Hunan University of Chinese MedicineProfessor Wang Ruoguang, Doctoral Tutor (medical doctor, postdoctoral Biology)Turn:Journal of Practical
Hunan University of Chinese Medicine
Professor Wang Ruoguang, Doctoral Tutor (medical doctor, postdoctoral Biology)
Journal of Practical Obstetrics and Gynecology, March 2004, Vol. second, No. twentieth
Cervical cancer was once the leading cause of death in patients with gynecologic malignancies. However, due to the wide application of cervical cytology in screening of cervical cancer, the invasive cervical cancer has been relatively rare, the mortality rate has dropped, then relegated to ovarian cancer. However, relying solely on cervical cytology is not enough to prevent cervical cancer. In order to prevent the occurrence of cervical cancer, it is necessary to eliminate cervical precancerous lesions (cervical intraepithelial, CIN) in time. In recent years, the incidence of CIN in young women has increased significantly due to the infection of HPV, and the report of the American Society of pathology shows that more than 1 million of women suffer from CIN, and women with CIN II, III. Methods of treatment of CIN were observed (follow up), local excision, electrocautery, cryotherapy, laser, cervical loop electrosurgical excision procedure (LEEP), conization and hysterectomy. The treatment of CIN has been widely used in the clinic, obstetrics and gynecology doctors are not unfamiliar, this article will not repeat them. However, how to properly select these methods to treat different levels of CIN, to achieve the correct treatment, to avoid excessive or inadequate treatment, but it is a confusing and worthy of discussion. To this end, the American Society for colposcopy and cervical pathology (ASCCP) treatment guidelines in 2001 held a special seminar to develop the relevant histological diagnosis of CIN, after 2 years of clinical practice, published in July 2003, to provide guidance for clinical treatment of CIN we .
1 related terms
The diagnosis of CIN once established, which relates to the treatment of the problem, in the treatment of clear 3 problems, it is necessary for the selection of treatment methods:  without treatment, much CIN development possibilities for cervical cancer have? The CIN is associated with invasive cancer? The patient's age and have no fertility requirements. Therefore, the clinical treatment of CIN should comply with the principles of evidence-based medicine, carefully consider the benefits of the selected treatment methods and the possible complications and damage. For different levels of CIN, some processing methods have different ASCCP, therefore, according to the principles of evidence-based medicine grading assessment of clinical data provide evidence of the recommended degree term for treatment options are divided into: recommended (recommended): refers to the only selection method has good evidence to support; the best use of (preferred): refers to the best choice for a variety of methods to select the methods of treatment; it can be used (acceptable): refers to the evidence that the selection method outperforms other methods, without evidence or inclined to any kind of treatment methods; not by the (unacceptable): refers to the good the evidence against the choice of processing method.
2CIN a large number of studies have shown that, due to the differences observed between pathologists, resulting in histological diagnosis of CIN I is not very accurate case. In the National Cancer Institute in the clinical study of ASCUS/LSIL, the initial diagnosis of CIN I, and later by the expert review committee confirmed that only 43% CIN I, the remaining 41% were normal, and the other was CIN II, III. In addition, most of the diagnosis of CIN is under colposcopy biopsy, the sample is limited. Colposcopy biopsy confirmed CIN I, after LEEP treatment, 23%~55% was eventually diagnosed as CIN II, III.
The natural course of untreated CIN I is characterized by a high natural extinction rate and a low rate of canceration. Ostor review of 4504 cases of CIN I found that, of the patients with spontaneous regression, 11% of patients developed CIN II, III or cancer, of which only 0.3% of the development of invasive cancer. At present, there is no definitive way to determine which CIN I can naturally subside, persist or progress.
Follow up of 2.1CINI is recommended for patients with biopsy proven CIN I, with clinical follow-up or treatment. Since most CIN I lesions after treatment can be naturally dissipated, and a handful of cancer also usually occurs in some lost cases, therefore, many experts argue that if colposcopy with satisfactory results, for the CIN I can not only make lesions treatment and follow-up.
