Normal colposcopic findings following LBC prediction of LSIL or HSIL

From Cancer Guidelines Wiki


Evidence

Systematic reviews were conducted to answer the following questions:

  • For women with a positive oncogenic HPV test result (not in treatment follow-up) with negative or LSILLow-grade squamous intraepithelial lesionThe low-grade squamous intraepithelial lesion (LSIL) category is the morphological correlate of productive viral infection. It is to be used when the scientist/pathologist observes changes that would have been described as ‘HPV effect’ or ‘CIN 1’ in the previous Australian terminology and represents part of the previous ‘low-grade squamous epithelial abnormality’ category. cytology and normal colposcopy, what is the safety and effectiveness of 12-month follow-up testing with a HPV test alone, compared with co-testingHPV test and LBC both requested and performed on a cervical sample.?
  • For women with a positive oncogenic HPV test result (not in treatment follow-up) with negative or LSILLow-grade squamous intraepithelial lesionThe low-grade squamous intraepithelial lesion (LSIL) category is the morphological correlate of productive viral infection. It is to be used when the scientist/pathologist observes changes that would have been described as ‘HPV effect’ or ‘CIN 1’ in the previous Australian terminology and represents part of the previous ‘low-grade squamous epithelial abnormality’ category. cytology and normal colposcopy, which factors predict the presence of high-grade cervical neoplastic disease (CIN2, CIN3, cervical cancer, adenocarcinoma in situ (AISAdenocarcinoma in situ) or cervical cancer mortality)?
  • For women with a positive oncogenic HPV test result and pHSILPossible HSIL in the Australian Modified Bethesda System is broadly equivalent to ASC-H in US Bethesda system./HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology). referral cytology but pLSILPossible LSIL in the Australian Modified Bethesda System is broadly equivalent to ASCUS in US Bethesda system./LSILLow-grade squamous intraepithelial lesionThe low-grade squamous intraepithelial lesion (LSIL) category is the morphological correlate of productive viral infection. It is to be used when the scientist/pathologist observes changes that would have been described as ‘HPV effect’ or ‘CIN 1’ in the previous Australian terminology and represents part of the previous ‘low-grade squamous epithelial abnormality’ category. or less after cytologic review, and colposcopy is normal (negative), what is the safety and effectiveness of conservative management compared with excision of the TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone.?
  • For women with a positive oncogenic HPV test result and pHSILPossible HSIL in the Australian Modified Bethesda System is broadly equivalent to ASC-H in US Bethesda system./HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology). referral cytology, confirmed pHSILPossible HSIL in the Australian Modified Bethesda System is broadly equivalent to ASC-H in US Bethesda system./HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology). after cytologic review, and colposcopy is normal (negative), what is the safety and effectiveness of cytological and colposcopic follow-up at 3–6 months, compared with excision of the TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone.?

Back to top

Outcomes for women with normal colposcopic findings following referral cytology prediction of LSILLow-grade squamous intraepithelial lesionThe low-grade squamous intraepithelial lesion (LSIL) category is the morphological correlate of productive viral infection. It is to be used when the scientist/pathologist observes changes that would have been described as ‘HPV effect’ or ‘CIN 1’ in the previous Australian terminology and represents part of the previous ‘low-grade squamous epithelial abnormality’ category.

No randomised or pseudorandomised controlled trials were identified that compared HPV testing with co-testingHPV test and LBC both requested and performed on a cervical sample. (HPV and LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory.) at 12-month follow-up for women with a positive oncogenic HPV (any type)Women with a positive HPV test result of any oncogenic HPV types detected using routine HPV testing in a pathology laboratory. test result, a cytology report of negative or LSILLow-grade squamous intraepithelial lesionThe low-grade squamous intraepithelial lesion (LSIL) category is the morphological correlate of productive viral infection. It is to be used when the scientist/pathologist observes changes that would have been described as ‘HPV effect’ or ‘CIN 1’ in the previous Australian terminology and represents part of the previous ‘low-grade squamous epithelial abnormality’ category. and normal colposcopy, and which reported high grade-disease outcomes.

No studies were found that reported the risk of high-grade disease associated with follow-up cytology or HPV status.

