The Follow-up Visit

Histology versus cytology interpretation.

Be concerned if a significant discrepancy is found between the colposcopic impression, Pap cytology, and biopsy histology. Be especially concerned if the biopsy reports are significantly less than Pap cytology. For instance, a Pap smear indicating carcinoma-in-situ and biopsies of only mild dysplasia could signify that the worst area was not biopsied. In general, a difference of one grade (i.e., Pap = CIN 2 and biopsy = CIN 3) is common and acceptable. Repeating colposcopy is forgivable, even in the hands of the best. Freezing invasive cancer is not.

If you decide to repeat the colposcopy, remember to check the cul-de-sac and vagina carefully for lesions. Cone biopsy (cold cone, laser, or LEEP cone) is indicated if the endocervical curettage sample indicates dysplasia. It is a sin to freeze the cervix with disease in the canal. "Positive" ECCs are sometimes a result of contamination with dysplastic lesions at the verge of the os. Nonetheless, do not assume this! Know your limitations! Never be afraid to call in help with an uncertain lesion or result.

Candidates for outpatient cervical cryotherapy are patients with smaller lesions that do not enter the cervical os. Large lesions (over 1" in diameter, more than 1/2" from the os, or involving more than two cervical quadrants), even if they are only mild dysplasia, may be more appropriate loop or laser therapy candidates than a small focal severe dysplasia that may respond to ambulatory cryotherapy very well. Large lesions, lesions that enter the cervical os, or CIN 3 / CIS lesions are most appropiately treated with LEEP or laser therapy.

Follow-up is in 4- to 6-month intervals for 2 years, with colposcopy or colposcopy interspersed with Pap smears. Recurrence is most common in the first 2 years after therapy. Recurrences are most common in the os and on the outside margins. A positive margin on a LEEP specimin requires colposcopic follow-up.