Prospective studies indicate that the CIN I patients with biopsy confirmed during follow-up become CIN II, III is the risk of 9%~16%, ASCUS and cytology development of CIN II, III the same risk, suggesting that CIN I patients using repeated cervical smear to follow-up biopsy is relatively safe. At sixth and twelfth months of follow-up, repeat cervical cytology smears revealed a cumulative incidence of in patients with CIN. In addition, can be detected by high-risk HPV DNA were followed up for 2 years, can be found in 95% CIN III patients. Can replace two repeat cytology in the detection of twelfth months were high-risk HPV DNA. However, there is no research show that the combined application of colposcopy follow-up method is better than the single application of cervical smear, colposcopy can reduce CIN II, III the misdiagnosis rate, but increased costs. After 24 months of follow-up, CIN patients showed a higher natural extinction rate and a higher risk of developing CIN.
For patients with biopsy proven CIN I who were not satisfied with colposcopy, conservative follow-up was controversial because of the presence of occult high-grade CIN or cancer foci in the cervical canal. In these patients, the detection rate of CIN II and III was 10%, and it was obvious that it was not appropriate to follow up without treatment.
2.2 treatment methods include lesion surface destruction and resection of the top two categories. The surface destruction is destruction and removal of cervical surface lesions, including cervical freezing, condensation, coagulation, microwave and laser treatment method, only recommended for colposcopy with satisfactory results and must exclude cervical canal invasive cervical cancer patients. Resection including LEEP, laser, and cold knife conization (diagnostic resection) and other methods commonly used in the surface damage of postoperative recurrence in patients with CIN, this is because of recurrent or persistent CIN lesions often occur in the cervical canal, could not be detected by colposcopy, and therefore should not be used for treatment of surface damage.
There are a number of randomized controlled studies have shown that the use of laser, cold knife and cutting etc. different methods for the treatment of CIN, the net cutting degree and complications were no significant difference, and the advantages of resection of pathologic specimens can be obtained in diseased tissue. Transurethral resection has the advantages of shorter operation time, less bleeding and easy observation after operation. However, the pathological changes of the incisal edge of the lesion were less than that of the cold knife. Therefore, how to choose the best treatment should depend on the experience of the doctor, the patient's wishes, the available therapeutic equipment, the desired therapeutic effect, and whether or not the invasive cancer, etc..
2.3 recommended treatment
2.3.1 colposcopy results satisfactory treatment for colposcopy with satisfactory results, I choose CIN patients with clinical follow-up, the best use of sixth and 12 months of repeated cervical smears, or twelfth months by high-risk HPV DNA detection method for follow-up. During follow-up, if the results of repeated cytological smears were ASC (atypical squamous cells) or more severe lesions, or HPV DNA positive, further colposcopy should be performed (preferably). If the results of two repeated cytological smears were negative, or HPV DNA negative at 12 months, it could be turned into an annual cytological screening (preferably). In addition, also can use the method of combining repeated smear and colposcopy at 12 months of follow-up, such as cytology and colposcopy found in high-risk patients with lesions subsided, recommended the use of repeated cytological examination in 12 months.
For patients who need to be treated, the lesion surface destruction and the diagnosis of lesion resection.
2.3.2 colposcopy examination results are not satisfied with the treatment of the best use of diagnostic lesion resection. For pregnant women, immunocompromised patients and patients with minor, can choose to follow up.
2.3.3 is not used in the treatment of colposcopy results are not satisfied with the CIN I patients, do not use lesion surface destruction. Hysterectomy is not the preferred treatment. For patients with recurrent or persistent CIN after treatment, the lesions are often located in the cervical canal, colposcopy is not easy to find, it is best to use cervical lesion resection, without the use of surface destruction.
3CIN II and CIN III
CIN II is equivalent to moderate atypical hyperplasia of cervical epithelium, CIN III is equivalent to severe atypical hyperplasia and carcinoma in situ. The literature showed that 43% of patients with untreated CIN II had a natural regression of the disease, with a sustained presence of 35% of the lesions, and a further development of 22% in situ and invasive carcinoma. In untreated patients with CIN III, 32% of patients developed spontaneous regression, and the other 14% lesions progressed.
