Guía 2006 Seguimiento mujeres con lesiones cervicales por VPH

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1/17Copyright @ 2007 American Society for Colposcopy and Cervical Pathology. Unauthorized reproduction of this article is prohibited.

2006 Consensus Guidelines for the

Management of Women With

Cervical Intraepithelial Neoplasiaor Adenocarcinoma In Situ

Thomas C. Wright Jr., MD,1 L. Stewart Massad, MD,2 Charles J. Dunton, MD,3

Mark Spitzer, MD,4 Edward J. Wilkinson, MD,5 Diane Solomon, MD;6

for the 2006 American Society for Colposcopy and

Cervical PathologyYsponsored Consensus Conference1Department of Pathology, College of Physicians and Surgeons of Columbia University,New York, NY, 2Department of Obstetrics and Gynecology, Washington University School

of Medicine, St Louis, MO, 3Department of Obstetrics and Gynecology, Lankenau Hospital,Wynnewood, PA, 4Department of Obstetrics and Gynecology, Brookdale University Hospitaland Medical Center, Brooklyn, NY, 5Department of Pathology, University of Florida College

of Medicine, Gainesville, FL, and6National Institutes of Health and National Cancer Institute,Bethesda, MD

h Abstract

Objective. To provide updated consensus guidelinesfor the management of women with cervical intraepithe-lial neoplasia (CIN) or adenocarcinoma in situ (AIS).

Participants. A group of 146 experts including repre-sentatives from 29 professional organizations, federalagencies, and national and international health organiza-tions met on September 18Y19, 2006, in Bethesda, MD, todevelop the guidelines.

Major Changes in the Guidelines. The management ofwomen with CIN grade 1 (CIN 1) has been modifiedsignificantly. In the earlier guidelines, managementdepended on whether the colposcopic examination wassatisfactory and treatment using ablative or excisionalmethods was acceptable for women with CIN 1. In the

new guidelines, cytological follow-up is the only recom-mended management option, regardless of whether thecolposcopic examination is satisfactory, for women withCIN 1 who have a low-grade referral cervical cytology.Treatment of CIN 1 is particularly discouraged in adoles-cents. The basic management of women in the generalpopulation with CIN 2,3 underwent only minor modifica-tions, but options for the conservative management ofadolescents with CIN 2,3 have been expanded. Moreover,management recommendations for women with biopsy-confirmed AIS are now included.

Conclusion. Updated evidenced-based guidelineshave been developed for the management of womenwith CIN or AIS. These guidelines reflect recent changes inour understanding of human papillomavirusYassociateddiseases of the cervix and the potential impact oftreatment on future pregnancies. h

Key Words: cervical intraepithelial neoplasia, treatment,

loop electrosurgical excision procedure, cryotherapy, adeno-

carcinomas in situ of the cervix

Cervical cancer, once one of the leading causes ofcancer death in women in the United States, is nowrelatively uncommon. This decline is frequently attrib-

uted to cervical cancer screening programs, but the

appropriate management of women with cervical

Reprint requests to: Thomas C. Wright Jr., MD, Room 16-404 P&S Bldg,

630 W 168th St, New York, NY 10032. E-mail: [email protected]

These evidenced-based Consensus Guidelines reflect recent changes in

our understanding of how to manage women with cervical intraepithelial

neoplasia and adenocarcinoma in situ of the cervix.

These guidelines were developed with funding from the American

Society for Colposcopy and Cervical Pathology and the National Cancer

Institute. Its contents are solely the responsibility of the authors and the

American Society for Colposcopy and Cervical Pathology and do not

necessarily represent the official views of the National Cancer Institute.

2007, American Society for Colposcopy and Cervical Pathology

Journal of Lower Genital Tract Disease, Volume 11, Number 4, 2007, 223Y239



intraepithelial neoplasia (CIN) is as critical a component

of cervical cancer prevention programs as screening and

managing abnormal screening test results. Cervical

intraepithelial neoplasia is a relatively common pro-

blem, especially in women of reproductive age. Labora-tory surveys from the mid-1990s from the College of

American Pathologists suggest that more than 1 million

women are diagnosed each year with low-grade cervical

intraepithelial lesions, referred to as CIN grade 1 (CIN

1), and that approximately 500,000 are diagnosed with

high-grade cervical cancer precursor lesions, referred to

as CIN 2,3 [1]. Since the mid-1990s, the rate of

abnormal cervical cytology has increased in the United

States, suggesting that the number of women with CIN is

continuing to increase [1]. A report from the Kaiser

Permanente Northwest health plan indicates a some-

what lower rate of CIN among women enrolled in a

prepaid health plan, with a projected annual incidence

per 1,000 women of 1.2 for CIN 1 and 1.5 for CIN 2,3

[2]. Improper management of CIN can increase risk of

cervical cancer on the one hand and can result in

complications from overtreatment on the other. It is

becoming increasingly clear that loop electrosurgical

excision, which is widely used to treat CIN, produces a

small, but significant, negative impact on subsequent

pregnancy [3, 4].

Approximately 5 years ago, the American Society for

Colposcopy and Cervical Pathology (ASCCP) joinedother professional societies and federal and international

organizations to develop the 2001 Consensus Guidelines

for Managing Women with Cervical Intraepithelial

Neoplasia [5]. The goal was to improve the care of

women with CIN by weighing the best available

evidence and developing consensus management guide-

lines. Since 2001, considerable new information has

become available on the natural history of CIN, par-

ticularly in adolescents and young women [6Y8]. Our

understanding of how to manage women with cervical

adenocarcinoma in situ (AIS), a human papillomavirus

(HPV)Yassociated precursor to invasive cervical adeno-carcinoma, also has progressed. Therefore, in 2005,

the ASCCP and its partner organizations (listed in

Appendix A), began the process of revising the 2001

Consensus Guidelines. This culminated in a consensus

conference held at the National Institutes of Health in

September 2006. This report provides the recommenda-

tions developed with respect to managing women with

CIN and AIS. Recommendations for managing women

with abnormal cervical cancer screening tests appear in

an accompanying article [9].

GUIDELINE DEVELOPMENT PROCESS

The process used to develop the 2006 guidelines was

similar to that for the 2001 guidelines and is described in

depth elsewhere [5, 9]. Guidelines were developed

through a multistep process. Nationally recognized

experts in cervical cancer prevention were recruited to

working groups. These groups met initially to define

areas where modifications to the existing guidelines

might be needed, establishing each as a research

question. They then performed literature reviews and

retrieved and rated articles published since 2000 on each

question. They next conducted Internet-based discus-

sions open to the professional community at large that

focused on the research questions. The working groups

presented draft guidelines and supporting evidence to

the full Consensus Conference, which voted on each,with revision as needed. All guidelines were passed by

at least 66% of participants.

