Management Guidelines for

Abnormal Pap Smear &

Preinvasive Disease of the Cervix

FOREWORD

Cervical cancer is the 4th most common cancer among women in

Singapore. The incidence of cervical cancer has declined from 18.1
per 100,000 population for the years 1968-72 to 14.2 per 100,000
population between 1993-97. However, the incidence rate in
Singaporean women remains higher than that of developed countries.
In 1998, the Ministry of Health set up the Cervical Cancer Screening
Committee to develop an organised population-based cervical cancer
screening programme to reduce cervical cancer mortality. It was
recognised that evidence-based management guidelines were necessary
for the evaluation and management of women with different grades
of cervical abnormality detected by the cervical cancer screening
programme. A workgroup, chaired by A/Prof Ho Tew Hong with
representatives from the Chapter of Obstetrics & Gynaecology,
Academy of Medicine, Singapore, Obstetrical & Gynaecological Society
of Singapore, Society for Colposcopy & Cervical Pathology of Singapore,
Singapore General Hospital, National University Hospital and KK
Womens & Childrens Hospital was formed to develop a set of
management guidelines for handling abnormal Pap smears.
The CervicalScreen Singapore: Management Guidelines for the
Abnormal Pap Smear and for Preinvasive Disease of the Cervix will be
a useful guide for clinicians in the management of patients with
abnormal Pap smears.
I would like to extend my sincere thanks to the workgroup for
their commitment and hard work in developing the guidelines.

Dr Lam Sian Lian

Chief Executive Officer
Health Promotion Board
i

PREFACE

Whilst the incidence of cervical cancer in Singapore has decreased

slightly in the last 25 years, much can still be done to reduce the rates
of cervical cancer further.
The primary aim of the CervicalScreen Singapore Programme is
to further reduce the incidence and mortality from cervical cancer
through early detection. An important aspect of this Programme is to
guide general practitioners on the management guidelines for screened
cervical abnormalities.
A Workgroup consisting of representatives from Chapter of
Obstetrics & Gynaecology, Academy of Medicine of Singapore,
Obstetrical and Gynaecological Society of Singapore, the Society for
Colposcopy and Cervical Pathology of Singapore, Singapore General
Hospital, National University Hospital and KK Womens & Childrens
Hospital met on several occasions to work out consensus management
guidelines for abnormal PAP smear and for preinvasive disease of the
cervix. Views from international experts were sought and the consensus
guidelines of Bethesda 2001 were also taken into account.
These consensus guidelines are formulated specifically for the
purpose of the oncoming CervicalScreen Singapore Programme.

Ho Tew Hong
Clinical Associate Professor
Chairman of Workgroup
CervicalScreen Singapore:
Management Guidelines
for Abnormal Pap Smear and
Preinvasive Disease of the Cervix
iii

CONTENTS

Foreword

Preface

iii

1. CervicalScreen Singapore

2. Terminology for Cervical Smear Reporting

3. Management Protocol for Negative for Malignant Cells Smears

4. Management Protocol for Unsatisfactory Smears

5. Management Protocol for Abnormal Smears

9
11

5.1 Management of Abnormal Smear

(no past history of CIN or genital tract cancer)

12

5.2 Management of Abnormal Smear

(following treatment for CIN or CGIN)

