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AGUS Pap SmearAka: Atypical Glandular Cells of Undetermined Significance

Epidemiology
1. Incidence: 0.18 to 0.74% of Pap Smears
Pathophysiology
1. Not equivalent to ASCUS Pap Smear
2. Much higher likelihood of associated Cervical Dysplasia
  1. No abnormality on Colposcopy: 50 to 80%
    1. See benign causes below
  2. Significant abnormality on Colposcopy: 20 to 50%
    1. See significant causes below
Causes of AGUS Pap Smear
1. Significant abnormalities
  1. Cervical Dysplasia associated with squamous lesions
  2. Adenocarcinoma in situ
  3. Adenocarcinoma
2. Benign abnormalities
  1. Metaplasia
  2. Endometriosis
  3. Arias-Stella reaction associated with pregnancy
  4. Endocervical polyps
Signs on Colposcopy of Adenocarcinoma and AIS (subtle)
1. Typical squamous Cervical Dysplasia findings not seen
2. Findings (observe before acetic acid application)
  1. Dull orange or yellow (adenocarcinoma)
  2. Occurs in transition zone under columnar epithelium
  3. Variegated red and white lesions
  4. Papillary lesions
  5. Large gland openings
  6. Unusual vascular patterns
    1. Vessels in pattern of tendrils or roots
    2. Vessels in pattern of written characters
Evaluation
1. Colposcopy with directed biopsy in all endocervical sample in all AGUS and
2. Endometrial Biopsy indications
  1. Age over 35 years or
  2. Abnormal Uterine Bleeding or
  3. Atypical endometrial cells on Pap Smear cytology
Management: AGUS Favor Reactive or Unqualified
1. Positive Colposcopy
  1. See 'Favor Neoplasia' below
2. Negative Colposcopy and ECC
  1. Repeat Pap Smear every 4 to 6 months for 2 years
  2. Repeat Pap Smears normal
    1. Return to annual Pap Smear
  3. Repeat Pap Smear with AGUS
    1. Conization
    2. See 'Favor Neoplasia' below
Management: AGUS Pap Smear Favor Neoplasia
1. Perform Colposcopy
  1. Negative ECC: Cone biopsy as below
  2. Positive ECC: Consider Hysterectomy
2. Perform Cone Biopsy (Cold-knife conization)
  1. Cone Biopsy positive for Cervical Cancer
    1. Radical Hysterectomy with or without radiation
  2. Cone Biopsy positive for Adenocarcinoma in situ
    1. Simple Hysterectomy
  3. Cone Biopsy negative
    1. Consider Endometrial Biopsy (esp. age over 35)
References

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This page was written by Scott Moses, MD. This page was last revised before 5/10/08, prior to consistent tracking of revision date. This page was last published on 5/10/2008. Please send comments and questions to the editor. Contact information may be found on the page About the Family Practice Notebook. These pages are best viewed with Microsoft Internet Explorer 6.0.