Four studies reported the risks associated with referral cytology and/or HPV status for women reported as pLSILPossible LSIL in the Australian Modified Bethesda System is broadly equivalent to ASCUS in US Bethesda system./LSILLow-grade squamous intraepithelial lesionThe low-grade squamous intraepithelial lesion (LSIL) category is the morphological correlate of productive viral infection. It is to be used when the scientist/pathologist observes changes that would have been described as ‘HPV effect’ or ‘CIN 1’ in the previous Australian terminology and represents part of the previous ‘low-grade squamous epithelial abnormality’ category. and normal (negative) colposcopic findings: two prospective cohort studies[1][2] (level II evidence) and two retrospective cohort studies[3][4] (level III-2 evidence) were identified. Follow-up ranged from 1 to 3 years. All four studies were considered at high risk of bias; none of the studies were specifically designed to answer the PICO question, so it was not clear as to whether women with different baseline cytology results or HPV status were similar in terms of important confounders such as smoking status. Furthermore, important study design aspects such as the potential blinded reading of subsequent colposcopies and histopathology (with respect to the baseline test status) were not described.

Two of the studies[3][4] examined the risks of cervical intraepithelial neoplasia (CINCervical Intraepithelial NeoplasiaRefers to abnormal changes in the cells on the surface of the cervix that are seen using a microscope (i.e. histologically-confirmed).CIN 1 – Mild dysplasiaCIN 2 – Moderate dysplasiaCIN 3 – Severe dysplasia to carcinoma in situ(The term CIN 2+ refers to CIN 2, 3, or invasive cervical cancer; CIN3+ refers to CIN 3 or invasive cervical cancer)CIN 2/3 refers to CIN 2 or CIN 3.) grade 3 or higher (CIN3+) associated with different baseline cytology results, and one study[2] examined the risks of CIN3+ associated with baseline HPV-positiveWomen with a positive HPV test result of any oncogenic HPV types detected using HPV testing platforms in a pathology laboratory. ASC-USAtypical squamous cells, undetermined significance and LSILLow-grade squamous intraepithelial lesionThe low-grade squamous intraepithelial lesion (LSIL) category is the morphological correlate of productive viral infection. It is to be used when the scientist/pathologist observes changes that would have been described as ‘HPV effect’ or ‘CIN 1’ in the previous Australian terminology and represents part of the previous ‘low-grade squamous epithelial abnormality’ category. (regardless of HPV status).Three studies[3][4][1] examined the risks of CIN2+ disease associated with different baseline cytology results, of which one study[1] examined the risks of CIN2+ associated with different baseline HPV status. Two studies[1][4] reported the risks associated with baseline cytology results in women who were HPV positiveWomen with a positive HPV test result of any oncogenic HPV types detected using HPV testing platforms in a pathology laboratory..

One of these studies[3] did not report HPV status. The remaining studies provided the following evidence:

  • In a cohort of women with a positive oncogenic HPV (any type)Women with a positive HPV test result of any oncogenic HPV types detected using routine HPV testing in a pathology laboratory. test result with normal colposcopy after referral cytology reported as ‘borderline dyskaryosis’ or ‘mild dyskaryosis’, rates of later detection of CIN3+ (median follow-up 27 months) were 3.5% and 2.1%, respectively.[4] This cohort may not be representative of women with a LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. prediction of pLSILPossible LSIL in the Australian Modified Bethesda System is broadly equivalent to ASCUS in US Bethesda system./LSILLow-grade squamous intraepithelial lesionThe low-grade squamous intraepithelial lesion (LSIL) category is the morphological correlate of productive viral infection. It is to be used when the scientist/pathologist observes changes that would have been described as ‘HPV effect’ or ‘CIN 1’ in the previous Australian terminology and represents part of the previous ‘low-grade squamous epithelial abnormality’ category. identified after primary HPV testing in the renewed NCSPNational Cervical Screening ProgramA joint program of the Australian, state and territory governments. It aims to reduce morbidity and mortality from cervical cancer, in a cost-effective manner through an organised approach to cervical screening. The program encourages women in the target population to have regular Pap smears.; the HPV test in this UK study used a higher cut-off than recommended, and the ‘borderline dyskaryosis’ group could have included women with pHSILPossible HSIL in the Australian Modified Bethesda System is broadly equivalent to ASC-H in US Bethesda system..
  • In a cohort of women with a referral cytology report of LSILLow-grade squamous intraepithelial lesionThe low-grade squamous intraepithelial lesion (LSIL) category is the morphological correlate of productive viral infection. It is to be used when the scientist/pathologist observes changes that would have been described as ‘HPV effect’ or ‘CIN 1’ in the previous Australian terminology and represents part of the previous ‘low-grade squamous epithelial abnormality’ category. and normal colposcopy, the rate of CIN3+ after 1 year follow-up was 4.0%.[2] This cohort included women who tested HPV positiveWomen with a positive HPV test result of any oncogenic HPV types detected using HPV testing platforms in a pathology laboratory. and women who tested HPV negativeWomen in whom oncogenic HPV types are not detected by the HPV testing platform..
  • In a cohort of women with a positive oncogenic HPV (any type)Women with a positive HPV test result of any oncogenic HPV types detected using routine HPV testing in a pathology laboratory. test result with normal colposcopy after referral cytology reported as ‘borderline dyskaryosis’ or ‘mild dyskaryosis’, rates of later detection of CIN2+ (median follow-up 2.6 years) were 6.2% and 12.9%, respectively.[1]

