Abnormal Pap Test


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Abnormal Pap Test

  1. 1. Management of Women with Abnormal Pap Test
  2. 2. Bethesda System 2001 <ul><li>Squamous cell Atypical squamous cells (ASC) of undetermined significance (ASC-US) cannot exclude HSIL (ASC-H) </li></ul><ul><li>Low-grade squamous intraepithelial lesion (LSIL) </li></ul><ul><li>High-grade squamous intraepithelial lesion (HSIL) </li></ul><ul><li>Squamous cell carcinoma </li></ul>
  3. 3. Bethesda System 2001 <ul><li>Glandular cell </li></ul><ul><ul><li>Atypical glandular cells (AGC) </li></ul></ul><ul><ul><li>Atypical glandular cells, favor neoplastic </li></ul></ul><ul><ul><li>Endocervical adenocarcinoma in situ (AIS) </li></ul></ul><ul><ul><li>Adenocarcinoma </li></ul></ul>
  4. 4. 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
  5. 5. Management strategy depends <ul><li>Availability of resources for diagnosis like Colposcope, HPV testing </li></ul><ul><li>Availability of resources for treatment like LEEP, Cryotherapy, LASER </li></ul><ul><li>Age of the woman </li></ul><ul><li>Need of reproductive life </li></ul><ul><li>Grade & extent of the lesion </li></ul><ul><li>Motivation for follow up </li></ul><ul><li>Expertise </li></ul>
  6. 6. 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
  8. 8. ATYPICAL SQUAMOUS CELLS <ul><li>Abnormal cells are seen due to an infection or irritation or may be precancerous </li></ul><ul><li>Least reproducible of cytological categories </li></ul><ul><li>Low risk of invasive ca (0.1-0.2%) </li></ul><ul><li>CIN 2,3 prevalence higher with ASC-H </li></ul><ul><li>ASC-H should be considered to represent equivocal HSIL </li></ul>
  9. 9. ASC-US <ul><li>Initial evaluation may be by 3 Approaches: </li></ul><ul><ul><li>2 repeat cytological exams performed at 6 month intervals </li></ul></ul><ul><ul><li>Testing for High-Risk HPV </li></ul></ul><ul><ul><li>Single colposcopic exam </li></ul></ul><ul><li>REFLEX TESTING: refers to testing for high risk HPV at the time of initial screening. This spares 40-60% of women from undergoing colposcopy. </li></ul><ul><li>Prevalence of HPV DNA positivity changes with age among women with ASC-US </li></ul><ul><ul><li>HPV testing only if 21years or over. </li></ul></ul><ul><ul><li>HPV testing more efficient in older women with ASC-US because it refers a lower proportion to colposcopy </li></ul></ul>
  10. 10. Recommended Management of Women with ASC-US <ul><li>ASC-US, HPV “-”: Repeat cytology 12 months </li></ul><ul><li>ASC-US, HPV “+”: Colposcopy </li></ul><ul><ul><li>Negative colpo: do ECC </li></ul></ul><ul><ul><li>Unsatisfactory colpo do ECC </li></ul></ul><ul><ul><li>Satisfactory colpo, with lesion present in TZ ECC (Acceptable) </li></ul></ul><ul><ul><li>POST COLPOSCOPY: </li></ul></ul><ul><ul><li>ASC-US, HPV “+”, No CIN do HPV* @ 12 months </li></ul></ul><ul><ul><li>-or- repeat cytology @6,12 months </li></ul></ul><ul><ul><li>Note: It is not recommended to perform HPV testing at intervals of < 12 months. </li></ul></ul>
  11. 11. 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
  12. 12. Recommended Management of ASC-US <ul><li>Excisional procedures unacceptable for ASC-US unless CIN II-III proven on histology </li></ul><ul><li>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. </li></ul><ul><li>On a Repeat test if ASC-US or greater cytological abnormality is found Colposcopy is recommended </li></ul>
