ISSN: 1223-1533

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THERAPEUTIC CONDUCT FOR CERVICAL PRECANCEROUS LESIONS


Authors: M. Craina, Elena Bernard, Luminita Cimpeanu, D. M. Anastasiu



Received for publication: 5th of July, 2008
Revised: 30th of August, 2008



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SUMMARY: (Hide the summary)
The paper presents a retrospective study realised in the "Bega" Clinic of Obstetrics and Gynecology between 01.01.2006 and 31.12.2007. In this study were included the women with CIN modifications at the uterine cervix level who have been surgically treated. The statistic processing of data points out a number of 19 patients during the year 2006 and 31 patients in 2007 institutionalized and diagnosticated with CIN lesions and treated using the excisional procedures. The actual treatment of cervical intraepithelial neoplasia is a conservative treatment. The patient should be evaluated very often by a gynecologyst in cooperation with a cytologyst, anatomopathologyst and colposcopy specialist. We consider that the therapeutic conduct of the cases detected with CIN lesions requires a tight collaboration between all these domain specialists and their decision must take into consideration both the advantajes and disadvantajes and possible complications of the therapeutic methods applied when we speak about a surgical intervention. Also, the presence of HPV at the uterine cervix level should not conduct to an aggressive treatment of the lesions in order to reduce the the risk of cervical cancer and high grade lesions, because it is demonstrated that spontaneous cure of the infection has the same frequency as the cure after treatment.


Key Words:
cervical intraepithelial neoplasia, cervical cytology, colposcopy

 


 

INTRODUCTION

 

It is wellknown that the cervical preinvazive lesions will evolve into invasive cancer. These type of lesions are characterized microscopically as a spectrum of events progressing from cellular atypia to various grades of dysplasia or cervical intraepithelial neoplasia (CIN) before progression to invasive carcinoma.

We can do a cytological examination using the Papanicolaou technique and, if it is necessary a colposcopic examination which can make us think at a CIN. The final diagnosis of CIN is established by the histopathological examination of a cervical fragment. There are most epidemiological studies which have identified some risk factors that contribute to the development of cervical preinvasive lesions and cervical cancer. So the involved factors are: infection with certain oncogenic types of human papillomaviruses (HPV), sexual intercourse at an early age, multiple sexual partners, multiparity, long-term oral contraceptive use, tobacco smoking, low socioeconomic status, infection with Chlamydia trachomatis, micronutrient deficiency and a diet deficient in vegetables and fruits.1 It is important to know the etiology, pathophysiology and natural history of CIN provides a strong basis both for visual testing and for colposcopic diagnosis and understanding the principles of treatment of these lesions.

 

MATERIAL AND METHOD

 

The paper presents a retrospective study realised in the “Bega” Clinic of Obstetrics and Gynecology between 01.01.2006 and 31.12.2007. In this study were included the women with CIN modifications at the uterine cervix level who have been surgically treated.

Nowadays are recognized as therapeutic methods for this cases the folowing procedures:

l Destructive procedures:

m Electrocauterization of the uterine cervix

m Cryocauterization

m CO2 laser vaporization

l Abscission:

m Wire loop excision/loop electrosurgical excision procedure (LEEP)

m Classical conization

m CO2 laser conization

m Conization with the ultrasound bistoury

Data were collected from the observation sheets of the institutionalized patients in this period of time. During the study were identified women with cervical modifications categorized as CIN and with recommandation for excizional procedures. The folowing procedures were performed: cervical amputation or conization, depending on the situation.

 

RESULTS AND DISCUSIONS

 

The statistic processing of data points out a number of 19 patients during the year 2006 and 31 patients in 2007 institutionalized and diagnosticated with CIN lesions and treated using the excisional procedures.(fig.1)

The statistic number of the cases rezolved with conization is significantly bigger than the cases rezolved with cervical amputation (table 1)

In all of the cases the excised pieces were sent to the laboratory for anatomopathological examination.

