Management of Women with
Abnormal Pap Test
Bethesda System 2001 Squamous cell
Atypical squamous cells (ASC) of undetermined significance (ASC-US) cannot exclude HSIL (ASC-H)
Low-grade squamous intraepithelial lesion (LSIL)
High-grade squamous intraepithelial lesion (HSIL)
Squamous cell carcinoma
Bethesda System 2001 Glandular cell
Atypical glandular cells (AGC)
Atypical glandular cells, favor neoplastic
Endocervical adenocarcinoma in situ (AIS)
Adenocarcinoma
Comparison of Terminology Bethesda System CIN system Dysplasia
ASCUS Cellular Atypia Unspecified Cellular changes
LSIL CIN I Mild Dysplasia
HSIL CIN II Moderate dysplasia
CIN III Severe Dysplasia/ CIS
Management strategy depends Availability of resources for diagnosis like Colposcope, HPV testing
Availability of resources for treatment like LEEP, Cryotherapy, LASER
Age of the woman
Need of reproductive life
Grade & extent of the lesion
Motivation for follow up
Expertise
Abnormal Pap test
ASCUS LSIL HSIL
HPV –ve HPV +ve
Rpt Pap Negative
Colposcopy LEEP
ECC
+ve -ve
Treat & Follow up Diagnostic cone
Treat & Follow up
ATYPICAL SQUAMOUS CELLS
ATYPICAL SQUAMOUS CELLS Abnormal cells are seen due to an infection or irritation or may
be precancerous
Least reproducible of cytological categories
Low risk of invasive ca (0.1-0.2%)
CIN 2,3 prevalence higher with ASC-H
ASC-H should be considered to represent equivocal HSIL
ASC-US Initial evaluation may be by 3 Approaches:
2 repeat cytological exams performed at 6 month intervals
Testing for High-Risk HPV
Single colposcopic exam
REFLEX TESTING: refers to testing for high risk HPV at the time of initial screening. This spares 40-60% of women from undergoing colposcopy.
Prevalence of HPV DNA positivity changes with age among women with ASC-US
HPV testing only if 21years or over.
HPV testing more efficient in older women with ASC-US because it refers a lower proportion to colposcopy
Recommended Management of Women with ASC-US ASC-US, HPV “-”:Repeat cytology 12 months
ASC-US, HPV “+”: Colposcopy
Negative colpo: do ECC
Unsatisfactory colpo do ECC
Satisfactory colpo, with lesion present in TZ ECC (Acceptable)
POST COLPOSCOPY:
ASC-US, HPV “+”, No CIN do HPV* @ 12 months
-or- repeat cytology @6,12 months
Note: It is not recommended to perform HPV testing at intervals of < 12 months.
Rpt Cytology@ 6 & 12 Months
HPV –ve HPV +ve
Rpt Cytology
@ 12 months
Colposcopy ECC if no lesions
or unsatisfactory colpo
No CIN CIN
Repeat Cytology @ 6, 12 months
Or HPV DNA test @12 months
Treat & follow up
ASCUS
Recommended Management of ASC-US Excisional procedures unacceptable for ASC-US unless CIN II-III proven
on histology
Follow up – with REPEAT 6 monthly CYTOLOGICAL TESTING is recommended, until two consecutive negative results for CIN or malignancy are obtained. Then annual Follow up is recommended.
