Squamous Lesions

A histopathologic classification and pathogenesis of the disease, and clinical behavior, and the treatment shall be considered. Information about precancerous lesions of the cervix developed rapidly last 50 years, in parallel with this terminology has changed frequently. Today the debate continues, and a term commonly used in low-and high-grade SIL is divided into 2 groups. To date kullanılagelmiş terms and provisions given in

"Flat condyloma / Koilositoz   

Mild dysplasia
   

CIN 1
   

L-SIL

Mild dysplasia
   

CIN 2
   

H-SIL

Severe dysplasia
   

CIN 3
   

H-SIL

SIL terminoljisini Advocates of these lesions, especially neoplasia, therefore, that L-Delete preneoplastik use of the term would be wrong, that does not require treatment of L-Delete is a lesion with mild dysplasia and CIN 1, or "flat condyloma" is the same as the findings of the morphological these two lesions can not be distinguished from each other, as well as cervicovaginal cytology in the same terminology used in the Bethesda system ensures the state that the preferred alignment for the cytology-histopathology (17,18). On the other hand using the terminology of CIN, neoplastic lesions, saying they were ignoring the potential, some of the invasive carcinoma, CIN 1s progressing, with CIN 1 "flat condyloma of" say it is possible to distinguish morphologically. The pathogenesis of precancerous and cancerous lesions of the cervix anlaşılana fully open until the terminology will change again. We have more than one mention the terminology of pathology reports, all three, but the Bethesda cytology histopathology in this system, I prefer to use reproach.

SIL, abnormal cell proliferation, maturation and cytologic atypia is characterized by loss. Cellular atypia in the nucleus hyperchromasia, pleomorphism and irregularity of the borders, an abnormal distribution of chromatin, nucleus / cytoplasm ratio is increased. Nucleus findings, regardless of the degree of cytoplasmic maturation of all layers of epithelium are observed. Mitozlar also observed increased mitotic activity and atypical (18).

Preneoplastik lesions traditional ratings, according to the area occupied by basaloid epithelium-undifferentiated cells. According to these cells, basaloid epithelium in CIN 1 1 / 3 lower part, CIN 2 in the lower 1/3-2/3 'fame, at CIN 3 2 / 3' covers more than. Bethesda grading system, it goes down to 2 groups. H-SIL'da nuclear pleomorphism, and nuclear / cytoplasmic ratio than the increase of L-SIL'a prominent, coarser chromatin, granular or ipliksidir. Nucleus of L-SIL'da irregular borders, while the H-SIL'da may be uncertain. H-SIL'da basaloid epithelium cells in the lower 1 / 3 than at level up. Both the L-SIL and H-SIL'da koilositler also monitored (18).

Group that uses the terminology of CIN, HPV infection koilositler, Dyskeratosis, multinükleasyon, parakeratosis / hyperkeratosis, intermediate cell nucleus growth irregularity, hyperchromasia, mitozlar, as basal cell hyperplasia to describe, in case of basal cell atypia is that the presence of CIN 1 with HPV infection (19) .

The most important differential diagnosis for the L-SIL due to the normal cytoplasmic glycogen vakuolizasyondur metaplastic epithelium. The most important criterion for the differential diagnosis of reactive events and cytoplasmic vakuolizasyonda nuclear atypia. For H-SIL in the differential diagnosis of immature metaplasia, atrophy, and is located in reperasyon. There is no nuclear pleomorphism immature metaplasia. Atrophic epithelium, nucleus / cytoplasm ratio increased, but nuclear pleomorphism, mitotic activity, atypia, there is loss of polarity. If there are atypical cells in the basal nuclei Reperasyonda but noteworthy for regular and prominent nucleoli.

Cervical biopsy specimen pathology report, according to the accepted terminology preneoplastik the degree of the lesion, whether or not endocervical gland involvement, had been investigated gözlenmediğini indicate changes due to HPV. Konizasyon report also surgical margins status, surgical margins, especially the endocervical canal should be emphasized.

