Lecture 1 - Intro To Gynae Cytology

Lecture1:
Introduction to
Gynae Cytology
En. Mohd Nazri Abu

Dip MLT, B (Hons) MLT, Post Basic (Cytology), MHs
Cervical Cancer in Asia
1. Highest Incidence & Mortality
2. Many cases unreported
3. Nearly 270,000 deaths in Asia every year
4. Second leading cause of cancer in

women after breast
Cervical Cancer Statistics
1. Incidence of Cervical Cancer
a. Worldwide - 560,000
b. USA & Europe - 90,000
c. Asia - 470,000
2. Mortality from Cervical Cancer
a. Worldwide - 310,000
b. USA & Europe - 40,000
c. Asia - 270,000
Source : American Cancer Society Report; Global Cancer - Facts & Figures, 2007
Estimated Numbers of New Cancer Cases
(Incidence) and Deaths (Mortality) in 2002
From Parkin, D. M. et al.

CA Cancer J Clin 2005;55:74-108.
Reasons for High Incidence in Asia
 Absence of screening programs
 Rural areas difficult to access
 Absence of basic medical facilities
 Poor Hygiene
 Low Health Awareness
 Illiteracy
 Other reasons
CANCER CERVIX- IN MALAYSIA
• National cancer registry :21.5 per 100,000 population
(second to cancer breast) in 2002
• High compared to developed countries

• 5/6th in Australia due to effective cervical screening
program
• 7th common ca in US women
PAP SMEAR
• A method to screen cervical cancer
• Aim: To reduced the incidence of invasive
cervical cancer
PAP SMEAR SCREENING PROGRAM-WHY
• In Malaysia it is one of the leading causes of death among
cancer in female.
• It occur in the reproductive age group
• Cervical cancer is known to have along latent period of pre-
malignancy(up to 15 years).
• If the pre-malignancy is detected early the disease is
potentially curable.
Risk Factor in SCC
• Infection agents: especially HPV (type 16,18,31,35) the most
important agent.
• Sexual intercourse at early age
• Early age at first pregnancy
• Multiparity
• Short term interval between pregnancies
• Female where spouse have wife with h/o ca cervix.
• Smokers
Evolution of SCC
• HPV
• CIN 1 LGSIL
• CIN II 10-15 yrs
• CIN III/CIS HGSIL
• Microinvasive Ca
• Frankly invasive Ca
Incident
• Mean age gradually decreasing (related to sexual behavior).
Based on study by Patten SF.
• Slight dysplasia : mean age 32.0 yrs
• Mod dysplasia : mean age 35.7 yrs
• Severe dysplasia : mean age 38.4 yrs
Origin and location
• Koss : 90% located at squamocolumnar junction or
transformation zone.
• Other 10% in the columnar epithelium
• Origin :probably basal cell / metaplastic squamous
cell.
Squamocolumnar junction
Pathogenesis of cervical Neoplasia.
•Both the secretory (IgA mediated) and cellular immune
systems are active within the cervical epithelium and
stroma.
•In particular, macrophages, including some Langerhans
cells, lymphocytes are present (mucosa associated
lymphoid cell)
Cause of Cervical Cancer – Human Papilloma Virus (HPV)
Well established
 Viral link (HPV) to cancer is well

established
 More than 100 different types of HPV
 18 high and intermediate risk types –

cause cervical cancer
 16, 18, 33 & 45 are the most prevalent

in invasive cancer
Human Papilloma Virus
Bosch, et al. Journal of Clin. Pathology 2002:55;244-65 .
Walboomers et al. Journal of Pathology 1999:189:12-19 .

Common HPV types associated with benign
and malignant disease
HPV Types Manifestations
HPV 6, 11, 40, 42, 43, Benign low-grade cervical changes
Low-Risk
44, 54, 61, 70, 72, 81 Condylomata acuminata (genital warts)
Indeterminant 53,66
HPV 16, 18, 31, 33, 35,

Low & high grade cervical changes
High-Risk 39, 45, 51, 52, 56, 58,
Cervical cancer, Anogenital & other cancers
59, 68, 73, 82
ACOG Bulletin 99 recommends:

“Testing for low-risk HPV types has no role in cervical cancer prevention. Low-risk
HPV types are associated with genital warts and with same low-grade intraepithelial
lesions of the cervix, vagina, and vulva”. 3
1 Cox. Baillière’s Clin Obstet Gynaecol. 1995;9:1.