The systematic reviews and their findings are described in detail in the Technical report.

As no studies were found that reported the risks of high-grade disease associated with follow-up cytology or HPV status, there was no directly relevant evidence on which to base an evidence-based recommendation. Detection of HPVHuman papillomavirus, especially persistent HPV 16/18Only HPV types 16 and or 18 detected using routine HPV screening tests in laboratory., is associated with an increased risk of high grade cervical lesions, and the HPV test is more sensitive than cytology (see Chapter 2. The rationale for primary HPV screening).

Back to top

Outcomes for women with normal colposcopy following referral cytology prediction of HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology).

Systematic literature searches did not identify any studies directly addressing the management of women with HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology). cytology and a normal (negative) colposcopy. The search strategies and inclusion and exclusion criteria used are described in detail in the Technical report.

In the absence of any direct evidence from the systematic review, a general review of the literature was performed on the management of women with cytological prediction of pHSILPossible HSIL in the Australian Modified Bethesda System is broadly equivalent to ASC-H in US Bethesda system./HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology). and normal (negative) colposcopy was undertaken to inform relevant consensus-based recommendations.

No studies were found that reported outcomes for women followed up after referral cytology prediction of pHSILPossible HSIL in the Australian Modified Bethesda System is broadly equivalent to ASC-H in US Bethesda system./HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology). and normal colposcopic findings, and which reported the results of cytopathology review.

One cross-sectional cohort study[5] reported outcomes for women participating in conventional cytology (Pap test) screening with no history of a cytological abnormality, who had a cytological prediction of HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology). between 2000 and 2007. Of 340 women who underwent colposcopy, 17 had normal colposcopic findings. BiopsyRemoval of tissue for medical examination. was performed in nine of these women, including endocervical curettage in at least four women.[5] Ages of the women and results of cytopathology review (if performed) were not reported.

Of the 17 women with normal colposcopy (HPV status unknown), two (11.8%) were diagnosed with cervical adenocarcinoma and another two (11.8%) with AISAdenocarcinoma in situ.[5] Findings for the other 13 women were not reported. No other cases of cervical adenocarcinoma or cervical adenocarcinoma in situ were identified among the 331 women with HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology). who underwent biopsy.[5] The degree to which these findings can be generalised to women in the renewed NCSPNational Cervical Screening ProgramA joint program of the Australian, state and territory governments. It aims to reduce morbidity and mortality from cervical cancer, in a cost-effective manner through an organised approach to cervical screening. The program encourages women in the target population to have regular Pap smears. is limited, because HPV status and the findings of cytopathology review are not available.

Another retrospective cohort study[6] reported outcomes for a subgroup of 59 women (mean age 26.8 years) who underwent a loop electrosurgical excision procedure (LEEPLoop electrical excision procedureLoop electrical excision procedure) after a cytological prediction of HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology). and a colposcopically directed target biopsy finding of no abnormality detected (n = 34) or CIN1mild dysplasia (n = 25). On excisional biopsy, histologically confirmed CIN3 was diagnosed in 14 (41%) women with normal target biopsy and 16 (64%) women with CIN1mild dysplasia on target biopsy. The degree to which these findings can be generalised to women in the renewed NCSPNational Cervical Screening ProgramA joint program of the Australian, state and territory governments. It aims to reduce morbidity and mortality from cervical cancer, in a cost-effective manner through an organised approach to cervical screening. The program encourages women in the target population to have regular Pap smears. is limited, because HPV status was unknown and the study did not report whether HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology). was reported at initial referral cytology or on cytopathology review. However, this study did demonstrate the failure of colposcopically directed biopsy to detect the high-grade lesion in 41% of cases, as high grade abnormality was subsequently confirmed in an excision biopsy.[6]

A summary of the literature considered can be found in the Technical report.

