Because all therapeutic modalities carry an inherent recurrence rate of up to 10%, surveillance at 6-month intervals with cytology and colposcopy or alternatively with high-risk HPV testing at 6 to 12 months is required (75). Surveillance is continued until two consecutive negative results occur. Referral to colposcopy for any abnormal results is mandatory.
Ablative therapy is appropriate when the following conditions exist: 1.
There is no evidence of microinvasive or invasive cancer on cytology, colposcopy, endocervical curettage, or biopsy.
2.
The lesion is located on the ectocervix and can be seen entirely.
3.
There is no involvement of the endocervix with high-grade dysplasia as determined by colposcopy and endocervical curettage.
Management Summary This summary of the management of these histologic lesions is based on ASCCP 2006 Consensus Guidelines (adapted from MJ Campion [93]) (Fig 19.16):
CIN 1 Preceded by ASC-US, ASC-H or LSIL Cytology 1.
Women with a histologic diagnosis of CIN 1 preceded by ASC-US, ASC-H or LSIL cytology should be followed by yearly HPV-DNA testing or Pap tests every 6–12 months (Fig. 19.16A). If HPV DNA testing remains positive or if repeat cytology is reported as ASC-US or greater, repeat colposcopy is recommended.
2.
If the HPV DNA test is negative or two consecutive Pap smears are reported as negative, return to routine screening is recommended.
3.
If CIN 1 persists for 2 years or more, continued follow-up or treatment is appropriate. Treatment can be ablative or excisional.
4.
If colposcopy is unsatisfactory or the endocervical sample is positive for a high-grade CIN, a diagnostic excisional procedure is recommended.
5.
Two consecutive negative Pap tests in follow-up of low-grade lesions is not absolute indication that the disease regressed.
1.
Women with a histologic diagnosis of CIN 1 diagnosed during the assessment of pap tests showing HSIL (CIN 2 or 3) or atypical glandular cells-not otherwise specified (AGC-NOS) can be managed by either an excisional diagnostic procedure or 6monthly colposcopy and cytology for 1 year (Fig 19.16B). Those with a cytological finding of AGC-NOS must have a satisfactory colposcopic examination and negative endocervical sampling.
2.
If the patient is followed expectantly, a diagnostic excisional procedure is recommended if the repeat cytology at either 6 or 12 months is HSIL or AGC-NOS. If the histology of a colposcopically directed biopsy confirms high-grade CIN, the management is according to guidelines regardless of the cytology result.
3.
After two consecutive negative for intraepithelial neoplasia or malignancy results in follow-up, routine cytologic screening can be resumed.
4.
If CIN 1 is preceded by HSIL or AGC-NOS cytology and colposcopy is unsatisfactory, a diagnostic excisional procedure is recommended, except in special circumstances (e.g., pregnancy).
1.
For adolescents with CIN 1, follow-up with annual cytology is recommended (Fig 19.16C). Only those with HSIL or greater at 12 months should be referred for colposcopy.
2.
At 24-months, those with ASC-US or greater should be referred.
3.
Prospective follow-up by HPV DNA testing in this age group is not useful because of the high rate of positive results.
1.