17

5.3 Management of the Abnormal Smear in Pregnancy

17

6. Pap Smears After Hysterectomy

18

7. Management of Preinvasive Disease of the Cervix

20

7.1 HPV

21

7.2 CIN 1

22

7.3 CIN 2 and CIN 3

23

7.4 Suspicion of Microinvasion on Cervical Biopsy

24

7.5 Adenocarcinoma-in-situ

25

7.6 Management of the Abnormal Smear and CIN in Pregnancy

26

7.7 Involvement of Margins after Cone Biopsy or LEEP for CIN

27

8. Special Situations

28

8.1 Abnormal Smear (ASC-US / LSIL) & Unsatisfactory or Normal

Colposcopy

29

8.2 Abnormal Smear (ASC-H / HSIL) & Unsatisfactory or Normal

Colposcopy

30

8.3 Atypical Glandular Cells

31

8.4 Endocervical Adenocarcinoma in-situ on Pap smear

32

8.5 Adenocarcinoma on Pap smear

33

References

34

Acknowledgements

38
iv

CERVICALSCREEN
SINGAPORE

1
CERVICALSCREEN
SINGAPORE

1. Age Group to be Screened and Screening Interval

1.1 Entry to Screening Programme
All women who have ever had sex are advised to have their first Pap
smear by the age of 25
1.2 Frequency of Screening
Pap smears are taken once every 3 years
1.3 Discharge from Screening
A woman can be discharged from screening at 65 years of age if the
smear taken at 65 years is negative and there was a previous negative
smear within the last 3 years
However if a woman, who has had sexual intercourse, has never had
a Pap smear, she should still undergo screening irrespective of her age
1.4 Women who have never had Sexual Intercourse
Women who have never had sexual intercourse need not have Pap
smear screening
However if these women have any symptoms, they should consult a
doctor
Note : Consider screening at an earlier age and at more frequent
intervals if high risk characteristics are present. High risk characteristics
include:

Multiple sexual partners (either partner)

Onset of sexual intercourse at an early age
HPV infection
History of STD
HIV infection
Immunosuppression
Cigarette smoking

TERMINOLOGY FOR
CERVICAL SMEAR
REPORTING

TERMINOLOGY FOR
CERVICAL SMEAR REPORTING

(A) List of terminology

1. Unsatisfactory
2. Negative for Malignant Cells
3. Abnormal Smears
3.1 Squamous Lesions
3.1.1 Atypical Squamous Cells
undetermined significance (ASC-US)
cannot exclude high grade lesion (ASC-H)
3.1.2 Low-Grade Squamous Intraepithelial Lesion (LSIL)
HPV effect
mild dyskaryosis
3.1.3 High-Grade Squamous Intraepithelial Lesion (HSIL)
moderate dyskaryosis
severe dyskaryosis
severe dyskaryosis, cannot rule out invasive carcinoma
3.1.4 Squamous Cell Carcinoma
3.2 Glandular Lesions
3.2.1 Atypical Glandular Cells
undetermined significance
favour neoplastic
3.2.2 Endocervical Adenocarcinoma-in-Situ
3.2.3 Adenocarcarcinoma
3.3 Others
3.3.1 Carcinoma
others - specify
not further specified
3.3.2 Other Malignant Tumours
specify

(B) Definitions

Unsatisfactory
A smear that is unreliable for the detection of cervical epithelial cell
abnormalities.
4

A smear comprising mainly endocervical cells is also considered

unsatisfactory, unless the smear was intended to specifically evaluate
the endocervical canal.

Negative for Malignant Cells

The smear shows no dyskaryotic or malignant cells ie. no cytological
evidence of Cervical Intraepithelial Neoplasia (CIN), glandular dysplasia
or malignancy.
This category includes those in which cells showing reactive changes are
present, and also those in which micro-organisms are identified.

Squamous Lesions
Atypical Squamous Cells
undetermined significance
cannot exclude high grade lesion
There are cells showing cytologic changes suggestive of a dysplastic
squamous lesion that is quantitatively or qualitatively insufficient for a
definitive interpretation.
Undetermined Significance (ASC-US)
Cytologic changes suggestive of a low grade squamous lesion but lack
criteria for definitive interpretation.
Cannot Exclude High Grade Lesion (ASC-H)
Cytologic changes suggestive of a high grade squamous lesion but lack
criteria for definitive interpretation.
Low-Grade Squamous Intraepithelial Lesion (LSIL)
HPV effect
mild dyskaryosis
HPV Effect
Squamous cells present showing stringent criteria of HPV effect ie.
koilocytes in superficial or intermediate squamous cells or sharply
delineated perinuclear halos in parabasal cells.
Mild Dyskaryosis
Cytologic changes indicative of CIN I.
5

TERMINOLOGY FOR
CERVICAL SMEAR REPORTING

If fewer than these are seen because of paucity of cells, poor fixation,
air- drying artefact, thick smearing, or covering of blood, inflammatory
exudate or other contaminants, the smear is considered unsatisfactory.

A satisfactory smear should show well-preserved and well-visualised

squamous cells covering at least one-third of the area of a regular glass
slide surface.

