Management of Abnormal Pap Smear

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Management of Abnormal Pap Smear
(Bethesda Classification 2001)
This section is an addendum to the Guidebook For Pap
Smear Screening, Division of Family Health Development,
Ministry of Health Malaysia, August 2004 page II to 16.
The information in those pages is replaced by this section
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CONTENTS
Paae
1.
Management of Unsatisfactory Smear.
1
2.
Management of Negative For Intraepithelial lesion or
Malignancy (NllM) Smear
2
3.
Management of Abnormal Pap Smear:
3.1 Squamous Cell abnormalities
3.1.1 Atypical Squamous Cells
3
3.1.2 low-grade Squamous Intraepithelial lesion
(lSll)
4
3.1.3 High-grade Squamous Intraepithelial lesion
(HSll) and Squamous CellCarcinoma
5
3.2 GlandularCellAbnormalities
3.2.1 Atypical Glandular Cells and Adenocarcinoma
6
4.
Pap Smear Guidelines After Hysterectomy.
7
5.
Management of Abnormal Pap Smear and CIN
in Pregnancy.
8
6.
Indications for colposcopy
8
References
Appendices
Appendix 1 : Pap Smear Request Note
Appendix 2 : Pap Smear Report Note
9
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Acknowledgement
List of Contributors:
Dato' Dr. Halimah Yahaya,
Consultant Pathologist,
Hospital Serdang,
Serdang.
Dr. Hj Mohamad Farouk Abdullah,
Head of Department and Senior Consultant
Obstetrician & Gynaecologist,
Hospital Tg Ampuan Rahimah, Klang.
Dr. Mohd Rushdan Md Noor,
Head of Department and Consultant
Gynaecological Oncologist,
Department of Obstetrics & Gynaecology,
Hospital Sultanah Bahiyah,
Alor Setar, Kedah.
Prof. Madya (K) Dr. Ahmad Zailani Hatta
Mohd Dali,
Consultant Gynaecological Oncologist,
Medical Faculty,
National University of Malaysia,
Cheras.
Dr. Vicknesh Visvalingam,
Consultant Gynaecological Oncologist,
Department of Obstetrics & Gynaecology,
Hospital Kuala Lumpur.
Prof. Madya Dr. Nik Mohamed Zaki Nik
Mahmood,
Head of Department & Gynaecological,
Oncologist,
School of Medical Sciences,
Universiti Sains Malaysia, Kubang Kerian,
Kelantan.
Dr. Zaridah Shame AMP,
Head of Department and Consultant
Gynaecological Oncologist,
Hospital Tuanku Fauziah, Kangar, Perlis.
Prof. Madya Dr. Eugene Leong Weng Kong,
Consultant Gynaecological Oncologist,
Pusat Perubatan Universiti Malaya,
Kuala Lumpur.
Dr. Mukaramah Ayub,
Consultant Pathologist,
Hospital Raja Perempuan Zainab II,
Kota Bharu, Kelantan.
Dr. Zanariah Alias,
Pathologist,
Hospital Ampang.
Dr. Razmin Ghazali,
Pathologist,
Hospital Kuala Lumpur.
Dr. Majdah Hj Mohamed,
Principal Assistant Director,
Family Health Development Division,
Ministry of Health.
iv
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Dr. Rosliza Abd Manaf,
Senior Assistant Director,
Family Health Development Division,
Ministry of Health.
1.
Management of Unsatisfactory Smear.
PAP SMEAR
1
UNSATISFACTORY
FOR EVALUATION
2nd smear
Negativefor
malignant cells
unsatisfactory
3rd smear
unsatisfactory
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Note:
Women with clinically suspicious looking cervix, irrespectiveof the
Pap Smear result must be referred for colposcopy.
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2.
Management of Negative For Intraepithelial Lesion or Malignancy (NILM)
Smear
PAP SMEAR
I
.
