Colposcopy and Pap Smear Triage Guidelines September 5, 2003

ASCUS PAP Recurrent ASCUS PAP ASC-H PAP AGC (AGUS) LSIL PAP HSIL PAP Guidelines for treatment of abnormal histology Biopsy Confirmed CIN 2 or 3 Colposcopy in Pregnancy Immunosuppressed Patients

ASCUS PAP Automatically sent for HPV DNA testing Index Next Slide

Positive (+)

Negative (-)

Colpo

(+)

Repeat Pap 12 mos.

(-)
Routine Screening

Colpo

CIN/CA Per ASCCP Guidelines

(-) Routine Screening

Normal

HPV DNA 12 Mos.

=ACS or HPV+ Repeat Colpo

For recurrent ASCUS with apparently normal colpo bring in for colpo of vagina and vulva, as well as looking carefully for vaginitis. Empiric treatment of vaginitis is not recommended.

For postmenopausal women (even on HRT) with ASCUS can consider treating with estrogen vaginal cream for two weeks, then discontinuing one week prior to repeat pap smear. If negative, repeat pap again after estrogen treatment in 4-6 months. If negative again can resume routine screening. If>=ASC must send for colposcopy.

Index

Next Slide

ASC-H Pap
Index Next Slide
Colposcopy with ECC for all patients.

Biopsy confirmed CIN

No lesion identified

See following Guidelines

Ask pathologist to review all specimens

No change HPV DNA @ 12 mos.

Change in Dx: As per guidelines

AGC (AGUS)

Index
AGUS pap

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Colposcopy with ECC and EMB for all patients.

No invasive disease

Invasive disease approp referral

Initial pap AGC-NOS

Initial pap AGC-favor Neopolasia or AIS

Diagnostic excisional procedure (CKC preferred

Neoplasia

No Neoplasia ASC or LSIL Repeat colpo or refer

Per following Guidelines

Repeat cytology @ 4-6 mo intervals X4

HSIL or AGC

Diagnostic excisional Procedure or refer

LSIL PAP

Index
Colposcopy with ECC for all patients

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No CIN/CA
HPV testing at 12 Months >=ASC or HPV+ Negative

CIN/CA

Manage as per Following Guidelines

Recommend treating patients with persistent histologically proven LSIL At 12 months unless and adolescent (<=20 years old). Recommend Following adolescents who are reliable and can understand and accept Risk of possible progression of disease for 24 months before treating Persistent LSIL because of the higher rate of spontaneous disease Clearance and lower rate of progression to cancer in this population. For post menopausal women with first LSIL pap and suspected atrophy, Can treat in the same manner as for post menopausal women with ASCUS (see prior pages)

Repeat Colpo

Routine Screening

HSIL
Index
Satisfactory Colpo

Colposcopy and ECC for all patients

Unsatisfactory Colpo

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No CIN or Only CIN 1

CIN 2, 3 On biopsy

No lesion seen

CIN of any Grade on bx

Review of Material and colpo Of entire genital tract

See CIN 2, 3 Guidelines

Review of Material and colpo Of entire genital tract

See CIN 2,3 Guidelines

No change

Change Dx

No Change Diagnostic Excisional Procedure

Per Guidelines

Diagnostic Excisional Procedure

Per Guidelines

Per Guidelines

Guidelines for treatment of abnormal histology Index Next Slide

Biopsy confirmed CIN 1 and satisfactory colposcopy Follow up without treatment is preferred (assuming no history of CIN and patient agrees to follow up. Can offer patient treatment at this time)

HPV testing at 12 Mos

.
HPV positive

Negative Repeat colposcopy Persistent CIN 1

No CIN

CIN 2,3

Per Guidelines Annual Screening Consider treating patients With persistent LSIL At 12 months

Guidelines for treatment of abnormal histology (Continued) Index Next Slide

For adolescent patients (<=20 years old) with persistent CIN1 on colposcopy, consider watching for 24 months if patient is reliable to follow up and can accept to possible risk of progression of disease. This population of patients have a higher spontaneous clearance rate of CIN, and a lower rate of progression to cancer. Acceptable treatment options include cryotherapy or LEEP. Excisional methods are preferred for recurrent (as opposed to persistent) CIN1

Biopsy confirmed CIN1 and unsatisfactory colposcopy

Diagnostic excisional procedure is recommended. Exceptions: Pregnant women (see following) Adolescents: follow up without treatment is acceptable in a reliable patient. HPV typing and colposcopy at 12 months. If not resolved, perform diagnostic excisional procedure.

Index
Satisfactory Colpo

Biopsy Confirmed CIN 2 or 3 Next Slide

Unsatisfactory Colpo

Excision or ablation of T-zone (ablation for Small, <2 quadrant Lesions only)

Diagnostic excisional procedure

HPV typing and Cytology in 6 mos

(+)

(-)

Exceptions: adolescents with CIN 2 with satisfactory colposcopy who are reliable can be followed for 12 months for spontaneous clearance of disease. Recommend q 6 months colposcopy x2 with HPV typing at 12 months. Patients with persistent CIN should be treated. Patients with normal colposcopy but positive HPV should be followed closely until resolution is documented.

Colposcopy

Annual screening (stress need for indefinite Routine screening)

Colposcopy in Pregnancy Index Next Slide

Repeat colposcopy every three months in pregnancy, and again 8 weeks after delivery. Treatment of lesion should be based on post partum colposcopy and histology. If colposcopic impression or pathology during pregnancy suggests CIS, patient needs to be referred to an OB/GYN for possible excisional procedure while pregnant. Cervical biopsies are considered safe in pregnancy, although there is an increased risk of bleeding. ECC IS CONTRAINDICATED.

Immunosuppressed Patients
(HIV, immunosuppressive therapy including chronic steroid use) Index
Treatment of low grade lesions in immunosuppressed women results in poor clearance rates and no observable decrease in the rate of progression to high grade disease. The literature therefore supports observational management of immunosuppressed women with low grade disease.

Treatment of CIN 2, 3 results in high rates of recurrence for CIN , but does appear to be effective in preventing progression to invasive cancer. The addition of 5-FU after treatment of CIN 2,3 halved the reoccurrence rate in one study. In HIV positive women, the administration of highly active antiretroviral therapy (HAART) at the time of treatment may help to clear disease. Consider OB/GYN and ID consultation prior to treating this group of women.