Figure 19.15 A–J: Algorithms from the 2006 Consensus Guidelines for the Management of Women with Cervical Cytologic Abnormalities. Reprinted from the Journal of Lower Tract Disease, vol. 11, issue 4, with the permission of the ASCCP (c American Society for Colposcopy and Cervical Pathology 2007. No copies of the algorithms may be made without the prior consent of the ASCCP.)
Figure 19.15 (continued)
Figure 19.15 (continued)
CHAPTER 19 Intraepithelial Disease of the Cervix, Vagina, and Vulva
Figure 19.15 (continued)
Testing for HPV DNA is the preferred method when liquid-based cytology is used or when co-collection is feasible. Women who have positive test results should be referred for colposcopy, and those with negative results should receive yearly cytology assessment (75). Adolescent women with ASC-US or LSIL should have a repeat cytology in 12 months (Fig. 19.15B). Women with ASC-H should be referred to colposcopy, they do not benefit from triage with high-risk HPV testing (Fig 19.15C). The management of cytologic abnormalities with findings of LSIL and HSIL are presented in Figure 19.15 D–F, and AGC in Figures 19.15H and 19.15I, and for adolescent women with HSIL in Figure 19.15H.
The spontaneous regression rate of biopsy-proven CIN 1 is 60% to 85% in prospective studies. The regressions typically occur within a 2-year follow-up with cytology and colposcopy (4,75,85–88). Patients who have biopsy proven CIN 1 (after a cytologic finding of ASC, ASC-H, LSIL) with satisfactory colposcopy and who agree to the evaluation every 6 months may be followed with Pap testing performed at 6 and 12 months or HPV DNA testing at 12 months. After two negative test results or a single negative HPV DNA test, routine screening may be resumed (75). Colposcopy and repeat cytology at 12 months or a diagnostic excisional procedure may be necessary if the CIN 1 biopsy was preceded by an HSIL or AGC cytology (75). Regression of CIN 1 decreases after 24 months, with the regression rate becoming the same as for CIN 2 by 5 years (89).
For patients with persistent CIN 1 after 24 months, the choice of treatment is optional. Expectant management is acceptable, as long as the patient is cooperative with follow-up.
Patients with chronic systemic disease associated with immunosuppression, such as those requiring steroids, chemotherapy, or antirejection drugs, may have chronically persistent low-grade abnormalities. Ablative therapies, including cryotherapy or laser ablation, seem preferable to excisional procedures including loop electrosurgical excision procedure (LEEP) (75). A randomized prospective trial comparing cryosurgery with laser and LEEP showed no difference in persistent disease rate (4%) or recurrent disease rate (17%). Cryosurgery has the advantage of low cost and ease of use. The disadvantages are lack of tissue specimen, inability to adapt to lesion size, and posttreatment vaginal discharge. If colposcopy findings are unsatisfactory, ablative therapy should be avoided.
All CIN 2 and 3 lesions require treatment in women 21 years of age and older (75). This recommendation is based on a meta-analysis showing that CIN 2 progresses to CIS in 20% of cases and to invasion in 5%. Progression of CIS to invasion is 5% (90).
B Management of Women with a Histological Diagnosis of Cervical Intraepithelial Neoplasia Grade 1 (CIN 1) Preceded by HSIL or AGC-NOS Cytology
There are 3 Acceptable Options