A 29-year-old woman comes to the office for a colposcopy after a cervical cancer screening last week revealed abnormal intraepithelial lesions. The patient feels well and has had no abnormal vaginal bleeding or discharge. She has no chronic medical conditions and has had no prior surgery. The patient's only medication is an oral contraceptive. She does not use tobacco, alcohol, or illicit drugs. BMI is 23 kg/m². On colposcopy, the squamocolumnar junction is not completely visualized, and an ectocervical biopsy reveals cervical intraepithelial neoplasia (CIN) 1. An endocervical curettage shows CIN 3. Which of the following is the best next step in management of this patient?

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11ec25c8_d9ae_79fc_bc81_0165d32d76c7_MD0003_00 Colposcopy, which provides an illuminated and magnified view of the vulva, vagina, and cervix, can identify precancerous cervical lesions (eg, cervical intraepithelial neoplasia [CIN]); it is performed in patients with abnormal cervical cancer screening results. However, patients with an unsatisfactory colposcopy (ie, squamocolumnar junction not completely visualized) and high likelihood of cervical dysplasia require an endocervical curettage (ie, sampling of the endocervical canal) to fully evaluate the cervix for lesions. Colposcopy endocervical curettage In this patient, colposcopy with ectocervical biopsy showed CIN 1 (low risk of cancer progression); however, the results were unsatisfactory because the squamocolumnar junction was not completely visualized. Therefore, endocervical curettage was performed; it revealed high-grade CIN 3, a high-risk precancerous lesion with a 15%-40% risk of progression to invasive cancer. CIN 3 is also a significant risk factor for concurrent invasive cervical cancer. Therefore, treatment of CIN 3 (whether in the endo- or ectocervix) is with immediate cervical conization. Cervical conization is both a diagnostic and a therapeutic procedure, typically removing the entire lesion and allowing for examination of the full depth of invasion. Management after conization depends on pathology results: If there is no evidence of invasive cancer and the specimen margins are free of disease (ie, all CIN removed), management is with Pap testing and human papillomavirus cotesting at 1 and 2 years. In contrast, patients with invasive cancer or margins with residual CIN require additional treatment. (Choice B) Endometrial biopsy is indicated in patients with abnormal uterine bleeding to evaluate for endometrial cancer. This patient has no abnormal bleeding and is at low risk for endometrial cancer (eg, normal BMI, oral contraceptive use). Endometrial biopsy (Choices C and D) Patients with CIN 3 require a prompt excisional biopsy (ie, cervical conization) due to the high risk of concurrent invasive cancer and/or progression to cancer if management is delayed. Therefore, repeat Pap testing in several months or years is inappropriate. (Choice E) Topical trichloroacetic acid can treat anogenital warts; however, it is not used to treat high-grade cervical intraepithelial lesions. Educational objective: Patients with cervical intraepithelial neoplasia 3 on biopsy (eg, endocervical curettage) require cervical conization, a type of excisional biopsy, due to the high risk of concurrent invasive cervical cancer and/or progression to cancer. References: 2012 updated consensus guidelines for the management of abnormal cervical cancer screening tests and cancer precursors. (http://www.ncbi.nlm.nih.gov/pubmed/23519301) ACS/ASCCP/ASCP guidelines for the early detection of cervical cancer. (http://www.ncbi.nlm.nih.gov/pubmed/23062041) Management of histologic abnormalities of the cervix. (http://www.ncbi.nlm.nih.gov/pubmed/16417073)

A 29-Year-Old Woman Comes to the Office for a Colposcopy