Now you most likely hold a smear result, on which ascus is written, in your hand or one of your friends, wife or girlfriend has such a result shared with you if you read such an article, which may probably be found boring by the people of our country beyond measure, related to what this interesting word means.
I know, I know, this one word easy to spell and read as “askus” gets into your life in an instant and you start to investigate the information trash, which is called internet. Moreover you don’t like what you have found. But let’s start with a good news, you are not cancer as mentioned in some articles, also you have the possibility of not carrying HPV (human papilloma virus) at all.
Therefore, let’s take a deep breath, lead back and at least try to calmly read what I write.
Although classic story is always told in connection with human papilloma virus (HPV) in a way, detecting ASCUS in your smear test does not mean you have HPV. In fact, “ASCUS” briefly means nondescript cell.
They are identified as atypical inflammation (inflammation) by World Health Organization (WHO) and I think it is a correct description. Mentioned cells are used to describe cells to occur in presence of any kind of cervical infection not only inflammation developing depending on HPV infection.
HPV virus is an interesting “friend”. If you are sexually active for a time, if you do not continue your life asexually (and it is also a preference), know that you will meet it at 50% and 80% rate and you will “shake hands” .
Although it has hundreds of types, only 40 of them infect genital region and by sexual intercourse. The region they like the most is metaplasia cells included in the region we call transformation zone located between the uterus and the vagina. They consider these cells as their residences and they like to settle immediately.
In general, HPV virus is removed at 70% rate in 1 year and at 95% rate in 2 years, when it is infected in female’s genital region. The problem is 3-5% group. In terms of the group, in which HPV remains as a chronic infection, the process may conclude by cancer at the end of a period of 8-15 years. Therefore we insist on you to regularly visit your gynecologist and to have smear performed but we are not listened . Anyway I wouldn’t like to upset you.
If HPV initiates the process causing change in the cells and these “abnormal” cells occur at the bottom layer of the tissue in cervix, we call this case “cervical intraepithelial neoplasia= CIN 1= CIN 1”.
I will mention about the details later, though they are boring, but the most important point is that if we leave you as you are or if we pray for you and make you drink onion juice , lesion in CIN 1 level will quite likely get normal within 1 year.
This becoming “normal” possibility is expresed by different rates in different publications. As a result, smear findings of patient with CIN 1 become normal at 60% and 80% rate within 2 or 5 years without treatment (1, 2).
Inflammatory cells confusing the pathologist occur just at that moment
He/she sees a cell while investigating the preparation of the patient, from whom smear is received. The cell is not in degenerated rate to define it as CIN I but it is also not normal.
The question confusing the pathologist is related to where the cell comes from and where it goes to.
Does the cell get normal in CIN 1? Or does it go to CIN 1 from normal? It is unknown and may not be determined. Here the pathologist diagnoses these cells as ASCUS (Atypical squamous cells of undetermined significance) in other words nondescript cells.
However, ASC-H is completely out of the story I have explained by a vast HOWEVER. And it is much more important than ASCUS if we consider it in terms of importance.
ASC-H, in other words “atypical squamous cells-cannot exclude high-grade squamous intraepithelial lesion” is the smear, in which high risk (high grade CIN 2 and CIN 3) lesions may not be excluded and demonstrates the existence of atypical cells.
It should NEVER be confused with ASCUS. ASC-H existence requires performing colposcopy without losing time and even if any lesion is detected in colposcopy, the patient should be followed-up closely (3).
It will be sufficient to review the rates I detail below in order to explain the difference in between (2, 4):
While CIN2 risk is 1.1%i CIN 3 risk is 0.4% and cancer detection risk is NONE in terms of the results of biopsy received in colposcopy of a patient,
whose HPV is Negative but ASCUS is detected in smear, CIN2 risk is 18%i CIN 3 risk is 6.8% and cervical cancer risk is 0.41% in terms of the results of biopsy received in colposcopy of a patient, whose HPV is Positive and ASCUS is detected in smear.
CIN2 risk is 35%i CIN 3 risk is 18% and cervical cancer risk is 2.6% of a patient, in whom ASC-H is detected in smear!!!
As you see, risk is really high in the patient with ASC-H. Therefore ASC-H directly requires colposcopy indication.
3 different options are relevant in the patient, in whom ASCUS is detected in smear: Smear repetition 3 months later, HPV DNA observation (if it is positive, definitely colposcopy) or directly applying colposcopy (2,5).
Now if you know English and if you search information trash called internet, you may achieve some treatment charts dominated by the United States of America. However, as in any issue, while directives offered by the United States of America are based on really strong academic knowledge, at the same time they have directions trying to protect the system financially as much as possible.
Obviously, the doctors provide expensive services there and we provide cheap services here. Therefore when ASCUS is detected in smear, what I do is to directly perform colposcopy and to receive biopsy in suspicious circumstances. If any suspicious area is not detected in colposcopy, receiving biopsy is controversial.
In terms of ASC-H, there is no issue to discuss, the patient is directly guided to colposcopy. If no problem is detected, the patient, who has AC-H should be followed.
The treatment of the patient is arranged according to the results of biopsy received. HPV typing definitely has importance. The problem for our country is that it is expensive. We can perform HPV typing now free of charge in KETEMs thanks to our government. But naturally it has criteria and if you are not suitable for these criteria, it means you will spend money. However, HPV typing is really important and it is important in terms of managing the patient, it should be performed if there is no financial problem.
The point to discuss is when it should be performed. In case of cervical dysplasia in the biopsies received (detection of CIN 1, 2 or 3), HPV typing should be performed and recurrence possibility may be shared with the patient. Relapse possibilities of oncogenic HPV types (for instance: Type 16 – 18 – 45 – 33 etc) are high and periods of removal from the body (cervix) is long.
Petry KU. Management options for cervical intraepithelial neoplasia. Best Pract Res Clin Obstet Gynaecol 2011;25(5):641–651.
Stoler MH, Schiffman M. Atypical Squamous Cells of Undetermined Significance-Low-grade Squamous Intraepithelial Lesion Triage Study (ALTS) Group. Interobserver reproducibility of cervical cytologic and histologic interpretations: realistic estimates from the ASCUS-LSIL Triage Study. JAMA 2001;285(11):1500–1505.
Bentley J; Society of Canadian Colposcopists. Colposcopic management of abnormal cervical cytology and histology. J. Obstet Gynaecol Can. 2012 Dec;34(12):1188-206.
Katki H.A., Schiffman M., Castle P.E., et al. Five-year risks of CIN 3+ and cervical cancer among women with HPV testing of ASC-US Pap results. J Low Genit Tract Dis 2013; 17: 36.
Carmichael JA. The management of minor degrees of cervical dysplasia associated with the human papilloma virus. Yale J Biol Med. 1991 Nov-Dec;64(6):591-7