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1 Workshop: Case Management of Abnormal Pap Smears and Colposcopies Rebecca Jackson, MD Professor Obstetrics, Gynecology & Reproductive Sciences and Epidemiology & Biostatistics I have no financial interests to disclose. Case Based Problems Emphasis on 2012 guidelines by ASCCP (American Society of Colposcopy and Cervical Pathology) and how they differ from last Changes for <25yos Who needs colposcopy vs who can be managed expectantly? Next steps after colposcopy Treatment options: cryotherapy, laser, LEEP and cone biopsy Post-treatment surveillance Recommended Guidelines ASCCP guidelines 2012 For work-up of abnormal cytology and treatment of CIN: (or just search ASCCP guidelines) Algorithms%204%2011%2013%20-%20PDF.pdf Rationale behind guidelines: ObstetGynecol: 2013; 121(4); SFGH 2010 guidelines in your syllabus (developed by Dr. George Sawaya, very similar to ASCCP but not yet updated with the new 2013 recommendations) 1

$7.00 Laminated cards with tabs at top so can find the algorithm you need $9.99 $9.

reaffirmed, easier to read, guidance for no ECC s on pap & discordant co-test results Bad news: even more complex than prior guidelines What s New (2012 ASCCP)

w/u of ASC-US How to manage discordant cotest results: (HPV+/PapNl; HPV-/Pap ASC-US), unsatisfactory cytology and missing endocervical or t- zone cells

Graded based on proportion of epithelium involved CIN 1: indicates active HPV infection; treatment discouraged since spontaneous resolution is high CIN 2: most

2 $7.00 Laminated cards with tabs at top so can find the algorithm you need $9.99 $9.99 Either enter pt info and it gives you the recommendation and assoc algorithm OR you can simply view the algorithms Good news: most prior guidelines reaffirmed, easier to read, guidance for no ECC s on pap & discordant co-test results Bad news: even more complex than prior guidelines What s New (2012 ASCCP) **Extend adolescent (age <21) management guidelines to women < age 25: there are now 2 pathways for most algorithms One for<25 and one for >25 Less aggressive w/u of ASC-US How to manage discordant cotest results: (HPV+/PapNl; HPV-/Pap ASC-US), unsatisfactory cytology and missing endocervical or t- zone cells Post-colpo management now includes co-testing, even in <25 yo Treat CIN1 on ECC as CIN1 (not as +ECC) Histology Primer Cervical intraepithelial neoplasia (CIN) Graded based on proportion of epithelium involved CIN 1: indicates active HPV infection; treatment discouraged since spontaneous resolution is high CIN 2: most are treated, but about 40% resolve over 6 month period; treatment may be deferred in young women CIN 3: the most proximal cancer precursor, also known as carcinoma in situ always treat Adenocarcinoma in situ (AIS): widely considered a cancer precursor always treat 2

CIN 1 CIN 3 Case List Case 0 0. Pap normal, HPV positive 1.

3 CIN 1 CIN 3 Case List Case 0 0. Pap normal, HPV positive 1. ASC-US, not young 2. 19yo ASC-H; CIN2 on colpo 3. 78yo ASC-USx2, CIN1 on colpo 4. AGC 5. 22yo ASC-US/HPV+, colpo neg 6. 24yo CIN3 on colpo 7. 58yo CIN3, can t r/o invasion 8. 27yo positive endocervical LEEP margins CIN yo pregnant, HSIL A 35 yo woman has co-test result: HR-HPV positive, cytology normal. What are next steps? 3

4 Pap normal, HPV positive Remember: Use co-test only in women >30yo (b/c HPV often + in younger women and is transient) 2 options: 1. Repeat co-test at 12 months. If both negative 3yr co-test If still HPV+ or if >=AS-CUS colposcopy. 2. HPV genotype-specific typing for 16 & 18 If positive for either colposcopy. If negative repeat co-test at 12 months. Case 1 A 32 year old woman s Pap smear comes back AS-CUS What are your management options? Case 1: AS-CUS, not adolescent Repeat cyto at 1 yr (not 6 mos) OR HPV test. If Neg cotest at 3 yrs 3 equivalent 2 options (HPV preferred): 1. Repeat cytology at 6, 12 months Colpo if >ASC; (if neg cyto in 3 yrs) 2. Immediate colpo 3. Reflex HPV test (preferred) If neg rescreen in 12 months with cytology. Cotest at 3 yrs If pos colposcopy * 2012 guidelines: Less aggressive w/u of AS-CUS 4

Case 2 A 19 year old Go woman, sexually active since the age of 15, has a Pap smear read as ASC-H. What are your management options?

