1. health and fitness
2. disease
3. cancer

Management Guidelines for
Abnormal Pap Smear &
Preinvasive Disease of the Cervix
FOREWORD
Cervical cancer is the 4th most common cancer among women in
Singapore. The incidence of cervical cancer has declined from 18.1
per 100,000 population for the years 1968-72 to 14.2 per 100,000
population between 1993-97. However, the incidence rate in
Singaporean women remains higher than that of developed countries.
In 1998, the Ministry of Health set up the Cervical Cancer Screening
Committee to develop an organised population-based cervical cancer
screening programme to reduce cervical cancer mortality. It was
recognised that evidence-based management guidelines were necessary
for the evaluation and management of women with different grades
of cervical abnormality detected by the cervical cancer screening
programme. A workgroup, chaired by A/Prof Ho Tew Hong with
representatives from the Chapter of Obstetrics & Gynaecology,
Academy of Medicine, Singapore, Obstetrical & Gynaecological Society
of Singapore, Society for Colposcopy & Cervical Pathology of Singapore,
Singapore General Hospital, National University Hospital and KK
Women’s & Children’s Hospital was formed to develop a set of
management guidelines for handling abnormal Pap smears.
The CervicalScreen Singapore: Management Guidelines for the
Abnormal Pap Smear and for Preinvasive Disease of the Cervix will be
a useful guide for clinicians in the management of patients with
abnormal Pap smears.
I would like to extend my sincere thanks to the workgroup for
their commitment and hard work in developing the guidelines.
Dr Lam Sian Lian
Chief Executive Officer
Health Promotion Board
i
PREFACE
Whilst the incidence of cervical cancer in Singapore has decreased
slightly in the last 25 years, much can still be done to reduce the rates
of cervical cancer further.
The primary aim of the CervicalScreen Singapore Programme is
to further reduce the incidence and mortality from cervical cancer
through early detection. An important aspect of this Programme is to
guide general practitioners on the management guidelines for screened
cervical abnormalities.
A Workgroup consisting of representatives from Chapter of
Obstetrics & Gynaecology, Academy of Medicine of Singapore,
Obstetrical and Gynaecological Society of Singapore, the Society for
Colposcopy and Cervical Pathology of Singapore, Singapore General
Hospital, National University Hospital and KK Women’s & Children’s
Hospital met on several occasions to work out consensus management
guidelines for abnormal PAP smear and for preinvasive disease of the
cervix. Views from international experts were sought and the consensus
guidelines of Bethesda 2001 were also taken into account.
These consensus guidelines are formulated specifically for the
purpose of the oncoming CervicalScreen Singapore Programme.
Ho Tew Hong
Clinical Associate Professor
Chairman of Workgroup
CervicalScreen Singapore:
Management Guidelines
for Abnormal Pap Smear and
Preinvasive Disease of the Cervix
iii
CONTENTS
Foreword
i
Preface
iii
1. CervicalScreen Singapore
1
2. Terminology for Cervical Smear Reporting
3
3. Management Protocol for ‘Negative for Malignant Cells’ Smears
7
4. Management Protocol for Unsatisfactory Smears
5. Management Protocol for Abnormal Smears
9
11
5.1 Management of Abnormal Smear
(no past history of CIN or genital tract cancer)
12
5.2 Management of Abnormal Smear
(following treatment for CIN or CGIN)
17
5.3 Management of the Abnormal Smear in Pregnancy
17
6. Pap Smears After Hysterectomy
18
7. Management of Preinvasive Disease of the Cervix
20
7.1 HPV
21
7.2 CIN 1
22
7.3 CIN 2 and CIN 3
23
7.4 Suspicion of Microinvasion on Cervical Biopsy
24
7.5 Adenocarcinoma-in-situ
25
7.6 Management of the Abnormal Smear and CIN in Pregnancy
26
7.7 Involvement of Margins after Cone Biopsy or LEEP for CIN
