Download Management of Abnormal Pap Smears

Cervical Cancer
Screening
Dale Akkerman
Ob/Gyn, Burnsville office
Remember
• Goal of cervical cancer screening program
is to detect neoplasia to allow intervention
to prevent early invasive cervical cancer
and to reduce mortality
• Goal is not to prevent any or all abnormal
cytologic reports
Cervical Cancer Screening
• No screening before age 21 regardless of
age of onset of sexual activity
• Screening every two years between ages
of 21-29 and every three years after age
30 after three consecutive normal Pap
tests.
• Stop screening between ages 65-70 if no
abnormal Pap tests in 10 years.
Caveat
• Does not apply to women who are
immunosuppressed, HIV positive, have
been exposed to DES in utero, or have
prior history of CIN 2/3+
• Source: American Cancer Society and
ACOG
Sources for Abnormal Pap
Smear Management
• Definitive reference for abnormal Pap
smear management is ASCCP (American
Society for Colposcopy and Cervical
Pathology). May download guidelines at
asccp.org
• Simplification found in Initial Management
of Abnormal Cervical Cytology. May
download at icsi.org
Concept of CIN-2/3+
• CIN (cervical intraepithelial neoplasia) is a
histologic, not cytologic diagnosis
• Various cytologic reports are meant to
convey more accurately the
cytopathologist’s concern that a patient’s
lesion has risk of CIN-2, CIN-3, AIS, or
cervical cancer
CIN-2/3+ (continued)
• This significant risk is referred to as
CIN-2/3+
• Screening results which suggest a high
probability of CIN-2/3+ should alert the
clinician the patient needs immediate and
thorough evaluation to rule out
gynecologic malignancy
Concept of Equivalent Risk
• Presence of HPV+ DNA in an ASC
cytology result carries an equivalent risk of
CIN-2/3+ as an LSIL cytology result
• Hence, these results should be managed
similarly (colposcopy and ongoing followup for adult women)
Special Case: Pregnancy
• Only diagnosis which alters clinical
management of the pregnancy is invasive
cancer
• If screening suggests high risk for CIN2/3+, patient should undergo colposcopy
without endocervical sampling
• If low risk for CIN-2/3+, either colposcopy
as above or wait 8-12 weeks postpartum
Special Case: Younger Women
• Spontaneous resolution of CIN-1 and CIN2 occurs at 70% and 50% rates
• Most HPV+ infections resolve within 24
months
• Risk of invasive cancer approaches zero
• For these reasons, no cervical cancer
screening is recommended for patients
age 20 or younger
ASCUS (Atypical Squamous Cells)
• Need to known HPV status
• Concern centers on high-risk subtypes
(HPV+)
• Risk of CIN-2/3+ is 5-10%
ASCUS, HPV negative (HPV-)
• This Pap smear is considered normal
• Repeat Pap smear in 12 months
• If persistent for two years, consider referral
for evaluation of findings: source of
inflammation or rare circumstance of HPV
subtype not in current testing profile
ASCUS, HPV positive (HPV+)
• Colposcopy
• Endocervical sampling if no lesion
visualized or if colposcopic exam is
unsatisfactory
ASCUS and HPV+:
Colposcopy shows no CIN
• Cytology in 6 and 12 months OR
• Only HPV testing in 12 months
• If cytology ≥ ASC or HPV +, repeat
colposcopy
• If cytology normal or HPV-, return to
routine screening
LSIL
(Low-grade squamous Lesion)
•
•
•
•
Colposcopy
15-30% risk CIN-2/3+
80% HPV+
Endocervical sampling if colposcopic
exam unsatisfactory except for pregnant
patients
LSIL: CIN-2/3+
• Per ASCCP guidelines
LSIL: No CIN-2/3+
• Cytology at 6 and 12 months OR
• Only HPV testing at 12 months
• If cytology ≥ ASC or HPV +, repeat
colposcopy
• If cytology normal or HPV-, return to
routine screening
