8. Management of discordant colposcopic impression, histopathology and referral LBC prediction

Various clinical scenarios may present difficulties for diagnosis and management when there is discordance between cytological and colposcopic or histopathological reports for women referred for colposcopic assessment on the basis of the results of human papillomavirus (HPV) testing and liquid-based cytology (LBC):

• A woman with a cytological prediction of a high-grade squamous intraepithelial lesion (HSIL) may have a normal colposcopy.
• Colposcopically directed biopsy may confirm a low-grade lesion after a cytological prediction of HSIL.
• A woman with a positive oncogenic HPV (any type) test result and a LBC report of negative, or prediction of a low-grade squamous intraepithelial lesion (LSIL) or HSIL, may have Type 3 transformation zone (TZ) colposcopy (previously termed ‘unsatisfactory’ colposcopy).
• A woman may have a positive oncogenic HPV (16/18) test result, a negative LBC report, and colposcopy that is either normal or Type 3 TZ.

The following clinical scenarios are considered in this chapter:

• Normal colposcopic findings following a LBC prediction of a low-grade or high-grade lesion (see also Management of women with histologically confirmed low-grade squamous abnormalities)
• Type 3 TZ (unsatisfactory) colposcopy following LBC prediction of a low-grade or high-grade lesion (see Summary of IFCPC colposcopic terminology of the cervix).

Normal colposcopic findings following LBC prediction of a low-grade or high-grade lesion

Guidelines for the pre-renewal National Cervical Screening Program (NCSP)[1] recommended the following management for women with normal colposcopy (Type 1 or Type 2 TZ):

• Women with normal colposcopy following a cytological prediction of LSIL should have annual cytological surveillance until two normal smears are obtained, and then resume routine screening according to the recommendation for the average population.
• Women with normal colposcopy following a cytological prediction of possible HSIL (pHSIL) should have a repeated Pap test and colposcopy 3–6 months later. If repeat colposcopy was normal, the Pap test was to be repeated in another 6–12 months.

In the context of primary HPV-based screening and reflex LBC, it is necessary to determine the following:

• the optimal follow-up protocol (HPV testing, LBC testing or co-testing, and interval) for women with a positive oncogenic HPV (any type) test result and a LBC report of pLSIL/LSIL, followed by normal colposcopy
• the safety and effectiveness of conservative treatment (follow-up testing with HPV and/or LBC) relative to diagnostic excision of the TZ in women with a positive oncogenic HPV (any type) test result and a LBC prediction of pHSIL/HSIL followed by normal colposcopy, when cytology is downgraded on cytopathology review
• the safety and effectiveness of conservative treatment relative to diagnostic excision of the TZ in women with a positive oncogenic HPV (any type) test result and a LBC prediction of pHSIL/HSIL (confirmed on review) but normal colposcopy.

Type 3 TZ (previously termed ‘unsatisfactory’) colposcopy following LBC prediction of a low-grade or high-grade lesion

Guidelines for the pre-renewal NCSP[1] recommended that, in cases where the colposcopic assessment was unsatisfactory (TZ not fully visible; Type 3 TZ in new IFCPC terminology)[2] in women with a cytological prediction of LSIL on a Pap test, the clinician should consider repeating the Pap test in 6–12 months. The guidelines recommended that failure to visualise the transformation zone in women with a cytological prediction of HSIL on a Pap test was an indication for diagnostic excision of the TZ.[1]

The American Society for Colposcopy and Cervical Pathology[3] recommends diagnostic excision of the TZ for women with cytological prediction of HSIL and unsatisfactory colposcopy, except during pregnancy. European guidelines for clinical management of abnormal cervical cytology[2][4] recommend diagnostic excision of the TZ should be considered for women with HSIL cytology and unsatisfactory colposcopy. Canadian guidelines for the colposcopic management of abnormal cervical cytology and histology[5] recommend that diagnostic excision of the TZ should be considered in this situation if endocervical curettage and/or biopsy results are negative.

In Australia endocervical curettage is not routinely practised (see Endocervical curettage in Chapter 7. Colposcopy and Chapter 11. Management of glandular abnormalities). The American Society for Colposcopy and Cervical Pathology[3] recommends endocervical sampling (either brushing or curettage) for women with a cytology report of atypical squamous cells of undetermined significance or LSIL when the entire squamocolumnar junction and the margins of any visible lesion cannot be visualised on colposcopy. European guidelines for clinical management of abnormal cervical cytology[2][4] recommend endocervical curettage after diagnostic excision of the transformation zone and excision of the lower third of the endocervical canal if the squamocolumnar junction is not visible and a high-grade cytological abnormality has been confirmed on cytopathology review.

In the context of primary HPV-based screening, it is necessary to determine the following:

• the optimal follow-up protocol (HPV testing, LBC testing or co-testing, and interval) to predict risk in the follow-up of women with a positive oncogenic HPV (any type) test result and a LBC prediction of pLSIL/LSIL, when Type 3 TZ (unsatisfactory) colposcopy is reported
• the safety and effectiveness of conservative treatment (follow-up testing with HPV and/or LBC) relative to diagnostic excision of the transformation zone in women with a positive oncogenic HPV (any type) test result and a LBC prediction of pHSIL/HSIL, when Type 3 TZ (unsatisfactory) colposcopy is reported and pHSIL/HSIL is confirmed at cytopathology review.

See:

• Normal colposcopic findings following LBC prediction of Negative, LSIL or HSIL
• Type 3 TZ (previously termed ‘unsatisfactory’) colposcopy following LBC prediction of Negative, LSIL or HSIL
• Discussion: Management of discordant colposcopic impression, histopathology and referral LBC prediction