High-Grade Squamous Intraepithelial Lesion (HSIL)

TERMINOLOGY FOR
CERVICAL SMEAR REPORTING

moderate dyskaryosis
severe dyskaryosis
severe dyskaryosis, cannot rule out invasive carcinoma
Moderate Dyskaryosis
Cytologic changes indicative of CIN 2.
Severe Dyskaryosis
Cytologic changes indicative of CIN 3.
Severe Dyskaryosis, Cannot Rule Out Invasive Carcinoma
Cytologic changes indicative of at least CIN 3, but with features of
possible invasive tumour.
Squamous Cell Carcinoma
Cytologic changes indicative of an invasive squamous cell carcinoma.

Glandular Lesions
Atypical Glandular Cells
undetermined significance
favour neoplastic
There are cells showing cytologic changes suggestive of a dysplastic
glandular lesion that are quantitatively or qualitatively insufficient for a
definitive interpretation. Where possible, these are qualified as to whether
the abnormal cells are of endocervical or endometrial origin.
Undetermined Significance
Cytologic changes which exceed those of a reactive process but lack
criteria for a definitive interpretation of a dysplastic glandular lesion.
Favour Neoplastic
Cytologic changes suggestive of a glandular dysplasia or adenocarcinomain-situ or adenocarcinoma, but lack criteria for definitive interpretation.
Endocervical Adenocarcinoma-in-Situ
Cytologic changes indicative of endocervical adenocarcinoma-in-situ.
Adenocarcarcinoma
Cytologic changes indicative of an invasive adenocarcinoma.

Others
Carcinoma
others - specify
not further specified
Other Malignant Tumours
specify
6

MANAGEMENT PROTOCOL
FOR NEGATIVE FOR
MALIGNANT CELLS SMEARS

PAP SMEAR

NEGATIVE SMEARS

Negative for malignant cells

Atrophic
changes

No endocervical
cells seen

(without
inflammation)

Repeat in 1 year
(use of an
endocervical
brush in addition
to the cervex
brush/spatula is
recommended)

Specific
micro-organisms
identified

Treat appropriately changes

&
resolve
as clinically
indicated

Inflammatory
changes

Endometrial
cells
seen

Treat any
infection
or atrophy
Repeat in
4 6 months

Correlate
with clinical
findings,
patients
age,
hormonal
and
menstrual
status

2nd smear
similar changes

changes
resolve

Treat any
infection
or atrophy
Repeat in
4 6 months

3rd smear
similar changes

Routine
screening
schedule

Routine
screening
schedule

Refer
gynaecologist

Refer
gynaecologist
if necessary

Note : Clinically suspicious looking cervix irrespective of the Pap smear result
must be referred for colposcopy.
8

MANAGEMENT PROTOCOL
FOR UNSATISFACTORY
SMEARS

PAP SMEAR

UNSATISFACTORY
SMEARS

Unsatisfactory

Treat any infection

Give a course of estrogen if
post-menopausal with atrophic changes
Repeat in 3 months

2nd smear unsatisfactory

Repeat in 3 months

Negative for malignant cells

Satisfactory and negative

3rd smear unsatisfactory

Refer for colposcopy

Routine screening schedule

Note : Clinically suspicious looking cervix irrespective of the Pap smear result
must be referred for colposcopy.
10

MANAGEMENT PROTOCOL
FOR ABNORMAL
SMEARS

11

5.1

Management of Abnormal Smear

(No past history of CIN or genital tract cancer)

PAP SMEAR

Atypical squamous cells

Undetermined significance
(ASC-US)

Refer for colposcopy

Repeat in 6 months

ABNORMAL
SMEARS

Cannot exclude high grade lesion

(ASC-H)

- Atypical squamous cells

- Low-grade squamous
intraepithelial lesion
- High-grade squamous
intraepithelial lesion

Negative for
malignant cells

Refer for colposcopy

Repeat in 6 months

Resume routine
screening if negative
for malignant cells

12

PAP SMEAR

Low-grade squamous intraepithelial lesion

(LSIL)

Mild dyskaryosis
or
not otherwise specified

HPV effect

ABNORMAL
SMEARS

Repeat in 6 months

Negative for
malignant cells

HPV effect
and / or more
severe abnormality

Repeat in 1 year
If negative for
malignant cells,
may resume
routine screening

Colposcopy

13

Colposcopy

PAP SMEAR

Squamous cell carcinoma

ABNORMAL
SMEARS

High-grade squamous
intraepithelial lesion
(HSIL)

Moderate
dyskaryosis
or
Severe
dyskaryosis

Severe
dyskaryosis,
cannot rule out
invasive
carcinoma

Colposcopy

Colposcopy
(urgent appointment)