Prognosis:

Regression rate of CIN 1, 2%, 22% persistence and progression is 16%. Regression of CIN 2, 28%, progression 50%. CIN 3 is much higher than the potential for progression. CIN'ların invasive carcinoma is also known that progression. One of the most important points to remember, however, micro-invasive carcinoma-preneoplastik lesions constitute a spectrum of invasive carcinoma, the lesion of any stage, passing the previous stages of "de novo" may develop.

ASCUS (atypical squamous cells belirlenemiyen Importance) , constituting 5-10% of all Pap smears. This terminology is very depressed, leaving gynecologists. In fact, a vague entity could not identify a pathology kidnapping korkusundaki sitoloğun full. Dysplasia in 18-70% of the cases, 5-10% H-SIL, a very small portion of the available invasive cancer. The importance of this classification in the actual separation of the H-SIL yapılamıyan ASC-H cases. The pathological diagnosis should be taken seriously and further examination.

Glandular lesions



In the last 30 years in women under the age of 35 increase in cervical adenocarcinoma and glandular precursors intensified the interest in this subject. 20-30% of cases of invasive cervical carcinoma adenokarsinomdur u today. Glandular neoplasia is usually associated with HPV-18. Glandular carcinoma in the same frequency situya rastlanmadığından, glandular premalignant diseases thought to have rapidly turned into invasive disease. In addition, use of oral contraceptives was related to cervical adenocarcinoma. The first in the 1950s the first adenocarcinoma of the cervix is about precursors, and later, this non-invasive glandular lesions, the term has been used for adenocarcinoma in situ (20) Today, according to Bethesta glandular cell abnormalities: atypical glandular cells (AGC), atypical glandular cells (favor neoplasia), endocervical classified as adenocarcinoma in situ and adenocarcinoma.

AGC, according to ASCUS'a reflect a more serious pathology and, therefore, recommended that colposcopic examination and evaluation of the endocervical canal.

AIN endocervical atypia is characterized by cells lining the glands. Similar but not adenocarcinoma invasion. Hyperchromatic nuclei, long and blunt-ended, narrow sitoplazmalıdır, mucin content, minimal. Congest cells, are psödostratifikasyon. Focal, multifocal, may be diffuse. Some sharp transition from normal glands is evident. AİS'li budding glands, complex branching papillary and cribriform structure can be observed.

The differential diagnosis of inflammatory, radiation atypia, Arias-Stella reaction, mikroglandüler hyperplasia, endometriosis, tubal metaplasia, and invasive adenocarcinoma remains are mezonefrik. Nuclear hyperchromasia, psödostratifikasyon, the sudden transition from normal, papillary-cribriform pattern, mitotic activity, the findings in favor of AIN. AİS'li desmoplazi-cloth around the stromal reaction, excessive budding-cribriform structure, fabric structures, has given back to back, endocervical papillary formation on the surface to be düşündürmesi invasion findings.



Management of CIN 1 lesions

The last 30 years, at the end of the natural history of CIN 1, CIN 3, CIN will be changed to all forms of thought adopted by physicians to treat the general met with the opinion (21). However, in patients with normal immunity, low-grade lesions associated with HPV, this view has changed after being presented with 70% back dönenebileceği (22). In addition, inter and intra-observer differences in the diagnosis of CIN is higher led to the emergence of doubts about the accuracy of diagnosis (23). In 2001 by the American National Cancer Institute, the 'atypical squamous cells of undetermined significance of (ASC-US), low-grade squamous intraepithelial lesion triage study '(ALTS) (24), and the results of this study was published expert pathologists re-evaluated by the diagnoses of CIN 1% 40 were found to be normal, the diagnosis of CIN 2-3 was changed to 13% of cases (25). The results of the two-year follow-up of ALTS study (26), a compilation made in this regard (27) and the results of a meta-analysis (28) according to the 10-15% of CIN 2-3, CIN 1 lesions progress and top of this 0.3% ü turn into cancer. But which of CIN 1 lesions CIN 2-3 propagation of CIN 2-3 lesions and CIN 1 lesions, which developed in the management of histologic lesions saptanamadığı CIN for HPV DNA typing has become more important today.