  13. 13. Recommended Management of Women with ASC-H (CANNOT EXCLUDE HSIL) <ul><li>All should undergo Colposcopy </li></ul><ul><ul><li>In women in whom CIN 2,3 is not identified at coloposcopy,follow up: </li></ul></ul><ul><ul><ul><li>with HPV testing at 12 months </li></ul></ul></ul><ul><ul><ul><li>Or </li></ul></ul></ul><ul><ul><ul><li>Cytological testing at 6&12 months is acceptable </li></ul></ul></ul><ul><li>On repeat Cytological testing, refer to Colposcopy, if </li></ul><ul><ul><li>Subsequently test ‘+’ for HPV </li></ul></ul><ul><ul><li>Subsequently have ASC-US or greater </li></ul></ul>
  14. 14. ASC-H Colposcopy ECC if no lesions or unsatisfactory colpo CIN 2,3 > ASC or HPV+ Treat & Follow up Rpt Cytology @ 6, 12 months OR HPV DNA Test @ 12 mths No CIN 2,3 Colposcopy Negative Routine screening
  15. 15. Low Grade SIL
  16. 16. LSIL <ul><li>Cytological diagnosis of LSIL, 2% of women </li></ul><ul><li>2nd most common abnormal cytology report (ASC-US is most common) </li></ul><ul><li>85% with LSIL, have biopsy-confirmed CIN </li></ul><ul><ul><li>18% CIN II-III </li></ul></ul><ul><ul><li>.03% invasive cervical cancer </li></ul></ul><ul><li>LSIL is highly predictive of HPV infection </li></ul><ul><li>COLPOSCOPY: recommended with LSIL </li></ul>
  17. 17. LSIL <ul><li>ECC is preferred for </li></ul><ul><ul><li>Non-pregnant women in whom no lesions are identified </li></ul></ul><ul><ul><li>Women with an ‘unsatisfactory colposcopy’ </li></ul></ul><ul><li>ECC is acceptable for </li></ul><ul><ul><li>‘ Satisfactory colposcopy’ & a Lesion identified in the transformation zone </li></ul></ul>
  18. 18. LSIL Colposcopy Negative Unsatisfactory colpo No lesion Satisfactory Colpo Lesion in TZ ECC No CIN CIN 2,3 Cytology @ 6, 12 mths OR HPV testing Treat & Follow up
  19. 19. LSIL – Post Colposcopy Management <ul><li>In the absence of histologically identified CIN, diagnostic excisional or ablative procedures are unacceptable for the initial management of patients with LSIL </li></ul>
  21. 21. High-grade Squamous Intraepithelial Lesion (HSIL) <ul><li>0.45% OF cytology reports </li></ul><ul><li>75% will have biopsy-confirmed CIN II-III </li></ul><ul><li>1-2 % invasive Cervical Ca </li></ul><ul><li>An immediate Leep or Colposcopy/ECC is acceptable (except in pregnancy or adolescents) </li></ul>
  22. 22. HSIL Colposcopy ECC Unsatisfactory colpo Satisfactory Colpo No CIN 2,3 Diagnostic Excisional procedure Observe with Cytology / Colposcopy Treat & Follow up LEEP CIN 2,3
  23. 23. Managing Women with HSIL UNACCEPTABLE STRATEGIES <ul><li>Ablation is unacceptable in the following circumstances: </li></ul><ul><ul><li>Colposcopy has not been performed </li></ul></ul><ul><ul><li>CIN II-III is not identified histologically </li></ul></ul><ul><ul><li>ECC identifies CIN of any grade </li></ul></ul><ul><li>Triage utilizing either of the following is unacceptable </li></ul><ul><ul><li>Repeat cytology </li></ul></ul><ul><ul><li>HPV DNA testing </li></ul></ul>
  24. 24. SIL in Pregnancy <ul><li>Aim of Colposcopy is to Identify invasive Ca </li></ul><ul><ul><li>Lesser lesions never treated </li></ul></ul><ul><ul><li>Colposcopy is preferred for pregnant, non-adolescent with LSIL, HSIL </li></ul></ul><ul><ul><li>In LSIL Deferring Colpo until at least 6 wks PostPartum is acceptable </li></ul></ul><ul><ul><li>In HSIL Colposcopy is recommended Performed by experienced clinician </li></ul></ul>