27
8. Special Situations
28
8.1 Abnormal Smear (ASC-US / LSIL) & Unsatisfactory or Normal
Colposcopy
29
8.2 Abnormal Smear (ASC-H / HSIL) & Unsatisfactory or Normal
Colposcopy
30
8.3 Atypical Glandular Cells
31
8.4 Endocervical Adenocarcinoma in-situ on Pap smear
32
8.5 Adenocarcinoma on Pap smear
33
References
34
Acknowledgements
38
iv
1
CERVICALSCREEN
SINGAPORE
1
1
CERVICALSCREEN
SINGAPORE
1. Age Group to be Screened and Screening Interval
1.1 Entry to Screening Programme
• All women who have ever had sex are advised to have their first Pap
smear by the age of 25
1.2 Frequency of Screening
• Pap smears are taken once every 3 years
1.3 Discharge from Screening
• A woman can be discharged from screening at 65 years of age if the
smear taken at 65 years is negative and there was a previous negative
smear within the last 3 years
• However if a woman, who has had sexual intercourse, has never had
a Pap smear, she should still undergo screening irrespective of her age
1.4 Women who have never had Sexual Intercourse
• Women who have never had sexual intercourse need not have Pap
smear screening
• However if these women have any symptoms, they should consult a
doctor
Note : Consider screening at an earlier age and at more frequent
intervals if high risk characteristics are present. High risk characteristics
include:
•
•
•
•
•
•
•
Multiple sexual partners (either partner)
Onset of sexual intercourse at an early age
HPV infection
History of STD
HIV infection
Immunosuppression
Cigarette smoking
2
2
TERMINOLOGY FOR
CERVICAL SMEAR
REPORTING
3
TERMINOLOGY FOR
CERVICAL SMEAR REPORTING
2
(A) List of terminology
1. Unsatisfactory
2. Negative for Malignant Cells
3. Abnormal Smears
3.1 Squamous Lesions
3.1.1 Atypical Squamous Cells
• undetermined significance (ASC-US)
• cannot exclude high grade lesion (ASC-H)
3.1.2 Low-Grade Squamous Intraepithelial Lesion (LSIL)
• HPV effect
• mild dyskaryosis
3.1.3 High-Grade Squamous Intraepithelial Lesion (HSIL)
• moderate dyskaryosis
• severe dyskaryosis
• severe dyskaryosis, cannot rule out invasive carcinoma
3.1.4 Squamous Cell Carcinoma
3.2 Glandular Lesions
3.2.1 Atypical Glandular Cells
• undetermined significance
• favour neoplastic
3.2.2 Endocervical Adenocarcinoma-in-Situ
3.2.3 Adenocarcarcinoma
3.3 Others
3.3.1 Carcinoma
• others - specify
• not further specified
3.3.2 Other Malignant Tumours
• specify
(B) Definitions
•
Unsatisfactory
A smear that is unreliable for the detection of cervical epithelial cell
abnormalities.
4
A smear comprising mainly endocervical cells is also considered
unsatisfactory, unless the smear was intended to specifically evaluate
the endocervical canal.
•
Negative for Malignant Cells
The smear shows no dyskaryotic or malignant cells ie. no cytological
evidence of Cervical Intraepithelial Neoplasia (CIN), glandular dysplasia
or malignancy.
This category includes those in which cells showing reactive changes are
present, and also those in which micro-organisms are identified.
•
Squamous Lesions
Atypical Squamous Cells
• undetermined significance
• cannot exclude high grade lesion
There are cells showing cytologic changes suggestive of a dysplastic
squamous lesion that is quantitatively or qualitatively insufficient for a
definitive interpretation.
Undetermined Significance (ASC-US)
Cytologic changes suggestive of a low grade squamous lesion but lack
criteria for definitive interpretation.
Cannot Exclude High Grade Lesion (ASC-H)
Cytologic changes suggestive of a high grade squamous lesion but lack
criteria for definitive interpretation.
Low-Grade Squamous Intraepithelial Lesion (LSIL)
• HPV effect
• mild dyskaryosis
HPV Effect
Squamous cells present showing stringent criteria of HPV effect ie.
koilocytes in superficial or intermediate squamous cells or sharply
delineated perinuclear halos in parabasal cells.