The terminology utilized for the new guidelines is

identical to that used previously, as is the 2-part rating

system and is provided in the Table 1. The terms

recommended, preferred, acceptable, and unacceptable

Table 1. Rating the Recommendations

Strength of recommendationa

A Good evidence for efficacy and substantial clinical

benefit support recommendation for use

B Moderate evidence for efficacy or only limited

clinical benefit supports recommendation for use

C Evidence for efficacy is insufficient to support a

recommendation for or against use, but

recommendations may be made on other grounds

D Moderate evidence for lack of efficacy or for adverse

outcome supports a recommendation against use

E Good evidence for lack of efficacy or for adverse

outcome supports a recommendation against use

Quality of evidencea

I Evidence from at least 1 randomized controlled trial

II Evidence from at least 1 clinical trial without

randomization, from cohort or case-control

analytic studies (preferably from more than one

center), or from multiple time-series studies,

or dramatic results from uncontrolled experiments

III Evidence from opinions of respected authorities based

on clinical experience, descriptive studies, or reports

of expert committees

Terminology used for recommendationsb

Recommended Good data to support use when only one option

is available

Preferred Option is the best (or one of the best) when there are

multiple other options

Acceptable One of multiple options either when there are data

indicating that another approach is superior or when

there are no data to favor any single option

Unacceptable Good data against use

aModified from Gross et al. [89] and Kish [90].bTheassignment of these terms representsan opinion ratifiedby voteby the ConsensusConference.

224 & W R I G H T E T A L .



are used in the guidelines to describe various interven-

tions. For example, in some clinical situations, there are

multiple management options that have reasonable

evidence of efficacy, but, based on less-defined issues

such as costs or patient convenience, one approach maybe Bpreferred.[ The letters A through E are used to

indicate Bstrength of recommendation[ for or against the

use of a particular option. The strength of the

recommendation is based on consideration of several

criteria, including potential for harm if an intervention

did not occur, potential complications of a given

intervention, as well as the Bquality of the evidence.[

Therefore, an exact correlation does not exist between

Bstrength of the recommendation[ and the Bquality of

the evidence.[ Quality of evidence is designated using

Roman numerals I to III as defined in Table 1. A number

of terms that are used in the guidelines were specifically

defined at the beginning of the Consensus Conference,

and those definitions are provided in Appendix B.

2006 CONSENSUS GUIDELINES

General Comments

Although the 2006 Consensus Guidelines are Bevidenced

based,[ in many instances there was a limited amount of

evidence available on which to base recommendation for

a particular management decision, or the evidence

which was available to inform the development of a

guideline was quite limited. This resulted in instances in

which the guidelines had to be based on either relatively

small descriptive studies or simply on expert opinion. It

is also important to recognize that although the 2006

Consensus Guidelines are designed to provide guidance

to clinicians caring for women with cervical cancer

precursors in the United States, management approaches

will frequently need to be individualized to take into

account individual patients clinical findings and pre-

ferences. Guidelines should never be considered a

substitute for clinical judgment, and it is impossible to

develop guidelines comprehensive enough to apply to allclinical situations. Finally, both clinicians and patients

need to realize that although cervical cancer can often be

prevented through a program of screening and treatment

of cervical cancer precursor lesions, no screening or

treatment modality is perfect, and unfortunately, inva-

sive cervical cancer can develop in women who

participate in such programs.

The histological classification incorporated into

these guidelines is a 2-tiered system that applies the

terms CIN 1 to low-grade lesions and CIN 2,3 to high-

grade precursors. Cytological low-grade squamous

intraepithelial lesion (LSIL) is not equivalent to

histological CIN 1, and cytological high-grade squa-

mous intraepithelial lesion (HSIL) is not equivalent to

histological CIN 2,3.Treatment Methods. Both ablative treatment meth-

ods that destroy the affected cervical tissue in vivo and

excisional modalities that remove the affected tissue are

widely utilized for treating CIN lesions [10]. Ablative

methods include cryotherapy, laser ablation, electro-

fulguration, and cold coagulation. Ablative methods are

usually recommended only for women who have a

satisfactory colposcopic examination and in whom

invasive cervical cancer has been ruled out through a

combination of colposcopy and endocervical sampling

with cytological correlation [11, 12]. Pretreatment

endocervical sampling can help identify women with

occult invasive cervical cancer [13]. In one study of 391

women undergoing a diagnostic excisional conization,

none of the women with a negative endocervical

curettage before conization were found to have an

occult invasive lesion in the conization specimen,

whereas all of the 17 found to have invasive disease

had a positive endocervical sampling [13]. Studies of

patients diagnosed with invasive disease after ablative

therapy have found that many either did not have an

endocervical sampling before treatment or underwent

an ablative procedure despite having a positive endo-cervical sampling [14].

Excisional methods that provide a tissue specimen for

pathological examination include cold-knife conization,

loop electrosurgical excision procedures (widely referred

to as LEEP or LLETZ [large loop excision of the

transformation zone]), laser conization, and electrosur-

gical needle conization. Excisional methods are con-

sidered preferable in situations where invasive cervical

cancer cannot be ruled out through a combination of

colposcopy and endocervical sampling with cytological

correlation and in situations where the risk of occult

cervical cancer is high. Examples include women withunsatisfactory colposcopic examinations, positive endo-

cervical curettage, and large lesions with a high-grade

colposcopic appearance [12]. It is also often recom-

mended that women with posttreatment recurrence of

CIN 2,3 be treated using an excisional as opposed to an

ablative method [12]. Many recurrent or persistent CIN

lesions are found in the endocervical canal, where they

are not colposcopically visible and therefore are not

suitable for ablative therapy. Cold-knife conization was

the original conservative method for treating CIN, but

2006 Consensus GuidelinesVHistology & 225



today, cold-knife conization has been largely replaced by

other excisional methods that do not require general

anesthesia. Cold-knife conization is also associated with

a higher rate of complications, and there is clear

evidence that it produces pregnancy-related morbidity.Therefore, today, cold-knife conization is usually

restricted to selected patients such as older women in

whom there is a suspicion of microinvasion or those who

have glandular neoplasia that can be located deep in the

endocervical canal [15]. Hysterectomy is a radical

procedure which is infrequently used today for the

treatment of intraepithelial lesions [15]. Hysterectomy

carries a substantially greater risk of morbidity, and even

mortality, when compared with excisional and ablative

procedures. This usually outweighs any potential benefit

of using hysterectomy as primary therapy for women

with CIN 2,3.

Simple outpatient excisional methods such as loop

excision offer the potential to be used as part of a Bsee-

and-treat[ approach in which both evaluation and

treatment are performed at the same visit [16]. See-

and-treat has a number advantages, especially for

women with an HSIL referral cytology, most of whom

will eventually undergo treatment irrespective of the

findings at colposcopy. Performing a loop excision at the

time at the initial colposcopic examination reduces the

number of office visits, reduces the potential for women

being lost to follow-up before treatment, and is thoughtto reduce patient anxiety while they wait for biopsy

results [15]. It does, however, result in some over-

treatment of women without CIN 2,3. This can be

minimized by only performing see-and-treat when

women have an HSIL referral cytology [12]. One study

of see-and-treat found that when limited to women

referred with HSIL cytology, 84% of the treated patients

had histologically identified CIN 2,3 in the loop excision

specimens [17]. Another study reported that 94% of

loop excisions specimens obtained using a see-and-treat

approach in women referred with HSIL had histologi-

cally identified CIN 2,3 [18].All of the treatment methods listed above are widely

utilized for treating CIN lesions, and each of the

different modalities has its proponents [19]. Only a

relatively limited number of randomized trials have

directly compared the different treatment modalities. A

Cochrane Database Systematic Review evaluated 28

individual trials that in aggregate compared a total of 7

treatment modalities [10]. Many of the trials were not

randomized controlled trials. Data were extracted from

the published reports by 2 investigators independently.