  25. 25. SIL in Pregnancy <ul><li>Biopsy of lesions suspicious for CIN II-III or cancer is preferred </li></ul><ul><li>Biopsy of other lesions is acceptable </li></ul><ul><li>ECC is unacceptable in pregnancy </li></ul><ul><li>Re-evaluation with cytology / colposcopy is recommended no sooner than 6 weeks PP </li></ul>
  26. 26. ASCUS & LSIL in ADOLESCENTS <ul><li>Adolescent women Should not be screened unless they have been sexually active for 3 years </li></ul><ul><li>HPV testing is unacceptable for adolescent with ASCUS or LSIL </li></ul><ul><ul><li>>80% of sexually active adolescents test + for HPV over a 2 year obsv. period </li></ul></ul><ul><li>If HPV testing was performed, the results should not influence management </li></ul><ul><li>With LSIL, follow-up with annual cytological testing is recommended </li></ul><ul><ul><li>91% show regression at 36 months </li></ul></ul><ul><ul><li>CIN III before age 20, RARE </li></ul></ul>
  27. 27. LSIL in POSTMENOPAUSAL WOMEN <ul><li>Prevalence of HPV, CIN II-III decline with age in women with LSIL </li></ul><ul><li>Manage less aggressively, triage using HPV may be attractive </li></ul><ul><li>Postmenopause with LSIL, should be managed the same as premenopausal women with ASC-US </li></ul><ul><li>Postmenopausal & immunosuppressed women with ASC-US should be managed in the same manner as women in the general population. </li></ul>
  28. 28. ATYPICAL Glandular Cells
  29. 29. ATYPICAL GLANDULAR CELLS <ul><li>0.2% of Pap results </li></ul><ul><li>High incidence of underlying neoplasia (9-38% AGC have associated neoplasia CIN 2 or 3, AIS, Cancer) </li></ul><ul><li>Both Cytology or HPV lack sensitivity to be used alone as a triage test. </li></ul>
  30. 30. ATYPICAL GLANDULAR CELLS <ul><li>3 Categories: </li></ul><ul><ul><li>AGC, NOS </li></ul></ul><ul><ul><li>AGC, FAVOR NEOPLASIA </li></ul></ul><ul><ul><li>AIS (adenocarcinoma in situ) </li></ul></ul>
  31. 31. ATYPICAL GLANDULAR CELLS <ul><li>INITIAL EVALUATION includes multiple tests </li></ul><ul><ul><li>Colposcopy & ECC for all AGC </li></ul></ul><ul><ul><li>HPV testing </li></ul></ul><ul><ul><li>Endometrial evaluation ( if Age >35 yrs) </li></ul></ul><ul><ul><li>Diagnostic excisional procedure necessary inspite of initial negative testing (if AGC favor neoplasia or AIS) </li></ul></ul>
  32. 32. AIS Hysterectomy preferred Margins involved ECC +ve Reexcision recommended Long term Follow up Diagnostic excisional procedure If future fertility desired Conservative Management Margins negative
  33. 33. Management of CIN <ul><li>Observation </li></ul><ul><li>Conservative </li></ul><ul><li>A. Local Ablation </li></ul><ul><ul><li>Cryocautery </li></ul></ul><ul><ul><li>Cold Coagulation </li></ul></ul><ul><ul><li>Laser Vaporization </li></ul></ul><ul><ul><li>Electrocoagulation diathermy </li></ul></ul><ul><ul><li>B. Excisional Method </li></ul></ul><ul><ul><li>Excisional Biopsy </li></ul></ul><ul><ul><li>Cold Knife conization </li></ul></ul><ul><ul><li>Laser conization </li></ul></ul><ul><ul><li>LEEP or LLETZ </li></ul></ul><ul><li>3. Hysterectomy </li></ul>
  34. 34. TOP 10 KEY POINTS <ul><li>Initiate Pap smears at age 21, or 3 years after onset of sexual intercourse </li></ul><ul><li>Excisional procedures unacceptable for ASC-US unless CIN II-III (histology) </li></ul><ul><li>REFLEX testing with ASC-US spares 40-60 % colposcopy </li></ul><ul><li>ASC-H should be considered to represent equivocal HGSIL </li></ul><ul><li>HPV Screening used only for women >30 yrs. </li></ul><ul><li>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) </li></ul>