Mild Dyskaryosis
Cytologic changes indicative of CIN I.
5
TERMINOLOGY FOR
CERVICAL SMEAR REPORTING
If fewer than these are seen because of paucity of cells, poor fixation,
air- drying artefact, thick smearing, or covering of blood, inflammatory
exudate or other contaminants, the smear is considered unsatisfactory.
2
A satisfactory smear should show well-preserved and well-visualised
squamous cells covering at least one-third of the area of a regular glass
slide surface.
High-Grade Squamous Intraepithelial Lesion (HSIL)
TERMINOLOGY FOR
CERVICAL SMEAR REPORTING
2
• moderate dyskaryosis
• severe dyskaryosis
• severe dyskaryosis, cannot rule out invasive carcinoma
Moderate Dyskaryosis
Cytologic changes indicative of CIN 2.
Severe Dyskaryosis
Cytologic changes indicative of CIN 3.
Severe Dyskaryosis, Cannot Rule Out Invasive Carcinoma
Cytologic changes indicative of at least CIN 3, but with features of
possible invasive tumour.
Squamous Cell Carcinoma
Cytologic changes indicative of an invasive squamous cell carcinoma.
•
Glandular Lesions
Atypical Glandular Cells
• undetermined significance
• favour neoplastic
There are cells showing cytologic changes suggestive of a dysplastic
glandular lesion that are quantitatively or qualitatively insufficient for a
definitive interpretation. Where possible, these are qualified as to whether
the abnormal cells are of endocervical or endometrial origin.
Undetermined Significance
Cytologic changes which exceed those of a reactive process but lack
criteria for a definitive interpretation of a dysplastic glandular lesion.
Favour Neoplastic
Cytologic changes suggestive of a glandular dysplasia or adenocarcinomain-situ or adenocarcinoma, but lack criteria for definitive interpretation.
Endocervical Adenocarcinoma-in-Situ
Cytologic changes indicative of endocervical adenocarcinoma-in-situ.
Adenocarcarcinoma
Cytologic changes indicative of an invasive adenocarcinoma.
•
Others
Carcinoma
• others - specify
• not further specified
Other Malignant Tumours
• specify
6
3
MANAGEMENT PROTOCOL
FOR “NEGATIVE FOR
MALIGNANT CELLS” SMEARS
7
PAP SMEAR
NEGATIVE SMEARS
3
Negative for malignant cells
Atrophic
changes
No endocervical
cells seen
(without
inflammation)
Repeat in 1 year
(use of an
endocervical
brush in addition
to the cervex
brush/spatula is
recommended)
Specific
micro-organisms
identified
Treat appropriately changes
&
resolve
as clinically
indicated
Inflammatory
changes
Endometrial
cells
seen
Treat any
infection
or atrophy
Repeat in
4 – 6 months
Correlate
with clinical
findings,
patient’s
age,
hormonal
and
menstrual
status
2nd smear
similar changes
changes
resolve
Treat any
infection
or atrophy
Repeat in
4 – 6 months
3rd smear
similar changes
Routine
screening
schedule
Routine
screening
schedule
Refer
gynaecologist
Refer
gynaecologist
if necessary
Note : Clinically suspicious looking cervix irrespective of the Pap smear result
must be referred for colposcopy.
8
4
MANAGEMENT PROTOCOL
FOR UNSATISFACTORY
SMEARS
9
PAP SMEAR
UNSATISFACTORY
SMEARS
4
Unsatisfactory
Treat any infection
Give a course of estrogen if
post-menopausal with atrophic changes
Repeat in 3 months
2nd smear unsatisfactory
Repeat in 3 months
Negative for malignant cells
Satisfactory and negative
3rd smear unsatisfactory
Refer for colposcopy
Routine screening schedule
Note : Clinically suspicious looking cervix irrespective of the Pap smear result
must be referred for colposcopy.
