2006 ASCCP Guidelines

Evidence-based consensus guidelines for the clinical management of women with cervical abnormalities detected during cancer screening were recently developed and published by a multidisciplinary group. This group met on September 18-19, 2006 in Bethesda, Maryland, and consisted of 146 experts and 29 organizations and professional societies. The guidelines were officially released on October 5, 2007. Recommendations for managing atypical squamous cells of undetermined significance and low-grade squamous intraepithelial lesion (LSIL) are essentially unchanged. Changes were made for managing these conditions in adolescents for whom cytological follow-up for 2 years was approved. Recommendations for managing high-grade squamous intraepithelial lesion (HSIL) and atypical glandular cells (AGC) also underwent only minor modifications. More emphasis is placed on immediate screen-and-treat approaches for HSIL. Human papillomavirus (HPV) testing is incorporated into the management of AGC after their initial evaluation with colposcopy and endometrial sampling. The 2004 Interim Guidance for HPV testing as an adjunct to cervical cytology for screening in women 30 years of age and older was formally adopted with only very minor modifications. 1

Brief Overview

The Specifics

• Modified from references 1.

• The assignment of these terms represents an opinion ratified by vote by the Consensus Conference.

2001 ASCCP Guidelines are linked here for reference.

Additional Guidelines

• Prevalence: Benign endometrial cells-accuracy is difficult to assess due to variations in study reporting, varying from 0.5% up to 3% of women 40 years of age or older. Atypical endometrial cells-from 0.03 up to .1%, accounting for up to 5.25% of all glandular abnormalities reported. Overall AGC prevalence reported to be around 0.2%.
• Morphology: Under Bethesda 2001 criteria, include both glandular and stromal cells exfoliating in ball or gland-like clusters, rarely as single cells. Do not report abraded endometrial cells from lower uterine segment (LUS) or stromal cells and/or histiocytes as they do not carry the same risk for underlying endometrial pathology. Differential diagnosis of atypical endometrial cells includes: benign exfoliated endometrial cells, other types of atypical glandular and squamous processes, and adenocarcinoma. Many biopsies showing endometrial adenocarcinoma will have previous negative cytology or only benign endometrial cells. When the cytology shows malignant endometrial cells, the tumor grade is often higher and clinical stage more advanced.

• Clinical significance: Benign endometrial cells on cervical cytology are most often associated with benign endometrial pathology (22-97%). Some of the pathology which may be identified include: polyps (1-41%), hyperplasias with (0.6-8%) and without atypia (1-20%), low and high grade adenocarcinomas (1-15%), leiomyomata, atrophy, proliferative endometrium, immediate postpartum state, impending or early post abortion, acute endometritis, recent intrauterine instrumentation, IUD use, and cervical and vaginal endometriosis.

  • Hormone Replacement Therapy (HRT): There is controversy about the effect of hormone replacement therapy (HRT) on postmenopausal women and the presence of normal appearing endometrial cells on Pap tests. Tamoxifen use (>5 years) has been associated with and increased risk of endometrial pathology, including endometrial hyperplasia and adenocarcinoma. For women on Tamoxifen with benign endometrial cells on Pap, additional evaluation is recommended.
• Management: For immediate follow up, endometrial sampling, hysteroscopic dilation and curettage (D&C), and transvaginal ultrasound with or without sonohysterography are available options.
• Review of Current Guidelines: 1991 TBS placed the presence of endometrials occuring in the latter half of the cycle of a postmenopausal woman as an epithelial cell abnormality. The 2001 TBS changed this to include the reporting of endometrials cells in a woman over the age of 40, and not as an epithelial cell abnormality. More specific educational notes in the report may be necessary to guide the clinical management in order to reduce unnecessary endometrial evaluation. Clinicians should be advised of the current evidence that supports further evaluation in all postmenopausal women with benign endometrial cells in Pap tests regardless of the presence of symptoms (bleeding)(1-15% risk of carcinoma).

• Areas of Future Study:

  • Prospective studies needed.
  • Significant pathology should be defined as atypical complex hyperplasia and carcinoma or other malignancies.
  • Randomized assignment to evaluation methods.

1. 2006 consensus guidelines for the management of women with abnormal cervical cancer screening tests Thomas C. Wright , L. Stewart Massad , Charles J. Dunton , Mark Spitzer , Edward J. Wilkinson , Diane Solomon American Journal of Obstetrics & Gynecology- 2007 October (Vol. 197, Issue 4, Pages 346-355, DOI: 10.1016/j.ajog.2007.07.047) NOTE: For access to article without fee, choose Article via Elsevier Health Sciences - Elsevier imprints, theclinics.com, and ophsource.org . 2. The 2001 Consensus Guidelines for the Management of Women with Cytological Abnormalities. JAMA (2002;287:2120-2129). American Society for Colposcopy and Cervical Pathology (ASCCP)