HPV not helpful for triage all get colpo.

single quadrant. What are your management options?

5 Case 2 A 19 year old Go woman, sexually active since the age of 15, has a Pap smear read as ASC-H. What are your management options? Although you wish she hadn t had the pap given <21, you can t ignore it ASC-H requires colpo in adults and adolescents. HPV not helpful for triage all get colpo. Management after colpo differs greatly for <25yo Case 2--continued Colposcopy is satisfactory and biopsy-proven CIN 2 is diagnosed in a single quadrant. What are your management options? Be sure to read the fine print lots of info there Work-up and treatment differs for <25 yo (longer surveillance prior to treatment, less aggressive treatment options) Regression is common in younger women and usually occurs within 2 yrs Note now recommend co-test for f/u (even though it breaks the rule of no HPV co-test in <30yo) 5

Case 2: CIN 2/3 in adolescents Treatment (excision or ablation) OR observation For CIN2 observation is preferred (as long as colpo is satisfactory*) and patient is reliable (If CIN3

6 Case 2: CIN 2/3 in adolescents Treatment (excision or ablation) OR observation For CIN2 observation is preferred (as long as colpo is satisfactory*) and patient is reliable (If CIN3 excision/ablation) Colposcopy plus cytology q 6 months for 1 yr If normal cytology x2 co-test 1 yr later, if nl, co-test q 3yr If colpo worsens or high grade cytology or colpo lesion persists x 1yr repeat biopsy Treat only if CIN2 persists for >2 yrs * If colpo unsatisfactory, diagnostic excisional procedure preferred Case 3 A 78 year old woman who has never had any abnormal Pap smears now has a Pap smear read as ASC-US. She has not been sexually active for over 15 years. A repeat pap in 12 months is also ASC-US. Options? Case 3: continued Again, you wish she hadn t had a pap (stop age= 65 in women with prior normals). However, can t ignore.. Two consecutive paps with ASC-US colpo No difference in management of ASCUS for post-menopausal women. However, reflex HPV testing is more efficient than in younger women b/c fewer women will be referred to colposcopy Colposcopy reveals an attenuated, flush cervix. Unsatisfactory. ECC shows CIN 1. Management options? 6

Case 4 A 43 year old woman has a Pap smear read as AGC (atypical glandular cells)-not otherwise specified (NOS). Observation ok for CIN1 preceded by ASC-US, LSIL, HPV +.

Differential diagnosis of AGC Atypical endocervical cells Adenocarcinoma-in-situ Adenocarcinoma Squamous CIN Endometrial hyperplasia Endometrial adenocarcinoma Ovarian

7 Case 4 A 43 year old woman has a Pap smear read as AGC (atypical glandular cells)-not otherwise specified (NOS). Observation ok for CIN1 preceded by ASC-US, LSIL, HPV +. Only treat if persists for 2 years. HPV testing may help to avoid colpo if negative. What is the differential diagnosis of AGC? What are your management options? Differential diagnosis of AGC Atypical endocervical cells Adenocarcinoma-in-situ Adenocarcinoma Squamous CIN Endometrial hyperplasia Endometrial adenocarcinoma Ovarian carcinoma AGC needs more thorough work-up than ASC-US because underlying abnormalities are more serious and more common (40% have SIL, AIS, endometrial hyperplasia) Colpo plus ECC plus EMB (in many) 7

at 12 and 24 months 24 month pap is AGC again. Now what? Case 5 An 22year old transfers care to your practice.

