AGC-NOS (atypical glandular cells, not otherwise specified)

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AGC-neoplastic (atypical glandular cells, can’t rule out neoplasia): changes sugges-tive of but not adequate to call AIS or cancer

AIS (adenocarcinoma in situ)

Adenocarcinoma

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Chapter 4 l Disorders of the Cervix and Uterus

Cytology		Histology

CIN 1

Mild dysplastic

ASC changes

LSIL

CIN 2, CIN 3

HSIL Moderate/severe dysplastic changes

Cancer

Invasive

Cancer

Figure II-4-4. Classification of Cervical Dysplasias

Histology		CIN 1		CIN 2	CIN 3

	Normal	Very mild	Mild	Moderate	Severe	Cancer in
	Normal	dysplasia	dysplasia	dysplasia	dysplasia	situ
		dysplasia	dysplasia	dysplasia	dysplasia	situ

Cytology	Low-Grade	High-Grade
	SIL	SIL

Figure II-4-5. Histologic Appearance of Cervical Dysplasia with Progressive Severity

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USMLE Step 2 l Gynecology

Diagnostic Approach to Abnormal Pap Smears

• Accelerated repeat Pap. This is an option for the findings of ASC-US. Repeat Pap at4- to 6-month intervals until there are 2 consecutive negative Paps. If a repeat Pap is again ASC-US or worse, refer for colposcopy.

• HPV DNA testing. This is also an option for findings of ASC-US. If liquid-basedcytology was used on the initial Pap smear, this specimen can be used for DNA testing. If conventional methods were used, a second Pap needs to be performed. Colposcopy is performed only if high-risk HPV DNA is identified.

• Colposcopy.Once the patient is reported to have an abnormal Pap smear, she shouldbe evaluated by colposcopic examination. Colposcopy is a magnification of the cervix (10–12 times). Colposcopy is aided by acetic acid, which makes the vascular patterns more visible.

– Satisfactory or adequate colposcopy is diagnosed if the entire T-zone is visualized and no lesions disappear into the endocervical canal.

– Unsatisfactory or inadequate colposcopy is diagnosed if the entire T-zone cannot be fully visualized.

• Endocervical curettage (ECC). All nonpregnant patients undergoing colposcopywhich shows metaplastic epithelium entering the endocervical canal will undergo an

ECC to rule out endocervical lesions.

• Ectocervical biopsy. Lesions identified on the ectocervix by colposcopy (e.g., mosa-icism, punctation, white lesions, abnormal vessels) are biopsied and sent for histology.

• Compare Pap smear and biopsy. When the biopsy histology is complete, it is compared

with the level of Pap smear abnormality to ensure the level of severity is comparable.

• Cone biopsy. If the Pap smear is worse than the histology (suggesting the site ofabnormal Pap smear cells was not biopsied), then a cone biopsy is performed. Other indications for conization of the cervix include abnormal ECC histology, a lesion seen entering the endocervical canal, and a biopsy showing microinvasive carcinoma of the cervix. Deep cone biopsies can result in an incompetent cervix. Another risk of cone biopsy is cervical stenosis.

Any

Repeat cytology

Ages

age

12 months

21–24

ASC-US

LSIL