14

Urgent referral
to
gynaecologist

PAP SMEAR

Endocervical
adenocarcinomain-situ

Colposcopy *

Colposcopy

Adenocarcinoma

*Colposcopist to refer to management guidelines 8.3

15

Urgent referral to
gynaecologist

ABNORMAL
SMEARS

Atypical glandular
cells
-Undetermined
significance
-Favour neoplastic

PAP SMEAR

Carcinoma
(specified or not further specified)

Other malignant tumours

ABNORMAL
SMEARS

Urgent Referral To Gynaecologist

Other indications for referral :

a.

Abnormal vaginal bleeding, eg. post-coital, post-menopausal or

intermenstrual, should always be investigated and the woman
referred for a specialist opinion.

b.

Clinically suspicious looking cervix irrespective of the Pap smear result

must be referred for colposcopy.

16

5.2 Management of Abnormal Smear

(Following treatment for CIN or CGIN)

PAP SMEAR

Unsatisfactory

Atypical squamous or
glandular cells,
dyskaryosis
of any degree

Suspicious of invasive
carcinoma or
adenocarcinoma, or
malignant cells seen

Negative for
malignant
cells

Resume follow
up schedule
after treatment
for CIN

ABNORMAL
SMEARS

Treat any infection

Give a course of
estrogen if
post-menopausal
with atrophic changes
Repeat in 3 months

2nd smear
unsatisfactory

Colposcopy

Colposcopy

Colposcopy
(urgent appointment)

5.3 Management of the Abnormal Smear in Pregnancy

The same as in the non-pregnant patient

17

PAP SMEARS
AFTER
HYSTERECTOMY

18

1.

Hysterectomy for benign disease

(a) Normal Pap smear history
(b) Histopathology of cervix known and is benign with no dysplastic/
neoplastic changes

Subtotal hysterectomy
Should continue to have Pap smears according to the screening
programme

3.

Hysterectomy where histology not known

One base-line Pap smear of vaginal vault
If this is normal, then no further smears are required

4.

Immunosuppressed women (due to disease or therapy)

Should continue to have Pap smears of the vault at yearly intervals

5.

Women with a past history of CIN

(a) If excision margin was involved or not adequately assessed
histologically
Follow up should be at the discretion of the gynaecologist
Vault smears should in general be taken at least yearly
(b) CIN (CIN 1 / 2 / 3) completely excised at hysterectomy
Vault smears for five years yearly
Two yearly subsequently

6.

Women previously treated for VAIN, or invasive gynaecological

malignancy
These women should be followed up by the treating gynaecologist/
gynaecological oncologist

PAP SMEARS AFTER

HYSTERECTOMY

2.

These women, in the absence of symptoms, need not have any

further Pap smears

MANAGEMENT OF
PREINVASIVE DISEASE
OF THE CERVIX

20

7.1 HPV

HPV on Biopsy

Repeat Pap smear +

colposcopy in 6 months

Treat :
i. If any associated CIN,
according to guidelines
for CIN
ii. If condylomas present

HPV
No CIN

MANAGEMENT OF
PREINVASIVE DISEASE

Yearly Pap smear x 2

If negative for
malignant cells,
may return to routine
3 yearly screening

21

7.2 CIN 1

CIN 1 on Biopsy

Observation

Treatment

Repeat Pap smear and

colposcopy + biopsy
in 6 months

Ablation *
or
Excision

Persistent CIN I
- cytology
(ASC-US / LSIL)
- colposcopy +
biopsy

Refer Section 7.3

Treatment
Or
Observation

Normal

Follow-up

Pap smear at
3 6 months

MANAGEMENT OF
PREINVASIVE DISEASE

Progression
- cytology
(ASC-H / HSIL)
- colposcopy +
biopsy

- If observation, patient must be compliant

to follow-up
- Repeat Pap smear and colposcopy + biopsy
in 6 months
- Consider treatment if CIN I persistent
for 12 months from first histological diagnosis

Pap smear + colposcopy

at 12 months

Yearly Pap smear x 4

Return to routine 3
yearly screening

* Refer to criteria for ablation in 7.3

Note : The management of CIN I is controversial; patients can be managed
by either observation or treatment.
If immunocompromised patient, suggest treatment as CIN less likely
to regress.
22

