuclear features used to make diagnoses now.features used to make diagnoses now.

Studies of the accuracy of Studies of the accuracy of conventional cytology report:conventional cytology report:[4][4]

sensitivity 72% sensitivity 72% specificity 94% specificity 94%

Liquid based monolayer Liquid based monolayer cytologycytology

Since the mid-1990s, techniques Since the mid-1990s, techniques based around placing the sample based around placing the sample into a vial containing a liquid medium into a vial containing a liquid medium which preserves the cells have been which preserves the cells have been increasingly used. The media are increasingly used. The media are primarily primarily ethanolethanol based. based.

Two of the types are Two of the types are Sure-PathSure-Path ( (TriPath ImagingTriPath Imaging) and ) and Thin-PrepThin-Prep ( (Cytyc CorpCytyc Corp). ).

Smear sampling/slide preparation for liquid-based cytology  

Once placed into the vial, the sample is Once placed into the vial, the sample is processed at the laboratory into a cell processed at the laboratory into a cell thin-layer, stained, and examined by light thin-layer, stained, and examined by light microscopy. microscopy.

The liquid sample has the advantage of The liquid sample has the advantage of being suitable for low and high risk HPV being suitable for low and high risk HPV testing and reduced unsatisfactory testing and reduced unsatisfactory specimens from 4.1% to 2.6%.specimens from 4.1% to 2.6%.[5][5]

Proper sample acquisition is crucial to the Proper sample acquisition is crucial to the accuracy of the test; clearly, a cell that is accuracy of the test; clearly, a cell that is not in the sample cannot be evaluatednot in the sample cannot be evaluated

Studies of the accuracy of liquid Studies of the accuracy of liquid based monolayer cytology report:based monolayer cytology report:

sensitivity 61%sensitivity 61%[6][6] to 66% to 66%[4][4] specificity 82%specificity 82%[6][6] to 91% to 91%[4][4]

Some[5], but not all studies[4][6], report increased sensitivity from the liquid based smears

Human papillomavirus Human papillomavirus testingtesting

The presence of The presence of HPVHPV indicates that the indicates that the person has been infected, the majority of person has been infected, the majority of women who get infected will successfully women who get infected will successfully clear the infection within 18 months. It is clear the infection within 18 months. It is those who have an infection of prolonged those who have an infection of prolonged duration with high risk typesduration with high risk types[7][7] (e.g. (e.g. types 16,18,31,45) that are more likely types 16,18,31,45) that are more likely to develop Cervical Intraepithelial to develop Cervical Intraepithelial Neoplasia due to the effects that HPV Neoplasia due to the effects that HPV has on DNAhas on DNA

Studies of the accuracy of Studies of the accuracy of HPVHPV testing report:testing report:

sensitivity 88% to 91% (for detecting sensitivity 88% to 91% (for detecting CIN 3 or higher)CIN 3 or higher)[6][6] to 97% (for to 97% (for detecting CIN2+)detecting CIN2+)[8][8]

specificity 73% to 79% (for detecting specificity 73% to 79% (for detecting CIN 3 or higher)CIN 3 or higher)[6][6] to 93% (for to 93% (for detecting CIN 3 or higher)detecting CIN 3 or higher)[8][8]

By adding the more By adding the more sensitivesensitive HPV Test, the HPV Test, the specificityspecificity may may decline. However, the drop in specificity is not definite. decline. However, the drop in specificity is not definite. [9][9]

If the If the specificityspecificity does decline, this results in increased does decline, this results in increased numbers of false positive tests and many women who did numbers of false positive tests and many women who did not have disease having colposcopynot have disease having colposcopy[10][10] and treatment. and treatment.

A worthwhile A worthwhile screeningscreening test requires a balance between the test requires a balance between the sensitivitysensitivity and and specificityspecificity to ensure that those having a to ensure that those having a disease are correctly identified as having it and equally disease are correctly identified as having it and equally importantly those not identifying those without the disease importantly those not identifying those without the disease as having it. Due to the liquid based pap smears having a as having it. Due to the liquid based pap smears having a false negative rate of 15-35%, the false negative rate of 15-35%, the American College of Obstetricians and GynecologistsAmerican College of Obstetricians and Gynecologists[[citation neededcitation needed] and ] and American Society for Colposcopy and Cervical PathologyAmerican Society for Colposcopy and Cervical Pathology[11][11] have recommended the use of have recommended the use of HPVHPV testing in addition testing in addition to the pap smear in all women over the age of 30.to the pap smear in all women over the age of 30.

