Workshop: Case Management of Abnormal Pap Smears and Colposcopies Rebecca Jackson, MD Professor Obstetrics, Gynecology & Reproductive Sciences and Epidemiology & Biostatistics
I have no financial interests to disclose.
Case Based Problems Emphasis on 2012 guidelines by ASCCP (American Society of Colposcopy and Cervical Pathology) and how they differ from last Changes for <25yos Who needs colposcopy vs who can be managed expectantly? Next steps after colposcopy Treatment options: cryotherapy, laser, LEEP and cone biopsy Post-treatment surveillance
Recommended Guidelines ASCCP guidelines 2012 – For work-up of abnormal cytology and treatment of CIN: ( or just search ASCCP guidelines ) http://www.asccp.org/Portals/9/docs/Updated%20ASCCP%20 Algorithms%204%2011%2013%20-%20PDF.pdf Rationale behind guidelines: – ObstetGynecol: 2013; 121(4); 829 – 846 SFGH 2010 guidelines in your syllabus (developed by Dr. George Sawaya, very similar to ASCCP but not yet updated with the new 2013 recommendations)
$7.00 $9.99 $9.99 Laminated cards with tabs Either enter pt info and it gives you the at top so can find the recommendation and assoc algorithm OR you algorithm you need can simply view the algorithms
Good news: most prior guidelines reaffirmed, easier to read, guidance for no ECC’s on pap & discordant co-test results Bad news: even more complex than prior guidelines
What’s New (2012 ASCCP) **Extend adolescent (age <21) management guidelines to women < age 25: there are now 2 pathways for most algorithms — One for<25 and one for >25 Less aggressive w/u of ASC-US How to manage discordant cotest results: (HPV+/PapNl; HPV- /Pap ≥ ASC-US), unsatisfactory cytology and missing endocervical or t- zone cells Post-colpo management now includes co-testing, even in <25 yo Treat CIN1 on ECC as CIN1 (not as +ECC)
Histology Primer Cervical intraepithelial neoplasia (CIN) Graded based on proportion of epithelium involved CIN 1: indicates active HPV infection; treatment discouraged since spontaneous resolution is high CIN 2: most are treated, but about 40% resolve over 6 month period; treatment may be deferred in young women CIN 3: the most proximal cancer precursor, also known as carcinoma in situ always treat Adenocarcinoma in situ (AIS) : widely considered a cancer precursor always treat
CIN 1
CIN 3
CIN2 — hard to diagnose
Case List 0. Pap normal, HPV positive ASC-US, not young 1. 19yo ASC-H; CIN2 on colpo 2. 78yo ASC-USx2, CIN1 on colpo 3. AGC 4. 22yo ASC-US/HPV+, colpo neg 5. 24yo CIN3 on colpo 6. 58yo CIN3, can’t r/o invasion 7. 27yo positive endocervical LEEP margins CIN3 8. 16yo pregnant, HSIL 9.
Case 0 A 35 yo woman has co-test result: HR-HPV positive, cytology normal. What are next steps?
Pap normal, HPV positive Remember: Use co-test only in women >30yo (b/c HPV often + in younger women and is transient) 2 options: 1. Repeat co-test at 12 months. If both negative 3yr co-test If still HPV+ or if >=AS-CUS colposcopy. 2. HPV genotype-specific typing for 16 & 18 If positive for either colposcopy. If negative repeat co-test at 12 months.
Case 1 A 32 year old woman’s Pap smear comes back “AS - CUS” What are your management options?
Repeat cyto at 1 yr (not 6 mos) OR HPV test. If Neg — cotest at 3 yrs
Case 1: AS-CUS, not adolescent 3 equivalent 2 options (HPV preferred): Repeat cytology at 6, 12 months 1. Colpo if >ASC; (if neg cyto in 3 yrs) Immediate colpo 2. Reflex HPV test (preferred) 3. – If neg rescreen in 12 months with cytology. Cotest at 3 yrs – If pos colposcopy * 2012 guidelines: Less aggressive w/u of AS-CUS
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Case 2 A 19 year old Go woman, sexually active since the age of 15, has a Pap smear read as “ASC - H.” What are your management options?
Although you wish she hadn’t had the pap given <21, you can’t ignore it… ASC-H requires colpo in adults and adolescents. • HPV not helpful for triage — all get colpo. • Management after colpo differs greatly for <25yo •
Case 2--continued Colposcopy is satisfactory and biopsy-proven CIN 2 is diagnosed in a single quadrant. What are your management options?