The primary conclusion of the Cochrane Review was

that there is no significant difference in the success rate

of the different modalities [10]. Other reviews have also

concluded that both ablative and excisional modalities

have a similar efficacy with respect to eliminating CINand reducing a womans risk of future invasive cervical

cancer [15, 20Y22]. It should be cautioned, however,

that the number of randomized controlled trials directly

comparing any 2 treatment modalities is limited, and

most trials are only powered to identify large differences

in outcomes. Moreover, there are difficulties inherent in

interpreting the pooled data for very diverse trials that

have different enrollment criteria, depth of excision, and

other variables associated with treatment [12].

Several randomized clinical trials and clinical case

series have directly compared the efficacy of cold-knife

conization with loop excisional procedures in women

requiring conization [23, 24]. These trials have reported

equivalent success rates and comparable rates of

complications for both methods. It remains unclear,

however, whether there is a significant difference

between cold-knife conization and loop excision with

respect to pathologic margins. Some, but not all, studies

have found that pathologic margins are less frequently

involved by CIN and are easier to interpret when cold-

knife conization is used [23, 25Y27].

It has been recognized for some time that cold-knife

conization increases a womans risk of future pretermlabor, low-birth-weight infant, and cesarean section

[28]. Other treatment methods such as loop excision

were thought to have no adverse effects on future

pregnancies since most of the studies published in the

early 1990s showed little impact on obstetric outcomes.

This has changed. Over the last few years, several large

retrospective series have reported that all forms of

excisional procedures present obstetrical risks [3, 15,

29Y31]. A recent systematic review of the published

literature on obstetric outcomes after treatment of CIN

found that all types of excisional procedures result in

pregnancy-related morbidity [3]. Loop excision wasfound to have a significant association with preterm

delivery (11% risk in treated women versus 7% risk in

untreated women), low-birth-weight infants (8% in

treated women versus 4% in untreated women), and

premature rupture of membranes (5% in treated women

versus 2% in untreated women). Although there were no

significant increases in neonatal intensive care unit

admissions or perinatal mortality in women who had

undergone loop excision versus those who had not,

nonsignificant increases were observed. In most studies,

226 & W R I G H T E T A L .



ablative methods have not been shown to be associated

with a similar adverse effect on pregnancy outcome;

however, it is difficult to measure small effects on

pregnancy outcome [3, 30, 31]. A large record linkage

study from Finland that evaluated national data on8,210 subsequent singleton births among 25,827

women who had been treated for CIN has recently

reported that any form of treatment including ablative

methods and loop excision increases the risk of preterm

delivery [32]. Thus, it is possible that ablative methods

may also have an adverse effect on future pregnancies.

Of interest, a recent Australian study showed that both

treated and untreated women with CIN were at

increased risk for preterm birth compared with the

general population, suggesting that treatment may be a

proxy for other risks [31].

There are no accepted nonsurgical therapies for CIN

[33]. Several topical agents have been either evaluated or

are in clinical trials, but none has been proven as

effective as excision or ablation. Similarly, although

there is considerable interest in therapeutic HPV

vaccines, none has been proven effective [34].

These considerations indicate that the decision as to

which therapeutic option to use in an individual patient

depends on considerations such as patient age, parity,

desire for future childbearing, preferences, prior cytol-

ogy and treatment history, and history of default from

follow-up, operator experience, and nonvisualization ofthe transformation zone.

Posttreatment Follow-up. The reported treatment

failure rate using either ablative or excisional methods

varies between 1% and 25% [10, 20, 35Y37].

Systematic reviews indicate overall pooled failure

rates of 5% to 15% for the different modalities,

with no significant difference between the modalities

[20]. Most failures occur within 2 years after treat-

ment [35, 38]. In addition to developing recurrent/

persistent CIN, women who have been treated for CIN

2,3 remain at increased risk for developing invasive

cervical cancer for a protracted period [22, 39]. Arecent systematic review reported that the incidence of

invasive cervical disease in treated women remains

about 56 per 100,000 for at least 20 years after

treatment, substantially greater than that in the general

US population (5.6/100,000 woman-years) [22, 40].

Therefore, decades-long follow-up is essential.

A number of posttreatment follow-up protocols have

been recommended [41, 42]. These include cytology,

colposcopy, combinations of cytology and colposcopy,

and testing for high-risk (oncogenic) types of HPV,

performed at a variety of intervals. None of the follow-

up protocols has been evaluated in randomized clinical

trials, and because the various follow-up approaches are

so different, it is difficult to compare them [38].

Systematic reviews of the performance of high-riskHPV DNA testing for posttreatment follow-up have

found that its performance is quite good and exceeds

that of cytological follow-up [38, 42]. Overall, the

pooled sensitivity of high-risk HPV testing for identify-

ing recurrent/persistent CIN reaches 90% by 6 months

after treatment and has been shown to remain at this

level for at least 24 months. In contrast, the pooled

sensitivity of cytology is approximately 70% [38]. In

some studies, but not others, use of a combination of

HPV testing and cytology resulted in an increased

sensitivity [38].

Special Populations. Adolescents (aged 13Y20 years)

and young women are considered a Bspecial population.[

There is a very low risk for invasive cervical cancer in this

group, but cytologically diagnosed squamous intraepithe-

lial lesions are common [2, 43]. Squamous intraepithelial

lesions in adolescents have a very high rate of sponta-

neous regression [8].

Pregnant women are another special population. The

risk of progression of CIN 2,3 to invasive cervical cancer

during pregnancy is minimal, and the rate of sponta-

neous regression postpartum is relatively high [44, 45].

In fact, many oncologists follow early-stage cervicalcancer during pregnancy until fetal viability is achieved

[46]. Treatment of CIN during pregnancy is associated

with a high rate of complications including severe

intraoperative hemorrhage [47]. Moreover, there is a

high rate of incomplete excision which results in a high

rate of recurrence or persistence [48, 49]. Therefore,

treatment for CIN during pregnancy should be avoided,

and the only indication for therapy of cervical neoplasia

in pregnant women is invasive cancer.

Cervical Intraepithelial Neoplasia Grade 1

It is important for clinicians to recognize that bothhistopathology and cytology are relatively poor pre-

dictors of the biological potential of an individual lesion.

Based on biomarkers as well as biological behavior

during long-term follow-up, it is now clear that some

lesions that are histologically and cytologically low-

grade have biological features of a high-grade lesion.

Moreover, some lesions that are histologically and

cytologically high-grade behave biologically like low-

grade lesions, with substantial rates of regression [50].

