CASE N°40 – Management of women with Low-grade squamous intraepithelial lesion
gynecological examination: nothing to report
cytological speciemen: Pap Test
Low-grade squamous intraepithelial lesion (L-SIL)
… Management of women with the cytologic diagnosis of low-grade SIL varies considerably according to the availability of medical resources and socio-economic status of women.
Immediate colposcopy after cytologic diagnosis of low-grade SIL is costly and may cause unnecessary stress on patients and the health system in countries where colposcopy is not a routine part of the gynaecologic examination. However, delay of histopathologic confirmation by 6 months or longer may lead to underdiagnosis and worsening of prognosis.
In health-care systems where high-risk HPV testing is available, triaging in high-risk HPV-positive and high-risk HPV-negative lesions is performed. However, for clinical practice, no clear guidelines have been established as to testing of smears or biopsies and choice of HPV test. Tests that include only a certain amount of pooled high-risk HPVs and that show crossreaction between high- and low-risk types are clinically not useful due to low specificity.
There is a need to coordinate the diversing algorithms for the management of patients with low-grade SIL in order to avoid overtreatment: The majority of women with diagnosis of low-grade SIL are young and still desire conception. Standard treatment is still invasive, either using excisional or ablative procedures, which are associated with a peri- and postoperative morbidity rate of up to 10%. The data presented in this enquiry should therefore serve as a basis to start a discussion of a coordinated effort to improve the quality and result of the management of this highly prevalent diagnosis in order to improve women’s health.
- Anonymous The 1988 Bethesda system for reporting cervical/vaginal cytological diagnoses. National Cancer Institute Workshop. JAMA. 1989;262:931–934.[PubMed]
- Arbyn M. Triage of women with atypical or low-grade cytological abnormalities of the cervix by HPV testing 2001. IPH/EPI – Report Nr. 2001-019
- Feoli-Fonseca JC, Oligny LL, Brochu P, Simard P, Falconi S, Yotov WV. Human papillomavirus (HPV) study of 691 pathological specimens from Quebec by PCR-direct sequencing approach. J Med Virol. 2001;63:284–292.[PubMed]
- Holowaty P, Miller AB, Rohan T, To T. Natural history of dysplasia of the uterine cervix. J Natl Cancer Inst. 1999;91:252–258.[PubMed]
- Klaes R, Benner A, Friedrich T, Ridder R, Herrington S, Jenkins D, Kurman RJ, Schmidt D, Stoler M, van Knebel Doeberitz M. p16INK4a immunohistochemistry improves interobserver agreement in the diagnosis of cervical intraepithelial neoplasia. Am J Surg Pathol. 2002;26:1389–1399.[PubMed]
- Koutsky LA, Holmes KK, Critchlow CW, Stevens CE, Paavonen J, Beckmann AM, DeRouen TA, Galloway DA, Vernon D, Kiviat NB. A cohort study of the risk of cervical intraepithelial neoplasia grade 2 or 3 in relation to papillomavirus infection. N Engl J Med. 1992;37:1272–1278.[PubMed]
- Nasiell K, Roger V, Nasiell M. Behavior of mild cervical dysplasia during long-term follow-up. Obstet Gynecol. 1986;67:665–669.[PubMed]
- Nobbenhuis MA, Helmerhorst TJ, van den Brule AJ, Rozendaal L, Vaarhorst FJ, Bezemer PD, Verheijen RH, Meijer CJ. Cytological regression and clearance of high-risk human papillomavirus in women with an abnormal cervical smear. Lancet. 2001;358:1782–1783.[PubMed]
- Nobbenhuis MA, Walboomers JM, Helmerhorst TJ, Rozendaal L, Remmink AJ, Risse EK, van der Linden HC, Vorhoorst FJ, Kenemans P, Meijer CJ. Relation of human papillomavirus status to cervical lesions and consequences for cervical-cancer screening: a prospective study. Lancet. 1999;354:20–25.[PubMed]
- Östor AG. Natural history of cervical intraepithelial neoplasia: a critical review Int J Gynaecol Pathol 1993. 12186–192.1922 [PubMed]
- Petry KU, Bohmer G, Iftner T, Davis P, Brummer O, Kuhnle H. Factors associated with an increased risk of prevalent and incident grade III cervical intraepithelial neoplasia and invasive cervical cancer among women with Papanicolaou tests classified as grades I or II cervical intraepithelial neoplasia Am J Obstet Gynecol 1999. 18628–34.341 [PubMed]
- Richart RM. A modified terminology for cervical intraepithelial neoplasia. Obstet Gynecol. 1990;75:131–133.[PubMed]
- Stoler MH. HPV testing is not useful for LSIL Triage – but stay tuned. Adv Anat Pathol. 2001;8:160–164.[PubMed]