.__.._-----------

- - -- -----------------1iii

MANAGEMENT OF

ABNORMAL SMEAR LGSIL/HGSIL

.:. Key points:

• These are practices guidelines should not be

considered rule or standard of care

• Clinical care must always take into account the

individual patient

• Developed for US setting - all may not be

appropriate in other country

2001 Consensus Guidelines

Bethesda (ASCCP)

.:. Key points:

• These are practices guidelines should not be

considered rule or standard of care

• Clinical care must always take into account the

individual patient

28

Developed for USsetting - all may not be appropriate in

other country .

•:. The Bethesda System

• Terminologi pelaporan hasil tes Pap terbaru

yang berorientasi klinik

• Perkembangan:

1988: Pengembangan sistem pelaporan sebagai

sistem terminologi yang seragam untuk

panduan penatalaksanaan klinik.

1991: Modifikasi setelah implementasi

pengalaman klinik dan laboratorium aktual

2001: Re-evaluasi dengan adanya teknologi

dan penemuan baru

• Rekomendasi:

• Laporan sitopatologi adalah konsultasi medik

• Klasifikasi Papanicolaou sudah tidak layak

digunakan pada praktek diagnostik sitopatologi

modern

29

Sistem Bethesda berfungsi sebagai petunjuk pelaporan

sitopatologi serviksjvagina. Merupakan penyempurnaan

dari sistern Bethesda 1991. Termasuk metoda pengenalan

tes tambahan dan automatisasi .

• Rekomendasi final: khususnya penyempurnaan

adekuasi spesimen dan kategori umum .

•:. Pelaporan TBS

• Adekuasi spesime

• Kategori umum

• Interpretasi j hasil

30

32

-Infection" I . Repair I1'.'"'' ,".c', .'

Epithelial Cell Abnonnality:Squamous Cells

• ASCUS (atypical squamous cellsof lWldelcnnined significance)- Favor reactive- Favordysplasia- NOI oiherwise specified (NOS)

• LSIL• HSIL• Squamous cel! carcinoma

Epithelial Cell Abnonnality:Glandular Cells

• AGUS (alypicaigiandlilar cells ofundetermined significance)- Favor reactive- Favor neoplasia- NOS

• Adenocarcinoma

II11

il

.:. Kategori Umum TBS 2001

Abnormalitas sel epitel

Sel skuamosa

• Atypical Squamous Cells (ASC):

• ASC-US, ASC-H (cannot exclude HGSIL)

• Low Grade Squamous Intraepithelial Lesion

(LGSIL)

• High Grade Squamous Intraepithelial Lesion

(HGSIL)

Karsinoma sel skuamosa

.:. Kategori Umum TBS 2001

Abnormalitas sel epitel

Sel glanduler

• Atipik (Not Otherwise Specified): sel endoserviks,

sel endometrium, sel glanduler

• Atipik (Favor neoplastic): sel endoserviks, sel

glanduler

• Adenokarsinoma insitu serviks (AIS)

Adenokarsinoma: endoserviks, endometrium, extrauterin,

NOS.

33

.:. Atypical Squamous Cell

• ASC-US of Undetermined Significance

• ASC-H Cannot exlude HSIL

.:. Tes Pap ASCUS

Tes Pap ASCUS dahulu dilaporkan:

Pap II (Papanicolaou)

Inkonklusif(Reagan)

Atipia sel (Richart)

.:. Atypical Squamous Cell-Undetermined Significance

Burden of disease in ASC-US

Individual risk of CIN 2,3 is 5 - 17%

Approximately 30-50% of CIN 2,3 occurs in

women with ASC Pap result

Risk of Ca. only about 1 : 1000

Management needs to take into account patient

/provider convenience, cost

34

2001 Consensus Guidelines

Management of ASC-US

• All three standard modalities are considered

safe & effective. Because of costs, and patient

convenience reflex HPV testing is prefered if

liquid based cytology or co-collection available

!

Treat according to grade

* IfHPV DNA (+) more aggressive follow-up recommended

35

.:. HPV DNA Testing

Important points

• Must use a highly sensitive method such as HC II

orPCR

• Test only for high -risk HPV types

Testing of residual liquid - based cytology fluid or co-

collected sample preferred

ASC-US (postmenopausal withatrophy)

Course of intravaginal estrogen *1

Repeat pap(@ 1 week after treatment and again 4-'6mos.later)---------=------ .