At present, we consider that in this cases the therapeutic conduct must take into consideration the folowing aspects:

1. Identification of precancerous lesions trough the use of Babes-Papanicolau test correlated with colposcopic examination, and applying the proper treatment without overtreating insignificant lesions;

2. Choosing the proper therapeutic method for each case individually, depending on the situation and the age of the patient, and also take consideration of the infertility problems(if they exist);

3. The presence of known asociated risk factors as HPV or other associated pathologies;

4. Socio-econimic conditions of the patient;

5. The lesion characteristics- gravity, extension, localisation.

Post treatment complications :

1. infertility

2. cervical stenosis

3. obstetrical complications – abortion, premature births, dynamic distocies.

As the authors specifies, the Bethesda 2006 recomandations concerning the management of patients with CIN or adenocarcinoma in situ are an extraordinary guide for this cases but the guideliness should never be thought of as a substitute for a doctor`s medical judgement (should never subtitute for clinical judgement)2, so the individualisation of treatment is necessary.

So there are randomized comparative studies comparing ablative and excisional techniques who have similar eficacity for the patients with CIN, diminishing the risk of developing cervical neoplasias3-7. There were also described many post operative follow-up protocols wich include: citology, colposcopy, combinations of citology and colposcopy , and HPV deoxyribonucleic acid - ADN-HPV testing at a variety of intervals 8,9.

Lot of studies that have evaluated the performance of HPV-DNA postoperatory detection proved that its performance is quite good and exceeds that’s of citologycal follow-up 9,10.

 

CONCLUSIONS

 

The actual treatment of cervical intraepithelial neoplasia is a conservative treatment. The patient should be evaluated very often by a gynecologyst in cooperation with a cytologyst, anatomopathologyst and colposcopy specialist. We consider that the therapeutic conduct of the cases detected with CIN lesions requires a tight collaboration between all these domain specialists and their decision must take into consideration both the advantajes and disadvantajes and possible complications of the therapeutic methods applied when we speak about a surgical intervention.

Also, the presence of HPV at the uterine cervix level should not conduct to an aggressive treatment of the lesions in order to reduce the the risk of cervical cancer and high grade lesions, because it is demonstrated that spontaneous cure of the infection has the same frequency as the cure after treatment.

 

REFERENCE:

 

1. IARC; Bosch et al., 19.5; Schiffman et al., 1996; Walboomers et al., 1999; Franco et al., 1999; Ferenczy & Franco, 2002. 2. www.AJOG.org

3. Martin-Hirsch PL, Paraskevaidis E, Kitchener H. Surgery for cervical intraepithelial neoplasia. Cochrane Database Syst Rev 2000:CD001318.

4. Kyrgiou M, Tsoumpou I, Vrekoussis T, et al. The up-to-date evidence on colposcopy practice and treatment of cervical intraepithelial neoplasia: the Cochrane colposcopy and cervical cytopathology collaborative group (C5 group) approach. Cancer Treat Rev 2006;32:516-23

5. Nuovo J, Melnikow J, Willan AR, Chan BK. Treatment outcomes for squamous intraepithelial lesions. Int J Gynaecol Obstet 2000; 68:25-33

6. Kalliala I, Nieminen P, Dyba T, Pukkala E, Anttila A. Cancer free survival after CIN treatment: comparisons of treatment methods and histology. Gynecol Oncol 2007;105:228-33.

7. Soutter WP, Sasieni P, Panoskaltsis T. Long-term risk of invasive cervical cancer after treatment of squamous cervical intraepithelial neoplasia. Int J Cancer 2006;118:2048-55.

8. Bornstein J, Schwartz J, Perri A, Harroch J, Zarfati D. Tools for post LEEP surveillance. Obstet Gynecol Surv 2004;59:663-8.

9. Zielinski GD, Bais AG, Helmerhorst TJ, et al. HPV testing and monitoring of women after treatment of CIN 3: review of the literature and meta-analysis. Obstet Gynecol Surv 2004; 59:543-53.

10. Paraskevaidis E, Arbyn M, Sotiriadis A, et al. The role of HPV DNA testing in the follow-up period after treatment for CIN: a systematic review of the literature. Cancer Treat Rev 2004;30:205-11.



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