A 38-year-old woman comes to the office for follow-up of cervical dysplasia. She has no chronic medical conditions, and her only surgery was a tubal ligation after the birth of her second child. The patient does not use tobacco, alcohol, or illicit drugs. Last month, routine cervical cancer screening revealed a high-grade squamous epithelial lesion. She then underwent a colposcopy, which confirmed high-grade cervical intraepithelial neoplasia (CIN) 3. Cervical conization was performed. The pathology report shows CIN 3 with all surgical margins free of disease. Which of the following is the best next step in management of this patient?

Question

A 38-year-old woman comes to the office for follow-up of cervical dysplasia.  She has no chronic medical conditions, and her only surgery was a tubal ligation after the birth of her second child.  The patient does not use tobacco, alcohol, or illicit drugs.  Last month, routine cervical cancer screening revealed a high-grade squamous epithelial lesion.  She then underwent a colposcopy, which confirmed high-grade cervical intraepithelial neoplasia (CIN) 3.  Cervical conization was performed.  The pathology report shows CIN 3 with all surgical margins free of disease.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d9af_163d_bc81_9d097c098f42_MD0003_00 Cervical intraepithelial neoplasia (CIN) 3 is a high-grade cervical dysplasia associated with human papillomavirus (HPV) infection, particularly the high-risk oncogenic strains (types 16, 18). Patients with CIN 3 require cervical conization, which is a diagnostic (ie, evaluation for invasive cancer) and therapeutic (ie, excision of dysplastic lesion) procedure. The excised specimen is assessed for depth of invasion and surgical margins (ie, whether all dysplasia was removed). procedure In patients without invasive cancer, management is based on surgical margins: Patients with positive surgical margins have residual cervical dysplasia that can progress to cancer. Therefore, these patients require additional surgical excision with either repeat conization (if future fertility is desired) or hysterectomy (if no future fertility is desired) (Choice B). In contrast, those with negative surgical margins, such as this patient, have no evidence of residual dysplasia. However, because these patients have persistent HPV infection that has caused prior high-grade disease, they are at high risk for recurrent cervical dysplasia and cancer. Therefore, these patients require more frequent cervical cancer screenings with repeat Pap and HPV cotesting at 1 and 2 years postprocedure. (Choice A) Endocervical curettage is performed for an unsatisfactory colposcopy (ie, entire transformation zone not visualized) or atypical glandular cells on cervical cancer screening. This patient underwent conization, which excised the entire transformation zone; therefore, she does not require further endocervical sampling. Endocervical curettage (Choices C and E) Delay in follow-up (eg, no further Pap testing, Pap testing alone in 3 years) increases this patient's risk of developing recurrent cervical dysplasia and/or progression to cervical cancer. Educational objective: Patients who undergo cervical conization for cervical intraepithelial neoplasia 3 and have surgical margins free of disease remain at risk for recurrent dysplasia and cancer. Therefore, these patients require more frequent cervical cancer screenings with repeat Pap and HPV cotesting at 1 and 2 years postprocedure. 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)

A 38-Year-Old Woman Comes to the Office for Follow-Up of Cervical