Nevertheless, the histological diagnosis of CIN remains




the standard for determining clinical management.

Literature cited at the time of the 2001 Consensus

Conference recognized that CIN 1 represents a hetero-

geneous group of lesions [51]. This heterogeneity is due to

several factors including the poor reproducibility of ahistological diagnosis of CIN 1 [52]. In the National

Cancer Institutes ASCUS/LSILTriage Study (ALTS), it was

found that less than half of lesions diagnosed as CIN 1 by

the clinical site pathologists were subsequently classified as

CIN 1 when reviewed by a study pathologist [52]. In most

instances, this was attributable to lesions initially classified

as CIN 1 being Bdowngraded[ to normal by the study

pathologists. This occurred in 41% of cases. Nonconcor-

dance in the opposite direction was less common, but did

occur. Twelve percent of CIN 1 lesions were Bupgraded[

by the study pathologist to CIN 2,3. There also is more

heterogeneity with respect to associated HPV types for

CIN 1 lesions than for CIN 2,3 lesions.

Although most CIN 1 lesions are associated with

high-risk types of HPV, the distribution of high-risk

types in CIN 1 is different than that seen in CIN 2,3 [53].

A meta-analysis of HPV types associated with CIN 1

found that HPV-16 was the single most common

genotype identified. HPV-16 is found in 26.3% of all

HPV-positive CIN 1 [53]. HPV-31, -51, and -53 were the

next most commonly identified HPV types. Each type is

identified in 10% to 12% of CIN 1 lesions. CIN 1

lesions can also be associated with low-risk types ofHPV [53]. However, HPV-6 or -11 was detected in only

12% of the HPV DNAYpositive CIN 1. In addition to

being heterogeneous with respect to HPV types, CIN 1

lesions are also heterogeneous with respect to ploidy

status and other markers of neoplasia [54].

Low-grade cervical lesions have a high rate of

spontaneous regression in the absence of treatment. A

prospective study of Brazilian women with a cytological

result of LSIL found that more than 90% regressed

within 24 months [55]. Another study from the Nether-

lands found that over a 4-year period all women with

LSIL who were infected with nonYhigh-risk types ofHPV regressed to normal cytology, as did 70% of those

infected with high-risk types of HPV [56]. Even higher

rates of regression occur in adolescents and young

women. Moscicki et al. [8] found that 91% of

adolescents and young women with LSIL spontaneously

cleared their lesions with 36 months, irrespective of

associated HPV type.

Recent data suggest that CIN 1 uncommonly

progresses to CIN 2,3, at least within 24 months of

being diagnosed. In ALTS, the risk for having a CIN 2,3

lesion identified during the subsequent 2 years after

initial colposcopy was nearly identical in women with a

histological diagnosis of CIN 1 (13%) and in women

whose initial colposcopy and biopsy were negative

(12%) [57]. The risk of having an undetected CIN 2,3or AIS lesion is expected to be greater in women with

CIN 1 preceded by an HSIL or atypical glandular cells

(AGC) cytology result than for women with CIN 1

preceded by an ASC or LSIL cytology result. CIN 2,3 is

identified in 84% to 97% of women with HSIL cytology

evaluated using a LEEP [17, 18, 58]. Therefore, in the

2006 guidelines, separate recommendations are made

for women with CIN 1 preceded by an HSIL or AGC

cytology result.

Recommended Management of Women With CIN 1.

CIN 1 PRECEDED BY ASC-US, ASC-H, OR LSIL CYTOLOGY. The

recommended management of women with a histologi-

cal diagnosis of CIN 1 preceded by an ASC-US (atypical

squamous cells of undetermined significance), ASC-H

(atypical squamous cells, cannot exclude HSIL), or LSIL

cytology is follow-up with either HPV DNA testing

every 12 months or repeat cervical cytology every 6 to

12 months (BII) (Figure 1). If the HPV DNA test is

positive or if repeat cytology is reported as ASC-US or

greater, colposcopy is recommended. If the HPV test is

negative or 2 consecutive repeat cytology tests are Bnega-

tive for intraepithelial lesion or malignancy,[ return to

routine cytological screening is recommended (AII).If CIN 1 persists for at least 2 years, either continued

follow-up or treatment is acceptable (CII). If treatment is

selected and the colposcopic examination is satisfactory,

either excision or ablation is acceptable (AI). A

diagnostic excisional procedure is recommended if the

colposcopic examination is unsatisfactory, the endocer-

vical sampling contains CIN, or the patient has been

previously treated (AIII).

Treatment modality should be determined by the

judgment of the clinician and should be guided by

experience, resources, and clinical value for the specific

patient (A1). In patients with CIN 1 and an unsatisfac-tory colposcopic examination, ablative procedures are

unacceptable (EI). Podophyllin or podophyllin-related

products are unacceptable for use in the vagina or on the

cervix (EII). Hysterectomy as the primary and principal

treatment for histologically diagnosed CIN 1 is unac-

ceptable (EII).

CIN 1 PRECEDED BY HSIL OR AGC-NOS CYTOLOGY. Either a

diagnostic excisional procedure or observation with

colposcopy and cytology at 6 month intervals for one

year is acceptable for women with a histological

228 & W R I G H T E T A L .



diagnosis of CIN 1 preceded by HSIL or AGC-NOS

(atypical glandular cells not otherwise specified) cytol-

ogy, provided in the latter case that the colposcopic

examination is satisfactory and endocervical sampling is

negative (Figure 2) (BIII). In this circumstance, it is also

acceptable to review the cytological, histological, and

colposcopic findings; if the review yields a revised

interpretation, management should follow guidelines

for the revised interpretation (BII).

If observation with cytology and colposcopy is

elected, a diagnostic excisional procedure is recom-

mended for women with repeat HSIL cytological results

at either the 6- or 12-month visit (CIII). After 1 year of

observation, women with 2 consecutive Bnegative for

intraepithelial lesion or malignancy[ results can return

to routine cytological screening. A diagnostic excisional

procedure is recommended for women with CIN 1

preceded by an HSIL or AGC-NOS cytology in whom

the colposcopic examination is unsatisfactory, except in

special populations (e.g., pregnant women) (BII).

CIN 1 in Special Populations.

ADOLESCENT WOMEN. Follow-up with annual cytolo-

gical assessment is recommended for adolescents

with CIN 1 (Figure 3) (AII). At the 12-month

follow-up, only adolescents with HSIL or greater

on the repeat cytology should be referred to colpo-

scopy. At the 24-month follow-up, those with an

ASC-US or greater result should be referred to

Figure 1.

Figure 2.




colposcopy (AII). Follow-up with HPV DNA testing

is unacceptable (EII).

PREGNANT WOMEN. The recommended management of

pregnant women with a histological diagnosis of CIN 1

is follow-up without treatment (BII). Treatment of

pregnant women for CIN 1 is unacceptable (EII).

