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In the Name of GodIn the Name of God
Screening of CervicScreening of Cervicalal CancerCancer
Pap smear and colposcopyPap smear and colposcopy
F.BehnamfarF.Behnamfar
Gynecology Oncology FellowshipGynecology Oncology Fellowship
Associate ProfessorAssociate Professor
Isfahan University of medical SciencesIsfahan University of medical Sciences
Epidemiology and Risk FactorsEpidemiology and Risk Factors
Second most common cancer among Second most common cancer among women worldwidewomen worldwide83% of cases in developing countries83% of cases in developing countries
12,200 new cases and 4210 cancer 12,200 new cases and 4210 cancer related deaths in USA,2010related deaths in USA,201050-60 million pap tests are performed in 50-60 million pap tests are performed in the US each year,3.5 million abnormal and the US each year,3.5 million abnormal and 2.5 million colposcopy each year 2.5 million colposcopy each year
Natural HistoryNatural History
External genital warts ,1%External genital warts ,1%
Cervical intraepithelial neoplasia (CIN)Cervical intraepithelial neoplasia (CIN)
Slow malignant transformationSlow malignant transformation long latency period for cervical cancerlong latency period for cervical cancer CIN I,II,IICIN I,II,II
Papanicolaou SmearPapanicolaou Smear
ConventionalConventional
Thin layer,liquid basedThin layer,liquid based
Cytology report includesCytology report includesAdequacyAdequacy
General categorizationGeneral categorization
Epithelial cell abnormalityEpithelial cell abnormality
Glandular cell abnormalityGlandular cell abnormality
Bethesda SystemBethesda SystemWithin normal limitsInfection (organism should be specified)Reactive and reparative changesSquamouscell abnormalities
Atypical squamouscells(0)of undetermined significance
(ASC-US)(1)exclude high-grade lesions
(ASC-H)
Low-grade squamousintraepithelial lesion(LSIL)
High-grade squamousintaepithelial lesion(HSIL)
squamouscell carcinoma
Abnormal pap smearAbnormal pap smear
ASCUS LSIL ASCUS LSIL
HSIL
Cytologic diagnosisCytologic diagnosis
Pap test yeilds cytologic diagnosisPap test yeilds cytologic diagnosis
Diagnosis of CIN or cervical cancer Diagnosis of CIN or cervical cancer requiers a requiers a tissue sampletissue sample for histologic for histologic diagnosisdiagnosis
Pap TestPap Test
Screening test rather than diagnostic testScreening test rather than diagnostic test
Sensitivity and specificitySensitivity and specificity
Liquid based/ conventional pap smearLiquid based/ conventional pap smear
EffectivenessEffectivenessNo pap in last five years, No pap in last five years, risk of cervical cancer risk of cervical cancer
is threefoldis threefold
90% risk reduction 90% risk reduction
Follow up of abnormal cytologyFollow up of abnormal cytology
ASCUSASCUS
ASC-HASC-H
AGC AGC Risk for CIN 2-3 and AIS ,serious Risk for CIN 2-3 and AIS ,serious precursor of adenocarcinomaprecursor of adenocarcinoma
LSIL(CIN I- HPV infection)LSIL(CIN I- HPV infection)
HSILHSIL
HPV testHPV test
High risk HPV,16-18…High risk HPV,16-18…
Transient InfectionTransient Infection
ScreeningScreening
triagetriage
Screening ParametersScreening Parameters
Initial screeningInitial screening
Discontinuing screeningDiscontinuing screening
Frequency of screeningFrequency of screening
Perior hysterectomyPerior hysterectomy
HPV VaccinationHPV Vaccination
Shortcut to Picture7.lnk
Shortcut to Picture7.lnk
THANKS
ManagementManagement
HPV and CIN 1:Follow up(60-85% regress HPV and CIN 1:Follow up(60-85% regress spontaneously in 2 years)spontaneously in 2 years)
CIN 2-3: LEEP (loop electro surgical CIN 2-3: LEEP (loop electro surgical exision of T zone)exision of T zone)
Cryo ,Laser,Hysterectomy Cryo ,Laser,Hysterectomy
Pap smearPap smear
79% reduction in cervical cancer79% reduction in cervical cancer47-62%sensitivity(30% of cervical cancers…)47-62%sensitivity(30% of cervical cancers…)Liquid based,80% sensitiveLiquid based,80% sensitiveAuto prepAuto prep
Inadequacy,repeat in 6-12 monthsInadequacy,repeat in 6-12 monthsGenerally:Generally:negative for intraepithelial lesionnegative for intraepithelial lesionEpithelial cell abnormalityEpithelial cell abnormalityOther:glandular cell abnormalitiesOther:glandular cell abnormalities
ScreeningScreening
Beginning at 21y,or 3y after onset of Beginning at 21y,or 3y after onset of sexual activitysexual activity
Can stop at 70Can stop at 70
Yearly<30 Yearly<30
2-3 years>30(if pap&HPV neg) 2-3 years>30(if pap&HPV neg) HPV>99%sensitiveHPV>99%sensitive
Cervical CancerCervical Cancer
33rdrd most common gyn cancer in USA most common gyn cancer in USASquamous most commonSquamous most commonAdenocarcinoma increasingAdenocarcinoma increasingClinically stagedClinically stagedRisk factorsRisk factorsEvaluation(vaginal bleeding,post coital,irregular, Evaluation(vaginal bleeding,post coital,irregular, post menopausal)post menopausal)DischargeDischargeObvious tumorObvious tumorSuspicious ,colposcoy biopsy,conizationSuspicious ,colposcoy biopsy,conization
StagingStagingStage I(1a1, 1a2 ,1b1, 1b2)Stage I(1a1, 1a2 ,1b1, 1b2)StageIIStageIIStageIIIStageIIIStageIVStageIV