On a Repeat test if ASC-US or greater cytological abnormality is found Colposcopy is recommended
Recommended Management of Women with ASC-H (CANNOT EXCLUDE HSIL)
All should undergo Colposcopy
In women in whom CIN 2,3 is not identified at coloposcopy,follow up:
o with HPV testing at 12 months
Or
o Cytological testing at 6&12 months is acceptable
On repeat Cytological testing, refer to Colposcopy, if
Subsequently test ‘+’ for HPV
Subsequently have ASC-US or greater
ASC-H
ColposcopyECC if no lesions or unsatisfactory colpo
CIN 2,3
> ASC or HPV+
Treat & Follow upRpt Cytology @ 6, 12 months OR
HPV DNA Test @ 12 mths
No CIN 2,3
Colposcopy
Negative
Routine screening
Low Grade SIL
LSIL
Cytological diagnosis of LSIL, 2% of women
2nd most common abnormal cytology report (ASC-US is most common)
85% with LSIL, have biopsy-confirmed CIN
18% CIN II-III
.03% invasive cervical cancer
LSIL is highly predictive of HPV infection
COLPOSCOPY: recommended with LSIL
LSIL
ECC is preferred for
Non-pregnant women in whom no lesions are identified
Women with an ‘unsatisfactory colposcopy’
ECC is acceptable for
‘Satisfactory colposcopy’ & a Lesion identified in the transformation zone
LSIL
Colposcopy
Negative Unsatisfactory colpoNo lesion
Satisfactory ColpoLesion in TZ
ECC
No CIN CIN 2,3
Cytology @ 6, 12 mthsOR
HPV testingTreat & Follow up
LSIL – Post Colposcopy Management
In the absence of histologically identified CIN, diagnostic excisional or ablative procedures are unacceptable for the initial management of patients with LSIL
HIGH GRADE SILHSIL
High-grade Squamous Intraepithelial Lesion (HSIL) 0.45% OF cytology reports
75% will have biopsy-confirmed CIN II-III
1-2 % invasive Cervical Ca
An immediate Leep or Colposcopy/ECC is acceptable (except in pregnancy or adolescents)
HSIL
ColposcopyECC
Unsatisfactory colpo Satisfactory Colpo
No CIN 2,3
Diagnostic Excisional procedure
Observe with Cytology / Colposcopy
Treat & Follow up
LEEP
CIN 2,3
Managing Women with HSILUNACCEPTABLE STRATEGIES Ablation is unacceptable in the following circumstances:
Colposcopy has not been performed
CIN II-III is not identified histologically
ECC identifies CIN of any grade
Triage utilizing either of the following is unacceptable
Repeat cytology
HPV DNA testing
SIL in Pregnancy
Aim of Colposcopy is to Identify invasive Ca
Lesser lesions never treated
Colposcopy is preferred for pregnant, non-adolescent with LSIL, HSIL
In LSIL Deferring Colpo until at least 6 wks PostPartum is acceptable
In HSIL Colposcopy is recommended Performed by experienced clinician
SIL in Pregnancy
Biopsy of lesions suspicious for CIN II-III or cancer is preferred
Biopsy of other lesions is acceptable
ECC is unacceptable in pregnancy
Re-evaluation with cytology / colposcopy is recommended no sooner than 6 weeks PP
ASCUS & LSIL in ADOLESCENTS
Adolescent women Should not be screened unless they have been sexually active for 3 years
HPV testing is unacceptable for adolescent with ASCUS or LSIL
>80% of sexually active adolescents test + for HPV over a 2 year obsv. period
If HPV testing was performed, the results should not influence management
With LSIL, follow-up with annual cytological testing is recommended
91% show regression at 36 months
CIN III before age 20, RARE
LSIL in POSTMENOPAUSAL WOMEN
Prevalence of HPV, CIN II-III decline with age in women with LSIL
Manage less aggressively, triage using HPV may be attractive
Postmenopause with LSIL, should be managed the same as premenopausal women with ASC-US
Postmenopausal & immunosuppressed women with ASC-US should be managed in the same manner as women in the general population.
ATYPICAL Glandular Cells
ATYPICAL GLANDULAR CELLS
0.2% of Pap results
High incidence of underlying neoplasia (9-38% AGC have associated neoplasia CIN 2 or 3, AIS, Cancer)
Both Cytology or HPV lack sensitivity to be used alone as a triage test.
ATYPICAL GLANDULAR CELLS
3 Categories:
AGC, NOS
AGC, FAVOR NEOPLASIA
AIS (adenocarcinoma in situ)
ATYPICAL GLANDULAR CELLS
INITIAL EVALUATION includes multiple tests
Colposcopy & ECC for all AGC
HPV testing
Endometrial evaluation ( if Age >35 yrs)
Diagnostic excisional procedure necessary inspite of initial negative testing (if AGC favor neoplasia or AIS)
AIS
Hysterectomypreferred
Margins involvedECC +ve
Reexcision recommended
Long term Follow up
Diagnostic excisional procedure
If future fertility desiredConservative Management
Margins negative
Management of CIN1. Observation
2. Conservative
A. Local Ablation Cryocautery Cold Coagulation Laser Vaporization Electrocoagulation diathermy
B. Excisional Method Excisional Biopsy Cold Knife conization Laser conization LEEP or LLETZ
3. Hysterectomy
TOP 10 KEY POINTS
1. Initiate Pap smears at age 21, or 3 years after onset of sexual intercourse
2. Excisional procedures unacceptable for ASC-US unless CIN II-III (histology)
3. REFLEX testing with ASC-US spares 40-60 % colposcopy
4. ASC-H should be considered to represent equivocal HGSIL
5. HPV Screening used only for women >30 yrs.
6. For CIN I: cytological follow-up is the only recommended management option, regardless of whether the colposcopic exam is satisfactory. (LGSIL pap; CIN-1 histology)