2 Munoz et al. N Engl J Med. 2003;348:518
3 ACOG Practice Bulletin, Number 99. Obstet Gynecol. 2008;112:1419-1444.
Reduction & Prevention of Cervical Cancer
Strategy
 Primary Prevention  Secondary Prevention  Tertiary Prevention
- Vaccines - Screening - Treatments
- Age Group 9 - 26 - Age Group >20- 60 - Colpos, Cryo, LEEP ...

Reasons why Pap Smear is used to screen
cervical cancer
• Easy/simple to perform
• Safe/low risk to patient
• Generally acceptable to women
• Cheap
• Sensitive/accurate
Conventional Pap Smear
• The Papanicolaou Test (Pap smear)
• The study of cells in a smear done on a glass slide.
• The slide has to be fixed and stain using a Papanicolaou
method.
• Examine for abnormal/malignant cell under microscope
SENSITIVITY AND SPECIFICITY
• For high grade lesion: up to 96%
• For low grade lesion: 50-64%
• Overall: around 65%
• Specificity:65-75%
• False negative rate: 14-33%
• 2/3 limitation in sampling
• 1/3 screening
Pap smear reporting:The Bethesda system(TBS)
• In 1988 NCI called for a workshop in Bethesda

• The aim was to develop a uniform descriptive terminology
for cervicovaginal cytopathology.
• The format now known as TBS
• In 1991: modification and streamlined.
• Latest- Bethesda System 2001
SPECIMEN ADEQUACY
• Important component of Quality Assurance

• Provide feedback regarding sampling
technique and reliability
SATISFACTORY SMEAR
A smear is satisfactory if it is properly labeled,
accompanied by relevant clinical information,
appropriately fixed and demonstrate
adequate number of well preserved and
evenly distributed cells
(SATISFACTORY FOR EVALUATION )
Pap smear report-satisfactory
smear(min:8000 to 12000 squamous cell)
Squamous cell Endocervical cell

SATISFACTORY FOR EVALUATION
• Presence or absence of endocervical

cells/transformation zone cells
• An indication of good sampling
UNSATISFACTORY FOR EVALUATION
• Broken slide
• Scanty squamous cell component
• Obscuring blood, inflammation, thick areas
• Poor fixation, air drying artifact
(if a positive finding is present despite
unsatisfactory smear it will not be reported as
unsatisfactory)
Satisfactory for evaluation and NILM
HOW TO TAKE A GOOD SMEAR
• Ideally during mid cycle

- epithelial surface of the cervix are influenced
by circulating ovarian hormone
- late secretary phase-cytolysis
- menstrual blood
• Avoid sexual intercourse within a period of 24

hours prior to screening
- spermatozoa
- Seminal fluid- large degenerate cells from
seminal vesicle to distinguish from dyskaryotic
cells
HOW TO TAKE AGOOD SMEAR
• Do not douche or use any form of

medication(suppositories) into the vagina 24
hours prior to screening
- to avoid contamination
• Prepare equipment beforehand i.e.. Slides, forms, fixative(95% alcohol), speculum,
labels, spatula/and brush
• Dip slide immediately into fixative or spray fixed immediately(for a minimum 30
minutes) to avoid fixation artifact
• Please don’t allow the slide specimen to dry before fixation
• Change the fixative at least once a week
Cont.
• Good lighting and exposure of cervix
• Look for ectropion/erosion/TZ zone
• Choose sampling instrument best suit for
shape of cervix and os
• Place instrument firmly into the os
• Turning around carefully 3x through 360
degrees and ensure the TZ is sampled
Normal Cervix
Mild Dysplasia Moderate dysplasia
• In peri/postmenopausal, the TZ junction is

