PAP Smears

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-Albert Einstein once said He who joyfully
marches in rank and file, Has already earned my
contempt. He has been given a large brain by
mistake, Since for him the spinal cord would
suffice! 
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PAP Smears

• Dr. VM Shashidhar
• Senior Lecturer in Pathology
• Fiji School of Medicine

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Introduction

• Since the Pap examination was introduced after
  World War II, death rates from uterine cervical
  cancer have decreased by 70 in the US.
• PAP smear is the most effective cancer screening
  test so far

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PAP Smear test-Relevance

• Pap smear has been accountable for a decrease in
  deaths from cervical cancer of over 60 during
  the years from 1950 to 1980 (in USA).
• 14,000 women still die from cervical cancer every
  year, related primarily to the fact that 80 of
  these women have never had a Pap smear or are
  tested only infrequently

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Cytopathology

• Cytopathology is diagnosis of disease in cells.
• Exfoliative Non-Exfoliative - cytology.
• Exfoliative Cell samples are collected from
  normally shedding tissues like epithelium.
  spatula or brush to enhances collection.
• Non-Exfoliative Cells samples collected by
  needles with suction pressure. (FNAC)
• Cytology specimen is fixed, stained and studied
  under microscope.

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What is a Pap Smear?

• Screening test for cervical cancer. It is a type
  of exfoliative cytology test.
• Simple, safe, non-invasive method
• Developed by George Papanicolaou
• Exfoliated cells from cervix are collected
  usually enhanced by using a variety of spatulas
  or brushes.
• The specimen is processed and studied for
  morphology.

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Who should have PAP test

• Every woman should have an annual Pap examination
  when she becomes sexually active or turns 18
  years old --- whichever comes first.
• Regular Pap examinations (yearly) should continue
  even after menopause and after a hysterectomy

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What is the best time for PAP

• The best time for a Pap examination is during the
  two weeks following the end of menstrual flow.
  (Proliferative phase)
• If menopause, Pap examination can be scheduled
  anytime

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Who are at more risk of Cx Ca.

• Any woman can develop Ca Cx.
• multiple sex partners or a partner who has had
  multiple female partners.
• have had genital warts.
• sexual relations before the age of 18.
• previous abnormal Pap examination.
• (Rare in virgins and with use of condoms)

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Pathology of Cervix

• the uterine cervix is continually being bombarded
  by a variety of stress including mechanical,
  microbiologic, chemical, and hormonal insults.
• The cervix responds by
• Acute or chronic inflammatory reactions
• Adaptive proliferative responses like
  Hyperplasia, Metaplasia Dysplasia.
• Anaplasia - Benign Malignant tumors.

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Normal Cervix
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Carcinoma Cervix
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Normal Cervix
SUPER F INTERM BASAL
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Chronic Cervicitis
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PAP Smear Normal
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Low grade squamous intraepithelial lesion (LSIL)
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High grade squamous intraepithelial lesion (HSIL)
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Low grade squamous intraepithelial lesion (LSIL)
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Low grade squamous intraepithelial lesion (LSIL)
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Pathogenesis (non-neoplastic)

• HPV Infection
• Chronic cervicitis
• Hyperplasia Number
• Metaplasia Change to squamous
• DNA damage BRCA12, E6,7
• Dysplasia no-maturation, disorder (CIN 1-3,
  CIS)
• Further DNA damage ? invasion
• Carcinoma

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Pathogenesis (Neoplastic)

• Malignant (Cervical Cancer)
• Invasion Spreading.

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Pap Smear Results
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PAP Smear reporting (Aus)

• Negative or benign Pap smears
• inconclusive Pap smears
• low grade changes requiring an early repeat Pap
  smear -
• high grade lesions biopsy

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PAP Smear - Herpes
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Cervical Dysplasia
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Cervical Dysplasia
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Cervical HPV infection
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PAP Smear - HPV
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Infiltrating Carcinoma Cx
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Squamous Carcinoma
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PAP Smear dysplasia
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PAP Smear Dysplastic cells
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PAP Smear Carcinoma
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Pap Smear Results

• Class I Normal
• Class II Atypical, inflammation or uterine cells
  seen
• Class III Dysplasia (CIN I, II III, CIS)
• mild, moderate or severe
• Class IV Carcinoma-in-situ
• Class V Invasive cancer (?)