10
5
MANAGEMENT PROTOCOL
FOR ABNORMAL
SMEARS
11
5.1
Management of Abnormal Smear
(No past history of CIN or genital tract cancer)
PAP SMEAR
Atypical squamous cells
Undetermined significance
(ASC-US)
Refer for colposcopy
Repeat in 6 months
ABNORMAL
SMEARS
5
Cannot exclude high grade lesion
(ASC-H)
- Atypical squamous cells
- Low-grade squamous
intraepithelial lesion
- High-grade squamous
intraepithelial lesion
Negative for
malignant cells
Refer for colposcopy
Repeat in 6 months
Resume routine
screening if negative
for malignant cells
12
PAP SMEAR
Low-grade squamous intraepithelial lesion
(LSIL)
Mild dyskaryosis
or
not otherwise specified
5
HPV effect
ABNORMAL
SMEARS
Repeat in 6 months
Negative for
malignant cells
HPV effect
and / or more
severe abnormality
Repeat in 1 year
If negative for
malignant cells,
may resume
routine screening
Colposcopy
13
Colposcopy
PAP SMEAR
Squamous cell carcinoma
ABNORMAL
SMEARS
5
High-grade squamous
intraepithelial lesion
(HSIL)
Moderate
dyskaryosis
or
Severe
dyskaryosis
Severe
dyskaryosis,
cannot rule out
invasive
carcinoma
Colposcopy
Colposcopy
(urgent appointment)
14
Urgent referral
to
gynaecologist
PAP SMEAR
Endocervical
adenocarcinomain-situ
Colposcopy *
Colposcopy
Adenocarcinoma
*Colposcopist to refer to management guidelines 8.3
15
Urgent referral to
gynaecologist
ABNORMAL
SMEARS
5
Atypical glandular
cells
-Undetermined
significance
-Favour neoplastic
PAP SMEAR
Carcinoma
(specified or not further specified)
Other malignant tumours
ABNORMAL
SMEARS
5
Urgent Referral To Gynaecologist
Other indications for referral :
a.
Abnormal vaginal bleeding, eg. post-coital, post-menopausal or
intermenstrual, should always be investigated and the woman
referred for a specialist opinion.
b.
Clinically suspicious looking cervix irrespective of the Pap smear result
must be referred for colposcopy.
16
5.2 Management of Abnormal Smear
(Following treatment for CIN or CGIN)
PAP SMEAR
Unsatisfactory
Atypical squamous or
glandular cells,
dyskaryosis
of any degree
Suspicious of invasive
carcinoma or
adenocarcinoma, or
malignant cells seen
Negative for
malignant
cells
Resume follow
up schedule
after treatment
for CIN
ABNORMAL
SMEARS
5
Treat any infection
Give a course of
estrogen if
post-menopausal
with atrophic changes
Repeat in 3 months
2nd smear
unsatisfactory
Colposcopy
Colposcopy
Colposcopy
(urgent appointment)
5.3 Management of the Abnormal Smear in Pregnancy
The same as in the non-pregnant patient
17
6
PAP SMEARS
AFTER
HYSTERECTOMY
18
1.
Hysterectomy for benign disease
(a) Normal Pap smear history
(b) Histopathology of cervix known and is benign with no dysplastic/
neoplastic changes
Subtotal hysterectomy
Should continue to have Pap smears according to the screening
programme
3.
Hysterectomy where histology not known
• One base-line Pap smear of vaginal vault
• If this is normal, then no further smears are required
4.
Immunosuppressed women (due to disease or therapy)
• Should continue to have Pap smears of the vault at yearly intervals
5.
Women with a past history of CIN
(a) If excision margin was involved or not adequately assessed
histologically
• Follow up should be at the discretion of the gynaecologist
• Vault smears should in general be taken at least yearly
(b) CIN (CIN 1 / 2 / 3) completely excised at hysterectomy
• Vault smears for five years yearly
• Two yearly subsequently
6.
Women previously treated for VAIN, or invasive gynaecological
malignancy
• These women should be followed up by the treating gynaecologist/
• gynaecological oncologist
PAP SMEARS AFTER
HYSTERECTOMY
2.
