Management Of Abnormal Smear LGSIL/HGSIL.

-------

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

VUTSRQPONMLKJIHGFEDCBA

M ANAGEM ENT OF
ABNORM AL

S M E A R L G S I L /H G S I L

. : . K e y p o i n t s : rqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA

•

These are practices guidelines should not be
consideredNMLKJIHGFEDCBA
r u le o r s ta n d a r d

•

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

C o n s e n s u s G u id e lin e s

B e th e sd a

(A S C C P )

.: . K e y p o in t s :

•

These are practices guidelines should not be
considered

•

r u le o r s ta n d a r d

of care

Clinical care must always take into account the
individual patient

28

Developed for US setting - all may not be appropriate in
other country .VUTSRQPONMLKJIHGFEDCBA
•: .

T h e B e th e sd a

•

S y ste m

Terminologi pelaporan

hasil tes Pap terbaru

yang berorientasi klinik
•

Perkembangan:
1988:

sistem

Pengembangan sistem pelaporan sebagai
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
modernZYXWVUTSRQPONMLKJIHGFEDCBA

29

Sistem Bethesda
sitopatologi

berfungsi

sebagai

serviksjvagina.

petunjuk

Merupakan

pelaporan

penyempurnaan

dari sistern Bethesda 1991. Termasuk metoda pengenalan

tes tambahan dan automatisasi .
•

Rekomendasi final: khususnya penyempurnaan

adekuasi spesimen dan kategori umum .VUTSRQPONMLKJ
•: . P e l a p o r a n

TBS

•

Adekuasi spesime

•

Kategori umum

•

Interpretasi j hasil

30

-In fe c tio n

" I

. ZYXWVUTSRQPONMLKJIHGFEDCBA
R e p a ir
I

1 '.'" ''
.c',

.'

E p ith e lia l

Squamous

C e ll

,"

rqponmlkjihgfedcbaZYXWVUTSRQP

A b n o n n a lity :

Cells

• A S C U S (a ty p ic a l s q u a m o u s c e lls
o f lW ld e lc n n in e d s ig n ific a n c e )
- F a v o r re a c tiv e
- F a v o r d y s p la s ia
- N O I o ih e rw is e s p e c ifie d (N O S )
• L S IL
• H S IL
•

S q u a m o u s

E p ith e lia l

c e l!

C e ll

c a r c in o m a

A b n o n n a lity :

Glandular Cells
• A G U S (a ly p ic a ig ia n d lila r
u n d e te r m in e d

c e lls o f

s ig n ific a n c e )

- F a v o r re a c tiv e
- F a v o r n e o p la s ia
- NOS
• A d e n o c a r c in o m a

3 2 BA

II11

il

.: .

K a te g o r i

Um um

T B S 2 0 0 1 rqponmlkjihgfedcbaZYXWVUTSRQPONM

Abnormalitas sel epitel
Sel skuamosaNMLKJIHGFEDCBA
•

A ty p ic a l

Squam ous

•

A S C -U S , A S C -H (c a n n o t

•

Low

G rade

C e lls ( A S C ) :
e x c lu d e H G S I L )

Squam ous

I n tr a e p ith e lia l

L e s io n

Squam ous

I n tr a e p ith e lia l

L e s io n

(L G S IL )
•

H ig h

G rade

(H G S IL )

Karsinoma sel skuamosa
.: .

K a te g o r i

Um um

T B S 2001

Abnormalitas sel epitel
Sel glanduler
•

Atipik

( N o t O th e r w is e

S p e c ifie d ) :

sel endoserviks,

sel endometrium, sel glanduler
•

Atipik

(F a v o r

n e o p la s tic ) :

sel endoserviks, sel

glanduler
•

Adenokarsinoma insitu serviks (AIS)

Adenokarsinoma:

endoserviks,

N O S.

33

endometrium,

extrauterin,

. : . A t y p i c a l S q u a m o u s C e l l rqponmlkjihgfedcbaZYXWVUTSRQPONML

•

ASC-US of Undetermined

•

ASC-H

Cannot exlude HSIL

ASCUS

.: . T e s P a p

Tes

Significance

ASCUS

Pap

Pap II

dahulu

dilaporkan:

(Papanicolaou)

Inkonklusif(Reagan)
Atipia sel

(Richart)

.: . A t y p ic a l S q u a m o u s C e ll- U n d e t e r m in e d
B u r d e n o f d is e a s e

S ig n ific a n c e

in A S C -U S

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 : 1000NMLKJIHGFEDCBA
M a n a g e m e n t n e e d s to ta k e in to a c c o u n t p a tie n t
/p r o v id e r c o n v e n ie n c e , c o s t

34

2 0 0 1 C o n s e n s u s G u i d e l i n e s rqponmlkjihgfedcbaZYXWVUTSRQPONMLK

Management
•

of ASC-US

All three

standard

safe & effective.

modalities

Because

are

of costs, and patient

convenienceNMLKJIHGFEDCBA
r e fle x HPV testing

is

liquid based cytology or co-collection

!

Treat according to grade

* IfHPV DNA

(+) more aggressive

35

considered

follow-up recommended

p r e fe r e d

if

availableZYXWVUTSRQPONMLKJIHG

.:.