ASC-H (cannot exclude HSIL)
• Colposcopy
• If no CIN-2/3+, manage as LSIL: no CIN2/3+
• If CIN-2/3+, manage as per ASCCP
guidelines
Pregnant, ASCUS or LSIL
• Preferably immediate colposcopy or defer
at least 6 weeks after delivery (better 8-12
weeks postpartum)
• If colposcopy during pregnancy shows no
CIN-2/3+, do follow-up screening
postpartum
HSIL (High-grade squam lesion)
• Up to 95% risk for CIN-2/3+
• Either colposcopic exam or immediate
LEEP are acceptable options
• No LEEP for pregnant women
HSIL: no CIN-2/3+
• If unsatisfactory colposcopy, perform
diagnostic excisional procedure (LEEP)
• If satisfactory, may observe with
colposcopy and cytology at 6 and 12
months OR perform diagnostic excisional
procedure (LEEP)
• If negative cytology X 2, routine screening
• If HSIL, needs diagnostic excision (LEEP)
AGC (Atypical Glandular Cells)
• Several subtypes for this cytologic class
• Also includes AIS (adenoca in situ)
• For any subtype, need colposcopy; HPV
testing; endocervical and endometrial
sampling
• ICSI guidelines streamline ASCCP
recommendations
Subsequent Management
for AGC
• Numerous arms and options
• Refer to ASCCP guideline for particular
plan of action based on initial cytology
report: AGC favor neoplasia, AGC (NOS),
AGC favor endometrial origin, AGC favor
endocervical origin, AIS
BEC (Benign Endometrial Cells)
• Only reported if patient age 40 or older
• Determine if patient has irregular bleeding,
risk factors for endometrial cancer, or if
patient is postmenopausal
• If “yes” for any of these categories, patient
needs endometrial sampling
• Otherwise repeat cytology in 12 months
Risk Factors for Endometrial Ca
• Tamoxifen or other SERM use
• Family or personal history of ovarian,
breast, colon or endometrial cancer
• Chronic anovulation
• Obesity
• Prior endometrial hyperplasia
Primary HPV Testing
• Patient ≥ 30 years old
• Cytology must be negative and no recent
change in sexual partner
• If HPV-, routine screening not needed for
at least 3 years
• If HPV +, repeat cytology and HPV testing
in 12 months
Primary HPV testing, HPV+
• If both repeat cytology and HPV-, routine
screening no sooner than 3 years
• If cytology negative and HPV+, needs
colposcopy
• If cytology abnormal, follow usual category
algorithm
HPV Vaccination
• Minimum age is 9 years old
• There is a quadrivalent vaccine (HPV4) for
prevention of cervical, vaginal and vulvar
cancer and genital warts
• There is a bivalent vaccine (HPV2) for
prevention of cervical cancer
• Best administered before exposure to HPV
from sexual contact
HPV Vaccination, continued
• Typically administer first dose to females
at age 11 or 12
• Second dose 1-2 months after first dose
and third dose 6 months after first dose
(minimum of 24 weeks between first and
third dose)
• Can administer to females between ages
of 13 and 18
HPV Vaccination, continued
• Can do catch-up immunization to age 26
• Relatively older females typically have
only one strain of HPV and will benefit
from the vaccination series
• HPV4 can be administered as a threedose series to males aged 9 to 18 to
prevent genital warts
HPV Vaccination, continued
• If pregnancy occurs during series,
postpone subsequent doses until after
pregnancy completed
• No evidence of increased fetal
abnormalities or fetal wastage from
exposure
HPV Vaccination Reactions
• Alum agent causes 85% to complain of
pain and 25% to have redness at site
• Syncopal episodes not greater than for
other vaccinations in same age group
• 70% of syncopal episodes occur in first 15
minutes; patient should recline for than
span of time
• Source: icsi.org