Be sure to read the fine print — lots of info there • Work-up and treatment differs for <25 yo (longer surveillance • prior to treatment, less aggressive treatment options) Regression is common in younger women and usually occurs • within 2 yrs Note now recommend co-test for f/u (even though it breaks • the rule of no HPV co-test in <30yo)
Case 2: CIN 2/3 in adolescents Treatment (excision or ablation) OR observation • • For CIN2 — observation is preferred (as long as colpo is satisfactory*) and patient is reliable (If CIN3 excision/ablation) • Colposcopy plus cytology q 6 months for 1 yr • If normal cytology x2 co-test 1 yr later, if nl, co-test q 3yr • If colpo worsens or high grade cytology or colpo lesion persists x 1yr repeat biopsy • Treat only if CIN2 persists for >2 yrs * If colpo unsatisfactory, diagnostic excisional procedure preferred
Case 3 A 78 year old woman who has never had any abnormal Pap smears now has a Pap smear read as ASC-US. She has not been sexually active for over 15 years. A repeat pap in 12 months is also ASC-US. Options?
Again, you wish she hadn’t had a pap (stop age= 65 in women with prior normals ). However, can’t ignore….. Two consecutive paps with ASC-US colpo No difference in management of ASCUS for post-menopausal women. However, reflex HPV testing is more efficient than in younger women b/c fewer women will be referred to colposcopy
Case 3: continued Colposcopy reveals an attenuated, flush cervix. Unsatisfactory. ECC shows CIN 1. Management options?
Observation ok for CIN1 preceded by ASC-US, LSIL, HPV +. Only treat if persists for 2 years. HPV testing may help to avoid colpo if negative.
Case 4 A 43 year old woman has a Pap smear read as AGC (atypical glandular cells)-not otherwise specified (NOS). What is the differential diagnosis of AGC? What are your management options?
Differential diagnosis of AGC Atypical endocervical cells Adenocarcinoma-in-situ Adenocarcinoma Squamous CIN Endometrial hyperplasia Endometrial adenocarcinoma Ovarian carcinoma
AGC needs more thorough work-up than ASC-US because underlying abnormalities are more serious and more common (40% have SIL, AIS, endometrial hyperplasia) Colpo plus ECC plus EMB (in many)
Note that if initial cytology had been AGC-favor neoplasia and colpo had been negative, cone recommended as next step
Case 4 continued Pt reports occasionally irregular periods. Colposcopy is satisfactory without lesions. ECC is normal. EMB is normal. Given it it AGC-NOS, you follow as per guidelines with co-test at 12 and 24 months 24 month pap is AGC again. Now what?
Repeat AGC: pelvic ultrasound to evaluate ovaries/tubes. If ultrasound negative, cone biopsy
AIS within os
Case 5 An 22year old transfers care to your practice. 8 months ago, she had “ ASC-US with HPV DNA test positive for a high- risk type.” She then had colposcopy at other practice, 6 mos ago, which was noted to be satisfactory with no lesions seen. Next steps?
Cytology preferred for f/u AS-CUS in young women (reflex HPV testing ok) If HPV pos repeat cytology only at 12 mos (ie shouldn’t have had colpo)
What to do when pts receive testing that was not recommended per guidelines or who are lost to f/u after abn pap and then have repeat pap nl? In general, act on most severe abnormality. EG, If 30yo had LSIL pap then lost to f/u and has repeat nl pap, still needs colpo In this case, can follow per guidelines after nl colpo b/c f/u is essentially the same as if she hadn’t had colpo
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Case 6 A 24 yo G0 woman has biopsy-proven CIN 3, a satisfactory colposcopy and a negative endocervical curettage. What are your management options? What if the ECC were positive?
Potential adverse effects of LEEP Preterm delivery 70% Low birth weight 82% PPROM 169% Lancet 2006 367:489-98 Potential adverse effects of cone biopsy 187% Perinatal mortality 178% Severe preterm delivery 186% Extreme low birthweight BMJ 2008 Sep 18;337 No randomized trials.
Given ablative and excisional methods are equally efficacious, choose ablation for women desiring fertility (as long as colpo satisfactory, ECC negative and lesion <2cm and completely visible)
Case 7 A 58 year old widow has a Pap smear read as ASC-US and you send a test for HPV. It is positive. Colposcopy is unsatisfactory. ECC shows severe dysplasia (CIN 3) cannot rule out invasion. What are your management options?
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