Pap maneg

1. Management Of Abnormal Pap
Test, When To Refer For
Colposcopy
Ahmed Mousa MBBS, M.Sc, FRCSC, FACOG
Assistance Professor and Consultant of Gynecology
Oncology
King Abdulaziz University

2. ∗ The importance of cervical cancer screening
∗ The modality of screening
∗ The advantages and the disadvantages of each
modality.
∗ The interpretation of cytological abnormalities.
∗ The management of of abnormal result.
Objectives

3. ∗ Is the fourth most common cancer affecting women
worldwide
∗ 528,000 cases estimated in 2012
∗ 85% occur in developing countries
∗ 266,000 estimated death from cervical cancer
∗ account for 7.5% of all female cancer related death
∗ 87% of cervical cancer death occur in developing
countries.
GLOBOCAN 2012 (IARC)
Cervical Cancer

4. ∗ Human Papillomavirus is the etiological risk factor
∗ Is the most common sexually transmitted disease with a
79% estimated life time risk of cervical infection. (CDC
Fact sheet 2013)
∗ HPV DNA detected in 99.7% cervical carcinoma.
(Walboomers, J.M., et al.)
Cervical Cancer Etiology

5. ∗ HPV are classified based on their oncogenic
characteristics into
∗ High risk type (oncogenic)
∗ HVP 16 & 18 account for 73% of cervical cancer cases.
∗ HPV 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66 and 68 account
for the remaining cases
∗ Low risk type
Cervical Cancer Etiology

6. Woodman et al. Nature Reviews Cancer 7, 11–22 (January 2007) | doi:10.1038/nrc2050
HPV-mediated progression of cervical
cancer
10 -13years90% clear the infection within 2 years

7. ∗ Pap test
∗ Conventional
∗ Liquid based cytology
∗ HPV
∗ Primary
∗ Reflex
∗ Co-testing
Screening for cervical cancer

8. ∗ Since the introduction of Pap test as screening
method, there has been 70% decreased in the
incidence and mortality from cervical cancer
Pap test

9. ∗ Conventional vs liquid based cytology
∗ Both have similar sensitivity and specificity for detection
high grade and low grade intraepithelial lesion
∗ conventional pap smear is more specific than LBC for
ASCUS
∗ LBC reduces unsatisfactory pap test in subgroup of
patients with obscured blood and inflammatory cells.
∗ LBC cytology offer the advantage of performing HPV
test
Pap test
Whitlock EP et al, Arbyn M et al, Davey E et all

10. ∗ Overall the sensitivity of Pap test range between 50-
70%
∗ Reasons for failure
∗ Failure to screen
∗ Failure to detect abnormality in the first Pap test
∗ Failure to follow up abnormal Pap test
Pap test
Leyden et all, 2005

11. Solomon et al 2001

13. ∗ hrHPV vs Pap test
∗ Primary hrHPV or in combination with cytology is more
sensitive than pap test in the detection of HSIL and
cancer.
∗ Use of hrHPV alone or in combination with cytology
reduce the incidence of HSIL (RR:0.34 for primary and
RR: 0.30 for cotetsting) and invasive cervical cancer
(RR:0.44) compared to Pap test.
∗ Improved detection of ADK
HPV

14. ∗ Role of genotyping
∗ HVP 16 and 18
∗ Cumulative incidence of HSIL over 3 years 21-26%
∗ Other types
∗ Cumulative incidence of HSIL over 3 years 5-6.5 %
HPV

15. ∗ <21
∗ No screening
∗ 21-29
∗ Cytology alone every 3 years
∗ 30-65
∗ HPV co-testing every 5 years
∗ Or cytology every 3 years
∗ >65
∗ No screening unless
∗ Inadequate screening
∗ History of CIN 2/3, cervical ca
∗ Following Hysterectomy
∗ No screening following benign disease
∗ Screen if history of CIN 2/3, cervical cancer
Screening Per ASCCP 2012