7.3 CIN 2 and CIN 3

CIN 2 / CIN 3 on Biopsy

Treat

Excision
- LEEP / LLETZ
- Laser cone
- Cold knife cone

Follow-up

Pap smear at 3 - 6 months

Pap smear + colposcopy at 12 months

Pap smear 6 monthly for second year

Yearly Pap smear

23

MANAGEMENT OF
PREINVASIVE DISEASE

Ablation
- The upper limit of the lesion is completely
visualised
- The whole transformation zone is seen on
colposcopy
- There is no discrepancy of more than one grade
between cytology, colposcopy or biopsy
- There is no suspicion of microinvasive / invasive
disease on cytology, colposcopy or biopsy
- There is no suspicion of any glandular
lesion on cytology, colposcopy or biopsy
- The patient will be compliant to follow up

7.4 Suspicion of Microinvasion on Cervical Biopsy

SUSPICION OF MICROINVASION
on Biopsy

Cone biopsy of cervix

MANAGEMENT OF
PREINVASIVE DISEASE

Subsequent management
according to histology of
cone biopsy

Note : For suspected microinvasion a single large cone biopsy specimen

with clear margins is necessary for adequate histopathological
interpretation. A LEEP may not be adequate. A cold knife cone under
anaesthesia is preferred.

24

7.5 Adenocarcinoma-in-situ

ADENOCARCINOMA-IN-SITU
on Biopsy

Cone biopsy + endocervical curettage (ECC)

Invasion present

Manage according to
guidelines for
cervical cancer

No invasion

Margins involved

Adequate specimen
and margins clear

If fertility desired
or desire
to preserve uterus

Total
hysterectomy

Follow patient
closely

Note : For cone biopsy for adenocarcinoma-in-situ, a single large specimen

with clear margins is necessary for adequate histopathological
interpretation. A LEEP may not be adequate. A cold knife cone under
anaesthesia is preferred.

25

MANAGEMENT OF
PREINVASIVE DISEASE

Completed
family

Recommend
expert opinion

7.6 Management of the Abnormal Smear and CIN in Pregnancy

1.

Colposcopic evaluation should be undertaken to exclude invasive disease,

by a colposcopist experienced in colposcopy in pregnancy.

2.

If a high grade lesion is suspected on colposcopy, a biopsy is indicated to

exclude possible invasive disease. Cervical biopsy is safe in pregnancy.

3.

If CIN 2 or 3 is present, colposcopic review should be done in the second or

third trimester to exclude any possible progression to invasive disease.

4.

Treatment of CIN should be deferred till at least 8 weeks post-partum, when

the lesion should be reassessed. If the patient is breast feeding, local
application of estrogen before the colposcopic reassessment may assist
accurate evaluation.

MANAGEMENT OF
PREINVASIVE DISEASE

Note : The management of labour is not influenced in any way by the

presence of CIN, irrespective of severity.

26

7.7 Involvement of Margins after Cone Biopsy or LEEP for CIN

Involvement of Resection Margins

Margin positive
for CIN I

Margin positive
for CIN 2 or 3

Repeat Pap smear and colposcopy

at 3 months

Repeat excision
or hysterectomy

Pap smear abnormal

colposcopy
unsatisfactory
or normal

Biopsy

Follow up
according to
schedule for CIN

Review Pap smear

by pathologist

CIN I

CIN 2 / CIN 3

Individualise
treatment

Ablation*
or
excision

Excision
or
hysterectomy
Consider
expert
opinion

* Refer to criteria for ablation in 7.3

27

MANAGEMENT OF
PREINVASIVE DISEASE

Pap smear negative

for malignant cells
Colposcopy normal

SPECIAL
SITUATIONS

Note:
Management should be individualised.
Consider expert opinion including pathology review.