Due to the liquid based pap smears Due to the liquid based pap smears having a false negative rate of 15-35%, having a false negative rate of 15-35%, the the American College of Obstetricians and American College of Obstetricians and GynecologistsGynecologists[[citation neededcitation needed] and ] and American Society for Colposcopy and CAmerican Society for Colposcopy and Cervical Pathologyervical Pathology[11][11] have recommended the use of have recommended the use of HPVHPV testing in addition to the pap testing in addition to the pap smear in all women over the age of 30.smear in all women over the age of 30.

Regarding the role of Regarding the role of HPVHPV testing, testing, randomized controlled trialsrandomized controlled trials have have compared compared HPVHPV to to colposcopycolposcopy..

HPVHPV testing appears as testing appears as sensitivesensitive as as immediate immediate colposcopycolposcopy while reducing the while reducing the number of colposcopies needed.number of colposcopies needed.[12][12]

Randomized controlled trialRandomized controlled trial have have suggested that suggested that HPVHPV testing could follow testing could follow abnormal cytologyabnormal cytology[6][6] or could precede or could precede cervical cytology examination.cervical cytology examination.[8][8]

A study published in April 2007 suggested A study published in April 2007 suggested the act of performing a Pap smear the act of performing a Pap smear produces an inflammatory produces an inflammatory cytokinecytokine response, which may initiate immunologic response, which may initiate immunologic clearance of HPV, therefore reducing the clearance of HPV, therefore reducing the risk of cervical cancer. risk of cervical cancer.

Women who had even a single Pap smear Women who had even a single Pap smear in their history had a lower incidence of in their history had a lower incidence of cancer. "A statistically significant decline cancer. "A statistically significant decline in the HPV positivity rate correlated with in the HPV positivity rate correlated with the lifetime number of Pap smears the lifetime number of Pap smears received."received."[13][13]

Automated analysisAutomated analysis

In the last decade there have been In the last decade there have been successful attempts to develop successful attempts to develop automated, computer image analysis automated, computer image analysis systems for screening.systems for screening.[14][14]

Automation may improve Automation may improve sensitivitysensitivity and and reduce unsatisfactory specimens.reduce unsatisfactory specimens.[15][15]

One of these has been FDA approved and One of these has been FDA approved and functions in high volume reference functions in high volume reference laboratories, with human oversight.[laboratories, with human oversight.[citation neededcitation needed]]

Automated Slide Interpretation:Automated Slide Interpretation:

Because the interpretation of cervical cytology is Because the interpretation of cervical cytology is labor intensive, there has been great interest in labor intensive, there has been great interest in the development of computer-based systems that the development of computer-based systems that can read cervical cytology accurately. can read cervical cytology accurately.

The FocalPoint slide profiler has been approved The FocalPoint slide profiler has been approved by the FDA for primary screening of cervical by the FDA for primary screening of cervical cytology. This device identifies up to 25% of cytology. This device identifies up to 25% of slides as negative for CIN for which no human slides as negative for CIN for which no human review is required (4). Because computerized review is required (4). Because computerized interpretation may decrease turn-around time interpretation may decrease turn-around time and can potentially be cost saving, a number of and can potentially be cost saving, a number of corporations are developing slide interpretation corporations are developing slide interpretation products.products.

Various Diagnostic Various Diagnostic Terminologies:Terminologies:

Traditional Nomenclature :Squamous Traditional Nomenclature :Squamous atypia, Condyloma, Mild dysplasia, atypia, Condyloma, Mild dysplasia, Moderate dysplasia, Severe dysplasiaModerate dysplasia, Severe dysplasia

CIN Nomenclature: squamous atypia , CIN Nomenclature: squamous atypia , Condyloma, CIN I, CIN II, CIN III, Condyloma, CIN I, CIN II, CIN III, Carcinoma-in-situ (CIS) carcinoma invasiveCarcinoma-in-situ (CIS) carcinoma invasive

Bethesda System Nomenclature (SIL): Bethesda System Nomenclature (SIL): ASCUS. Low-grade SIL, High-grade SIL.ASCUS. Low-grade SIL, High-grade SIL.

