Abnormal Pap smear - know the different steps for follow up.

Every pap smear is reported by the Bethesda system. It has 3 descriptors.
1. Adequacy of specimen: Vaginal and endocervical component present or not.
2. Diagnostic categorization: Normal or other
3. Detailed description of findings.

It is falsely negative in 5-10% of cases.

Routine screening in general population yields about 6 abnormal results per 1000 tests. Highest prevalence of abnormality is seen in women aged 31-35, African -american and Puerto Rican women, women using hormonal birth control & those who have a long duration or early onset of sexual activity. Due to lack of innate immunity and defense mechanisms, HIV patients too have a high prevalence of abnormality and should be screened twice in the first year and if normal then once a year. Same guidelines apply for othe immunocompromised individuals. Examples include those with organ transplants, long term corticosteroid therapy and those with In Utero exposure of DES. HPV is a high risk too as >95% of Squamous cell cancer specimens have HPV.

Management of abnormal Paps: If atypical squamous cells (ASC) it may either be  subcategorized as ASC of undetermined significance (ASC-US) or as ASC but cannot exclude high-grade squamous intraepithelial lesion (HSIL) (ASC-H).

ASC-US should be managed by doing  2 repeat cytology tests, or DNA testing for high-risk types of human papillomavirus (HPV - particularly if liquid based cytology-i.e. thin prep was done).  If any of the above is positive then immediate colposcopy.

ASC-H, low-grade squamous intraepithelial lesion, HSIL, and atypical glandular cells should get colposcopic evaluation.

Questions based on this topic could be as follows:

1. 35 year old lady with 2 children comes to office with no H/O prior abnormal pap smear. She gets a liquid based pap smear. The results show: ASC US. Which of the following should be done next?
a. Repeat pap immediately
b. Repeat pap in 3 months
c. DNA testing for HPV and typing
d. Colposcopy

The answer is choice c. c is the best choice in this patient because she underwent a liquid prep test and it is immediately do-able. It will also quickly tell us what is to be done next. If Positive, immediate colposcopy and if negative, then routine testing.

Now the scenario would be completely different if the patient had any of the following: HIV, organ transplants, long term corticosteroid therapy and those with In utero exposure of DES or HPV in the past too calls for colposcopy as the next step.

Patients who have had a hysterectomy need not get a pap done unless hysterectomy was done for pre-malignant or malignancy reasons.

After 65 years age, those with 3 normal paps and No abnormal paps in the last 10 years need not get paps.

Other types of reports:

• AGC—atypical glandular cells. Glandular cells are mucus-producing cells found in the endocervical canal or in the lining of the uterus. The glandular cells do not appear normal, but uncertain about what the cell changes mean.
   Colposcopy done immediately unless glands are of endometrial origin - then EB/EC done.
  
• AIS—endocervical adenocarcinoma in situ. Precancerous cells are found in the glandular tissue.
  Colposcopy and endocervical curettage are done.
  
• LSIL—low-grade squamous intraepithelial lesion. Low-grade means there are early changes in the size and shape of cells. LSILs are considered mild abnormalities caused by HPV infection.
  Colposcopy is done.
  
• HSIL—high-grade squamous intraepithelial lesion. High-grade means that there are more marked changes in the size and shape of the abnormal (precancerous) cells, meaning that the cells look very different from normal cells. HSILs are more severe abnormalities and have a higher likelihood of progressing to invasive cancer.
  Colposcopy with endocervical curettage is done.

Methods used to treat HSILs include cryosurgery (freezing that destroys tissue), LEEP (loop electrosurgical excision procedure, the removal of tissue using a hot wire loop), as well as conventional surgery

CIN1 is followed by colposcopy.

CIN 2/3  - do colposcoppy to guide the performance of Ablation/excision.

EB = Endoetrial biopsy

EC = Endoetrial curettage.