28

8.1 Abnormal Smear (ASC-US / LSIL) & Unsatisfactory or Normal

Colposcopy
Atypical squamous cells-undetermined significance (ASC-US) /
Low-grade squamous intraepithelial lesion (LSIL)

Colposcopy satisfactory + normal

vulva / vaginal normal

Colposcopy unsatisfactory
vulva / vagina normal

Do ECC

Pap smear
abnormal
colposcopy
normal

ECC
positive

Repeat Pap
smear in
6 months

ASC-US
or LSIL

Negative
for
malignant
cells

Repeat Pap smear

+ colposcopy
in 6 months,
consider cone
biopsy or LEEP
if persistent
at 12 months

ASC-H/
HSIL

ECC
negative

Pap smear &

colposcopy
normal

Repeat Pap smear

+ colposcopy
in 6 months

Abnormal

Normal

Repeat Pap
smear in
6 months

Yearly Pap
smear x 2

Negative for
malignant cells

If negative
for malignant
cells, resume
3 yearly
screening

Yearly Pap
smear x 2

Legend : ECC
Note :

Pap smear
abnormal
colposcopy
unsatisfactory

Cone biopsy
or LEEP

Endocervical currettage

Cone
biopsy
or LEEP

If negative for malignant

cells, resume 3 yearly
screening

Management should be individualised. Consider expert opinion

including pathology review.
29

Pap smear &

colposcopy
normal

Estrogen treatment if
post-menopausal. Repeat Pap
smear & colposcopy in 3 months

SPECIAL
SITUATIONS

Repeat Pap smear & colposcopy

in 6 months

8.2 Abnormal Smear (ASC-H / HSIL) & Unsatisfactory or Normal

Colposcopy
Atypical squamous cells cannot exclude high grade lesion (ASC-H) /
High-grade squamous intraepithelial lesions (HSIL)

Colposcopy satisfactory & normal

Vulva / vagina normal

Colposcopy unsatisfactory
Vulva / vagina normal

Review Pap smear by pathologist

Not conclusive
for ASC-H / HSIL

ASC-H / HSIL

Repeat Pap smear &

colposcopy
in 3 - 6 months

SPECIAL
SITUATIONS

Pap smear &

colposcopy normal

Repeat Pap
smear in 6 months

If negative for
malignant cells,
yearly Pap
smear x 2

Review Pap smear by

pathologist

ASC-H / HSIL

Not conclusive
for ASC-H / HSIL

Pap smear abnormal

colposcopy normal

ASC-US
or LSIL

ASC-H / HSIL

Repeat Pap smear +

colposcopy in 6 months,
consider cone biopsy or
LEEP if persistent
at 12 months

If negative for
malignant cells,
to resume
3 yearly screening

30

Cone biopsy or
LEEP

Follow
algorithm
as in 8.1

8.3 Atypical Glandular Cells

Atypical glandular cells
-undetermined significance
-favour neoplastic
Colposcopy

Abnormal

Biopsy

Normal or unsatisfactory

Review Pap smear by pathologist

AIS / SIL

High suspicion of
neoplastic lesion

Manage according
to guidelines
for cervical cancer

Low suspicion of
neoplastic lesion

Repeat Pap smear &

colposcopy + ECC
in 4 6 months

Consider pelvic ultrasound

Cone biopsy and D&C or
endometrial sampling *

Normal

Normal

Pap smear 6 mthly x 2

If negative for malignant cells, yearly Pap smear x 2

If negative for malignant cells, resume 3 yearly screening

* If risk factors for Ca endometrium are present, or the patient is

symptomatic or > 40 years
D&C (+ hysteroscopy) is advised for
endometrial tissue evaluation
Note : If histology of cone biopsy and D&C normal
to investigate for
disease in ovary, fallopian tubes and peritoneum.
31

Manage according
to histology of lesion

AGUS

SPECIAL
SITUATIONS

Carcinoma

8.4 Endocervical Adenocarcinoma-in-situ on Pap Smear

Endocervical Adenocarcinoma-in-situ on Pap Smear

Colposcopy

No lesion on cervix

Lesion on cervix

SPECIAL
SITUATIONS

Squamous intraepithelial
lesion

Cone biopsy
+ ECC
D&C if risk factors
for Ca endometrium
present,
symptomatic or
>40 years

Legend: ECC

Cone biopsy
+ ECC
D&C if risk factors
for Ca endometrium
present,
symptomatic or
>40 years

AIS

biopsy

Adenocarcinoma

Cone biopsy
+ ECC

Manage
according to
guidelines for
cervical cancer

Endocervical currettage

Note : If histology of cone biopsy and D&C normal

to investigate for
disease in ovary, fallopian tubes and peritoneum.
32

8.5 Adenocarcinoma on Pap Smear

Adenocarcinoma on Pap Smear

Lesion on cervix

No lesion on cervix
Colposcopy normal

AIS

Manage according
to guidelines
for cervical cancer

Cone biopsy
+ ECC
and D&C

SPECIAL
SITUATIONS

Adenocarcinoma

D&C + hysteroscopy
Cone biopsy of cervix

Squamous
intraepithelial lesion
or no dysplasia

Biopsy

Note : If histology of D&C and cone biopsy normal

to investigate for
for disease in ovary, fallopian tubes and peritoneum.

