Atypical Squamous Cells of Undetermined Significance (ASCUS) - USMLE Forums
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  #1  
Old 04-26-2012
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ObGyn Atypical Squamous Cells of Undetermined Significance (ASCUS)

A 35-year-old asymptomatic woman has a routine Pap smear that reveals atypical squamous cells of undetermined significance. She regularly undergoes routine Pap smear screening, and results of these studies have always been normal. Her most recent Pap smear was 3 years ago. She has been in a monogamous sexual relationship for 10 years and takes no medications. Serologic studies for HIV 1 year ago were negative. A physical examination, including pelvic examination, 1 week ago was normal.

Which of the following is the most appropriate management for this patient?
A Repeat Pap smear in 1 month
B Repeat Pap smear in 1 year
C Testing for human papillomavirus
D Reassurance
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Old 04-26-2012
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C. Testing for HPV
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C Testing for human papillomavirus

Quote:
HPV DNA testing. More than 75 subtypes of the HPV have now been identified, of which HPV 16, 18, 31, 33, and 35 are most commonly associated with premalignant and invasive cancer lesions. In patients with ASCUS Pap smears, this technique may be help-ful as the cells reported to be consistent with ASCUS can be evaluated better for which type of HPV is present. If it is HPV 6 or 11, then the patient should have a repeat Pap smear in 1 year; however, if it is HPV DNA 16 or 18, then these are the patients that should be evaluated by colposcopy and biopsy.
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If premenopausal women with ASCUS and cin1 then colposcopy with biopsy and if postmenopausal women then hpv subtyping...but there is no choice here for colposcopy and biopsy so i am between A and b...i think i will go with A
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Old 04-26-2012
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Summary of 2012 Screening Guidelines from the American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology
Parameters ACS Recommendations Age to start screening Begin screening with cytology at 21 years old, regardless of sexual history Screening interval age 21–29Screen with cytology alone every 3 years.* HPV testing should not be used in this age group.Screening interval age 30-65Screen with a combination of cytology and HPV testing every 5 years (preferred) or cytology alone every 3 years. Screening by HPV testing alone is generally not recommended.* Age to stop screening Age 65, if the woman has adequate negative prior screening and is not otherwise at high risk for cervical cancer Screening after hysterectomy Not indicated for women without a cervix and without a history of a high-grade precancerous lesion (eg, CIN2 or CIN3) in the past 20 years or cervical cancer ever HPV-vaccinated women Screen according to the same recommendations as for unvaccinated women These guidelines do not address special populations (eg, women with a history of cervical cancer, women who were exposed in utero to diethylstilbestrol, women who are immunocompromised) who may require more intensive or alternative screening.


Women age 21 or greater with ASC-US
  • Perform reflex HPV testing
  • If positive for HPV, then proceed with colposcopy
  • If negative for HPV, then repeat Pap smear in 12 months
-women age 20 or less
  • Repeat Pap smear at 12 months
  • If repeat cytology shows HSIL or worse, perform colposcopy; otherwise repeat cytology after 12 months
  • If second repeat cytology is negative, routine screening may be resumed; if ASC or greater, proceed with colposcopy.
Pregnant women with ASC-US
  • Managed same as nonpregnant women; endocervical curettage (ECC) is contraindicated in pregnant women and should not be collected if colposcopy is performed. Deferring colposcopy until at least 6 weeks postpartum is also possible.
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full text of guidelines available at:
http://journals.lww.com/jlgtd/Publis...Guidelines.pdf
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Correct Answer = C

The most appropriate management for this patient is immediate human papillomavirus (HPV) testing. Cervical cytologic studies commonly show atypical squamous cells of undetermined significance (ASCUS). Before HPV testing was available, a repeat Pap smear every 4 to 6 months until two consecutive studies for intraepithelial lesions were negative was recommended in this setting. The presence of cytologic abnormalities, including ASCUS, on a repeat Pap smear warranted referral for colposcopy. Immediate colposcopy also was an acceptable option but was not cost effective or convenient for patients. However, colposcopy is warranted if HPV testing reveals infection with a high-risk type of HPV (HPV-16 or HPV-18). Continued routine Pap smear screening is warranted even if results of HPV testing are negative.

One month is too short of an interval to wait before performing a repeat Pap smear and would increase the overall number of unnecessary Pap smears and possibly follow-up colposcopy; conversely, 1 year is most likely too long an interval to wait. In 5% to 17% of patients with ASCUS on cytologic studies, biopsy confirms the presence of grade II or III cervical intraepithelial neoplasia. Cervical intraepithelial neoplasia is characterized by a precancerous cervical lesion that, if untreated, may progress to cervical cancer. Grade III cervical intraepithelial neoplasia is the most severe type and has the greatest risk of progressing to invasive cervical cancer. Reassurance would be misleading and potentially harmful to this patient.
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