Transformation zone and endocervical curettage is seen to be negative all cases, the clinician can rely on cytologic diagnosis. But knowledge and experience of the clinician should be enough to colposcopy. Inadequate colposcopy and endocervical curettage is positive if the result under the low-grade lesions of CIN 2-3 or cancer, and further diagnostic tests should be made, there might be. Satisfactory colposcopic examination after the cases of CIN 1 and CIN 1 as viewed in the diagnosis of lesions regress spontaneously in most cases of CIN 2-3 to the rate of progress also is known to vary between 9-16% (26) and the rate of CIN 2-3 cases of ASC-US presence The risk is similar to (29).

According to the ALTS study were diagnosed as ASC-US patients, 6 and 12 85% of CIN 3 lesions in the months of smear tekrarlarıyla naturalise, the HPV DNA test in a 2-year follow-up period 95% of CIN 3 lesions tanınabilmiştir (30). For patients with untreated CIN 1; tiplendirmesinin high sensitivity of HPV DNA is only persistent HPV infections and CIN 3 lesions can progress, taking into account 12 the HPV DNA tiplendirmesinin months, 6 and 12 months can be preferred to repeat the smear was concluded that (31). Colposcopy to exclude CIN 2-3 for these cases is possible, this approach will increase the cost and the need for colposcopy.

Colposcopy and endocervical curettage is inadequate in cases of CIN 1 is a positive rather than observational approach should be preferred diagnostic excisional approaches. Ablative lesions for the treatment of CIN 1 lesions (cryotherapy, laser ablation, cold coagulation) used in idiyse, excisional methods ablative methods should be preferred. Recurrent and persistent cases, excisional methods used, especially because lesions in these cases was mostly localized in the endocervical canal.

Adequate treatment of cases of CIN 1 on colposcopic examination, excisional modalities used in the comparison of different ablative methods are similar to the results of success (32). Cold konizasyon compared with LEEP konizasyon with less blood loss and shorter hospital stay olsalda, positive surgical margins are more common, and this makes it difficult to evaluate the results of treatment.

Treatment of biopsy diagnosis of CIN 1

Patients with adequate follow-up colposcopic examination is to be made, cytology 6 and 12 or 12 months should be per month for high-risk types of HPV DNA typing should be done. Repeated cytology of atypical squamous cells (ACS) or more advanced lesions are detected or if the DNA test results positive for high-risk HPV types colposcopy should be repeated. Two consecutive negative cytology and negative HPV DNA test result of a one-year patient follow-up smear is taken. Protokollüne follow-up colposcopy is recommended. Adequate colposcopic examination and biopsy were diagnosed with CIN 1 patients in the ablative or excisional modalities suggested. Endocervical curettage should be done before treatment seçilecekse ablative approach. Previously received ablative treatment modalities, particularly excisional and should be applied to patients with the diagnosis of recurrent CIN 1. Ablative treatment indications are summarized in table 3.

Biopsy diagnosis but is inadequate colposcopic examination of diagnostic excisional procedures should be preferred in cases of CIN 1 approach. This will include the transformation zone and endocervical canal will be an example of a way, LEEP, laser, or cold can be done in the form of konizasyon (table 4). Patients undergoing follow-up of this group, but pregnancy, in cases of imümsüpresyon or adolescent age group is recommended.

Management of CIN 2-3 lesions

Untreated, 43% of CIN 2 lesions, 32% in CIN 3 lesions spontaneously regressed, while 35% of CIN 2 lesions, CIN 3 and CIN 2 lesions, 56% will have persistent lesions, 22%, CIN 3 lesions 14% of cancer in situ or invasive cancer progresses (33). For these reasons, CIN 2 and 3 lesions should be treated. In order to be effective in the treatment of CIN 2-3's entire transformation zone should be excised. We will make it impossible for the diagnosis of microinvasive or invasive cancer ablative methods recommended in this patient group. LEEP or cold konizasyon for these patients and for diagnostic and therapeutic interventions. Konizasyonda postoperative complications encountered in the cold more often than LEEP'e, this method seems to be less positive in the boundary cerhi after surgery. Positive surgical margin and endocervical sampling is to be a risk factor for recurrent and persistent CIN personalized treatment for this patient group, explained to the patient the potential risks that follow the decision has been made. Hysterectomy is applicable to eligible patients.