NILM
[
Atrophic
changes
(without
inflammation)
J
No
endocervical I
Transfonnation
zone cells seen
Repeat
smearin 1
year
I
Specific
microorganisms
identified
I
I
II
I
resolve
Treat
appropriate Iy
as clinically
indicated
..
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Inflammatory
changes
II
Endometrial
cells seen
--Treatany
Correlate
infectionor
atrophy.
with clinical
findin s
Repeat smear
in 3-6 mths
J
d
2" smear
with similar
changes
.
g"
chents s
age,
hormonal
. and
menstrual
I t.status
::t:
changes
resolve
resolve
I
-
Treat any
infection or
Iatrophy.
Repeat smear
in 3-6 mths.
-
3rdsmear
with similar
changes
2
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Routine
screening
schedule
I
I
Routine
screening
schedule
II
Refer
Gynaecologist
Refer
Gynaecologist
if necessary
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Note: Women with clinically suspicious looking cervix, irrespective of the
Pap Smear result must be referred for colposcopy.
3. Management of Abnormal Pap Smear:
3.1 Squamous Cell Abnormalities
3.1.1 Atypical Squamous Cells
PAP SMEAR
.
ATYPICALSQUAMOUS CELLS
Cannot exclude
high grade
lesion (ASC-H)
Undetermined
significance
(ASC-US)
~
HPV DNA testing should
be considered if available
If positive for high risk
HPV, to refer for
colposcopy
r~~ox*.fI ("'"iffI*.F
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. ASC-US
. ASC-H
. Low-grade
squamous
intraepithelial
lesion
. High-grade
squamous
intraepithelial
lesion
..
NILM
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3.1.2
Low1Jrade Squamous Intraeplthellal Lesion (LSIL)
PAP SMEAR
LOW-GRADESQUAMOUS
INTRAEPITHELIALLESION
(LSIL)
Yes
No
Presence of at least one
criteria:
. Age> 30 years
. Poor compliance
. Immunocompromised
. Symptomatic
. History of pre invasive
lesion
. Positive for high risk
HPV
NILM
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Low-grade
squamous
intraepithelial
lesion (LSIL)
3.1.3
High-grade Squamous Intraepithelial Lesion (HSIL) and Squamous Cell
Carcinoma
r
PAP SMEAR
I
..
HIGH-GRADE
SQUAMOUS
INTRAEPITHELIAL
LESION (HSIL)/
SUSPICIOUSFOR
INVASION
~
SQUAMOUS CELL
CARCINOMA
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Glandular Cell Abnormalities
3.2
3.2.1 Atypical Glandular Cells and Adenocarcinoma
PAP SMEAR
ATYPICAL
ENDOMETRIAL
CELLS
ALL ATYPICAL
GLANDULAR CELLS
(except Atypical
Endometrial Cells)
Refer to
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ADENOCARCINOMA
IN SITU (AIS)
&
ADENOCARCINOMA
4.
Pap Smear Guidelines After Hysterectomy
No.
4.1
Status
Action
Hysterectomyfor benign disease: In the absenceof symptoms,may not
require any further screening.
Normal pap smear history.
.
.
Histopathology of cervix
known and is benign with no
dysplastic / neoplastic
changes
4.2
Subtotal hysterectomy
Should continue to have pap smears
according to normal screening
schedule.
4.3
Hysterectomy where histology is
not known
Should have one baseline vault smear.
If this is normal, further screening
should be based on clinical indications.
4.4
Immunosuppressed women
Should continue to have vault smears at
yearly intervals.
4.5
Women with past history of CIN:
. If excision margin was involved
or histological assessment
inadequate
. CIN 1 I 2/ 3 completely
excised at hysterectomy
4.6
Women previously treated for
invasive gynecological
malignancy
Follow up should be at the discretion of
the Gynecologist. In general, vault
smears should be taken at least yearly.
Vault smears yearly for 5 years followed
by two yearly smears.