Cervical Intraepithelial Neoplasia Grade 2,3

In the 2001 Consensus Guidelines, a decision was made

to utilize CIN 2,3 as the threshold for treatment

decisions. CIN 2,3 includes lesions previously referred

to as moderate dysplasia (i.e., CIN 2) and severe

dysplasia/carcinoma in situ (i.e., CIN 3) [54]. There

are a number of reasons for combining CIN 2 with CIN

3 for treatment decisions. Follow-up studies have shown

that despite marginal relative differences in behavior,

both of these lesions are more likely to persist or

progress than to regress [50, 59, 60]. A systematic

review of published follow-up studies found that 43% of

untreated CIN 2 lesions regress in the absence of

treatment, whereas 35% will persist, and 22% willprogress to carcinoma in situ or become invasive [60].

For CIN 3 lesions, the rates of regression, persistence,

and progression were 32%, 56%, and 14%, respec-

tively. Another reason for combining CIN 2 with CIN 3

for clinical management decisions is that a histological

diagnosis of CIN 2 is poorly reproducible [61, 62]. In

ALTS, only 43% of lesions histologically diagnosed as

CIN 2 by the clinical site pathologists were subsequently

classified as CIN 2 when reviewed by a study pathologist

[62]. Twenty-seven percent of all lesions originally

diagnosed as CIN 2 were upgraded to CIN 3 by the

study pathologists. Nonconcordance in the opposite

direction was also common. The study pathologists

downgraded 29% of lesions initially classified as CIN 2

to CIN 1 or normal.

Although CIN 2 lesions are more likely to regress

during long-term follow-up than are CIN 3 lesions,

CIN 2 and CIN 3 lesions share a number of biological

characteristics usually associated with true cervical

cancer precursors [54]. In contrast to CIN 1 lesions,

almost all CIN 2 and CIN 3 lesions are monoclonal

proliferations of cells that show evidence of genetic

instability [54, 63]. The majority of CIN 2 and CIN 3

lesions are aneuploid and have loss of heterozygosity

at nonrandom chromosomal loci that may be asso-

ciated with neoplastic development [54, 64]. CIN 2

and CIN 3 lesions also have much less heterogeneity

with respect to associated HPV types than do CIN 1

lesions. A meta-analysis recently reported that just 5

high-risk types of HPV (16, 18, 31, 33, and 58) are

associated with 75% of high-grade cervical lesions[65]. Therefore, CIN 2 is generally utilized as the

threshold for treatment in the United States to provide

an added measure of safety [54, 62].

Treatment of Women With Biopsy-Confirmed CIN

2,3. There is widespread agreement that treatment of

CIN 2,3 reduces both incidence and mortality from

invasive cervical cancer. To be effective, treatment

needs to remove the entire transformation zone,

rather than selectively targeting the colposcopically

identified lesion [66]. As discussed previously, data

Figure 3.

230 & W R I G H T E T A L .



from clinical trials have generally failed to show

significant differences in outcome after treatment

using different modalities. Therefore, both ablative

and excisional methods can be utilized to treat

women with biopsy-confirmed CIN 2,3 and asatisfactory colposcopic examination. However, exci-

sional methods allow pathological assessment of the

excised tissue and should reduce the risk that a

microinvasive or occult invasive carcinoma is treated

as a noninvasive lesion. This is particularly an issue

for women with large high-grade lesions or lesions

extending into the endocervical canal and for women

who have been previously treated for CIN. Up to 7%

of women with an unsatisfactory colposcopic exam-

ination and CIN 2,3 have an occult carcinoma

detected when they undergo a diagnostic excisional

conization [13, 23]. Therefore, a diagnostic excisional

conization that allows pathological assessment of the

excised tissue should be used in these instances.

Pathologic margin status is generally considered to be

a risk factor for the development of recurrent or

persistent CIN [67Y70]. When performed at the time

of a diagnostic excisional procedure, endocervical

sampling correlates with endocervical margin status

and a positive endocervical sampling is predictive of

residual disease [13, 70]. Rates of recurrent or persistent

CIN when the margin is involved have ranged from 10%

to 33% in recent studies [68, 71Y

74]. Although anumber of studies have reported that recurrent or

persistent CIN is more frequent in women with involved

resection margins, relatively few studies have been able

to control for other variables that might account for the

higher failure rates in these patients. The few studies that

have utilized multivariate analysis to adjust for other

potential contributing factors have found that margin

status is not an independent predictor of residual disease

[75, 76]. It must be emphasized that most women withinvolved margins will not develop recurrent or persistent

CIN and that up to 40% of all women undergoing loop

excision have pathologic margin involvement [77, 78].

Based on these considerations, it is generally recom-

mended that women with positive margins be counseled

about their elevated risk for recurrent or persistent CIN,

but that in most instances they should be closely

followed up rather than receive immediate treatment

[72Y74]. For cases in which further treatment is decided

upon, repeat excision offers a balance between the risk

of treatment complications and the desire to eradicate

potential residual CIN. Hysterectomy may be appro-

priate in selected instances.

Recommended Management of Women With CIN 2,3.

INITIAL M ANAGEMENT. Both excision and ablation are

acceptable treatment modalities for women with a

histological diagnosis of CIN 2,3 and satisfactory

colposcopy, except in special circumstances (see below)

(Figure 4) (AI). A diagnostic excisional procedure is

recommended for women with recurrent CIN 2,3 (AII).

Ablation is unacceptable and a diagnostic excisional

procedure is recommended for women with a histolo-

gical diagnosis of CIN 2,3 and unsatisfactory colpo-scopy (AII). Observation of CIN 2,3 with sequential

cytology and colposcopy is unacceptable, except in

special circumstances (see below) (EII). Hysterectomy is

unacceptable as primary therapy for CIN 2,3 (EII).

Figure 4.




FOLLOW-UP AFTER TREATMENT. Acceptable posttreat-

ment management options for women with CIN 2,3

include HPV DNA testing at 6 to 12 months (BII).

Follow-up using either cytology alone or a combination

of cytology and colposcopy at 6 months intervals is alsoacceptable (BII). Colposcopy with endocervical sam-

pling is recommended for women who are HPV DNA

positive or have a repeat cytology result of ASC-US or

greater (BII). If the HPV DNA test is negative or if 2

consecutive repeat cytology tests are Bnegative for

intraepithelial lesion or malignancy,[ routine screening

for at least 20 years commencing at 12 months is

recommended (AI). Repeat treatment or hysterectomy

based on a positive HPV DNA test is unacceptable (EII).

If CIN 2,3 is identified at the margins of a diagnostic

excisional procedure or in an endocervical sample

obtained immediately after the procedure, reassessment

using cytology with endocervical sampling at 4 to 6

months posttreatment is preferred (BII). Performing a

repeat diagnostic excisional procedure is acceptable

(CIII). Hysterectomy is acceptable if a repeat diagnostic

procedure is not feasible.

A repeat diagnostic excision or hysterectomy is

acceptable for women with a histological diagnosis of

recurrent or persistent CIN 2,3 (BII).

CIN 2,3 in Special Populations.

