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3. Diagnosis

3.1 Investigation of Abnormal Pap Smears

Cervical Pap smears remain the most effective method of identifying the patient with possible preinvasive or preclinical cervical neoplasia. Pap smears taken in the presence of bleeding, spotting or discharge are often difficult to interpret and may be unreliable. It is recommended that women aged 25-69 be screened every 3 years. Women who have a history of prior abnormal smears (CIN) should continue with annual smears. Refer to section 2 above for Pap smear guidelines.

The optimum time for taking smears in the pre-menopausal women is in mid-cycle. However, for practical purposes this is not always possible, but if there is difficulty in obtaining good smears in these individuals then repeat smears should be scheduled for this interval. There is no single sampling device which is adequate for all cases, but in the vast majority of individuals the standard wooden Ayres spatula is satisfactory. Individuals who are post-menopausal or in whom the squamocolumnar junction may be placed within the endocervical canal because of previous surgery or other factors, may require sampling with an endocervical cytobrush or other devices to obtain specimens from this area. If a cytobrush is used immediate fixation with cytospray is required. Conversely, individuals who have a large area of columnar epithelium on the ectocervical surface need to have sampling from the peripheral margins of this transformation zone. If an endocervical specimen is taken as well as the standard scrape both specimens should be placed on the same slide using the opposite half of the glass slide.

Simple lack of endocervical cells in the Pap smear report does not necessarily mean that the smear in itself is inadequate. In older individuals where difficulties may be present in obtaining good quality smear, particularly in the post-menopausal women or women who have undergone radiation treatments to the pelvis, often a short course of topical or oral estrogen therapy will thicken the epithelium and produce a much better quality smear for evaluation.

It should be emphasized that an office punch biopsy should be taken of any clinically suspicious or so-called "target lesion" noted at the time of pelvic examination. The biopsy would take place in the colposcopy clinic if the GP didn’t have cervix biopsy equipment in their clinic. 

3.2 Indications for Colposcopy

The recommended method of investigation of patients with abnormal Pap smears where no target lesion exists is with colposcopy. Regional colposcopy clinics have been established throughout the province for this purpose and their locations are listed in Appendix V. It is to be noted that patients are referred to the regional clinics for assessment, not to the individual performing colposcopy at these locations. Patients are then returned to the original physician for decision as to further management and disposition based on the results and findings of the colposcopic examination. Private practice office colposcopy is not part of the BC Cancer Provincial Colposcopy Program and as such is not subject to BC Cancer's Quality Control Program. 

To find the colposcopy guidelines, please click here.

To find the list of regional colposcopy clinics please click here.

3.3 Histologic classification of invasive carcinomas

WHO histological classification of tumours of the uterine cervix – 2017

Epithelial tumours

  • Squamous tumours
    • Squamous cell carcinoma, not otherwise specified
      • Keratinizing
      • Non-keratinizing
      • Basaloid
      • Verrucous
      • Warty
      • Papillary
      • Lymphoepithelioma-like
      • Squamotransitional
  • Early invasive (microinvasive) squamous cell carcinoma
  • Glandular tumours
    • Adenocarcinoma
      • Mucinous adenocarcinoma
        • Endocervical
        • Interstinal
        • Signet-ring cell
        • Minimal deviation
        • Villoglandular
    • Endometrioid adenocarcinoma
    • Clear cell adenocarcinoma
    • Serous adenocarcinoma
    • Mesonephric adenocarcinoma
    • Early invasive (microinvasive) squamous cell carcinoma
  • Other epithelial tumours
    • Adenosquamous carcinoma
    • Glassy cell carcinoma variant
    • Adenoid cystic carcinoma
    • Adenoid basal carcinoma
    • Neuroendocrine tumours
      • Carcinoid
      • Atypical carcinoid
      • Small cell carcinoma
      • Large cell neuroendocrine carcinoma
    • Undifferentiated carcinoma

3.4 Microscopic description for cervical tumours should include the following features:

  1. Histologic type
  2. Histologic grade (1-3 or well, moderately well and poorly differentiated)
  3. Presence or absence of lymphatic, vascular or neural involvement
  4. Presence or absence of parametrial involvement
  5. Presence or absence of associated lesion
  6. Depth of stromal invasion measured from the base of the epithelium and horizontal spread

SOURCE: 3. Diagnosis ( )
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