Papanicolau y Colposcopía

IFER - 2005
TEST DE PAPANICOLAU
Es un examen citológico
que consiste en la
exfoliación inducida de
células del cuello uterino
EN QUE MOMENTO DEL CICLO?

• Fase intermenstrual
• Espátula de Ayre
• 24 hs. sin :
– RELACIONES SEXUALES
– TRATAMIENTOS CON LOCALES
– DUCHAS VAGINALES
 FIJACION
ALCOHOL ETÍLICO AL 95%
> DE 15 MINUTOS
< DE 10 DIAS
 Clasificación de Papanicolau

• I y II negativos DLN ACB

• III sospechoso ASCUS ASCGUS LSIL.
• IV positivo HSIL
 CAUSAS DE ERRORES

1. obtención inadecuada
2. presencia de sustancias interpuestas
3. problemas técnicos
4. errores de lectura
 Falsos positivos 1-2%

Falsos negativos 10%-30%

 PAP ANORMALES

1-3% de la población general

Riesgo de Ca de Cervix es de 0,8 %
Es el 6% de los casos de ca en
mujeres
40% de las lesiones de alto grado
progresan a Cancer en 10 años
 ACS Statistics, 1992:

Incidence Mortality

corpus 32,000 4400

ovary 21,000 13,000
cervix 13,500 5600
other 4500 1000
 Risk Factors:
Cervix

• HPV, HPV, HPV...

• Smoking
• Immunosuppression
• ETS
• ?low beta-carotene
intake
• Bajo nivel socioec
 Histopathology
Cervix
• Squamous Cell (85%)
• Adenocarcinoma
• Clear Cell
• Mesonephric
 Cuando comenzar?
• A partir de los 18 años o a partir de que es
sexualmente activa
• ANUAL
• En HIV cada 6 meses
• Hasta los 65-70 años
 Metodología del examen colposcópico

Examen colposcópico Tiempos

•Filtro verde
•CERVICAL •Ac. Acético al 5%
•VAGINAL •Prueba de Schiler (Lugol)
•VULVAR •Colpotopografía
•Biopsias Dirigidas
 Imágenes no asociadas con
malignidad
• Mucosa original
• Ectopía o ectropión
• Zona de transformación (abierta o cerrada)
• Mucosa atrófica
• Pólipos
• Endometrosis
• Condilomas
• endocervicitis
 Imágenes asociadas a malignidad
Indicaciones de
Biopsias
• Mosaico
• Leucoplasias
• Vascularización anormal
• Puntillado grueso
• Imágenes atípicas o con contornos
irregulares
• Imágenes ubicadas sobre ZT
 Squamocolumnar junction
• Squamous epithelium to the left and
columnar epithelium to right.
 Transformation zone
• TZ with gland
opening,sq.metaplasia,columnar epithelium
 Squamous Metaplasia
• The normal physiologic process by which
columnar epithelium evolves into squamous
epithelium.The outermost border is the
original SCJ while the innermost border is
the present SCJ.Histologically, in the early
stages of this process, immature squamous
cells push up columnar cells.Columnar
epithelium later become degenerted and
replaced by mature squamous epithelium
 Leukoplakia
• Refers to a white plaque visible without
magnification and without application of
acetic acid.
• It is usually elevated from
• surrounding surfaces with a
• sharp border and Lugol’s non-
• staining.Histologically..hyperkeratosis
 Cervical Intraepithelial
Neoplasia
• The term cervical intraepithelial
neoplasia refers to a spectrum of
abnormalities of the surface
epithelium. The spectrum includes
changes in the TZ ranging from
CIN I(mild dysplasia) to CIS
(carcinoma in situ)
 CIN
• Maduración desordenada
• Hipercromasia nuclear
• Rn nucleo citoplasma
• Pleomorfismo
 CIN Histology
• CIN grading is based upon the
proportion of the surface
epithelium composed of
undifferentiated cells characteristic
of the basal layer. Increasing grade
is associated with a progressive
loss of epithelial maturation
 CIN I
• Represents atypical cells with
increased nuclear to cytoplasmic
ratio and hyperchromatic nuclei
present in the lower 1/3 of the
epithelial layer from the basement
membrane
 CIN I