Overall, this body of evidence is insufficient to enable accurate prediction of risk in women with normal colposcopic findings despite a LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. report of HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology)..

In Australia, it is recommended that discordant findings between referral cytology and colposcopy warrant review of the cytology prior to further management decisions.

Current evidence does suggest that, in women with a normal colposcopy and HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology). on cytopathology review, the risk of CIN3 and/or invasive cervical cancer is high enough to warrant diagnostic excision of the TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone.. In women with a normal colposcopy and pHSILPossible HSIL in the Australian Modified Bethesda System is broadly equivalent to ASC-H in US Bethesda system. on cytopathology review, the risk of CIN3 and/or invasive cervical cancer is high enough to warrant diagnostic excision of the transformation zone in most cases, but in some situations a short period of observation may be appropriate (see Chapter 9. Management of histologically confirmed low-grade squamous abnormalities).

Back to top

Recommendations

Flowchart 8.1. Normal colposcopy after LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. prediction of pLSILPossible LSIL in the Australian Modified Bethesda System is broadly equivalent to ASCUS in US Bethesda system./LSILLow-grade squamous intraepithelial lesionThe low-grade squamous intraepithelial lesion (LSIL) category is the morphological correlate of productive viral infection. It is to be used when the scientist/pathologist observes changes that would have been described as ‘HPV effect’ or ‘CIN 1’ in the previous Australian terminology and represents part of the previous ‘low-grade squamous epithelial abnormality’ category.

Normal colp after LBC prediction of pLSILLSIL.png












Flowchart 8.2. Normal colposcopy after LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. prediction of possible HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology).

Normal colp after LBC prediction of possible HSIL.png












Flowchart 8.3. Normal colposcopy after LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. prediction of HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology).

Normal colp after LBC prediction of HSIL.png


Consensus-based recommendationQuestion mark transparent.png

REC8.1: Normal colposcopy following LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. prediction of negative or pLSILPossible LSIL in the Australian Modified Bethesda System is broadly equivalent to ASCUS in US Bethesda system./LSILLow-grade squamous intraepithelial lesionThe low-grade squamous intraepithelial lesion (LSIL) category is the morphological correlate of productive viral infection. It is to be used when the scientist/pathologist observes changes that would have been described as ‘HPV effect’ or ‘CIN 1’ in the previous Australian terminology and represents part of the previous ‘low-grade squamous epithelial abnormality’ category.
For women with a positive oncogenic HPV (any type)Women with a positive HPV test result of any oncogenic HPV types detected using routine HPV testing in a pathology laboratory. test result, a LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. report of negative or pLSILPossible LSIL in the Australian Modified Bethesda System is broadly equivalent to ASCUS in US Bethesda system./LSILLow-grade squamous intraepithelial lesionThe low-grade squamous intraepithelial lesion (LSIL) category is the morphological correlate of productive viral infection. It is to be used when the scientist/pathologist observes changes that would have been described as ‘HPV effect’ or ‘CIN 1’ in the previous Australian terminology and represents part of the previous ‘low-grade squamous epithelial abnormality’ category., and normal colposcopy, the HPV test should be repeated in 12 months:

  • If HPV is not detected at 12 months, the woman should return to routine 5-yearly HPV screening.
  • If the woman has a positive oncogenic HPV (not 16/18)Women with a positive HPV test result of other oncogenic HPV types other than types 16 and 18 detected using routine HPV testing in a pathology laboratory. test result at 12 months and a LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. report of negative or pLSILPossible LSIL in the Australian Modified Bethesda System is broadly equivalent to ASCUS in US Bethesda system./LSILLow-grade squamous intraepithelial lesionThe low-grade squamous intraepithelial lesion (LSIL) category is the morphological correlate of productive viral infection. It is to be used when the scientist/pathologist observes changes that would have been described as ‘HPV effect’ or ‘CIN 1’ in the previous Australian terminology and represents part of the previous ‘low-grade squamous epithelial abnormality’ category., the HPV test should be repeated in another 12 months.
  • If the woman has a positive oncogenic HPV ( any type) test at the 24 month HPV test, she should be referred directly for colposcopic assessment, which will be informed by the result of the reflex LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory..
  • If the woman has a positive oncogenic HPV (not 16/18)Women with a positive HPV test result of other oncogenic HPV types other than types 16 and 18 detected using routine HPV testing in a pathology laboratory. test result at 12 months and a LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. prediction of pHSILPossible HSIL in the Australian Modified Bethesda System is broadly equivalent to ASC-H in US Bethesda system./HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology). or any glandular abnormality, she should be referred for colposcopic assessment at the earliest opportunity, ideally within 8 weeks.
  • If the woman has a positive oncogenic HPV (16/18)Women with a positive HPV test result of HPV types 16 and/or 18 detected using routine HPV testing in a pathology laboratory. test result at 12 months, she should be referred directly for colposcopic assessment at the earliest opportunity, ideally within 8 weeks, and the reflex LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. result will inform the colposcopy.
Practice pointQuestion mark transparent.png

REC8.2: Normal colposcopy following LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. prediction of HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology).: cytopathology review
Cytopathology review is recommended to confirm HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology). before proceeding to excisional treatment for women with a normal colposcopy after a positive oncogenic HPV (any type)Women with a positive HPV test result of any oncogenic HPV types detected using routine HPV testing in a pathology laboratory. test result and an initial LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. prediction of pHSILPossible HSIL in the Australian Modified Bethesda System is broadly equivalent to ASC-H in US Bethesda system./HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology)..

Practice pointQuestion mark transparent.png

REC8.3: Normal colposcopy following LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. prediction of HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology).: exclude VAINVaginal intra-epithelial neoplasia
When colposcopic impression is discordant with a referral LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. prediction of HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology)., colposcopic examination of the vagina is indicated to exclude a vaginal intraepithelial neoplasia before diagnostic excisional treatment.

Consensus-based recommendationQuestion mark transparent.png

REC8.4: Normal colposcopy following LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. prediction of HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology).: diagnostic excision of TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone.
For women who have a positive oncogenic HPV (any type)Women with a positive HPV test result of any oncogenic HPV types detected using routine HPV testing in a pathology laboratory. test result, normal colposcopy, and a LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. prediction of HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology). on cytopathology review, diagnostic excision of the TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone. should be performed.

Consensus-based recommendationQuestion mark transparent.png

REC8.5: Normal colposcopy following LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. prediction of pHSILPossible HSIL in the Australian Modified Bethesda System is broadly equivalent to ASC-H in US Bethesda system.: consider diagnostic excision of TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone.
For women who have a positive oncogenic HPV (any type)Women with a positive HPV test result of any oncogenic HPV types detected using routine HPV testing in a pathology laboratory. test result, normal colposcopy, and a LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. prediction of pHSILPossible HSIL in the Australian Modified Bethesda System is broadly equivalent to ASC-H in US Bethesda system. on cytopathology review, diagnostic excision of the TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone. should be considered, though observation is an option.

Practice pointQuestion mark transparent.png

REC8.6: Normal colposcopy following LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. prediction of pHSILPossible HSIL in the Australian Modified Bethesda System is broadly equivalent to ASC-H in US Bethesda system.: diagnostic excision or observation
Some women with a positive oncogenic HPV test result for whom diagnostic excision of the TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone. is recommended due to a confirmed LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. prediction of pHSILPossible HSIL in the Australian Modified Bethesda System is broadly equivalent to ASC-H in US Bethesda system. on cytopathology review, despite normal colposcopic findings, may be concerned about the possibility of having unnecessary treatment. The colposcopist may have similar concerns.
Women who opt to defer treatment, particularly younger women with concerns about fertility, can be offered observation:

  • A HPV test and colposcopy should be repeated at 6 months, and a diagnostic excisional procedure should be reconsidered based on the test results (HPV and reflex LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory., if performed) obtained at that time.
  • If oncogenic HPV is not detected, and the colposcopic impression is unchanged, the HPV test should be repeated in 12 months and if oncogenic HPV is not detected, the woman can return to routine 5-yearly screening.
Consensus-based recommendationQuestion mark transparent.png