Both (-) ive Either ASC (+)

R tl. .C ·1···1 .ou me screenmg· ... ;~ po?~copy. .

37

.:. Management of ASC-US

Immunosuppresed patients:

• Relatively few studies are available

Studies that are available show a high rate of biopsy

confirmed - CIN. High rate of high-risk HPV-DNA

positivity.

ASC-US(Immunosuppresed women)

IColposcopy *

*Includes all HIV-Infected women, irrespective of

CD4 count, HIV viral load, or antiretroviral therapy

38

::ct-

t-I

-~

IC

-IC

(l)

00

(j)

U

"

cY')

{;

CIl

= 0e~~

<::r;:

~I

=U

U

0'"

~~

Vl

-e<

- ~U..•Q..

0<

Women with ASC-H cytology

Colposcopy

CIN identified No CIN Identified

1Review all material

~Revised Dx ASr-H

Pap (6 & 12 mo)orHPV(12mo)

.:. Management of ASC

See and treat

Because of the potential for overtreatment, diagnostic

excisional procedures (LEEP) should not be routinely used in

the absence of biopsy confirmed CIN.

40

.:. Following an ASC-UScytology

• Repeat cytology with monolayer cytology at

ASC-US + threshold X 2 or one HPV test at 12

months, using Hybrid capture-2 at 1 pg +

threshold have high triage sensitivity for CIN 3

• A single + HPV test at 12 months has lower

referral to re-colposcopy than repeat cytology at

the ASC-US threshold

Repeat cytology at LSIL + threshold provides

inadequate sensitivity to detect CIN 3

.:. Liquid-based cytology

• Better specimen adequacy

o Unsatisfactory decreased 40-94 %

o Satisfactory but limited by decreased by 52-

96%

• Better detection of HSIL , LSIL

o 29-233 % more HSIL

o 65-110 % more LSIL

Decreased ASC-US

41

.:. Direct to VIAHSIL+ multisite outcome trials

• Increased detection

o 112,1 % LSIL

o 92,4 % HSIL

• True increase in detection both LSILand HSIL

o Fewer false positives

o Reduction in false negative rate

LB-cytologyas able to identify more biopsy proper HSIL+

.:. The Bethesda workshop 2001

Terminology changes for AGUS (Atypical Glandular

Undetermined Significance)

* The term of undetermined significance has been dropped ....

......AGUS is now atypical glandular cells or AGe

.:. Atypical glandular cells and Adenocarcinoma in

stu

.:. Glandular cells abnormalities:

• AGe (either endocervical, endometrium, or

glandular cells) not otherwise spesified (AGe

NOS)

• AGe (either endocervical or glandular cells)

• Favour neoplasia (AGe-favour neoplasia)42

Endocervical adenocarcinoma in situ (AIS)

Women with Atypical Glandular Cells (AGC)AGe Atypical endometrial cells

! !Endometrial sampling

.:. Recommendations managing women with AGe and

AIS

./ Colpsoscopy and endocervical sampling is

recommended with all subcategories of AGC

(exception if endometrial cell(+), should initially

be evaluated with endometrial sampling)

./ Women with AGC or AIS (+) is unacceptable

using repeat cervical cytology program

The preferred DxExProc. Is cold knife conization

43

Endocervical adenocarcinoma in situ (AIS)

Women with Atypical Glandular Cells (AGC)AGC Atypical endometrial cells

! 1Colposcopy (+endocervical sampling) Endometrial samplingand Endometrial sampling (~35 yrsor abn. Bleeding)

N'~'dl~" -R<fu," S_H"Initial Pap Initial Pap DX•.Excisional proc.ArC-NOS AGC-favour neoplasia- (cold knife cone)

.. ,~ ..·':qN1A:IS.··~o Ne?pl!l~.ia' ...., ,

. ',,' Rep~Jt~~t::\:"

'(i£~'~f~4=:~

.:. Recommendations managing women with AGe and

AIS

../ Colpsoscopy and endocervical sampling is

recommended with all subcategories of AGC

(exception if endometrial cell(+), should initially

be evaluated with endometrial sampling)

../ Women with AGC or AIS (+) is unacceptable

using repeat cervical cytology program

The preferred DxExProc. Is cold knife conization

43