8 Case 4 continued Pt reports occasionally irregular periods. Colposcopy is satisfactory without lesions. ECC is normal. EMB is normal. Note that if initial cytology had been AGC-favor neoplasia and colpo had been negative, cone recommended as next step Given it it AGC-NOS, you follow as per guidelines with co-test at 12 and 24 months 24 month pap is AGC again. Now what? Case 5 An 22year old transfers care to your practice. 8 months ago, she had ASC-US with HPV DNA test positive for a high-risk type. She then had colposcopy at other practice, 6 mos ago, which was noted to be satisfactory with no lesions seen. Repeat AGC: pelvic ultrasound to evaluate ovaries/tubes. If ultrasound negative, cone biopsy Next steps? 8

Cytology preferred for f/u AS-CUS in young women (reflex HPV testing ok) If HPV pos repeat cytology only at 12 mos (ie shouldn t have had colpo) What to do when

In general, act on most severe abnormality.

the same as if she hadn t had colpo Case 6 A 24 yo G0 woman has biopsy-proven CIN 3, a satisfactory colposcopy and a negative endocervical curettage.

9 Cytology preferred for f/u AS-CUS in young women (reflex HPV testing ok) If HPV pos repeat cytology only at 12 mos (ie shouldn t have had colpo) What to do when pts receive testing that was not recommended per guidelines or who are lost to f/u after abn pap and then have repeat pap nl? In general, act on most severe abnormality. EG, If 30yo had LSIL pap then lost to f/u and has repeat nl pap, still needs colpo In this case, can follow per guidelines after nl colpo b/c f/u is essentially the same as if she hadn t had colpo Case 6 A 24 yo G0 woman has biopsy-proven CIN 3, a satisfactory colposcopy and a negative endocervical curettage. What are your management options? What if the ECC were positive? Potential adverse effects of LEEP Preterm delivery Low birth weight PPROM Perinatal mortality Severe preterm delivery Extreme low birthweight No randomized trials. 70% 82% 169% Potential adverse effects of cone biopsy Lancet : % 178% 186% BMJ 2008 Sep 18;337 9

10 Case 7 A 58 year old widow has a Pap smear read as ASC-US and you send a test for HPV. It is positive. Given ablative and excisional methods are equally efficacious, choose ablation for women desiring fertility (as long as colpo satisfactory, ECC negative and lesion <2cm and completely visible) Colposcopy is unsatisfactory. ECC shows severe dysplasia (CIN 3) cannot rule out invasion. What are your management options? Case 7: CIN3, can t r/o invasion Typically, CIN3 is treated with LEEP However, if can t r/o invasion, cone biopsy is indicated in order to get a pathologic specimen from which depth of invasion can be assessed Case 8 A 29 yo with biopsy proven CIN3 had a LEEP showing CIN3 with positive endocervical margins. What are the management options? 10

Positive LEEP margins If CIN2,3 is identified at the margins of an excisional procedure or post-procedure ECC, cytology and ECC at 4-6mo is preferred, but repeat excision is acceptable and

11 Positive LEEP margins If CIN2,3 is identified at the margins of an excisional procedure or post-procedure ECC, cytology and ECC at 4-6mo is preferred, but repeat excision is acceptable and hysterectomy is acceptable if reexcision is not feasible. 5 fold higher rate of recurrence compared to complete excision High grade dz post-treatment in 18% (82% didn t develop it) vs 3% with complete excision Ghaem-Maghami, Lancet-Oncol, 2007 Endocervical vs Ectocervical margins: ASCCP doesn t differentiate. In our practice, we do ECC plus colpo in 6 mos for positive endocervical margins, colpo only for + ectocervical margins Repeat Excision acceptable? Given 82% do not have persistent high grade dz, we advise f/u Case 9 A 16 year old is pregnant within six months of becoming sexually active. She was late to care at 22 weeks at which time she had a Pap smear that was read as HSIL. What are your management options? Case 9: pregnant, hsil Although you wish she d never gotten the pap, now you must act on the HSIL In pregnancy, colpo should be done by experienced colposcopist b/c biopsy will only be done if lesion appears to be invasive cancer. 11

