Mosaic Terminal capillaries surrounding roughly circular or polygonal-shaped blocks of acetowhite epithelium crowded together are called mosaic because their appearance is similar to mosaic tile (Fig. 19.11). These vessels form a “basket” around the blocks of abnormal epithelium. They may arise from a coalescence of many terminal punctate vessels or from the vessels that surround the cervical gland openings (5). Mosaicism tends to be associated with higher-grade lesions and CIN 2 (Fig. 19.12) and CIN 3 (Fig. 19.13).
Atypical Vascular Pattern Atypical vascular patterns are characteristic of invasive cervical cancer and include looped vessels, branching vessels, and reticular vessels.
Endocervical Curettage ASCCP guidelines do not require endocervical curettage. In cases when an endocervical sample is needed, a cytobrush is sufficient for sampling the endocervical canal.
Cervical Biopsy The cervical biopsy is performed at the area most likely to have dysplasia. If the lesion is large or multifocal, multiple biopsies may be necessary to ensure a complete sample of the affected tissue.
Correlation of Findings Ideally, both the pathologist and colposcopist should review the colposcopic findings and the results of cytologic assessment, cervical biopsy, and endocervical sample before deciding therapy. This is particularly valuable when operators are learning the technique of colposcopy. Cytology results should not be sent to one laboratory and the histology results to another. When the cytology and biopsy results correlate, the colposcopist can be reasonably certain that the worst lesion was identified. If the cytology indicates a more significant lesion than the histology, the patient may require further evaluation, including repeat colposcopy, additional biopsies, and excisional diagnostic procedures under certain circumstances. An algorithm for the evaluation, treatment, and follow-up of abnormal Pap test results is presented in Figure 19.14.
CHAPTER 19 Intraepithelial Disease of the Cervix, Vagina, and Vulva
Figure 19.11 A: Mosaic pattern and punctation. This pattern develops as islands of dysplastic epithelium proliferate and push the ends of the superficial blood vessels away, creating a pattern that looks like mosaic tiles. B: Diagram of mosaic pattern.
Figure 19.12 Human papillomavirus (HPV)/cervical intraepithelial neoplasia 3 (CIN 3). Cribriform pattern of HPV at periphery with mosaicism and punctation near the squamocolumnar junction.
Figure 19.13 Cervical intraepithelial neoplasia grade 3 (CIN 3).
CHAPTER 19 Intraepithelial Disease of the Cervix, Vagina, and Vulva
Figure 19.14 An algorithm for the evaluation, treatment, and follow-up of an abnormal Pap test.
women, and the management of adenocarcinoma in situ led to a critical review of the Guidelines (75,83).
In 2006, the American Society for Colposcopy and Cervical Pathology (ASCCP) and the NCI sponsored a consensus conference to update evidence-based guidelines for abnormal cervical cancer screening. Comprehensive and specific guidelines for the management of cervical cytologic and histologic entities are available on the Web (84). The ASCCP 2006 Consensus Guidelines for management based on cytologic findings are presented in Figure 19.15 and those based on histologic findings are in Figure 19.16.
Based on these recommendations, women with ASC-US should be managed initially with either (i) two repeat Pap tests with referral for colposcopy for any significant abnormality, (ii) immediate colposcopy, or (iii) testing for high-risk type HPV (Fig. 19.15A).