H P V D N A T e s tin g rqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFED

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
atrophy)
Course of intravaginal

with

estrogen *

1

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

---------=------

Both (-) ive

.

Either ASC (+)

l.

R NMLKJIHGFEDCBA
ou t me screenmg·

37

.

C

·1···

1.

... ; ~ po?~copy. .

. : . M a n a g e m e n t o f A S C - U S rqponmlkjihgfedcbaZYXWVUTSRQPONML

Immunosuppresed
•

patients:

Relatively few studies are available

Studies that are available
confirmed

show a high rate of biopsy

- CIN. High rate

of high-risk

HPV-DNA

positivity.

A S C -U S(Im m u n o su p p r e se d

w o m e n ) ZYXWVUTS

I
C o lp o s c o p y

*INMLKJIHGFEDCBA
n c lu d e s a ll H I V - I n fe c te d
CD

4

w om en,

*

ir r e s p e c tiv e

c o u n t, H I V v ir a l lo a d , o r a n tir e tr o v ir a l

38

of

th e r a p y

::c

-I

(j)

t-

BA
t-ZYXWVUTSRQPONMLKJIHGFEDCBA

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IC

IC

c Y ')

00
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(l)

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CIl

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e
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0

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<

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Women with ASC-H cytology
Colposcopy
CIN identified

No CIN IdentifiedZYXWVUTSRQPONMLKJIHGFEDCBA

1

Review all material
~

Revised Dx

ASr-H
Pap (6 & 12 mo)
orHPV(12mo)

.:. Management

of ASC NMLKJIHGFEDCBA

S e e a n d tr e a t

Because of the potential
excisional procedures

for overtreatment,

diagnostic

(LEEP) should not be routinely

the absence of biopsy confirmed

40

CIN.

used in

.: . F o llo w in g

•

a n A S C - U S c y t o l o g y rqponmlkjihgfedcbaZYXWVUTSRQP

Repeat

cytology

with

monolayer

cytology

at

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

•

months,

using

Hybrid

capture-2

threshold

have high triage sensitivity

A single

+

at

HPV test at 12 months

referral to re-colposcopy

1 pg

+

for CIN 3
has lower

than repeat cytology at

the ASC-US threshold
Repeat

cytology

inadequate

sensitivity

.: . L iq u id - b a s e d

•

at

LSIL

+

threshold

to detect CIN 3

c y to lo g y

Better specimen adequacy
o

Unsatisfactory

decreased

40-94 %

oNMLKJIHGFEDCBA
S a tis fa c to r y b u t lim ite d b y decreased
96%
•

provides

Better detection

of HSIL , LSIL

o

29-233 % more HSIL

o

65-110 % more LSIL

Decreased ASC-US

41

by 52-

.: . D ir e c t t o V I A H S I L + m u lt is it e

•

o u t c o m e t r i a l s rqponmlkjihgfedc

Increased detection
o

% LSIL
112,1ZYXWVUTSRQPONMLKJIHGFEDCBA

o 92,4
•

%

HSIL

True increase in detection both LSILand HSIL
o Fewer false positives
o Reduction in false negative rate

LB-cytology as able to identify more biopsy proper HSIL +
.: . T h e B e t h e s d a

Terminology

workshop 2001

changes

for

AGUS (Atypical

Glandular

Undetermined Significance)

*NMLKJIHGFEDCBA
T h e te r m o f u n d e te r m in e d

s ig n ific a n c e h a s b e e n d r o p p e d ....

......AGUS is n o w a ty p ic a l g la n d u la r c e lls o r AGe
.: . A t y p ic a l g la n d u la r

c e lls a n d A d e n o c a r c in o m a

in

stu

.:. Glandular cells abnormalities:
•

AGe

( either

endocervical,

endometrium,

glandular cells) not otherwise

spesified (AGe

NOS)
•

AGe (either endocervical or glandular cells)

•

Favour neoplasia (AGe-favour neoplasia)
42

or

Endocervical adenocarcinoma in situ (AIS)
Women with Atypical Glandular Cells (AGC)
AGe

Atypical endometrial

cells

!ZYXWVUTSRQPONMLKJIHGFEDCBA
!
Endometrial samplingVUTSRQPONMLKJ

.: . R e c o m m e n d a t io n s

w i t h BA
A G

m a n a g in g w o m e n

e

and

A IS

./

Colpsoscopy
recommended

and

endocervical

sampling

with all subcategories

is

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

!ZYXWVUTSRQPONMLKJIHGFEDCBAEndometrial
1

Colposcopy (+endocervical sampling)
and Endometrial

sampling

sampling (~35 yrs

or abn. Bleeding)

N'~'dl~"
Initial Pap
ArC-NOS

..

DX •.E xcisional proc.

Initial Pap
AGC-favour neoplasia-

(cold knife cone)

..

,~

· ':qN1A:IS.· · ~o
.

S_H"

-R < fu ,"

',,'

Ne?pl!l~.ia' ....,

,

Rep~Jt~~t::\:"

'(i£~'~f~4=:~VUTSRQPONMLKJIHGFEDCBA
.: . R e c o m m e n d a t io n s

A G
w i t h BA

m a n a g in g w o m e n

e

and

A IS

../ Colpsoscopy
recommended

and

endocervical

sampling

with all subcategories

is

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