The Bethesda 2001 Terminology The Bethesda 2001 Terminology Committee suggested that whenever Committee suggested that whenever a slide is prepared or interpreted a slide is prepared or interpreted using any form of automation, that using any form of automation, that fact should be mentioned in the fact should be mentioned in the report that is returned to the clinician report that is returned to the clinician

Matrix of Diagnostic CategoriesMatrix of Diagnostic Categories

Cytology of Squamous Cytology of Squamous EpitheliumEpithelium

During normal maturation, the squamous epithelium of the uterine During normal maturation, the squamous epithelium of the uterine

cervix can be conceptualized as differentiating from basal/reserve cervix can be conceptualized as differentiating from basal/reserve cells to parabasal cells to intermediate cells to superficial cells. cells to parabasal cells to intermediate cells to superficial cells. These four cells are the keys to the most common daily diagnostic These four cells are the keys to the most common daily diagnostic problem in cytology. The cytoplasm provides information about problem in cytology. The cytoplasm provides information about the origin and functional differentiation of a cell. the origin and functional differentiation of a cell.

For this reason, cytoplasmic features are used to determine the For this reason, cytoplasmic features are used to determine the degree of squamous differentiation. The cytoplasmic hallmarks of degree of squamous differentiation. The cytoplasmic hallmarks of squamous differentiation are distinct cell boundaries and the squamous differentiation are distinct cell boundaries and the accumulation of dense cytoplasm. accumulation of dense cytoplasm.

The nucleus provides information about the health of the cell The nucleus provides information about the health of the cell (whether it is normal, inflamed, hyperplastic, or neoplastic). (whether it is normal, inflamed, hyperplastic, or neoplastic).

Nuclear features determine where in the continuum of neoplastic Nuclear features determine where in the continuum of neoplastic transformation, or carcinogenesis, the cell may be. Changes in transformation, or carcinogenesis, the cell may be. Changes in nuclear size, configuration, and chromatin (hyperchromasia, nuclear size, configuration, and chromatin (hyperchromasia, coarsening, and eventually irregular distribution) and the coarsening, and eventually irregular distribution) and the appearance of visible nucleoli are the main nuclear features of appearance of visible nucleoli are the main nuclear features of ensuing carcinogenesis. ensuing carcinogenesis.

Inflammatory Changes and Inflammatory Changes and Specific InfectionsSpecific Infections

Pruritis and vaginal discharge are among the Pruritis and vaginal discharge are among the most common reasons that a woman seeks most common reasons that a woman seeks medical advice from her gynecologist. Although medical advice from her gynecologist. Although Pap smear can be useful in identifying specific Pap smear can be useful in identifying specific infectious agents, it should not be used in lieu of infectious agents, it should not be used in lieu of more effective diagnostic tests. Many things can more effective diagnostic tests. Many things can cause inflammation; the mere presence of cause inflammation; the mere presence of inflammatory change on Pap smear is a poor inflammatory change on Pap smear is a poor indicator of the presence of infection. indicator of the presence of infection. Inflammatory change can mimic dysplasia. Inflammatory change can mimic dysplasia. Patients with persistent inflammatory change are Patients with persistent inflammatory change are at high-risk for a bonafide squamous abnormality at high-risk for a bonafide squamous abnormality (cervical intraepithelial neoplasia/ squamous (cervical intraepithelial neoplasia/ squamous intraepithelial lesion). intraepithelial lesion).

Trichomonas Vaginalis:Trichomonas Vaginalis: this is an oval this is an oval or pear-shaped organism that varies from or pear-shaped organism that varies from 8 to 30 micro m. The trichomonad 8 to 30 micro m. The trichomonad nucleus (thin, elliptical) must be nucleus (thin, elliptical) must be identified to diagnose this infection. Red identified to diagnose this infection. Red granules in cytoplasm may be seen. granules in cytoplasm may be seen. Slightly enlarged, dark nuclei and Slightly enlarged, dark nuclei and perinuclear halos are common, perinuclear halos are common, mimicking low grade dysplasia mimicking low grade dysplasia

Leptothrix: it is mixed lactobacilli. The organisms are long, thin (less than half as thick as Candida) and flexible. If leptothrix is present, Trichomonas is usually present, but reverse is not true

Candida Species:Candida Species: it is associated with a it is associated with a change in vaginal glycogen flora or pH. change in vaginal glycogen flora or pH. For example: Pregnancy, late luteal phase For example: Pregnancy, late luteal phase of cycle, diabetes mellitus, of cycle, diabetes mellitus, immunosuppression, debilitating disease, immunosuppression, debilitating disease, steroids, birth control pills, broad spectrum steroids, birth control pills, broad spectrum antibiotics, chemotherapy are associated antibiotics, chemotherapy are associated with candida infection. Pseudohyphae with candida infection. Pseudohyphae (sticks) and yeast (stones) are seen. (sticks) and yeast (stones) are seen.