12 General rules Less is better for adolescents/<25yo (start screening later, space out surveillence, less aggressive treatment) Don t use HPV test in <30yo unless it is to follow colpo (possibly can decrease need for repeat colpo, if negative) AGC is worse than ASC-US. Requires extensive work-up Typically don t need to treat CIN1 unless persists Consider getting pap/path results re-read if discordant Pearls Make sure women have adequate education about HPV if HPV DNA testing is used Involve women in decisions when uncertainty exists in guidelines Stress smoking cessation Consider HIV testing for women with biopsy proven dysplasia Final Thoughts Cervical cancer screening will never completely eliminate cervical cancer: must balance benefits (which occur rarely) and harms (which affect a large number of women) Goal: optimal strategies aim to identify HPV-related abnormalities that are likely to progress to invasive cancers while avoiding treating lesions not destined to become cancerous Additional summary from 2012 ASCCP guidelines 12

13 Unsatisfactory or Absent endocervical cells Unsatisfactory cytology: No HPV done or Neg HPV: repeat cytology 2-4 mos Pos HPV: either repeat cyto 2-4 mos or colpo 2 conseq unsats: colpo Cytology Neg but absent/insuff EC/TZ: <30yo: Routine screening (don t do HPV) >30yo, no HPV: Do HPV (pap 3 yr also ok) >30, HPV neg: routine screening > 30 HPV pos: co-test in one year Excision vs ablation Excision: CIN2+ AND unsatisfactory colpo ECC showing CIN2+ Recurrent cin2+ Negative colpo preceded by AIS, AGC-favor neoplasia, HSIL papx2 Ablation: Preferred in younger women (possibly less chance of preterm delivery) Lesion < 2 cm and completely visible 13

14 Guidelines for Screening for Cervical Cancer and its Precursors, 2010 San Francisco General Hospital These are guidelines for use of cervical cytology in asymptomatic women as a screening tool for cervical cancer and its precursors. Tests performed in symptomatic women should be evaluated in clinical context. Screening guidelines do not apply to women with prior treatment of high-grade cervical dysplasia (CIN 2 or CIN 3) or cervical cancer; see other aspects of this guideline for surveillance after treatment. Age to begin screening Age 21 years; avoid screening within 3 years of becoming sexually active and in known virgins. Interval of screening Screen every 2 years with cytology. At or after age 30 years, women with 3+ prior consecutive, normal tests may be screened every 3 years. Age to end screening Screening may end at or after age 65 years if 3+ consecutive, normal cytology tests have been documented within the prior 10 years and there is no history of treated CIN 2, CIN 3, AIS or cervical cancer. Special populations Pregnant women Women with HIV infection or immunocompromised After total hysterectomy in women with no prior history of CIN 2 or CIN 3 After total hysterectomy in women with a prior history of CIN 2 or CIN 3 After diagnosis and treatment of cervical cancer CIN indicates cervical intraepithelial lesion. Screen as above; do not screen within 3 years of becoming sexually active. Annual screening after 2 normal cytology tests 6 months apart in the year following initial HIV diagnosis or immunocompromised state. Screening should not be performed. Annual cytology. After 3 consecutive, normal tests, screening may be performed every 3 years. Surveillance as per gynecologic oncology protocols 1- Sawaya & Smith-McCune, August 2010