Should be followed up by a
Gynecologist, preferably a
Gynecological Oncologist.
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5.
Management of Abnormal Pap Smear and CINin Pregnancy.
.
.
Colposcopic examination should be undertaken to exclude invasive disease by a
Colposcopist.
If a high grade lesion is suspected on colposcopy, a biopsy is indicated to
exclude possible invasive disease. Cervical biopsy is safe in pregnancy.
.
If CIN 2 or 3 is present, colposcopic review should be done in the second and
third trimester to exclude any possible progression to invasive disease.
.
Treatment of CrN should be deferred tillat least 6 weeks postpartum, when the
lesion should be reassessed.
6.
Indications for colposcopy:
.
.
.
.
.
.
.
.
Suspicious lookingcervix.
Unexplained post-coital bleeding.
Persistent unsatisfactory smear on 3 occasions, 3 monthly.
Persistent inflammatory smear on 3 occasions, 3 monthly (despite treatment).
Persistent Atypical Squamous Cells of Undetermined Significance (ASC-US) on
2 occasions.
Atypical Squamous Cells of Undetermined Significance (ASC-US), positive for
high risk HPV.
Atypical Squamous Cells -cannot exclude high grade lesion (ASC-H)
Persistent Low Grade Squamous Intraepithelial Lesion (LSIL) on 2 occasions, 6
monthly.
.
Persistent Low Grade Squamous
Intraepithelial Lesion (LSIL) with high risk factors.
8
. High Grage Squamous Intraepithelial Lesion (HSIL).
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Squamous Cell Carcinoma (SCC).
. Atypical Glandular Cells (AGUS).
.
Adenocarcinoma.
.
Positive for high risk HPV DNA.
References:
.
Bethesda System 2001
. Management Guidelines for Abnormal Pap Smear and Preinvasive Disease of the
Cervix - Cervical Screen Singapore.
9
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PS 1/98(Pindaan 2007)
KEMENTERIAN KESIHATAN MALAYSIA
PERKHIDMATAN PATOLOGI
No. Sitologi:
BORANG PERMOHONAN PAP SMEAR
PAP SMEAR REQUEST FORM
Hospital / Klinik
Hospital / Clinic
BUTIRAN PELANGGAN / CLIENT’S BIODATA
i. Nama / Name
:
v. Alamat :
Address
ii. No Kad Pengenalan / IC. No
iii. Etnik / Ethnicity
:
iv. Umur / Age
:
vi. No Telefon:
(Rumah/ Home)
Phone No
(Pejabat/ Office)
BUTIRAN SARINGAN / SCREENING INFORMATION
i. Tarikh sampel diambil:
Date sample taken
v. No. sitologi terdahulu:
Previous cytology No.
ii. Jenis Sampel:
Type of sample
Conventional Pap Smear
Liquid-based preparation
vi. No. patologi terdahulu:
Previous pathology No.
iii. Bahagian sampel diambil:
Sample site
Serviks / cervix
Vagina / Vagina
vii. Tempat saringan terdahulu:
Place of previous screening
iv. Jenis saringan:
Type of screening
Pertama / new
Ulangan / repeat
viii. Keputusan terdahulu:
Previous diagnosis
RINGKASAN KLINIKAL / CLINICAL SUMMARY
i. Status Hormon:
Hormonal status
Hamil / Pregnant
Postpartum / Postpartum
Pra-menopos / Pre menopausal
Pos-menopos / Menopausal
ii. Tarikh Haid terakhir:
Last menstrual period
iii. Kontraseptif /Terapi
hormon:
Contraceptive/ hormonal
therapy:
iv. Sejarah Rawatan
Treatment history
ADR / IUCD
Hormon / Hormone
Nyatakan / Specify:....................................................
Tiada / None
v. Gejala / Tanda:
Symptom / Sign
Tiada / Nil
Lelehan dari faraj / Vaginal discharge
Pendarahan luar biasa / Abnormal bleeding
Nyatakan / specify :..............................................