ADOLESCENT AND YOUNG WOMEN. For adolescents and

young women with a histological diagnosis of CIN 2,3not otherwise specified, either treatment or observation

for up to 24 months using both colposcopy and cytology

at 6-month intervals is acceptable, provided colposcopy

is satisfactory (Figure 5) (BIII). When a histological di-

agnosis of CIN 2 is specified, observation is preferred

but treatment is acceptable. When a histological diag-

nosis of CIN 3 is specified or when colposcopy is

unsatisfactory, treatment is recommended (BIII).

If the colposcopic appearance of the lesion worsensor if HSIL cytology or a high-grade colposcopic lesion

persists for 1 year, repeat biopsy is recommended (BIII).

After 2 consecutive Bnegative for intraepithelial lesion or

malignancy[ results, adolescents and young women

with normal colposcopy can return to routine cytologi-

cal screening (BII). Treatment is recommended if CIN 3

is subsequently identified or if CIN 2,3 persists for 24

months (BII).

PREGNANT WOMEN. In the absence of invasive disease or

advanced pregnancy, additional colposcopic and cyto-

logical examinations are acceptable in pregnant women

with a histological diagnosis of CIN 2,3 at intervals no

more frequent than every 12 weeks (BII). Repeat biopsy

is recommended only if the appearance of the lesion

worsens or if cytology suggests invasive cancer (BII).

Deferring re-evaluation until at least 6 weeks postpar-

tum is acceptable (BII). A diagnostic excisional proce-

dure is recommended only if invasion is suspected (BII).

Unless invasive cancer is identified, treatment is unac-

ceptable (EII). Re-evaluation with cytology and colpo-

scopy is recommended no sooner than 6 weeks

postpartum (CIII).

Adenocarcinoma In Situ

Adenocarcinoma in situ (AIS) is much less commonly

encountered than is CIN 2,3. In 1991Y1995, the

overall incidence of squamous carcinoma in situ of

Figure 5.

232 & W R I G H T E T A L .



the cervix in white women in the United States was

41.4 per 100,000, whereas the incidence of AIS was

only 1.25 per 100,000 [40]. Although the overall

incidence of AIS remains rather low, the incidence

increased by approximately 6-fold from the 1970s to

1990s [40].

Management of women with AIS is both challen-

ging and controversial. Many of the assumptions

that are used to justify conservative management

approaches in women with CIN 2,3 lesions do notapply to AIS. For example, the colposcopic changes

associated with AIS can be minimal, so it can be

difficult to determine the extent of a lesion. AIS

frequently extends for a considerable distance into the

endocervical canal, making complete excision dif-

ficult. AIS is also frequently multifocal and frequently

has Bskip lesions.[ Thus, negative margins on a

diagnostic excisional specimen do not necessarily

mean that the lesion has been completely excised.

Because of these considerations, hysterectomy con-

tinues to be the treatment of choice for AIS in women

who have completed childbearing. However, AIS oftenoccurs in women who wish to maintain their fertility.

A number of studies have now clearly demonstrated

that an excisional procedure is curative in the

majority of these patients. The failure rate after an

excisional procedure (e.g., recurrent/persistent AIS or

invasive adenocarcinoma) ranges from 0% to 9%

[79Y83]. A comprehensive review of the published

literature conducted in 2001 identified 16 studies that

included a total of 296 women with AIS who had

been treated with a diagnostic excisional procedure

[82]. The overall failure rate was 8% [82]. Margin

status is one of the most clinically useful predictors of

residual disease [84Y87]. Recent data suggest that

endocervical sampling at the time of an excisional

biopsy is also predictive of residual disease [84].

Some, but not all, studies have suggested that there is

an increased recurrence rate as well as an increase in

positive margins when a loop excision procedure, as

opposed to cold-knife conization, is used [81, 82, 88].

Irrespective of conization method, clinicians shouldremember that margin status and interpretability of

the margins are important for future treatment

planning and management. Moreover, it should be

emphasized that a diagnostic excisional procedure is

required in all women with AIS before making any

subsequent management decisions.

Recommended Management of Women With Adeno-

carcinoma In Situ. Hysterectomy is preferred for

women who have completed childbearing and have a

histological diagnosis of AIS on a specimen from a

diagnostic excisional procedure (Figure 6) (CIII).

Conservative management is acceptable if futurefertility is desired (AII). If conservative management is

planned and the margins of the specimen are involved

or endocervical sampling obtained at the time of

excision contains CIN or AIS, re-excision to increase

the likelihood of complete excision is preferred. Re-

evaluation at 6 months using a combination of cervical

cytology, HPV DNA testing, and colposcopy with

endocervical sampling is acceptable in this circumstance.

Long-term follow up is recommended for women who do

not undergo hysterectomy (CIII).

Figure 6.




Acknowledgments

The authors thank all of the participants and formal

observers to the 2006 Consensus Conference who

worked so hard to develop the guidelines. Their names

and organizations can be viewed at www.asccp.org. The

authors also thank Ms Kathy Poole for administrative

support during the development of the guidelines and Dr

Anna Barbara Moscicki who chaired the Adolescent

Working Group.

Text for this article was first published in Wright TC Jr,

Massad LS, Dunton CJ, Spitzer M, Wilkerson EJ,

Solomon D. 2006 Consensus guidelines for the manage-

ment of women with cervical intraepithelial neoplasia

or adenocarcinoma in situ. Am J Obstet Gynecol

2007;197:340Y45. Elsevier/2007.

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APPENDICES

Appendix A: Participants and ParticipatingOrganizations

Organizer: American Society for Colposcopyand Cervical Pathology (ASCCP) (Also onhttp://www.asccp.org/consensus.shtml)Participants.