33

REFERENCES

34

Duncan ID (ed). Guidelines for clinical practice and programme management

2nd edition. National Health Service Cervical Screening Programme
Publication No. 8 1997.

2.

Screening to prevent cervical cancer: Guidelines for the management of

women with screen detected abnormalities. Report by the National Health
and Medical Research Council for the Organised Approach to preventing
cancer of the cervix. Australian Government Publishing Service, Canberra
1994.

3.

IARC Working Group on Evaluation of Cervical Cancer Screening Programmes.

Screening for squamous cervical cancer: Duration of low risk after negative
results of cervical cytology and its implication for screening policies.
Br Med J 1986; 293: 659-64.

4.

From the Centres for Disease Control and Prevention. Incidence of Pap test
abnormalities within 3 years of a normal Pap test - United States,
1991 - 1998. JAMA 2000; 284 (21): 2714-5.

5.

Gram IT, Macaluso M, Stalsberg H. Incidence of cervical intraepithelial

neoplasia grade III, and cancer of the cervix uteri following a negative Pap
smear in an opportunistic screening. Acta Obstet Gynecol Scand
1998; 77 (2): 228-32.

6.

Mitchell MF, Schottenfeld D, Tortolero-Luna G, Cantor SB, Richards-Kortum

R. Colposcopy for the diagnosis of squamous intraepithelial lesions: A metaanalysis. Obstet Gynecol 1998; 91 (4): 626-31.

7.

M I Shafi, DM Luesley, JA Jordan, JA Dunn, TP Rollason, M Yates. Randomised

trial of immediate versus deferred treatment strategies for the management
of minor cervical cytological abnormalities. British Journal of O&G
1997; 104: 590-4.

8.

Flannelly G, Kitchener H. Every woman with an abnormal cervical smear

should be referred for treatment: debate. Clin Obstet Gynecol 1995; 38 (3):
585-91.

9.

Manetta A, Keefe K, Lin F, Ahdoot D, Kaleb V. Atypical glandular cells of

undetermined significance in cervical cytologic findings. Am J Obstet Gynecol
1999; 180 (4): 883-8.

35

REFERENCES

1.

10. Kim TJ, Kim HS, Park CT, Park IS, Hong SR, Park JS, Shim JU. Clinical evaluation
of follow-up methods and results of atypical glandular cells of undetermined
significance (AGUS) detected on cervicovaginal Pap smears. Gynecol Oncol
1999; 73 (2): 292-8.
11. McIndoe WA, McLean MR, Jones RW, Mullins PR. The invasive potential of
carcinoma in situ of the cervix. Obstet Gynecol 1984; 64 (4) : 451-8.
12. Cox JT. Management of cervical intraepithelial neoplasia. Lancet 1999; 353
(9156): 857-9.
13. Shafi MI, Luesley DM. Management of low grade lesions: Follow-up or treat?
Ballieres Clin Obstet Gynaecol 1995; 9 (1): 121-31.
14. G Flannelly, D Anderson, HC Kitchener, E M F Mann, M Campbell, P Fisher, F
Walker. Management of women with mild and moderate cervical dyskaryosis.
BMJ; 308: 1399-403.
15. Martin-Hirsch PL, Paraskevaidis E, Kitchener H. Surgery for cervical
intraepithelial neoplasia. Cochrane Database Syst Rev 2, CD001318, 2000.
16. Duggan BD, Felix JC, Muderspach LI, Gebhardt JA, Groshen S, Morrow CP,
Roman LD. Cold-knife conization versus conization by the loop electrosurgical
excision procedure: a randomized, prospective study. Am J Obstet Gynecol
1999; 180 (2 Pt 1): 276-82.
17. Narducci F, Occelli B, Boman F, Vinatier D, Leroy JL. Positive margins after
conization and risk of persistent lesion. Gynecol Oncol 2000; 76 (3): 311-4.

