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)