Actinomyces: it is associated with IUD use; rarely is associated with other foreign objects (tampons or pessaries). The patient may be asymptomatic or have pelvic pain. Cytologic findings are colonies of variably gram-positive, long, thin, filamentous bacteria that are reddish, branch are irregularly beaded, and radiate from central area.

Herpes: it can be asymptomatic or present as blisters, which can ulcerate and be painful. Herpes simplex types I and II are morphologically indistinguishable. The most characteristic cells are multinucleated and the nuclei mold each other. The nuclei are enlarged and the chromatin marginates, resulting in a ground glass appearance. There may be red nuclear inclusions. Late changes are characteristic and diagnostic; early changes can mimic CIN III. Patients with herpes infection are in high-risk group for CIN/SIL.

Gardnerella vaginalis (Bacterial Vaginosis): it is a gram-negative, comma-shaped coccobacillus. The bacteria tend to agglomerate onto squamous cells (clue cells). Smears usually show a characteristic granular blue background of small coccobacilli, but the background is otherwise clean, often accompanied by slight parakeratosis.

Chlamydia trachomatis: it is an obligate intracellular bacterium that is associated with granular cytoplasmic inclusions. It is the most common cause of non-gonococcal urethritis/ cervicitis. It may cause 20 to 25% of cases of pelvic inflammatory disease, which can result in infertility and ectopic pregnancy. Chlamydia trachomatis is frequently asymptomatic.

The value of Pap smear in diagnosing Chlamydia is uncertain. Fine vacuolization of metaplastic cells (having a "moth eaten" appearance) may correlate with high risk of infection. Nebular bodies though rare and difficult to see, may be more specific. Chlamydia changes can mimic low-grade dysplasia.

Differential Diagnosis of Dysplasia vs Differential Diagnosis of Dysplasia vs

Inflammatory ChangeInflammatory Change:: Inflamed nuclei are big, but not dark; or Inflamed nuclei are big, but not dark; or

dark, but not big. Red nuclei indicate dark, but not big. Red nuclei indicate inflammation. inflammation.

Dysplastic nuclei are big and dark. Blue Dysplastic nuclei are big and dark. Blue nuclei indicate true dysplasia. Dysplasia vs nuclei indicate true dysplasia. Dysplasia vs inflammation: matter of degree: more inflammation: matter of degree: more pleomorphic, larger nuclei; more irregular pleomorphic, larger nuclei; more irregular nuclear outline; more abnormal chromatin nuclear outline; more abnormal chromatin crisp and distinct; more cellular disorder. crisp and distinct; more cellular disorder. Halos: inflammatory vs kilocytotic (5).Halos: inflammatory vs kilocytotic (5).

The Pap smear is only a screening test for The Pap smear is only a screening test for cervical cancer; it has a low, but significant cervical cancer; it has a low, but significant diagnostic error rate. diagnostic error rate.

A "negative" report does not guarantee the A "negative" report does not guarantee the absence of cervical cancer. absence of cervical cancer.

Close surveillance of high-risk patients, including Close surveillance of high-risk patients, including those with multiple infections and heavy those with multiple infections and heavy inflammation, is important. inflammation, is important.

All abnormal Pap smear results should be All abnormal Pap smear results should be followed up, and of great importance suspicious followed up, and of great importance suspicious lesions should be biopsied and suspicious lesions should be biopsied and suspicious symptoms investigated, even when the Pap is symptoms investigated, even when the Pap is negative negative

Cytology of the Glandular Cytology of the Glandular Epithelium:Epithelium:

Endocervical cells are tall and columnar, and can be secretory or ciliated. Endocervical cells can be seen singly or in strips or sheets. See pictures below:

