News and Updates

Pap Smear Follow-Up Recommendations

12/28/2009
TO: All Regional Medical Laboratory Clients
FROM: Stephanie C. Holt, MD, Chief of Cytopathology
DATE: December 28, 2009
SUBJECT: Pap Smear Follow-Up Recommendations

Effective January 4, 2010, RML will modify its recommendations for gynecologic cytology specimens to reflect the 2006 American Society for Colposcopy and Cervical Pathology (ASCCP) Consensus Guidelines. These are comprehensive, evidence-based recommendations intended to identify patients at high-risk for invasive carcinoma, particularly patients with CIN 2,3, which pose a greater risk of progression to invasive carcinoma than CIN 1. 

The 2006 ASCCP guidelines recommend different management strategies for different groups of women, because data have indicated that the same cytologic result can pose a different risk of CIN 2+ in various groups of women. Adolescents, defined as women 20 years old or younger, are considered a special population because of their simultaneous very low risk for invasive cervical carcinoma, but very high prevalence of HPV infection. Although they may be associated with cytologic abnormalities, most HPV infections spontaneously resolve within 2 years and are of little long term significance. Therefore, management recommendations for adolescents are generally less aggressive than for women in other age groups, and HPV testing is not recommended for this age group. Conversely, because the prevalence of high-risk HPV positivity declines with age, HPV testing may be an effective strategy to triage postmenopausal women with low grade cytologic abnormalities.

We have also added an additional diagnostic category “LSIL, cannot exclude HSIL (LSIL-H).” In a small number of cases, we are able to identify definite changes of low grade dysplasia, but there are a few additional abnormal cells which may represent HSIL. Studies have indicated a significantly increased risk of CIN 2+ in patients diagnosed with LSIL-H, compared to patients diagnosed with LSIL; however, the risk of CIN 2+ is less with LSIL-H than with HSIL. These patients should be managed in the same way as those diagnosed with ASC-H (atypical squamous cells of uncertain significance, cannot exclude HSIL). 

The updated recommendations are intended to provide guidance for initial management of newly diagnosed cervical cytologic abnormalities. For a more detailed discussion of long term follow-up and treatment options, including detailed algorithms, please refer to the ASCCP website @ www.asccp.org/consensus.shtml .

References:
Al-Nourhji, O, et al. Pathology correlates of a Papanicolaou diagnosis of low-grade squamous intraepithelial lesion, cannot exclude high-grade squamous intraepithelial lesion. Cancer Cytopathology 2008;114:469.

Shidham, VB, et al. Should LSIL with ASC-H (LSIL-H) in cervical smears be an independent category? A study on SurePath specimens with review of literature. CytoJournal 2007;4:7. 

Wright, TC, et al. 2006 Consensus guidelines for the management of women with abnormal cervical cancer screening tests. American Journal of Obstetrics and Gynecology 2007;197:346.

Wright, TC, et al. 2006 Consensus guidelines for the management of women with cervical intraepithelial neoplasia or adenocarcinoma in situ. American Journal of Obstetrics and Gynecology 2007;197:340.