The term "dysplasia" or "neoplasia" no longer surprises women, even those far from medicine. They understand that we are talking about the presence of atypical cells, which can be in both malignant and benign processes.
And yet, when you hold in your hands the result of a smear with incomprehensible abbreviations, there is always excitement.
Inna Subbotina, the oncogynecologist of the Israeli Oncological Hospital LISOD, will tell you what cytological screening is and why every woman should undergo it.
— Inna Vitalievna, tell us what a PAP test is and how often is it necessary to take it?
— The PAP test, which is also called cytological screening, helps to timely identify and treat pre-cancerous conditions of the cervix of moderate to severe degree. Regular screening prior to sexual intercourse significantly reduces the risk of cervical cancer. In most countries of the world, the PAP test is recommended to be taken once every three years from the age of 21, but Ukrainian doctors consider it advisable to start it in Ukraine earlier, at the age of 18, and complete it at 65, as in most countries of the world. This is due to certain epidemiological features: early onset of sexual activity, the prevalence of various forms of immunodeficiency, extremely low levels of HPV vaccination and a large number of cases of smoking among women.
— Do I need to prepare for the PAP test?
— It is best to get tested in the first dry days after your period. For women who take birth control pills, it doesn't matter what day of their cycle they take the test, and women in menopause can have it on any convenient day. 48 hours before the test, you must exclude sexual relations, do not use vaginal suppositories, irrigations, gels and creams.
The PAP test is a painless procedure. Some women may experience discomfort and aching pains in the lower abdomen during the collection of the test. This is normal.
The collection of cellular material is carried out with a special brush, which is placed in a container with a fixing transport solution or applied in a thin layer on a glass slide. The first, but confident steps are being taken in Ukraine by cotesting (simultaneous cytological examination and determination of the human papillomavirus (HPV) by the polymerase chain reaction method).
— What could be the results of this study? What is recommended for each of them?
— For a descriptive cytological report, the Bethesda classification is used, according to which the interpretation of the results is carried out:
- ASCUS — inflammation or mild dysplasia of unclear significance;
- LSIL — squamous intraepithelial lesion of low degree (according to traditional cytology CIN I (Cervical Intraepithelial Neoplasia) or "mild dysplasia";
- HSIL — high-grade squamous intraepithelial lesion (according to traditional cytology CIN III/CIN III) or "moderate to severe dysplasia";
- NILM — the absence of intracellular lesions or malignancy, that is, the "norm".
Often, women and especially young girls turn to the result of a cytological examination of the cervix that is incomprehensible to them and the exciting question "What to do next?" When receiving any of the results of the PAP-test, there are absolutely clear and scientifically grounded methods of follow-up examination and patient management tactics, which are based on international recommendations and evidence-based medicine data.
If you get a “poor cytology according to Bethesda classification” result, it is recommended to repeat the PAP-test after 2-4 months (regardless of age).
Conclusion ASCUS (Atipical Squamous Cells of Undetermined Significance, atypical squamous cells of unclear significance) characterizes such structural changes in cells that are qualitatively and quantitatively insufficient for the diagnosis of CIN. This means that the cytological picture does not allow differentiating changes in squamous epithelium between reactive and dysplastic, that is, precancerous. In the majority of patients with such results, the cellular composition is normalized during observation, but 10-20% progress to dysplasia. However, the risk of developing severe CIN III dysplasia in women with ASCUS and a negative HPV (-) result does not exceed 1-2%, therefore, such patients are observed without the use of invasive examination techniques, and the observation tactics depend on age and the presence or absence of highly oncogenic HPV types in study of urogenital secretions.
Screening result ASC-H (Atypical Squamous Cells Can not Exlude HSIL, atypical squamous cells that do not exclude HSIL) - regardless of HPV status, extended colposcopy is recommended, and for any signs of lesion, biopsy, cervical curettage is indicated. In women of peri- and menopausal age, if the zone of transition of the squamous and cylindrical epithelium of the cervix is NOT colposcopically visualized, and curettage did not provide reliable information, conization of the cervix can be considered as a diagnostic measure. Such an intervention should be performed by a specialist of an expert level. Further tactics depend on the results of the histological examination.
PAP test with the result of CIN I or LSIL (Low-grade Intraepitelial Lesion, mild epithelial involvement) - cytological changes caused by HPV (coylocytosis) and nonspecific inflammatory changes. CIN I often regresses on its own, therefore, the follow-up tactic is most often used in this group of patients. However, it is imperative to perform an HPV test to determine further tactics.
For women with CIN I and HPV (-) results, cytological control is recommended after 6 months, a double cotesting test is possible after 12 months. If after 12-18 months, according to the results of observation, we get NILM, it is recommended to switch to routine screening.