REFERENCES

18. Dobbs SP, Asmussen T, Nunns D, Hollingworth J, Brown LJ, Ireland D. Does
histological incomplete excision of cervical intraepithelial neoplasia following
large loop excision of transformation zone increase recurrence rates? A six
year cytological follow up. Br J Obstet Gynaecol 2000; 107 (10) : 1298-301.
19. K Mohamed-Noor, MA Quinn, J Tan. Outcomes after cervical cold knife
conization with complete and incomplete excision of abnormal epithelium:
A review of 699 cases. Gynecologic Oncology 1997; 67: 34-8.
20. Grainne Flannelly, Heather Langhan, Lata Jandial, Evelyn Mann, Marion
Campbell, Henry Kitchener. A study of treatment failures following large
loop excision of the transformation zone for the treatment of cervical
intraepithelial neoplasia. British Journal of O&G 1997; 104: 718-22.

36

21. ES Andersen, B Pedersen, K Nielsen. Laser conization : The results of treatment

of cervical intraepithelial neoplasia. Gynecologic Oncology 1994; 54: 201-4.
22. WP Soutter, A de Barros Lopes, Astrid Fletcher, JM Monaghan, ID Duncan, E
Paraskevaidis, HC Kitchener. Invasive cervical cancer after conservative therapy
for cervical intraepithelial neoplasia. Lancet 1997; 349: 978-80.
23. Shin CH, Schorge JO, Lee KR Sheets EE. Conservative management of
adenocarcinoma in situ of the cervix. Gynecol Oncol 2000; 79 (1): 6-10.
24. Ostor AG, Duncan A, Quinn M, Rome R. Adenocarcinoma-in-situ of the
uterine cervix : An experience with 100 cases. Gynecol Oncol 2000; 79 (2):
207-10.
25. Palle C, Bangsboll S, Andreasson B. Cervical intraepithelial neoplasia in
pregnancy. Acta Obstet Gynecol Scand 2000; 79 (4): 306-10.
26. Woodrow N, Permezel M, Butterfield L, Rome R, Tan J, Quinn M. Abnormal
cervical cytology in pregnancy: Experience of 811 cases. Aust N Z J Obstet
Gynaecol 1998; 38 (2) : 161-5.
27. Milne DS, Wadehra V, Mennim D, Wagstaff TI. A prospective follow up study
of women with colposcopically unconfirmed positive cervical smears. Br J
Obstet Gynaecol 1999; 106 (1) : 38-41.
28. Roche DH, Spicer N. The clinical significance of atypical squamous cells of
undetermined significance: A laboratory audit of cervical reporting. N Z Med
J 2001 23; 114 (1126) : 64-6.

30. Law KS, Chang TC, Hsueh S, Jung SM, Tseng CJ, Lai CH. High prevalence of
high grade squamous intraepithelial lesions and microinvasive carcinoma in
women with a cytologic diagnosis of low grade squamous intraepithelial
lesions. J Reprod Med 2001; 46 (1): 61-4.

37

REFERENCES

29. Lambert B, Boivin Y, Lepage Y. Atypical squamous cells of undetermined

significance (ASC-US): clinical-cytological significance. Int J Gynecol Cancer
1999; 9 (4): 329-32.

ACKNOWLEDGEMENTS

38

Workgroup Members

Chairperson
Clinical Assoc Prof Ho Tew Hong

Dr Chew Sung Hock

KK Womens & Childrens Hospital

Assoc Prof A Ilancheran

Academy of Medicine, Singapore

Dr Lee I Wuen

Raffles Hospital

Assoc Prof Lim Fang Kan

National University Hospital

Dr Lim-Tan Soo Kim

Singapore General Hospital

Dr Jeffrey Low

KK Womens & Childrens Hospital

Dr Quek Swee Chong

KK Womens & Childrens Hospital

Dr Pritam Singh

Society for Colposcopy & Cervical

Pathology of Singapore

Dr Tay Eng Hseon

Obstetrical & Gynaecological Society of

Singapore

Clinical Assoc Prof Tay Sun Kuie

Singapore General Hospital

Assoc Prof Tham Kok Fun

National University Hospital

39

ACKNOWLEGEMENTS

Members

3 Second Hospital Avenue, Singapore 168937

www.hpb.gov.sg / www.healthylife.org.sg
Copyright HPB B E 368-02
November 2002
Designed & printed by Grace Communications Pte Ltd