6
• These women, in the absence of symptoms, need not have any
• further Pap smears
7
MANAGEMENT OF
PREINVASIVE DISEASE
OF THE CERVIX
20
7.1 HPV
HPV on Biopsy
Repeat Pap smear +
colposcopy in 6 months
Treat :
i. If any associated CIN,
according to guidelines
for CIN
ii. If condylomas present
7
HPV
No CIN
MANAGEMENT OF
PREINVASIVE DISEASE
Yearly Pap smear x 2
If negative for
malignant cells,
may return to routine
3 yearly screening
21
7.2 CIN 1
CIN 1 on Biopsy
Observation
Treatment
Repeat Pap smear and
colposcopy + biopsy
in 6 months
Ablation *
or
Excision
Persistent CIN I
- cytology
(ASC-US / LSIL)
- colposcopy +
biopsy
Refer Section 7.3
Treatment
Or
Observation
Normal
Follow-up
Pap smear at
3 – 6 months
MANAGEMENT OF
PREINVASIVE DISEASE
7
Progression
- cytology
(ASC-H / HSIL)
- colposcopy +
biopsy
- If observation, patient must be compliant
to follow-up
- Repeat Pap smear and colposcopy + biopsy
in 6 months
- Consider treatment if CIN I persistent
for 12 months from first histological diagnosis
Pap smear + colposcopy
at 12 months
Yearly Pap smear x 4
Return to routine 3
yearly screening
* Refer to criteria for ablation in 7.3
Note : The management of CIN I is controversial; patients can be managed
by either observation or treatment.
If immunocompromised patient, suggest treatment as CIN less likely
to regress.
22
7.3 CIN 2 and CIN 3
CIN 2 / CIN 3 on Biopsy
Treat
Excision
- LEEP / LLETZ
- Laser cone
- Cold knife cone
Follow-up
Pap smear at 3 - 6 months
Pap smear + colposcopy at 12 months
Pap smear 6 monthly for second year
Yearly Pap smear
23
MANAGEMENT OF
PREINVASIVE DISEASE
7
Ablation
- The upper limit of the lesion is completely
visualised
- The whole transformation zone is seen on
colposcopy
- There is no discrepancy of more than one grade
between cytology, colposcopy or biopsy
- There is no suspicion of microinvasive / invasive
disease on cytology, colposcopy or biopsy
- There is no suspicion of any glandular
lesion on cytology, colposcopy or biopsy
- The patient will be compliant to follow up
7.4 Suspicion of Microinvasion on Cervical Biopsy
SUSPICION OF MICROINVASION
on Biopsy
Cone biopsy of cervix
MANAGEMENT OF
PREINVASIVE DISEASE
7
Subsequent management
according to histology of
cone biopsy
Note : For suspected microinvasion a single large cone biopsy specimen
with clear margins is necessary for adequate histopathological
interpretation. A LEEP may not be adequate. A cold knife cone under
anaesthesia is preferred.
24
7.5 Adenocarcinoma-in-situ
ADENOCARCINOMA-IN-SITU
on Biopsy
Cone biopsy + endocervical curettage (ECC)
Invasion present
Manage according to
guidelines for
cervical cancer
No invasion
Margins involved
Adequate specimen
and margins clear
If fertility desired
or desire
to preserve uterus
Total
hysterectomy
Follow patient
closely
Note : For cone biopsy for adenocarcinoma-in-situ, a single large specimen
with clear margins is necessary for adequate histopathological
interpretation. A LEEP may not be adequate. A cold knife cone under
anaesthesia is preferred.
25
MANAGEMENT OF
PREINVASIVE DISEASE
Completed
family
7
Recommend
expert opinion
7.6 Management of the Abnormal Smear and CIN in Pregnancy
1.
Colposcopic evaluation should be undertaken to exclude invasive disease,
by a colposcopist experienced in colposcopy in pregnancy.
2.
If a high grade lesion is suspected on colposcopy, a biopsy is indicated to
exclude possible invasive disease. Cervical biopsy is safe in pregnancy.
3.
If CIN 2 or 3 is present, colposcopic review should be done in the second or
third trimester to exclude any possible progression to invasive disease.
4.