15 Guidelines for Initial Management of Abnormal Cervical Cytology, 2010 San Francisco General Hospital Cytology Interpretation Common Benign Findings Unsatisfactory Satisfactory, but no endocervical cells Benign-appearing endometrial cells Epithelial Cell Abnormalities Atypical squamous cells of undetermined significance (ASC-US) ASC, cannot exclude HSIL (ASC-H) Low-grade SIL (LSIL) Action Repeat cytology next available Repeat cytology in 12 months Pre-menopausal: No action. Post-menopausal: Endometrial biopsy. Three different strategies may be adopted, but colposcopy is the least preferred: 1. Repeat cytology at 6 and 12 months. If ASC-US+, colposcopy. After 2 normal cytology tests, resume routine screening. 2. HPV testing for high-risk types. If positive, colposcopy. If negative, repeat cytology in one year; do not do HPV testing in women age 20 or less. 3. Colposcopy If age 20 or less, repeat cytology at 12 months (colposcopy if ASC-H or HSIL+) and at 24 months (colposcopy if ASC-US+). If normal, resume routine screening. For pregnant women age 21+, repeat cytology at 6 months; if ASC-US+, colposcopy 6 weeks post-partum. Colposcopy Colposcopy If age 20 or less, repeat cytology at 12 months (colposcopy if ASC-H or HSIL+) and at 24 months (colposcopy if ASC-US+). If normal, resume routine screening. For pregnant women age 21+, colposcopy may be deferred to 6 weeks postpartum. For post-menopausal women, LSIL may be managed identically to ASC-US. Colposcopy Colposcopy High-grade SIL (HSIL) Squamous cell carcinoma Glandular Cell Abnormalities Atypical glandular cells (AGC) endocervical Colposcopy with endocervical curettage (ECC) endometrial Colposcopy with ECC and EMB not otherwise specified Colposcopy with ECC; add EMB if abnormal bleeding, chronic anovulation or age 35+ Adenocarcinoma in situ (AIS) Common Infections shift in flora suggestive of bacterial vaginosis (BV) Colposcopy with ECC and EMB Consider evaluation of and treatment for BV if symptomatic. Repeat cytology at appropriate screening interval. Consider evaluation of and treatment for yeast vaginitis if symptomatic. Repeat cytology at appropriate screening interval. Diagnostic of HSV. Finding may indicate other STIs. Repeat cytology at appropriate screening interval. fungal organisms consistent with Candida. cellular changes consistent with herpes simplex virus (HSV) Trichomonas vaginalis (TV) Consider evaluation of and treatment for TV if symptomatic. Finding may indicate other STIs. Repeat cytology at appropriate screening interval. DEP indicates diagnostic excisional procedure (e.g., cone biopsy, loop excision). HSIL+ indicates HSIL, AGC, AIS and/or cancer. ASC-US + indicates ASC-US, ASC-H, LSIL and/or HSIL+. ECC indicates endocervical curettage. ECC should be performed in all non-pregnant women with unsatisfactory colposcopy and in those with cytology interpreted as AGC, AIS and cancer. Vaginal colposcopy with Lugol s solution should be performed in all women with no obvious lesion seen and cytology interpreted as HSIL, AGC, AIS or cancer. In pregnant women, ECC is contraindicated. 2- Sawaya & Smith-McCune, August 2010

16 Guidelines for Follow-up after Initial Colposcopy, 2010 San Francisco General Hospital These are guidelines for the most common clinical scenarios. Patients may be managed individually based on clinical judgment. Referral Cytology Findings at initial colposcopy (pre-colposcopy) No visible lesion Visible lesion, biopsy-proven Biopsy-proven ASC-US once ASC-US twice (unknown HPV status) ASC-US, positive high-risk HPV Atypical squamous cells, cannot exclude HSIL (ASC-H) Low- grade SIL (LSIL) CIN 1 Cytology in 12 months. If normal, resume routine screening; if ASC+, repeat colposcopy at the next available appointment. Cytology in 6 and 12 months. The 6-month cytology result should be managed as follows: If ASC or LSIL, repeat colposcopy at the next scheduled appointment (6 months). If ASC-H or HSIL+, repeat colposcopy at the next available appointment. If normal, repeat cytology at the next scheduled appointment (6 months); if cytology is normal at that time (i.e., at the 12-month visit), resume routine screening; if ASC+, repeat colposcopy at the next available appointment. CIN 2 or 3 See Guidelines for Treatment of biopsyproven cervical intraepithelial neoplasia (CIN) 2 (moderate dysplasia) and CIN 3 (CIS, severe dysplasia) High-grade SIL (HSIL) If colposcopy is satisfactory, ECC is normal and the vagina has no lesions, colposcopy and cytology every 6 months for 1 year is acceptable. DEP may also be performed (non-pregnant women only); review of outside cytology suggested prior to DEP. Treatment is preferred. If colposcopy is unsatisfactory, DEP is preferred (non-pregnant women only). Atypical glandular cells (AGC) Cytology in 6, 12, 18 and 24 months. Repeat colposcopy if ASC-US+. After 4 normal cytology tests, resume routine screening. If AGC recurs, perform cone biopsy. Pelvic sonogram to rule out adnexal malignancy is recommended in women with persistent AGC. Adenocarcinoma in situ, cancer Cone biopsy CIN indicates cervical intraepithelial neoplasia. SIL indicates squamous intraepithelial lesion. HSIL+ indicates HSIL, AGC, adenocarcinoma in situ and/or cancer. ASC-US + indicates ASC-US, ASC-H, LSIL and/or HSIL+. DEP indicates diagnostic excisional procedure (e.g., cone biopsy, loop excision). Smoking cessation is advised in all patients. HIV testing should be offered in all women with biopsy-proven CIN 3. Additional information on colposcopy by UCSF authors can be found by typing GLOWM and colposcopy into your search engine. 3- Sawaya & Smith-McCune, August 2010