• Cytology
 CIN II
• Shows further progression of
nuclear abnormalities with greater
involvement of the epithelial
thickness. In CIN II, immature
basaloid cells occupy the lower 2/3
of the epithelium
 CIN II
• Cytology
 CIN III
• Represents almost total
involvement of the epithelium with
only one or two layers of mature
cells remaining at the surface.
When the entire epithelium is
involved, the term carcinoma in
situ (CIS) is applied.
 CIN III

• Cytology Histology
•

•
 Invasive Cervical Cancer
• With all levels of CIN the basement
membrane of the epithelium remains intact.
Once the membrane is violated, invasive
cancer is diagnosed
 Pap Test
• The Pap test was introduced as a
cervical screening test in 1943 by
George Papanicolaou for whom it is
named. It is a way to examine cells
collected from the cervix and vagina.
This test can show the presence of
infection, inflammation, abnormal
cells, or cancer.
 Terms to describe abnormal
results
• Dysplasia is a term used to describe
abnormal cells.It is not cancer, although it
may develop into very early cancer.
Cervical cells undergo a series of changes
in their appearance. The cells look
abnormal under the microscope but do not
invade nearby healthy tissues.It is classified
into mild, moderate and sever depending on
how abnormal the cells appear.
 Terms to describe abnormal
results
• Squamous Intraepithelial Lesion (SIL)
• An intraepithelial lesion means that the
abnormal cells are present only in the
surface layers of the cells. SIL may be
described as low-grade(early changes in
size, shape and number of cells) or high-
grade(a large number of precancerous cells
the look very different from normal cells)
Terms used to describe abnormal
results
• Cervical Intraepithelial Neoplasia CIN
• Another term widely used to describe
abnormalities of surface epithelium. The
term CIN along with a number (1 to 3),
describes how much of the cervix contains
abnormal cells.Carcinoma in situ(CIS)
describes a preinvasive cancer that involves
only the surface cells.
 BETHESDA 1988
• LSIL Baja prob evol Ca. HPV CINI

• HSIL CIN II CIN III

 How do these terms compare?
• Mild dysplasia may be also classified as
low-grade SIL or CIN I
• Moderate dysplasia may also be classified
as high-grade SIL or CIN II
• Severe dysplasia may also be classified as
high-grade SIL or CIN III
• Carcinoma in situ may also be classified as
high-grade SIL or CIN III
False positive and False negative
Test
• A false positive Pap test occurs when a
specimen is called abnormal but the cells
are actually normal.
• A False negative Pap test occurs when a
specimen is called normal but the woman
has a lesion. It is at least 20%. This means
that biopsy is imperative for visible lesions.
 Prevalence of HPV
• Of more than 70 types of HPV, more than
35 are associated with anogenital disease
and 20 or more are associated with cancer.
The most common HPV types detected in
cervical lesions are those classified as high-
risk HPV types, including types,16,18,45,
and 56, found in 77% of HSIL(CIN II-III)
and in 84% of invasive cancer
 HPV
• 80-90% ca invasores

• 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58,

• BR 6, 11, 42, 42, 44

• LSIL + HPV HR 9% ca invasor
 LSIL
• 60% regresión espontánea
• 22% CINI
• 16% CIN II

• Colpo n Seguimiento. Si persiste Bx? Ttto

• 3 consec n Riesgo habitual
• S/ seguimiento. TTo
 Prevention and Screening
Cervical Cancer
• Because a vast majority (greater than
90%) of these cases can and should be
detected early through the use of Pap
smear, the current death rate is far
higher than it should be and reflects
that ,even today, Pap smears are not
done on approximately one-third of
eligible women.
Management of abnormal
Pap Smear (cont.)
• The standard evaluation of an abnormal
Pap smear is colposcopy and biopsies.
Endocervical curettage at the time of
colposcopy allows evaluation of cells
from the endocervicl canal.
• Biopsy should confirm the Pap smear
abnormality and then appropriate
treatment can be applied
 Management of Abnormal
Pap Smear(cont.)
• If there is discrepancy between
the Pap smear and the biopsy,
then a larger biopsy such as
leep or cold conization biopsy
may be needed
 Riesgo de Ca de cuello
• HSIL no tratado • 1/3

• LSIL c/vigilancia • 1/500

• Post TTO CIN • 1/250