Treatment of CIN should be deferred till at least 8 weeks post-partum, when
the lesion should be reassessed. If the patient is breast feeding, local
application of estrogen before the colposcopic reassessment may assist
accurate evaluation.
MANAGEMENT OF
PREINVASIVE DISEASE
7
Note : The management of labour is not influenced in any way by the
presence of CIN, irrespective of severity.
26
7.7 Involvement of Margins after Cone Biopsy or LEEP for CIN
Involvement of Resection Margins
Margin positive
for CIN I
Margin positive
for CIN 2 or 3
Repeat Pap smear and colposcopy
at 3 months
Repeat excision
or hysterectomy
Pap smear abnormal
colposcopy
unsatisfactory
or normal
Biopsy
Follow up
according to
schedule for CIN
Review Pap smear
by pathologist
CIN I
CIN 2 / CIN 3
Individualise
treatment
Ablation*
or
excision
Excision
or
hysterectomy
Consider
expert
opinion
* Refer to criteria for ablation in 7.3
27
MANAGEMENT OF
PREINVASIVE DISEASE
7
Pap smear negative
for malignant cells
Colposcopy normal
8
SPECIAL
SITUATIONS
Note:
Management should be individualised.
Consider expert opinion including pathology review.
28
8.1 Abnormal Smear (ASC-US / LSIL) & Unsatisfactory or Normal
Colposcopy
Atypical squamous cells-undetermined significance (ASC-US) /
Low-grade squamous intraepithelial lesion (LSIL)
Colposcopy satisfactory + normal
vulva / vaginal normal
Colposcopy unsatisfactory
vulva / vagina normal
Do ECC
Pap smear
abnormal
colposcopy
normal
ECC
positive
Repeat Pap
smear in
6 months
ASC-US
or LSIL
Negative
for
malignant
cells
Repeat Pap smear
+ colposcopy
in 6 months,
consider cone
biopsy or LEEP
if persistent
at 12 months
ASC-H/
HSIL
ECC
negative
Pap smear &
colposcopy
normal
Repeat Pap smear
+ colposcopy
in 6 months
Abnormal
Normal
Repeat Pap
smear in
6 months
Yearly Pap
smear x 2
Negative for
malignant cells
If negative
for malignant
cells, resume
3 yearly
screening
Yearly Pap
smear x 2
Legend : ECC
Note :
Pap smear
abnormal
colposcopy
unsatisfactory
Cone biopsy
or LEEP
Endocervical currettage
Cone
biopsy
or LEEP
If negative for malignant
cells, resume 3 yearly
screening
Management should be individualised. Consider expert opinion
including pathology review.
29
8
Pap smear &
colposcopy
normal
Estrogen treatment if
post-menopausal. Repeat Pap
smear & colposcopy in 3 months
SPECIAL
SITUATIONS
Repeat Pap smear & colposcopy
in 6 months
8.2 Abnormal Smear (ASC-H / HSIL) & Unsatisfactory or Normal
Colposcopy
Atypical squamous cells cannot exclude high grade lesion (ASC-H) /
High-grade squamous intraepithelial lesions (HSIL)
Colposcopy satisfactory & normal
Vulva / vagina normal
Colposcopy unsatisfactory
Vulva / vagina normal
Review Pap smear by pathologist
Not conclusive
for ASC-H / HSIL
ASC-H / HSIL
Repeat Pap smear &
colposcopy
in 3 - 6 months
SPECIAL
SITUATIONS
8
Pap smear &
colposcopy normal
Repeat Pap
smear in 6 months
If negative for
malignant cells,
yearly Pap
smear x 2
Review Pap smear by
pathologist
ASC-H / HSIL
Not conclusive
for ASC-H / HSIL
Pap smear abnormal
colposcopy normal
ASC-US
or LSIL
ASC-H / HSIL
Repeat Pap smear +
colposcopy in 6 months,
consider cone biopsy or
LEEP if persistent
at 12 months
If negative for
malignant cells,
to resume
3 yearly screening
30
Cone biopsy or
LEEP
Follow
algorithm
as in 8.1
8.3 Atypical Glandular Cells
Atypical glandular cells
-undetermined significance
-favour neoplastic
Colposcopy
Abnormal
Biopsy
Normal or unsatisfactory
Review Pap smear by pathologist
AIS / SIL
High suspicion of
neoplastic lesion
Manage according
to guidelines
for cervical cancer
Low suspicion of
neoplastic lesion
Repeat Pap smear &
colposcopy + ECC
in 4 – 6 months
Consider pelvic ultrasound
Cone biopsy and D&C or
endometrial sampling *
Normal
Normal
Pap smear 6 mthly x 2
If negative for malignant cells, yearly Pap smear x 2
If negative for malignant cells, resume 3 yearly screening
* If risk factors for Ca endometrium are present, or the patient is
symptomatic or > 40 years
D&C (+ hysteroscopy) is advised for
endometrial tissue evaluation
Note : If histology of cone biopsy and D&C normal
to investigate for
disease in ovary, fallopian tubes and peritoneum.
