Review Question - QID 102947

This patient with a Pap smear showing a high grade squamous epithelial lesion (HGSIL) should undergo either colposcopy or a diagnostic excisional procedure.

While colposcopy and a diagnostic excisional procedure both aim to obtain tissue from the cervical transformation zone as well as the endocervical canal for histology evaluation, colposcopic-guided biopsy often allows for a more targeted procedure. Specific techniques for diagnostic excisional procedures include: loop electrosurgical excision procedure (LEEP), laser conization, cold knife conization, or loop electrosurgical conization. Alternatively, colposcopy with endocervical assessment should allow for determination of whether the lesion is cervical intraepithelial neoplasia (CIN) 1, 2, or 3 versus carcinoma in situ. Depending on the nature of the lesion, treatment modalities can range from ablation or excision to hysterectomy.

Apgar et al. discuss the role of colposcopy as well as treatment options for different cervical biopsy results. Colposcopy uses illumination and magnification in conjunction with the application of acetic acid to the cervix to identify the location(s) of the most serious involvement and therefore most appropriate lesion(s) for biopsy. Interestingly, findings on colposcopy have been shown to not correlate very strongly with severity of cervical dysplasia. The sensitivity of colposcopy-directed biopsy is relatively low, highlighting the difficulty of identifying biopsy sites as well as the risk of obtaining a false-negative result.

Murta et al. discuss the management of HGSIL Pap smear results in pregnant patients. The authors recommend conservative management of HGSIL during pregnancy. Colposcopic evaluation should be conducted both during gestation as well as during the postpartum period, regardless of whether the route of deliver is vaginal or by C-section.

Illustrations A summarizes the guidelines of the American Society for Colposcopy and Cervical Pathology (ASCCP) for the management of patients with HGSIL. Illustrations B, C, and D depict the ASCCP algorithms for the management of Cervical Intraepithelial Neoplasia (CIN) 1, CIN 2/3, and carcinoma in-situ, respectively.

Incorrect Answers:
Answer 1: Repeat Pap smear in 1 year is indicated for patients with a result of atypical squamous cells of undetermined significance (ASCUS) or for patients undergoing co-testing who receive a Pap smear result of low grade squamous intraepithelial lesions (LSIL) with a negative HPV test.
Answer 2: A Pap smear every 3 years is a standard recommended screening schedule for women 30-65 years of age; a result of HGSIL on a Pap smear necessitates more urgent follow-up and further diagnosis.
Answer 3: Although it may be interesting to know the patient's HPV status, this will not affect whether or not this patient with HGSIL will require colposcopy or a diagnostic excisional procedure.
Answer 5: This is a treatment option for more advanced stages of cervical cancer; a more definitive diagnosis through tissue biopsy from either colposcopy or an excisional procedure is necessary before considering pursuit of a surgical treatment option.