1. MANAGEMENT OF THE ABNORMAL PAP SMEAR

2. 2001 Bethesda System Squamous Cell Atypical squamous cells (ASC)
Of undetermined significance (ASC-US)
Cannot exclude HSIL (ASC-H)
Low-grade squamous intraepithelial lesions (LSIL)
Encompassing human papillomavirus (HPV), mild dysplasia, and cervical intraepithelial neoplasia (CIN) 1
High-grade squamous intraepithelial lesions (HSIL)
Encompassing moderate and severe dysplasia, carcinoma in situ, CIN 2, and CIN 3
Squamous Cell carcinoma
Glandular Cell
Atypical glandular cells (AGC) (specify endocervical, endometrial, or not otherwise specified)
Atypical glandular cells, favor neoplastic (specify endocervical or not otherwise specified)
Endocervical adenocarcinoma in situ (AIS)
Adenocarcinoma

3. THE BAD NEWS
HPV is VERY COMMON, occurring at least once over a 3-year period in 60% of young women
Lifetime cumulative risk is at least 80%
The longer HPV is present and the older the patient, the greater the risk of CIN
Smoking DOUBLES the risk of progression to CIN 3 in HPV positive patients

4. THE GOOD NEWS
Vast majority clear the virus or suppress it to levels not associated w/ CIN 2/3+, and for most women this occurs promptly
The duration of HPV positivity is shorter and the likelihood of clearance is higher in younger women
Only 1 in 10 to 1 in 30 HPV infections are associated w/ abnormal cervical cytology

5. MORE GOOD NEWS
Only 15% of women w/ negative cytology reports and positive HPV will have abnormal cytology within 5 years
The risk of cervical cancer in women who do not harbor oncogenic HPV is extremely low
The time course from CIN 3 to invasive cancer averages between 8.1 and 12.6 years

6. STILL MORE GOOD NEWS Likelihood of regression to normal: CIN 1: 60%

7. TYPE OF TESTING Cytology vs. Cytology + HPV testing
Cytology alone low sensitivity
Cytology + HPV testing much higher sensitivity
HPV testing especially helpful in patients > 30 years old

8. Colposcopy Always biopsy any visible lesion
Up to 10% of lesions more sever than anticipated

9. Cytology normal/HPV positive
If combined testing is normal, repeat combined testing only every 3 years
If pap normal and HPV positive repeat pap in 6-12 months, then colposcopy if still positive
ASC - same

10. Atypical Squamous Cells
Most commonly reported abnormality
Risk of cancer %
Risk of CIN 2/3+ 6.4%-11.9%
Have the sample HPV tested
If positive, refer for colposcopy (15-27% chance of CIN 2/3+)
If negative, repeat cytology in 1 year (less than 2% chance of CIN 2/3+)
Exception: adolescent patients

11. Low Grade SIL Second most common result
83% test positive for high-risk HPV
15-30% risk of CIN 2/3+ at initial colposcopy
Recommendation: colposcopy
Exception: adolescent? Clearance high/cancer risk low

12. ASC-H HPV in up to 86% CIN 2/3+ in 24-94%
How does this category differ from HSIL?
Colpo normal? -> repeat cytology vs. excision
30+ year old patient
HPV testing makes sense as rate of positivity is much lower

13. ASC HPV +/ASC-H/LSIL If colposcopy normal:
Repeat cytology in 6 and 12 months or
HPV testing in 12 months
If repeat testing is again abnormal (i.e. ASC or higher or + HPV) colposcopy should be repeated

14. HSIL 70% + CIN 2/3 1-2% invasive cancer Always perform colposcopy
Endocervical assessment (nonpregnant)
Entire vagina should be examined
LEEP at colposcopy may be considered

15. What if HSIL colposcopy results are CIN 1 or less?
Review of histology and cytology and/or
Excision
Exception: adolescents
Since the risk of invasive cancer is still extremely low, colposcopy and cytology tests may be repeated at 4-6 months as long as the colposcopy results are adequate and the endocervical curettage is negative

16. If cervical cytology is AGC or AIS
The most common significant lesions associated w/ AGC are actually squamous
Management should include colposcopy and endocervical sampling
Age 35 and older: include endometrial sampling
Less than 35 if: morbidly obese, oligomenorrhea, abnormal uterine bleeding

17. Atypical Endometrial Cells
Always perform endometrial sampling
If endometrial sampling is negative -> colposcopy w/endocervical sampling

18. When should endocervical sampling be done?
Unsatisfactory colposcopy
Ablative therapy contemplated
Should be considered in: ASC-H, HSIL, AGC or AIS
May add 5-9% to CIN2/3+ diagnosis
NOT in the pregnant patient

19. Initial evaluation of AGC/AIS negative
AGC-NOS: follow-up endocervical sampling at 6 month intervals (x4)
Alternative: Test for HPV. If negative may repeat cytology and endocervical sampling at one year
AGC-favor dysplasia or AIS OR a second AGC-NOS: EXCISION (cold knife conization better than LEEP)

20. What you see is NOT what you get
Colposcopic impression of CIN1 correct only 43% of the time
Another study showed women with LSIL and colposcopic appearance of CIN1 had CIN 2 or CIN 3 21% of the time after excision
Therefore: any visible lesion should be biopsied

21. How should CIN 1 be managed?
For most women: observation
Especially the younger patient
Two cytology screenings 6 months apart

22. CIN 2 and CIN 3 Management 40% of CIN 2 regresses over 2 years
CIN 3 regression: rare
Immediate treatment is recommended
Exception: adolescent with CIN 2
Spontaneous clearance more likely
Risk of cancer approaches zero

23. Is excision or ablation better?
Laser, LEEP, cryotherapy: all the same
Perform endocervical sampling if ablation is planned
Do not perform ablation if dysplasia on endocervical curettage

24. Management of AIS
Excision required: Cold knife conization (CKC) is preferred:
Endocervical sampling w/ the CKC is more predictive of residual disease
LEEP is associated with an increase in the rate of positive margins and is not recommended
If margins are positive CKC should be repeated
Residual AIS in as many as 80%

25. Management of AIS
If margins are negative: risk of residual AIS (26%) and invasive cancer (1.9%)
Therefore hysterectomy is recommended when fertility is no longer desired
If fertility is desired: follow w/ sampling every 6 months
Hysterectomy is not appropriate until invasive cancer has been ruled out

26. Follow-up after treatment for CIN
For CIN 1: Cytology at 6 and 12 months or HPV testing at 12 months is reasonable
For CIN 2/3: Cytology 3-4 times at 6 month intervals or a single Pap + HPV at 6 months. Then annual screening
Positive margins may be treated w/ reexcision, but know that 84% remain disease free WITHOUT reexcision at five year follow-up

27. Care and follow-up during/after pregnancy
Only the diagnosis of invasive cancer alters management
Colposcopy should have as its primary goal the exclusion of invasive cancer
ASC or LSIL: colposcopy during pregnancy or 6-12 weeks postpartum
Higher grade test results: colposcopy without endocervical sampling. Biopsy only if colposcopic appearance consistent w/ CIN 3, AIS, or cancer
Repeat colposcopy each trimester w/ biopsy only if progression of disease is suggested or cytology is suggestive of invasive cancer

28. Last Thing What if the cytology report states “No endocervical cells”?
May repeat in 1 year if routine testing
Repeat soon if for specific indication