3.1 recommended treatment
The results of 3.1.1 colposcopy examination can be used in the diagnosis of cervical lesions after resection of invasive cancer or lesion surface destruction. In order to ensure the treatment effect, no matter which method to choose, we should pay attention to the operation not only to remove the lesion, but also to remove the entire migration zone, rather than simply remove the lesions seen under colposcopy. Despite research that lesion resection and the prognosis of similar surface damage, but the resection of cervical lesion can get pathological diagnosis by resection of lesion, thereby reducing the microinvasive carcinoma and invasive cancer risk of occult. A large sample of 4 patients with small invasive carcinoma was diagnosed in the follow-up of patients with cervical lesions who were followed up in a total of 3783 patients with invasive carcinoma (). Therefore, some experts recommend that, for CIN II, III lesions, should be treated with excision of cervical lesions, especially for patients with invasive cancer or occult invasive cancer risk. Hysterectomy is not the first choice for the treatment of CIN ii.
3.1.2 colposcopy examination results are not satisfactory for the treatment of patients with a diagnosis of cervical lesions resection, and then send specimens pathological diagnosis. According to statistics, about 7% of these patients were diagnosed as invasive cervical cancer after cervical conization.
In the period of pregnancy pregnancy 3.1.3 CIN II, III became a lower risk of invasive breast cancer, a relatively high proportion of spontaneous regression of puerperal disease. One study showed that 153 of the women with CIN II and III had a natural regression of the 69% lesions and no invasive carcinoma. Therefore, the main purpose of the treatment of CIN II, III is to identify the presence of invasive cancer or occult cancer. Patients undergoing diagnostic conization or LEEP during pregnancy may lead to bleeding and preterm birth, which is often the cause of CIN disease in pregnant women can not be diagnosed in time and the recurrence of the disease is high or persistent. Studies have shown that 47% of pregnant women received LEEP treatment, in the puerperium still found to have residual CIN. Therefore, the use of diagnostic resection during pregnancy is limited to women who do not rule out invasive cancer.
3.2 the analysis of the condition of the resection margin is generally believed that the pathological edge of the diagnosis of cervical lesions after resection is a risk factor for recurrence or persistence of CIN. Vedel et al. 381 patients with CIN underwent cold knife conization of cervix, and found that the positive rate of the patients with positive margin was 16%, while the negative margin was only about 4%. Most studies suggest that recurrence or persistence of CIN is more likely to occur in patients with positive margins, but several studies have shown that the margin is not an independent prognostic factor for residual disease. In addition, 40% of the patients who received LEEP had positive margins, but the majority of CIN did not show up at follow-up. Therefore, patients with positive margin should be informed of the relative risk of patients with further surgery, according to the patient's age, fertility requirements, personal wishes and other factors, individualized clinical treatment. For further treatment of patients, and patients with repeat resection should be the risk of surgical complications that weigh radical residual disease of cervical lesions of desire, again not resection, with total hysterectomy treatment.
3.3 follow up CIN II, III after the end of the treatment, cytology or cytology and colposcopy can be combined with the method of follow-up, interval of 4~6 months. The cytology follow-up examination results, if 3 consecutive "or malignant lesion" negative squamous intraepithelial, recommended by a year follow-up cytological examination results; if more than ASC, should be further colposcopy. It is also possible to select at least 6 months of HPV DNA testing as a follow-up method, if high-risk HPV DNA positive, the use of colposcopy is recommended; if HPV DNA negative, it is recommended to use annual cytology follow-up. Can not only be based on the results of the 1 HPV DNA examination, and no other examination (cytology, colposcopy, histology) on the repeat conization or hysterectomy. For the treatment of patients with CIN in the cutting edge or cervical canal, it is best to use colposcopy and cervical tube sampling method for follow-up, interval of 4~6 months. Resection in the diagnosis of cone, when the cervical margin or cervical canal samples confirmed that CIN II, III still is, can be used again diagnostic conization; if not again conization, with total hysterectomy for treatment; biopsy confirmed recurrent or persistent CIN II, III patients can use hysterectomy treatment.
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