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Abstract & Commentary
Synopsis: Women who have LGSIL cytology reports should undergo colposcopic evaluation.
Source: Law KS, et al. J Reprod Med. 2001;46:61-64.
The purpose of this article was to determine the actual disease that was present when a Pap smear was reported as low-grade squamous intraepithelial lesion (LGSIL). In order to make this determination, all cytology specimens from July 1994 through February 1998 (128,925 samples) were reviewed for a diagnosis of LGSIL. Eight hundred seventy-seven (0.7%) of the smears were reported as LGSIL. All women with this diagnosis were referred to the colposcopy clinic and approximately 90% had that procedure performed. Women who did not appear for colposcopy were excluded from the study. A total of 790 women with an LGSIL report and colposcopy comprised the study material for this paper.
A total of 145 women were found to have CIN 2 or CIN 3. Sixty-three percent of these were found at the time of initial colposcopy and biopsy; the remaining cases were found through conization or hysterectomy. A few women (13) had the high-grade lesion detected during follow-up after a negative colposcopy. Interestingly, there were 16 cases of microinvasive squamous cancer detected. Law and associates state that this high rate of cancer reflects the high prevalence in their country (Taiwan.)
Comment by Kenneth L. Noller, MD
In recent years, there has been great interest in following women with cervical intraepithelial neoplasia, grade 1 (CIN 1) without treatment. Fifty to 70% of women who are followed will have spontaneous resolution of their disease, with the remaining women being approximately equally divided between persistence of CIN 1 and progression to CIN 2/3. This approach—follow-up without treatment—seems particularly advantageous for young, nulliparous women.
Unfortunately, the fact that many women with CIN 1 (low-grade changes) are now followed without treatment has mysteriously morphed into the recommendation that women with LGSIL Pap smears be followed with cytology only. That is a particularly unfortunate concept, since, as this article clearly shows, a significant fraction of women with LGSIL cytology reports have high-grade lesions present. At the present time, it seems reasonable (and might even be cost effective) for all women with LGSIL changes to have colposcopy. If no lesion or only a low-grade lesion is identified, the patient can then be followed without therapy. On the other hand, if a high-grade lesion is discovered, appropriate therapy can be instituted. While the rate of high-grade lesions in the United States among women with LGSIL cytology is considerably less than was found in this Taiwan-based study, nonetheless, high-grade lesions occur with significance frequency that colposcopy is warranted.