Fadi Abdul-Karim, MD, University Hospitals of Cleveland, Cleveland, OH

Ronald D. Alvarez, MD, University of Alabama, Birmingham, AL*

Barbara Apgar, MD, MS, University of Michigan, Ann Arbor, MI*

Raheela Ashfaq, MD, University of Texas Southwestern, Dallas, TX* ,

R. MarshallAustin, MD, PhD,Magee-Womens Hospital of the University of

Pittsburgh, Pittsburgh, PA*

Mark M. Bajorek, MD, Oregon Health Sciences University, Portland, OR

Jonathan Berek, MD, Stanford University School of Medicine, Los Angeles,

CA*,

Monique Bertrand, MD, London Health Sciences Center, London, Ontario,

Canada*

Marluce Bibbo, MD, Thomas Jefferson University Hospital, Philadelphia,

PA*

George Birdsong, MD, Grady Health System, Atlanta, GA

Lori A. Boardman, MD, ScM, Brown University Women and Infants

Hospital, Providence, RI*

Fredrik F. Broekhuizen, MD, Medical College of Wisconsin, Milwaukee,WI

Carol L. Brown, MD, Memorial Sloan-Kettering Cancer Center, New York,

NY*,

S. C. Peter Bryson, MD, Queens University, Kingston, Ontario, Canada

Louis Burke, MD, Beth Israel/Deaconess Medical Center, Harvard Medical

School, Boston, MA

Robert A. Burger, MD, University of California Irvine, Irvine, CA*,

Philip Castle, PhD, MPH, National Cancer Institute, Bethesda, MD*

David Chhieng, MBA, MD, University of Alabama, Birmingham, AL

Carmel Cohen, MD, Columbia University, New York, NY*

Terrance Colgan, MD, Mount Sinai Hospital, Toronto, Ontario, Canada*

Terri Cornelison, MD, National Cancer Institute, Bethesda, MD*

J. Thomas Cox, MD, University of CaliforniaYSanta Barbara, Santa Barbara,

CA*

William Creasman, MD, Medical University of South Carolina, Charleston,

SC

Christopher P. Crum, MD, Harvard Medical School, Boston, MA*

Vanessa Cullins, MD, Planned Parenthood Federation of America, New

York, NY

Teresa M. Darragh, MD, University of CaliforniaYSan Francisco, San

Francisco, CA

Diane D. Davey, MD, University of Kentucky, Lexington, KY*

Gordon D. Davis, MD, Maricopa Medical Center, St Josephs Hospital and

Medical Center, Phoenix, AZ

Linda Dominguez, CNP, RN, Planned Parenthood of New Mexico,

Albuquerque, NMRebecca K. Donohue, PhD, RN, CS, Simmons College, Boston, MA

Charles Dunton, MD, Lankenau Hospital, Wynnewood, PA*

Juan C. Felix, MD, LAC-USC Medical Center, Los Angeles, CA

Francisco Garcia, MD, MPH, University of Arizona Health Sciences Center,

Tucson, AZ*

Kim R. Geisinger, MD, Wake Forest University School of Medicine, Winston

Salem, NC

Melvin V. Gerbie, MD, Northwestern University Medical School, Chicago, IL*

Michael A. Gold, MD, University of Oklahoma Health Sciences Center,

Oklahoma City, OK*

David L. Greenspan, MD, Maricopa Medical Center, St Josephs Hospital

and Medical Center, Phoenix, AZ*

Benjamin Greer, MD, University of Washington Medical Center, Seattle,

WA*

Richard Guido, MD, Magee-Womens Hospital of the University of

Pittsburgh, Pittsburgh, PA*

Fernando Guijon, MD, University of Manitoba, Winnipeg, Manitoba, CanadaHope K. Haefner, MD, University of Michigan, Ann Arbor, MI*

Kenneth D. Hatch, MD, University of Arizona Health Sciences Center,

Arizona Cancer Center, Tucson, AZ*,

Thomas J. Herzog, MD, Columbia University, New York, NY*,

Christine Holschneider, MD, UCLA School of Medicine, Los Angeles, CA

Beth C. Huff, MSN, NP, Vanderbilt University Medical Center, Nashville, TN

Warner K. Huh, MD, University of Alabama at Birmingham, Birmingham, AL*

Verda J. Hunter, MD, Gynecologic Resource Center for Gynecologic

Oncology, Kansas City, MO

Mujtaba Husain, MD, Wayne State University, Detroit, MI

Jose A. Jeronimo, MD, National Cancer Institute, Bethesda, MD

Howard W. Jones, III, MD, Vanderbilt University, Nashville, TN*

Beth Jordan, MD, Association of Reproductive Health Professionals,

Washington, DC




Thomas M. Julian, MD, University of Wisconsin, Madison, WI

Barbara F. Kelly, MD, AF Williams Family Medical Center, Denver, CO

Valerie J. King, MD, MPH, Oregon Health and Science University, Portland,

OR

Walter Kinney, MD, University of CaliforniaYDavis, Permanente Medical

Group, Sacramento, CA*

Marina Kondratovich, PhD, Food and Drug Administration, Rockville, MDEdwardR. Kost, MD,BrookeArmy Medical Center, Fort SamHouston, TX*,

Burton A. Krumholz, MD, Long Island, NY*,

Robert J. Kurman, MD, Johns Hopkins Hospital, Baltimore, MD

Hershel W. Lawson, MD, Centers for Disease Control and Prevention,

Atlanta, GA*

Neal M. Lonky, MD, MPH, Kaiser Permanente, Yorba Linda, CA*

Silvana Luciani, PhD, Pan-American Health Organization, Washington, DC

L. Stewart Massad, MD, Washington University School of Medicine, St

Louis, MO*

Edward J.Mayeaux,MD, Louisiana State University Health Sciences Center,

Shreveport, LA*

Alexander Meisels, MD, Laval University, Quebec City, Quebec, Canada

Kathleen McIntyre-Seltman, MD, Magee Womens Hospital, Pittsburgh, PA*

Anna-Barbara Moscicki, MD, University of CaliforniaYSan Francisco, San

Francisco, CA*

Carolyn Y. Muller, MD, University of New Mexico, Albuquerque, NM

Gary R. Newkirk, MD, Family Medicine Spokane, Spokane, WA

Hextan Y. S. Ngan,MBBS, MD, International Federation of Gynecology and

Obstetrics (FIGO), Hong Kong

Kenneth L. Noller, MD, Tufts University School of Medicine, Boston, MA*

Dennis M. OConnor, MD, Clinical Pathology Associates, Inc, Louisville, KY*

Edward Partridge, MD, University of Alabama at Birmingham, Birmingham, AL*

Diane M. Provencher, MD, CHUM-Hopital Notre-Dame, Montreal, Quebec,

Canada

Stephen Raab, MD, Allegheny General Hospital, Pittsburgh, PA

Eddie Reed, MD, Centers for Disease Control and Prevention, Atlanta, GA

Max Robinowitz, MD, Food and Drug Administration, Rockville, MD

William Rodgers, MD, University of Maryland Medical System, Baltimore, MD*

Mary Rubin, RNC, PhD, CRNP, University of CaliforniaYSan Francisco, San

Francisco, CA*

Mona Saraiya, MD, MPH, Centers for Disease Control and PreventionVUS

Public Health Service, Atlanta, GA

Debbie Saslow, PhD, American Cancer Society, Atlanta, GA*,

Mark Schiffman, MD, MPH, National Cancer Institute, Bethesda, MD*VolkerSchneider, MD, InternationalAcademy of Cytology, Freiburg, Germany

Karen Shea, MSN, CRNP, Planned Parenthood Federation, New York, NY

Mark Sherman, MD, National Cancer Institute, Bethesda, MD*

Mary Sidawy, MD, George Washington University, Washington, DC

Diane Solomon, MD, National Cancer Institute, Bethesda, MD*

Mark Spitzer, MD, Brookdale University Hospital and Medical Center,

Brooklyn, NY*

Mark Stoler, MD, University of Virginia Health Sciences Center, Charlottes-

ville, VA*

Pamela Stratton, MD, National Institutes of Child Health and Human

Development, Rockville, MD

Cornelia Trimble, MD, Johns Hopkins University, Baltimore, MD*

Edward G. Trimble, MD, MPH, National Cancer Institute, Bethesda, MD*

Leo B. Twiggs, MD, University of Miami School of Medicine, Miami, FL*

Elizabeth R. Unger, MD, PhD, Centers for Disease Control and Prevention

(CEVC), Atlanta, GA

Jeffrey Waldman, MD, Planned Parenthood Shasta-Diablo, Concord, CA*Alan G. Waxman, MD, Unversity of New Mexico, Albuquerque, NM*

Claudia L. Werner, MD, University of Texas Southwestern, Dallas, TX*

Edward Wiesmeier, MD, UCLA, Los Angeles, CA

David C. Wilbur, MD, Massachusetts General Hospital, Boston, MA

Edward J. Wilkinson, MD, Universityof Florida College of Medicine,Gainesville, FL*

Cheryl Wiseman, MPH, CT, Centers for Medicaid and Medicare Services,

Baltimore, MD

Jason D. Wright, MD, Columbia University, New York, NY*,

Thomas C. Wright, MD, Columbia University, New York, NY*

*Conference participants who were members of the working groups.Members of working groups who were unable to attend the conference.Designated delegates who participated in the public comment review periods anddelegate conference calls but were unable to attend the conference.

