What is the appropriate evaluation and management for a patient with an irregular brown‑white cervical lesion?

Evaluation and Management of Irregular Brown-White Cervical Lesion

Any visible cervical lesion—regardless of cytology results—requires immediate biopsy to exclude invasive cancer, as cervical cytology can be falsely negative even when invasive disease is grossly present. 1

Initial Diagnostic Approach

Perform direct biopsy of the visible lesion immediately. This is the critical first step, as gross cervical abnormalities mandate tissue diagnosis independent of screening test results. 1 The appearance of an irregular brown-white lesion raises concern for:

• High-grade squamous intraepithelial lesion (HSIL/CIN 2,3)
• Adenocarcinoma in situ (AIS)
• Invasive squamous or adenocarcinoma
• Atypical glandular lesions

Do not delay biopsy while awaiting cytology or HPV testing results. 1

Concurrent Evaluation

While performing the biopsy, obtain:

• Cervical cytology using the Bethesda System 2001 reporting 1
• Colposcopic examination to assess the full extent of the lesion and identify additional areas requiring biopsy 1
• Endocervical sampling if the lesion extends into the endocervical canal or if glandular pathology is suspected 2

The colposcopic examination should document whether the transformation zone is fully visualized (satisfactory colposcopy) versus unsatisfactory, as this critically impacts subsequent management. 1

Management Based on Histopathology

If Biopsy Shows CIN 1

For CIN 1 preceded by low-grade cytology (ASC-US, LSIL): Follow-up with HPV DNA testing every 12 months OR repeat cytology every 6-12 months is recommended, as over 90% of low-grade lesions regress spontaneously within 24 months. 1

For CIN 1 preceded by high-grade cytology (HSIL) or atypical glandular cells: Either diagnostic excisional procedure OR observation with colposcopy and cytology at 6-month intervals for 1 year is acceptable, provided colposcopy is satisfactory and endocervical sampling is negative. 1

If Biopsy Shows CIN 2,3

Treatment with excision or ablation is recommended for CIN 2,3. 1 A diagnostic excisional procedure (LEEP or cold knife conization) is mandatory if:

• Colposcopy is unsatisfactory 1
• Endocervical sampling contains CIN 1
• The patient has been previously treated 1

Observation without treatment is unacceptable for CIN 2,3 in adult women (exceptions exist for adolescents and pregnant women). 1

If Biopsy Shows Adenocarcinoma In Situ (AIS)

This finding requires aggressive management due to the multifocal nature of AIS and frequent skip lesions. 1

Hysterectomy is preferred for women who have completed childbearing, as approximately 30% of patients have residual disease even with negative excision margins. 1, 2

If fertility preservation is desired: Cold knife conization (CKC) is the preferred diagnostic excisional procedure—superior to repeat LEEP—as it provides an intact specimen with interpretable margins. 2 Concomitant endocervical sampling should be performed during CKC. 2

Critical caveat: A benign "top hat" (negative endocervical margin) does NOT reliably exclude residual disease in the endocervical canal. 2 Follow-up with cervical cytology with or without endocervical curettage every 6 months is required for patients undergoing conservative management. 2

If Biopsy Shows Invasive Cancer

Immediate referral to gynecologic oncology is mandatory. 1 Management follows cervical cancer treatment guidelines based on staging, which requires multidisciplinary assessment including specialist surgeon and radiotherapist. 1

Special Considerations

Glandular Lesions Require Enhanced Vigilance

Approximately 45% of patients with atypical glandular cells have clinically significant lesions including CIN, AIS, or invasive cancer. 2 Glandular abnormalities affect areas of the cervix that are harder to sample and visualize colposcopically. 2

Do not rely on colposcopy alone or HPV testing alone for initial triage of suspected glandular lesions. 2

Age-Specific Modifications

For adolescents and women under 21 years: Even with visible lesions, management is more conservative due to high HPV prevalence and frequent spontaneous regression. However, any grossly suspicious lesion still requires biopsy regardless of age. 1

For women 30 years and older: Co-testing with cytology and HPV is appropriate for routine screening, but visible lesions bypass screening algorithms and require immediate biopsy. 1

Common Pitfalls to Avoid

• Never assume a visible cervical lesion is benign based on normal cytology alone—cytology has poor sensitivity for grossly visible cancers 1
• Never treat cervical ectropion (a benign finding) without first excluding dysplasia or malignancy through appropriate screening 3
• Never perform ablative therapy without histologic confirmation of the lesion grade and extent 1
• Never assume negative margins after excision guarantee complete removal of AIS—30% residual disease rate persists 2