Pap smear of Lelawati 45 years female shows CIN grade III. Which of the following is the next step in management :
Ans. is c i.e. Colposcopy directed biopsy Now this is a tricky question. Most of us at first instant think of cone biopsy as the answer, as cone biopsy would be both diagnostic as well as therapeutic. But if you go through various texts carefully it has been clearly mentioned that a female who has either frankly malignant or higher grades of CIN on pap smear should undergo Colposcopic directed biopsy and Endocervical curettage to confirm the diagnosis and see the extent of lesion as Pap smear is only a screening test and not diagnostic. Post coital bleeding / irregular bleeding/Abnormal cervical cytology smear Do perspeculum examination If lesion is visible No visible lesion & cervical cytology shows Punch Biopsy ASUS* CIN I-CIN III Frankly malignant If Negative, go for colpo- * Repeat Pap Smear Colposcopy & Colposcopy & scopy & directed biopsies every 6 months X 1 year, if normal; if directed biopsies Directed biopsies abnormal do colposcopy Immediate colposcopy "Women with high grade CIN or frankly malignant PAP smear should have colposcopic directed biopsy." Harrison 17/e, p 608 Management of Abnormal cervical cytology smear / Irregular bleeding / Post coital bleeding : * ASUS - Atypical squamous cells of unknown significance. Thus from above cha it is clear In all visible lesions - Punch biopsy should be done In case of invisible lesion. For screening Pap smear is recommended. For diagnosis Colposcopic directed biopsy is the gold standard. Cone biopsy is indicated only : If limit of the lesion cannot be visualised with colposcopy.deg The squamo-columnar junction is not seen at colposcopy.deg Endocervical curettage shows histological findings positive for CIN-II CIN-III.deg Microinvasive carcinoma or adenocarcinoma in situ is suspected based on biopsy. colposcopy or cytology results.deg Lack of correlation between cytology biopsy and colposcopy results.deg
Punch biopsy
Large loop excision
Colposcopy directed biopsy
Cone biopsy