Formal Observers*.

Shaheen Ahmed, MD, Blue Springs, MO

Andrea Abati, MD, National Cancer Institute, Bethesda, MD

Edward A. Barker, MD, Medical Laboratory Associates, Seattle, WA

Henry W. Buck, MD, University of Kansas, Lawrence, KS

Catherine Copenhaver, MD, Bethesda, MD

Julia Corrado, MD, Food and Drug Administration, Rockville, MD

Maria L. Diaz, MD, Davie, FL

Mary C. Eiken, SGO National Office, Chicago, IL

Tremel Faison, Food and Drug Administration, Rockville, MD

Sarah Feldman, MD, MPH, Harvard Medical School, Cambridge, MA

Lisa Flowers, MD, Emory University School of Medicine, Atlanta, GA

Patricia Lynn Fontaine, MD, MS, University Family PhysiciansYNorth

Memorial Clinic, Minneapolis, MN

Julia C. Gage, MPH, Health Resources and Services Administration,

Rockville, MD

Chad A. Hamilton, MD, Stanford University Medical Center, Stanford, CA

Vivien W. Hanson, MD, University of Washington School of Public Health,

Seattle, WA

Robert D. Hilgers, MD, University of Louisville, Louisville, KY

Thomas M. Kastner, MD, Mayo Clinic, Rochester, MN

Jill Koshiol, PhD, National Cancer Institute, Bethesda, MD

Aimee R. Kreimer, PhD, National Cancer Institute, Bethesda, MD

Michelle D. Lavey, MS-FNP, Rockville, MD

Ronald D. Luff, MD, Quest Diagnostics, Teterboro, NJ

Louise E. Magruder, Food and Drug Administration, Rockville, MD

Sheila F. Mahoney, CNM, MPH, National Institute of Child Health and

Human Development, Bethesda, MD

William J. Mann, Jr, MD, Jersey Shore University Medical Center, Neptune,

NJ

Linda McWey-Price, MD, Carilion New River Valley Medical Center,

Christiansburg, VA

Gabriele Medley, AM, MBBS, FRCPA, FIAC, University of Melbourne,

Victoria, Australia

Melissa A. Merideth, MD, MPH, National Institute of Health, Bethesda, MD

Brigitte E. Miller, MD, Wake Forest University Baptist Medical Center,

Winston-Salem, NC

Mary F. Mitchell,ACOGYDepartment of Practice Activities, Washington, DC

Mary L. Nielsen, MD, University of Kansas School of Medicine, Wichita, KS

Catherine Platt, MD, Arlington, VAMarianne U. Prey, MD, Quest Diagnostics Incorporated, St Louis, MO

Mahboobeh Safaeian, MD, MPH, National Cancer Institute, Bethesda, MD

Ellen E. Sheets, MD, Cytyc Corporation, Malborough, MA

Mario G. Sideri, MD, European Institute of Oncology, Milan, Italy

Albert Singer, MD, Whittington Hospital, London, UK

Diane R. Smith, NP, Arlington, VA

Karen K. Smith-McCune, MD, UCSF Comprehensive Cancer Center, San

Francisco, CA

Nancy J. Swick, MSN, CRNP, Santa Rosa Memorial Hospital, Santa Rosa, CA

Candice A. Tedeschi, OGNP, North ShoreYLIJ Health Systems, Lake Success, NY

Leslie A. Tyska, MD, California State Polytechnic University, Pomona, CA

Joanne P. Walenga, RN, Rockville, MD

Amy J. Wendel, SCT, MP, Mayo Clinic, Rochester, MN

Donald S. Wiersma, MD, Potomac, MD

Barbara A. Winkler, MD, Quest Diagnostics Incorporated, Teterboro, NJ

Meggan Zsemlye, MD, University of New Mexico, Albuquerque, NM

*All observers were either members or employees of the participating organizationsand federal agencies.

Participating Organizations

American Academy of Family Physicians, American

Cancer Society, American College Health Association,

American College of Obstetricians and Gynecologists,

American Social Health Association, American Society for

Clinical Pathology, American Society for Colposcopy and

Cervical Pathology, American Society of Cytopathology,

238 & W R I G H T E T A L .


17/17

Association of Reproductive Health Professionals,

Centers for Disease Control and PreventionVDivision

of Viral and Rickettsial Disease, Centers for Disease

Control and PreventionVDivision of Cancer Preven-

tion and Control, Centers for Disease Control andPreventionVDivision of Laboratory Systems, Centers

for Medicaid and Medicare Services, College of

American Pathologists, Food and Drug Administra-

tion, International Academy of Cytology, International

Federation for Cervical Pathology and Colposcopy,

International Federation of Gynecology and Obstetrics,

International Gynecologic Cancer Society, International

Society of Gynecological Pathologists, National Cancer

Institute, National Association of Nurse Practitioners in

Womens Health, Papanicolaou Society of Cytopathol-

ogy, Pan-American Health Organization, Planned Par-

enthood Federation of America, Society of Canadian

Colposcopists, Society of Gynecologic Oncologists,

Society of Gynecologic Oncologists of Canada, and

Society of Obstetricians and Gynaecologists of Canada.

Appendix B: Definitions of Terms

Colposcopy is the examination of the cervix, vagina,

and, in some instances, the vulva, with the colposcope

after the application of a 3% to 5% acetic acid solution

coupled with obtaining colposcopically directed biopsies

of all lesions suspected of representing neoplasia.

Endocervical samplingincludes obtaining a specimen

for either histological evaluation using an endocervicalcurette or a cytobrush or for cytological evaluation using

a cytobrush.

Endocervical assessment is the process of evaluating

the endocervical canal for the presence of neoplasia

using either a colposcope or endocervical sampling.

Endometrial sampling includes obtaining a specimen

for histological evaluation using an endometrial biopsy

or a Bdilatation and curettage[ or hysteroscopy.

Diagnostic excisional procedure is the process of

obtaining a specimen from the transformation zone and

endocervical canal for histological evaluation and

includes laser conization, cold-knife conization, loop

electrosurgical excision (i.e., LEEP), and loop electro-

surgical conization.

Satisfactory colposcopy indicates that the entire

squamocolumnar junction and the margin of any visible

lesion can be visualized with the colposcope.

Adolescent women are women 13 to 20 years of age

(i.e., from 13th to 21st birthdays).


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