Abnormal Pap Test

1. Management of
Women with
Abnormal Pap Test

2. 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

3. Bethesda System 2001
Glandular cell
Atypical glandular cells (AGC)
Atypical glandular cells, favor neoplastic
Endocervical adenocarcinoma in situ (AIS)
Adenocarcinoma

4. Comparison of Terminology
Bethesda System CIN system Dysplasia
ASCUS Cellular AtypiaUnspecified Cellular
changes
LSIL CIN I Mild Dysplasia
HSIL CIN II Moderate dysplasia
CIN III Severe Dysplasia/ CIS

5. 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

6. Abnormal Pap test
ASCUS LSIL HSIL
HPV –veHPV +ve
Rpt PapNegative
Colposcopy
LEEP
ECC
+ve
-ve
Treat & Follow upDiagnostic cone
Treat & Follow up

7. ATYPICAL
SQUAMOUS CELLS

8. 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

9. 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

10. 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 CINdo HPV* @ 12 months
-or- repeat cytology @6,12 months
Note: It is not recommended to perform HPV testing at intervals of < 12 months.

11. Rpt Cytology
@ 6 & 12 Months
HPV –veHPV +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. 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

13. 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:
owith HPV testing at 12 months
Or
oCytological 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

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. Low Grade SIL

16. 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

17. 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

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. 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

20. HIGH GRADE SIL
HSIL

21. 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)

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. Managing Women with HSIL
UNACCEPTABLE 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

24. 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

25. 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

26. 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

27. 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.

28. ATYPICAL Glandular
Cells

29. 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.

30. ATYPICAL GLANDULAR CELLS
3 Categories:
AGC, NOS
AGC, FAVOR NEOPLASIA
AIS (adenocarcinoma in situ)

31. 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)

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. Management of CIN
1.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

34. 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)