Endometrial cells can also form three-dimensional clusters of glandular cells, without central stroma. Endometrial cells can also form three-dimensional clusters of glandular cells, without central stroma. The cells are small and crowded, and the nuclei are usually degenerated and hyperchromatic can The cells are small and crowded, and the nuclei are usually degenerated and hyperchromatic can mimic carcinoma in situ. A common everyday problem in Pap smear diagnosis is distinguishing mimic carcinoma in situ. A common everyday problem in Pap smear diagnosis is distinguishing endometrial cells from endocervical cells. This can be important, since shedding of endometrial cells endometrial cells from endocervical cells. This can be important, since shedding of endometrial cells is abnormal in the second half of the menstrual cycle (especially past 40 years of age) or any time in is abnormal in the second half of the menstrual cycle (especially past 40 years of age) or any time in postmenopausal women. Abnormal shedding of endometrial cells carries with it an increased risk of postmenopausal women. Abnormal shedding of endometrial cells carries with it an increased risk of endometrial hyperplasia or neoplasia. See picture below: endometrial hyperplasia or neoplasia. See picture below:

Treatment of Cervical Lesions:Treatment of Cervical Lesions: What happens if my Pap smear is What happens if my Pap smear is

abnormal?abnormal? The current means of screening for The current means of screening for

cervical cancer is the Pap smear. If your cervical cancer is the Pap smear. If your Pap smear is abnormal the next step is Pap smear is abnormal the next step is colposcopycolposcopy. This procedure is performed . This procedure is performed in the office. Your doctor will use a special in the office. Your doctor will use a special binocular instrument, a colposcope, to look binocular instrument, a colposcope, to look at your cervix.at your cervix.

Colposcopy results: biopsies of Colposcopy results: biopsies of the cervixthe cervix

What is colposcopy?What is colposcopy?

Colposcopy is a gynecological procedure Colposcopy is a gynecological procedure that allows a physician to look directly that allows a physician to look directly

at the cervix with a microscope in order at the cervix with a microscope in order to detect and examine abnormalities of to detect and examine abnormalities of

the cervix the cervix

Why is colposcopy done?Why is colposcopy done? Colposcopy is done in one of two Colposcopy is done in one of two

circumstances: either when the result of a circumstances: either when the result of a Pap smearPap smear is abnormal or when the cervix is abnormal or when the cervix looks abnormal during the collection of a looks abnormal during the collection of a Pap smear. Pap smear.

Even if a Pap smear result is normal, Even if a Pap smear result is normal, colposcopy is ordered when the cervix colposcopy is ordered when the cervix appears visibly abnormal to the clinician appears visibly abnormal to the clinician performing the Pap smear. performing the Pap smear.

The purpose of the colposcopy is to The purpose of the colposcopy is to determine what is causing the abnormal determine what is causing the abnormal looking cervix or the abnormal Pap smear so looking cervix or the abnormal Pap smear so that appropriate treatment can be given.that appropriate treatment can be given.

During colposcopy, special tests (acetic During colposcopy, special tests (acetic acid wash, use of color filters, and acid wash, use of color filters, and sampling (biopsy) of tissues from the sampling (biopsy) of tissues from the cervix) can be done.cervix) can be done.

Colposcopy is not to be confused with Colposcopy is not to be confused with culdoscopyculdoscopy, which is the insertion of an , which is the insertion of an instrument through the wall of the vagina instrument through the wall of the vagina in order to view the pelvic area behind the in order to view the pelvic area behind the vagina vagina

What are the most common What are the most common treatments for HSIL?treatments for HSIL?

If your doctor determines that you have a If your doctor determines that you have a cervical lesion that is of high enough cervical lesion that is of high enough grade, they may advise you to have the grade, they may advise you to have the lesion removed. The two most popular lesion removed. The two most popular methods of removing cervical lesions are methods of removing cervical lesions are by "LEEP" or "by Cold Knife Cone". Both of by "LEEP" or "by Cold Knife Cone". Both of these procedures are quick, fairly these procedures are quick, fairly unintrusive, and typically have a quick unintrusive, and typically have a quick recovery time.recovery time.

What can the patient expect after the surgical procedure?There may be some mild crampy discomfort. Discharge may be expected post operation. They should shower and avoid tub baths. Do not use tampons or douche. Do not have intercourse for the alotted time suggested by your doctor.

Structure of the ectocervix : details of Structure of the ectocervix : details of the superficial layers : superficial cells the superficial layers : superficial cells (5 or 6 layers). The N/C ratio is very (5 or 6 layers). The N/C ratio is very low and the axis of cells is parallel to low and the axis of cells is parallel to

the basement membranethe basement membrane

. Structure of the ectocervix - details of basal, parabasal and intermediate layers: connective tissue, basal cells (one layer), parabasal cells (two layers), intermediate cells (some layers) with inter-cellular bridges. The N/C ratio of basal and parabasal cells is high.