……………………………………………………….
vi. Serviks :
Cervix
Biasa / Normal
Luar Biasa / Abnormal
Tiada serviks / Absent cervix
vii. Maklumat tambahan:
Additional information
Kemoterapi / Chemotherapy
Radiasi dibahagian pelvik / Pelvic radiation
Nyatakan tarikh akhir rawatan:
Specify completion date:………………………………
Pembedahan ginekologi / Gynaecology surgery
Nyatakan / specify:…………………………………….
…………………………………………………………..
Tiada / none
MAKLUMAT PEMOHON / REQUESTING PRACTITIONER
Nama :
Name
Tanda Tangan :
Signature
Jawatan / COP:
Designation / Stamp
……………………………………………………………..
……………………………………………………………..
……………………………………………………………..
……………………………………………………………..
……………………………………………………………..
……………………………………………………………..
……………………………………………………………..
KEMENTERIAN KESIHATAN MALAYSIA
PERKHIDMATAN PATOLOGI
PS 2/ 2007
PAP SMEAR REPORT
Name:
Cytology No:
IC No:
A) Type of sample:
Conventional Pap Smear
Liquid-based preparation
B) Sample
Adequacy:
i) Satisfactory for evaluation :
ii) Unsatisfactory for evaluation:
Endocervical cells / transformation zone cells:
Present
With:
Scanty squamous epithelial component
Poor fixation / air drying artifact
Obscuring blood
Thick uneven smear
Thick inflammatory exudate
Broken slide beyond repair
Absent
Obscuring blood
Poor fixation / air drying artifact
Thick uneven smear
Thick inflammatory exudate
Lack of clinical data
C) Interpretation /
Result
i) Negative for intraepithelial lesion or malignancy (NILM)
a) Organism present :
Fungal organisms morphologically consistent with Candida spp.
Shift in flora suggestive of bacterial vaginosis
Bacteria morphologically consistent with Actinomyces spp.
Cellular changes associated with Herpes Simplex Virus
Trichomonas vaginalis
b) Other non-neoplastic findings:
Benign cellular changes associated with:
inflammation / typical repair
irradiation
Intrauterine contraceptive device ( IUCD)
Atrophy
Presence of glandular cells post hysterectomy
Presence of endometrial cells (in woman ≥40 yrs of age)
ii) Epithelial cells abnormalities
a) Squamous cell:
b) Glandular cells:
Atypical cells ( NOS ):
Atypical squamous cells:
of undetermined significance ( ASC-US)
cannot exclude HSIL ( ASC-H)
Low grade squamous intraepithelial lesion ( LSIL)
High grade squamous intraepithelial lesion ( HSIL):
Features suspicious for invasion
Squamous cell carcinoma
c) Other malignant neoplasm, specify:
………………………………………………………………………………….
………………………………………………………………………………….
………………………………………………………………………………….
Endocervical cells
Endometrial cells
Glandular cells
Atypical cells , favour neoplastic:
Endocervical cell
Glandular cells ( NOS)
Endocervical adenocarcinoma ( in-situ )
Adenocarcinoma:
Endocervical
Endometrial
Extrauterine
Not otherwise specified ( NOS )
D) Comments : …………………………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………………………
E) Suggestion
Repeat smear as scheduled
Repeat smear in 3 to 6 months
Repeat smear after antibiotic treatment
Repeat smear after oestrogen therapy
Repeat smear in 1 year
Colposcopy and biopsy
HPV DNA
Refer to Gynaecologist / Gynaecological Oncologist
LAB USE ONLY
Screener
Validated by
Designation
First Screener
Date reporting
Second Screener
Date Printing
Pathologist
Result reviewed by:
Designation / Stamp:
VALIDATION
Date :
Action :
Review of previous Pap smear slide :
YES / NO ( If YES Slide No:
)
MINISTRYOF HEALTHMALAYSIA