16. Recently updated guideline for
cervical cancer
Warner K. Huh , Kevin A. Ault , David Chelmow , Diane D. Davey , Robert A. Goulart , Francisco A.R. Garcia , Walte...
Use of primary high-risk human papillomavirus testing for cervical cancer screening: Interim clinical guidance
Gynecologic Oncology, Volume 136, Issue 2, 2015, 178 - 182
http://dx.doi.org/10.1016/j.ygyno.2014.12.022

17. ∗ Defined as
∗ Scanty cellularity
∗ Obscured by blood or inflammatory cells
∗ Or could not be processed for any reasons
Pap test should be repeated in 2-4 months
∗ OR
∗ HPV negative  repeat pap or HPV in 3 years
∗ HPV positive
∗ Colposcopy
∗ Or genotyping
∗ HPV 16/18  colpo
∗ Other types
∗ Pap test
∗ Abnormal colop
∗ Normal routine screen
Unsatisfactory

18. ∗ HPV status
∗ Unknown
∗ Offer HPV test
∗ Positive
∗ Cytology and HPV at 1 year
∗ Negative routine screening
NILM but absent EC/TZ

19. ∗ The most common abnormality (2.8%)
∗ Risk
∗ 7 % underlying CIN II
∗ 3% underlying CIN III
∗ 0.1% underlying invasive cancer
∗ 25% associated with HPV
∗ HPV +
∗ 18% underlying CIN II
∗ 7% underlying CIN III
∗ 0.4% underlying invasive cancer
∗ HPV –
∗ 1.5% underlying HSIL
∗ Options
∗ Repeat Pap test in one year
∗ ASCUS or more  colpo
∗ Normal  routine screen
∗ Preform HPV (Reflex test)
∗ Positive  colpo
∗ Negative  routine screen
ASCUS

20. ∗ Incidence 0.17%
∗ Risk
∗ CIN II: 35%
∗ CIN III: 18%
∗ Invasive cancer: 2.6 %
∗ Patient must be referred to colposcopy
∗ Do not perform HPV ( 67% of patients are positive)
ASC-H

21. ∗ Incidence 1 %
∗ Risk
∗ CIN II:16%
∗ CIN III: 5.2%
∗ Invasive cancer :0.16%
∗ HPV + in 88%
∗ HPV +
∗ CIN II: 19%
∗ CIN III: 6%
∗ HPV negative
∗ CIN II: 5%
∗ CIN III : 2%
∗ Two options
∗ Colposcopy
∗ HPV
∗ Positive  colposcopy
∗ Negative
∗ Repeat both test in one year
∗ If any abnormal colposcopy
∗ Normal routine screening
LSIL

22. ∗ Incidence 0.21%
∗ Risk
∗ CIN II: 70%
∗ CIN III: 47%
∗ Invasive cancer: 7%
∗ HPV positivity: 75%
∗ Even those with negative test the risk of CIN II/III
>30% and invasive cancer 6%
∗ Refer to colposcopy
HSIL

23. ∗ Incidence 0.1-2%
∗ AGC
∗ Endocervical
∗ Endometrial
∗ NOS
∗ 10% endometrial ca
∗ AGC-favor neoplasia
∗ Endocervical
∗ ADK 5%
∗ AIS 2.5
∗ Endometrial
∗ Endometrial ca: 27%
∗ CAH: 22%
∗ NOS
∗ AIS
∗ Adenocarcinoma
∗ Finding is benign in 60-70%
∗ Approximately 50% associated with squamous abnormality
AGC

24. ∗ AGC-endometrial
∗ Perform endometrial biopsy and ECC
∗ If negative refer to colposcopy
∗ AGC- other category
∗ Colposcopy
∗ ECC
∗ And endometrial biopsy if age > 35 and at risk of endometrial
ca
∗ AIS
∗ Colposcopy
∗ If no lesion identified cold knife biopsy
AGC

25. Thank you