Normal ectocervix   

. immunohistochemistry - . immunohistochemistry - antipankeratin (KL1) antibody, antipankeratin (KL1) antibody, positivity of intermediate and positivity of intermediate and superficial cells. Basal and superficial cells. Basal and

parabasal cells are negativeparabasal cells are negative PAS staining: intermediate and superficial cells rich in glycogen

. immunofluorescence - antibody against collagen IV - The epithelium has a continuous basement membrane (x). The basement membrane of the vessels is also labelled (arrow).

Normal endocervixNormal endocervix       

epithelium composed of one layer of mucin secreting cells with few ciliated cells (+).

epithelium composed of one layer of mucin secreting cells with numerous reserve cells. Slight hyperplasia of the reserve cells

transmission electron microscopy, endocervical cells covered with transmission electron microscopy, endocervical cells covered with microvilli (green arrows) and with numerous secretory vacuoles (red microvilli (green arrows) and with numerous secretory vacuoles (red

arrowsarrows

scanning electron microscopy, one ciliated cell with cilia (7 microns long)

. immunohistochemistry: the proliferative . immunohistochemistry: the proliferative activity as visualised by anti-Mib1 activity as visualised by anti-Mib1

antibody is limited to occasional basal antibody is limited to occasional basal and parabasal cells (circles)and parabasal cells (circles)

. immunohistochemistry with anti-CD1A antibody shows occasional dendritic cells (circles).

ReferencesReferences

• O'Dowd MJ, Philipp EE. The History of Obstetrics & Gynaecology. London: Parthenon Publishing Group; 1994: 547

• Raffle AE, Alden B, Quinn M, Babb PJ, Brett MT (2003). "Outcomes of screening to prevent cancer: analysis of cumulative incidence of cervical abnormality and modelling of cases and deaths prevented". BMJ 326 (7395): 901. doi:10.1136/bmj.326.7395.901. PMID 12714468.

• Martin-Hirsch P, Lilford R, Jarvis G, Kitchener HC. (1999). "Efficacy of cervical-smear collection devices: a systematic review and meta-analysis". Lancet 354 (9192): 1763–1770. PMID 10577637.

• Coste J, Cochand-Priollet B, de Cremoux P, et al (2003). "Cross sectional study of conventional cervical smear, monolayer cytology, and human papillomavirus DNA testing for cervical cancer screening". BMJ 326 (7392): 733. doi:10.1136/bmj.326.7392.733. PMID 12676841. ACP Journal Club

• Ronco G, Cuzick J, Pierotti P, et al (2007). "Accuracy of liquid based versus conventional cytology: overall results of new technologies for cervical cancer screening randomised controlled trial". doi:10.1136/bmj.39196.740995.BE. PMID 17517761.

• Kulasingam SL, Hughes JP, Kiviat NB, et al (2002). "Evaluation of human papillomavirus testing in primary screening for cervical abnormalities: comparison of sensitivity, specificity, and frequency of referral". JAMA 288 (14): 1749-57. PMID 12365959.

• Cuschieri KS, Cubie HA, Whitley MW, et al (2005). "Persistent high risk HPV infection associated with development of cervical neoplasia in a prospective population study". J. Clin. Pathol. 58 (9): 946-50. doi:10.1136/jcp.2004.022863. PMID 16126875.

• Cuzick J, Szarewski A, Cubie H, et al (2003). "Management of women who test positive for high-risk types of human papillomavirus: the HART study". Lancet 362 (9399): 1871-6. PMID 14667741.

• Arbyn M, Buntinx F, Van Ranst M, Paraskevaidis E, Martin-Hirsch P, Dillner J (2004). "Virologic versus cytologic triage of women with equivocal Pap smears: a meta-analysis of the accuracy to detect high-grade intraepithelial neoplasia". J. Natl. Cancer Inst. 96 (4): 280-93. PMID 14970277.

• Colposcopy and Treatment of Cervical Intraepithelial Neoplasia: A Beginner's Manual • Wright TC, Cox JT, Massad LS, Twiggs LB, Wilkinson EJ (2002). "2001 Consensus

Guidelines for the management of women with cervical cytological abnormalities". JAMA 287 (16): 2120-9. PMID 11966387.