Dr. Khalid Dr. Khalid Akkour
Providing insightful answers to questions on PAP screening for a 19-year-old patient and her mother, covering age to start screening, management of abnormal results, and next steps after colposcopy with CIN1 and AGC findings.
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Dr. Khalid Dr. Khalid Akkour Department of Obstetric and Gynecology Department of Obstetric and Gynecology College of Medicine, King Saud University College of Medicine, King Saud University Akkour
A 40 years old patient known to A 40 years old patient known to you brought her daughter who you brought her daughter who is an anxious 19 years girl to is an anxious 19 years girl to answer their questions answer their questions regarding PAP screening . regarding PAP screening . Please be prepared to answer Please be prepared to answer the examiner questions. the examiner questions.
At what age you start At what age you start doing PAP screening? doing PAP screening?
Answer: Answer: 21 yrs of age.
The daughter GP had The daughter GP had performed a PAP 6 months a performed a PAP 6 months a go and said she has LSIL on go and said she has LSIL on pap what should we do pap what should we do next? next?
Answer: Answer: If screening is done in a woman less than 21 years old, and an ASC-US or LSIL result is reported, cytology cytology should be repeated only per provincial or territorial guidelines.
You repeat the daughter You repeat the daughter PAP and the result came PAP and the result came back to you as AGC what back to you as AGC what should you do next? should you do next?
Answer: Answer: A woman less than 21 years old who has cytology results of ASC-H, HSIL, and AGC should be referred for colposcopy. colposcopy.
You took her for colposcopy You took her for colposcopy and did biopsies from her and did biopsies from her cervix, The biopsy result came cervix, The biopsy result came back CIN1 on top of AGC on back CIN1 on top of AGC on PAP , what is your PAP , what is your management? management?
Answer: Answer: In the case of a patient with biopsy-proven CIN 1 after HSIL or AGC, cytology and histology should be reviewed, where available. If a discrepancy remains, then an excisional biopsy may be considered.
After the pathologist reviewed After the pathologist reviewed the histology for the second the histology for the second time, he decided the result is for time, he decided the result is for sure CIN2, what is your sure CIN2, what is your management? management?
Answer: Answer: CIN 2 in women less than 25 years old should be observed with colposcopy at 6-month intervals for up to 24 months before treatment is considered.
You informed the patient You informed the patient about the result and she was about the result and she was crying on the phone asking crying on the phone asking you if she has cancer or you if she has cancer or not? not?
Answer: Answer: No it is not cancer, its pre invasive lesion.
She asked next what is She asked next what is the risk of having a the risk of having a cancer in her case? And cancer in her case? And what is the complete what is the complete regression rate? CIN2 regression rate? CIN2
Answer: Answer: Progression 40% Regression 40% ( 60% IN 8 MONTHS in this age group) Persistence 20% Progression to towards invasive 5%
Give 4 indications for Give 4 indications for colpo colpo referral? referral?
Answer: Answer: Persistent ASCUS Persistent or incident LSIL ASC-H HSIL AGC
What determines if the What determines if the colpo colpo is satisfactory or not? is satisfactory or not?
Answer: Answer: The squamocolumnar junction and transformation zone should be identified. If there is a lesion, the whole lesion should be seen.
You Identified a lesion on You Identified a lesion on Colpo Colpo what you are going to what you are going to do next? do next?
Answer: Answer: Take at least 2 biopsy specimens to improve the accuracy of colposcopy. A biopsy should be performed and specimens taken of the most severe area 2 biopsies improved the sensitivity (to detect CIN 2 or greater) to 81.8%, compared with 68.3% with 1 biopsy.
Name 3 indications Name 3 indications for ECC? for ECC?
Answer: Answer: Non-satisfactory colposcopy AGC smear > 40 y women with high- grade cytology.
What is the role of HPV What is the role of HPV testing in colposcopy testing in colposcopy referrals ? referrals ?
Answer: Answer: To triage ASCUS lesions To triage ASCUS lesions If a patient is having ASCUS & she tests positive for HPV, colposcopy referral If she is having ASCUS & tests negative for HPV, she ll go back to routine screening.
How to manage ASC How to manage ASC- -H? What is the risk of CIN2/3 What is the risk of CIN2/3 associated with ASC associated with ASC- -H? H? H?
Answer: Answer: Colposcopy referral Colposcopy referral CIN 2 or greater was detected in 70% Invasive carcinoma was reported in 2.9% AIS in 1.7%.
How to mange Negative How to mange Negative biopsy of ASC biopsy of ASC- -H on PAP? H on PAP?
Answer: Answer: Excisional biopsy: LEEP or Cone Bx
Why AGC cytology Why AGC cytology warrant warrant colpo colpo referral? referral?
Answer: Answer: CIN 1 (7%) CIN 2 or 3 (36%) AIS (20%) carcinoma of the cervix in 9% endometrial pathology in 29%, including carcinoma of the endometrium in 10%.
How to manage the How to manage the following: following:
A women with an AGC A women with an AGC Pap smear? Pap smear?
Answer: Answer: Colpo + Should all have endocervical curettage. Plus consider Women over 35 years of age or with a history of abnormal bleeding should have endometrial sampling.
Women with an AGC Women with an AGC- -N Pap smear without an smear without an identifiable lesion at identifiable lesion at colposcopy colposcopy N Pap
Answer: Answer: Should undergo a diagnostic excisional procedure
How to manage a 33 How to manage a 33 years old woman with years old woman with positive HPV but negative positive HPV but negative cytology? cytology?
Answer: Answer: Women 30 years old and over who test positive for HR-HPV and have negative cytology should have HR- HPV and cytology testing repeated at 12 months . Persistent positive HR-HPV tests warrant colposcopy.
What is the waiting time for What is the waiting time for colpo colpo be in the following be in the following cases? cases?
Women with ASC Women with ASC- -H or AGC or AGC: H
Answer: Answer: Within 6 weeks of referral.
Women with HSIL Women with HSIL:
Answer: Answer: Within 4 weeks of referral.
Women with a Pap smear Women with a Pap smear suggestive of carcinoma suggestive of carcinoma:
Answer Answer Within 2 weeks of referral.
All other women with All other women with abnormal results abnormal results:
Answer: Answer: Within 12 weeks of referral.