31
8
Manage according
to histology of lesion
AGUS
SPECIAL
SITUATIONS
Carcinoma
8.4 Endocervical Adenocarcinoma-in-situ on Pap Smear
Endocervical Adenocarcinoma-in-situ on Pap Smear
Colposcopy
No lesion on cervix
Lesion on cervix
SPECIAL
SITUATIONS
8
Squamous intraepithelial
lesion
Cone biopsy
+ ECC
D&C if risk factors
for Ca endometrium
present,
symptomatic or
>40 years
Legend: ECC
Cone biopsy
+ ECC
D&C if risk factors
for Ca endometrium
present,
symptomatic or
>40 years
AIS
biopsy
Adenocarcinoma
Cone biopsy
+ ECC
Manage
according to
guidelines for
cervical cancer
Endocervical currettage
Note : If histology of cone biopsy and D&C normal
to investigate for
disease in ovary, fallopian tubes and peritoneum.
32
8.5 Adenocarcinoma on Pap Smear
Adenocarcinoma on Pap Smear
Lesion on cervix
No lesion on cervix
Colposcopy normal
AIS
Manage according
to guidelines
for cervical cancer
Cone biopsy
+ ECC
and D&C
SPECIAL
SITUATIONS
Adenocarcinoma
D&C + hysteroscopy
Cone biopsy of cervix
8
Squamous
intraepithelial lesion
or no dysplasia
Biopsy
Note : If histology of D&C and cone biopsy normal
to investigate for
for disease in ovary, fallopian tubes and peritoneum.
33
REFERENCES
34
Duncan ID (ed). Guidelines for clinical practice and programme management
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3.
IARC Working Group on Evaluation of Cervical Cancer Screening Programmes.
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4.
From the Centres for Disease Control and Prevention. Incidence of Pap test
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5.
Gram IT, Macaluso M, Stalsberg H. Incidence of cervical intraepithelial
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6.
Mitchell MF, Schottenfeld D, Tortolero-Luna G, Cantor SB, Richards-Kortum
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M I Shafi, DM Luesley, JA Jordan, JA Dunn, TP Rollason, M Yates. Randomised
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ACKNOWLEDGEMENTS
38
Workgroup Members
Chairperson
Clinical Assoc Prof Ho Tew Hong
Dr Chew Sung Hock
KK Women’s & Children’s Hospital
Assoc Prof A Ilancheran
Academy of Medicine, Singapore
Dr Lee I Wuen
Raffles Hospital
Assoc Prof Lim Fang Kan
National University Hospital
Dr Lim-Tan Soo Kim
Singapore General Hospital
Dr Jeffrey Low
KK Women’s & Children’s Hospital
Dr Quek Swee Chong
KK Women’s & Children’s Hospital
Dr Pritam Singh
Society for Colposcopy & Cervical
Pathology of Singapore
Dr Tay Eng Hseon
Obstetrical & Gynaecological Society of
Singapore
Clinical Assoc Prof Tay Sun Kuie
Singapore General Hospital
Assoc Prof Tham Kok Fun
National University Hospital
39
ACKNOWLEGEMENTS
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