REC8.7: Downgrading of discordant results
For women who have a positive oncogenic HPV (any type)Women with a positive HPV test result of any oncogenic HPV types detected using routine HPV testing in a pathology laboratory. test result, normal colposcopy, and a subsequent LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. report of pLSILPossible LSIL in the Australian Modified Bethesda System is broadly equivalent to ASCUS in US Bethesda system./LSILLow-grade squamous intraepithelial lesionThe low-grade squamous intraepithelial lesion (LSIL) category is the morphological correlate of productive viral infection. It is to be used when the scientist/pathologist observes changes that would have been described as ‘HPV effect’ or ‘CIN 1’ in the previous Australian terminology and represents part of the previous ‘low-grade squamous epithelial abnormality’ category. or less on cytopathology review, management should be according to the reviewed cytological report (i.e. repeat HPV test in 12 months).

Practice pointQuestion mark transparent.png

REC8.8: Colposcopist should manage discordant results
Women with discordant colposcopy and LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. results should have their management supervised by the colposcopist until both the colposcopist and the woman are satisfied with the proposed management plan.

Back to top

Benefits and harms

If these recommendations, including review of cytology, are followed for women who have normal colposcopy in the presence of referral LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. predicting low-grade or high-grade grade lesions, they will benefit by avoiding over-investigation or unnecessary treatment.

See Chapter 5. Benefits, harms and cost-effectiveness of cervical screening in the renewed National Cervical Screening Program (NCSP).

Back to top

Health system implications of these recommendations

Clinical practice

It is not anticipated that there will be a significant change to clinical practice, apart from the addition of HPV testing to the recommended surveillance.

Resourcing

No material changes to the costs are anticipated.

Back to top

References

  1. 1.01.11.21.31.4 Cruickshank ME, Cotton SC, Sharp L, Smart L, Walker LG, Little J, et al. Management of women with low grade cytology: how reassuring is a normal colposcopy examination? BJOG 2015 Feb;122(3):380-6 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24947656.
  2. 2.02.12.2 Lukic A, Sbenaglia G, Carico E, DI Properzio M, Giarnieri E, Frega A, et al. Prediction of clinical outcome using p16INK4a immunocytochemical expression in low-grade squamous intraepithelial lesions and high-risk HPV-positive atypical squamous cells of undetermined significance in patients with and without colposcopic evident cervical disease. Exp Ther Med 2011 Sep;2(5):853-858 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22977588.
  3. 3.03.13.23.3 Smith MC, Keech SE, Perryman K, Soutter WP. A long-term study of women with normal colposcopy after referral with low-grade cytological abnormalities. BJOG 2006 Nov;113(11):1321-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17059394.
  4. 4.04.14.24.34.4 Kelly RS, Walker P, Kitchener H, Moss SM. Incidence of cervical intraepithelial neoplasia grade 2 or worse in colposcopy-negative/human papillomavirus-positive women with low-grade cytological abnormalities. BJOG 2012 Jan;119(1):20-5 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21624034.
  5. 5.05.15.25.3 Lerma Puertas E, Otal Salaverri C, Ríos Martín JJ, Sánchez Gómez A, Jiménez Caraballo A, González-Cámpora R. Human papillomavirus detection by PCR assay in a large series of high-grade squamous intraepithelial lesions with cytohistological correlation and follow-up. Acta Cytol 2011;55(5):426-32 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21986169.
  6. 6.06.1 Lanneau GS, Skaggs V, Moore K, Stowell S, Zuna R, Gold MA. A LEEP cervical conization is rarely indicated for a two-step discrepancy. J Low Genit Tract Dis 2007 Jul;11(3):134-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17596756.
Back to top

Appendices

Jutta's magnifying glass icon.pngPICO questions 2a, 2b & 2c View Systematic review report q 2aView Systematic review report q 2a View Systematic review report q 2bView Systematic review report q 2b View Systematic review report q 2cView Systematic review report q 2c
View General evidence summary table q 2bView General evidence summary table q 2b View General evidence summary table q 2cView General evidence summary table q 2c View Evidence Statement q 2aView Evidence Statement q 2a
Back to top