within the endocervical canal and not visible
• Both spatula and cytobrush should be used.
• The aim of the smear taker is to obtain a
representative sample of cells from the
transformation zone- 90% of ca cervix
originate from this area
HOW TO MAKE A GOOD SMEAR
• Avoid traumatizing the cervix because

excessive blood will obscure cells and will
retard fixation
• Spread the material evenly on the slide so that
cells won’t clump, well fixed and can be
identified by the screener
HOW TO MAKE A GOOD SMEAR
• Remove excessive discharge with cotton swab

then take pap smear- the discharge contain
mucus or inflammatory cells that may obscure
cells and prevent prompt fixation
OTHER COMPONENT OF SPECIMEN ADEQUACY
• Patient and specimen identification- ensure

specimen correspond to the correct patient.
Give the previous cytology number to locate
previous report or previous diagnosis
OTHER COMPONENT OF SPECIMEN ADEQUACY
• Clinical information- to increase sensitivity

and reliability
• Minimum: age and LNMP
• Other information- hormonal treatment,
contraception, IUCD, breastfeeding, previous
treatment/surgery/radiotherapy,HRT
symptoms, cervical abnormality
Staining of slide:
manual/automation
Microscopic examination and
reporting
Stringent Quality assurance in reporting pap smear

Toward 100% rescreening
Targeted rescreening by pathologist (all positive smear & abnormal
clinical history)
False positive.
• Repair
• Radiation
• Atrophy
• IUCD
-May mimic intraepithelial lesion or cancer.
SMEAR QUALITY
A B C D E
Transportation of slides
• Do not keep the slide too long in room
temperature
• Transport in slide mailer/folder to prevent
broken slide
• Keep in dry environment to prevent fungal
contamination
• Sent to HRPZII through District hospital with
consignment’s form for easy tracibility
CLINICAL IMPLICATION-Unsatisfactory for evaluation
• Another specimen should be obtained within 4-6 months

PAP SMEAR
The smear test, if properly carried out, is
sufficiently sensitive for screening for the
prevention of cervical cancer
LATEST TREND- more expensive
• Liquid based cytology
• Automated screening
• HPV screening-HPV DNA detection methode, ISH

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Lecture1:

En. Mohd Nazri Abu

1. Highest Incidence & Mortality

2. Many cases unreported

3. Nearly 270,000 deaths in Asia every year

4. Second leading cause of cancer in

1. Incidence of Cervical Cancer

2. Mortality from Cervical Cancer

From Parkin, D. M. et al.

 Absence of screening programs

 Rural areas difficult to access

 Absence of basic medical facilities

 Low Health Awareness

• High compared to developed countries

 Viral link (HPV) to cancer is well

 More than 100 different types of HPV

 18 high and intermediate risk types –

 16, 18, 33 & 45 are the most prevalent

Human Papilloma Virus

Bosch, et al. Journal of Clin. Pathology 2002:55;244-65 .

Walboomers et al. Journal of Pathology 1999:189:12-19 .

HPV 16, 18, 31, 33, 35,

ACOG Bulletin 99 recommends:

1 Cox. Baillière’s Clin Obstet Gynaecol. 1995;9:1.

 Primary Prevention  Secondary Prevention  Tertiary Prevention

- Vaccines - Screening - Treatments

- Age Group 9 - 26 - Age Group >20- 60 - Colpos, Cryo, LEEP ...

• In 1988 NCI called for a workshop in Bethesda

• Important component of Quality Assurance

Squamous cell Endocervical cell

• Presence or absence of endocervical

• Ideally during mid cycle

• Avoid sexual intercourse within a period of 24

• Do not douche or use any form of

• In peri/postmenopausal, the TZ junction is

• Avoid traumatizing the cervix because

• Remove excessive discharge with cotton swab

• Patient and specimen identification- ensure

• Clinical information- to increase sensitivity

Stringent Quality assurance in reporting pap smear

• Another specimen should be obtained within 4-6 months

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