17 Guidelines for treatment of biopsy-proven cervical intraepithelial neoplasia (CIN) 2 (moderate dysplasia) and CIN 3 (CIS, severe dysplasia), 2010 San Francisco General Hospital CIN 2 and 3 can be treated by either an ablative or an excisional procedure in non-pregnant women. Ablative methods include laser and cryotherapy; excisional methods include loop excision and cone biopsy. In adolescents and young women with satisfactory colposcopy, CIN 2 may be managed with colposcopy and cytology surveillance every 6 months; routine screening may resume after 2 normal cytology tests and colposcopic exams. If surveillance is chosen, CIN 2 may be followed for up to 24 months without treatment. Alternatively, ablative therapy (e.g., cryotherapy) is the preferred treatment. Treatment Factors affecting choice Cryotherapy Laser ablation Loop excision (aka LEEP) Cone biopsy Appropriate for CIN 2 or CIN 3 if following general criteria met: Satisfactory colposcopy No prior cervical treatment Lesion(s) completely visible and <2 cm in diameter Lesion(s) can be covered entirely with the cryoprobe Often used for large lesions (>2 cm) with or without vaginal extension. Candidacy same as for cryotherapy. Choose for CIN 2 or CIN 3 lesions in which cryotherapy is inappropriate (e.g., unsatisfactory colposcopy, endocervical curettage with dysplasia). Choose instead of loop excision if suspicion for malignancy or recurrent atypical glandular cells (AGC) on cytology and/or cervical architecture disrupted. Guidelines for follow-up after treatment of CIN 2 and CIN 3 Treatment Follow-up Cryotherapy or laser ablation Loop excision (LEEP) or cone biopsy Dysplasia in specimen, negative endocervical margin No dysplasia in specimen Dysplasia in specimen, positive endocervical margin Cytology in 6 and 12 months; colposcopy for ASC-US+. After 2 normal tests, annual cytology. Cytology in 6 and 12 months; colposcopy for ASC-US+. After 2 normal tests, annual cytology. Cytology and ECC in 6 months; colposcopy for ASC-US+. Then, cytology alone in 12 months; colposcopy for ASC-US+. Repeat excision if HSIL+ at any time. After 2 normal tests, annual cytology. Hysterectomy Annual cytology. After 3 consecutive, normal tests, screening may be performed every 3 years. ECC indicates endocervical curettage. ASC-US indicates atypical squamous cell of undetermined significance. HSIL indicates high-grade squamous intraepithelial lesion. HSIL+ indicates HSIL, AGC, adenocarcinoma in situ and/or cancer. ASC-US + indicates ASC-US, ASC-H, LSIL and/or HSIL+. Guidelines for treatment and follow-up of adenocarcinoma in situ Treatment Follow-up Hysterectomy (treatment of choice) Cone biopsy Annual cytology. After 3 consecutive, normal tests, screening may be performed every 3 years. Cytology and ECC every 4 months for 2 years, then every 6 months until hysterectomy. Smoking cessation is advised in all patients. HIV testing should be offered in all women with biopsy-proven CIN Sawaya & Smith-McCune, August 2010

Case Based Problems. Recommended Guidelines. Workshop: Case Management of Abnormal Pap Smears and Colposcopies. Disclosure

Case Based Problems. Recommended Guidelines. Workshop: Case Management of Abnormal Pap Smears and Colposcopies. Disclosure Disclosure Workshop: Case Management of Abnormal Pap Smears and Colposcopies Rebecca Jackson, MD Associate Professor Obstetrics, Gynecology & Reproductive Sciences and Epidemiology & Biostatistics This