Invasive cancer is low risk of progression of the lesions regressed and the postpartum period is likely to be detected during pregnancy is followed CIN 2-3 lesions. In addition, complications of pregnancy and pregnancy increases the risk of premature birth underwent excisional procedures. Immune response in the postpartum period, increasing and decreasing rates of up to 69% regression of lesions was the hormonal effect (34).

Adolescent age group tend to be CIN 2 lesions regressed spontaneously. Adequate colposcopy and negative endocervical curettage as a result of CIN 2 lesions can be followed with cytology will be intervals of 4-6 months. Risk of occult disease, but patients must be told. CIN 3 in the presence of diagnostic excisional procedures necessary should be done in adolescents.

Immunocompromised patient group, a large number of high prevalence of HPV type are seen together, increased CIN, cervical cancer and recurrent disease after treatment are at risk. In addition, sensitivity of cytology in this patient group is lower than the normal population. The success of these interventions in patients with CD4 cell number and excision depends on whether a positive surgical margin. 5-FU administered vaginally after surgery reduces the recurrence rate (35).

Treatment for the biopsy diagnosis of CIN 2-3:

The biopsy diagnosis of CIN 2-3 lesions, excisional or ablative treatment modalities to be applied after adequate colposcopic examination. Colposcopy is inadequate excisional procedure should be done in all cases. Untreated CIN 2-3 patients in follow-up is not recommended except for special cases. Hysterectomy as primary treatment is not recommended today.

All patients have been treated for CIN 2-3, every 4-6 months after treatment with cytology or colposcopy with cytology examinations done at least three reviews should be monitored until it is negative. Next year follow-up can be done. Six months after treatment, HPV DNA typing is proposed, tested positive for high-risk HPV types should be done if the colposcopy. If the HPV DNA test negative if the annual cytological examination is recommended. A single case of HPV DNA testing is positive and negative repeat cytology and colposcopy examination in the presence or hysterectomy konizasyonun recommended. Borderline endocervical or endocervical curettage after diagnostic excisional procedure in case of detection of CIN 2-3, repeat excision is proposed, it is not possible to do surgical procedures and hysterectomy should be recommended to patients with recurrent and persistent disease.

Table 3: Indications for Ablative therapy

1) Pap smear, cervical biopsy or colposcopy is not evidence of invasion

2) a lack of evidence of adenomatous lesions (AIS, or adenocarcinoma)

3) the lesion is seen as a colposcopy or all of SKJ'nın

4) endocervical curettage is negative

5) there is a conflict between the Pap smear and biopsy results.

6) be compatible with the patient for follow-up



Adenocarcinoma in situ ted avis



Has no place in the treatment of destructive methods. There are two treatment options to choose from. One of them is selected according to the patient's condition.

Konizasyon ; future fertility in young patients who thinks more is applied. The exact boundaries of the tissues konizasyonda The most important thing is completely tumor free. Close follow-up is good. Konizasyonda less tissue damage caused by laser excision may be preferred in mind.

Hysterectomy , the main treatment of adenocarcinoma of the situnun hysterectomy. Although the results removed konizasyonda eliminate cervical canal is not as reliable as hysterectomy. Vaginal or abdominal route can be done. There is no discontinuation of ovaries for any inconvenience.

Table 4: Konizasyon (cold, laser or LLETZ) Indications

1) Pap smear, cervical biopsy or colposcopy to be evidence of invasion

2) is evidence of an adenomatous lesion (AIS, or adenocarcinoma)

3) as a colposcopy to visualize the entire lesion or SKJ'nın

4) endocervical curettage is positive

5) the degree of dysplasia CIN come out worse than a Pap smear biopsy (eg, smear of CIN III, CIN I biopsy finding)

6) Kolposkopta görülmediği lesion is then repeated abnormal smears

7) is incompatible with the patient in follow-up to come