For women with CIN I / HPV (+), colposcopy is recommended, and if a severe lesion of the cervical epithelium is found, a biopsy is required, and in its absence, repeated cytological control after 6 months or a double test after 12 months. In such patients, it is necessary to create conditions for the elimination of HPV: it is recommended to stop smoking, if necessary, to treat chronic infections, correct the vaginal microbiome - candidiasis, bacterial vaginosis, chronic herpes infection, etc. It is worth remembering that 12-25% of HPV ( +) women with CIN I may progress to more severe CIN within 4 years.
In the presence of a cytological conclusion CIN II and CIN III or HSIL, in 70-80% of cases, patients have CIN II/III in the histological material after biopsy and cervical curettage, and in 1-3% - invasive cancer. Therefore, regardless of the HPV status, colposcopy is always recommended, by a trained specialist, biopsy of the altered areas - under the control of colposcopy, endocervical curettage in non-pregnant women with subsequent morphological examination of the material obtained. Colposcopic examination of the vagina is also recommended. In cases with a cytological result of CIN II/III, if no changes are found during colposcopy or a mild lesion is detected, a biopsy and endocervical curettage (if not performed before) and/or a diagnostic conical biopsy are recommended.
As an exception - girls under the age of 21. The risk of invasive cancer is extremely low, colposcopy and cytology should be repeated after 3-6 months, provided that colposcopy is adequate, that is, the transformation zone is visualized, and endocervical curettage is negative.
Before carrying out invasive interventions, it is always recommended to test for the carriage of the human immunodeficiency virus (HIV), since it is these women who are at increased risk for cervical neoplasia.
— What to do with histological confirmation of mild to moderate to severe cervical dysplasia?
— If biopsy reveals a low-grade LSIL lesion (mild dysplasia, CIN I) and satisfactory colposcopy results (type 1 transformation zone is fully visible), two approaches are possible: observation - recommended in most cases or active treatment, which can be considered if there are signs long-term persistence of CIN I.
Follow-up is the best management tactic, especially for young women and those planning a pregnancy. It consists in cytological control + HPV testing + colposcopy every 6 months, until there is cytological and colposcopic evidence of regression of mild dysplasia. It should be noted that patients with untreated CIN I have a 13% risk of detecting CIN II, CIN III within two years of follow-up.
Surgical, namely, excisional treatment of CIN I can be offered to patients with prolonged persistence of the lesion for more than 18 months, especially with a positive HPV status and in women over 30 years old; patients who do not have reproductive plans and refuse to undergo regular control gynecological examinations; women with positive HIV status.
With histological confirmation of HSIL, that is, CIN ІІ and CIN ІІІ, treatment tactics are more often inclined towards surgical intervention. However, it is worth remembering that about 40% of CIN II cases may regress within 2 years, especially in young women. CIN III regression is extremely rare.
Recommendations for the treatment of severe CIN III dysplasia are unanimous: the mandatory removal of the pathologically altered part of the cervix, that is, excision/conization in non-pregnant patients. The only exception is HSIL (CIN II) in girls under 21 years of age who are not HIV-positive, since young patients are more likely to regress. In this category of patients, it is also desirable to conduct an immunohistochemical study of the proliferative activity index using monoclonal antibodies to the p16 or p16/Ki67 protein to clarify the biological potential of dysplastic changes in the cervical epithelium. Observation is possible in the absence of p16 overexpression for no more than 12 months. With persistence of HSIL (CIN II) and HPV (+) for more than 12 months. the use of excisional methods of treatment is recommended. Surgical treatment of HSIL (CIN II/III) can be performed by trained expert-level specialists under the guidance of colposcopy.
Since the cervix is covered not only with flat, but also with a cylindrical glandular epithelium, which is located in the cervical canal, accordingly, oncological problems also occur here.
The cytological conclusion of the PAP test – AGC (cervical intraepithelial lesion of glandular cells) and AIS (adenocarcinoma in situ) in each case requires the consultation of a cytologist, gynecological oncologist, and expert gynecologist.
Atypical glandular cells in a cytological smear can be of endocervical origin, that is, from the cervix, or endometrial, that is, from the uterine cavity. Therefore, extended colposcopy and cervical curettage are recommended for all patients in this group. Examination over the age of 35 includes mandatory endometrial curettage or hysteroscopy, especially in the presence of concomitant extragenital pathology (obesity + diabetes mellitus + hypertension), pathological uterine bleeding and a family history of cancer burdened.
In the presence of atypia of glandular cells or AIS in the biopsy, but without signs of invasive cancer, conization of the cervix can be considered as a method of choice in young patients with reproductive plans for the future, however, women who have realized their reproductive function and do not plan to give birth in the future are recommended hysterectomy - removal of the uterus, especially with histologically confirmed AIS, taking into account the high likelihood of incomplete removal of the lesion during conization (up to 26%) or invasive cancer (1.2%), frequent relapses of the disease after treatment, the multifocal nature of the disease and the low information content of the cytological manifestations of AIS.
Remember that with timely detection of cervical cancer, the disease has a favorable prognosis for treatment and full recovery, so you yourself must first take care of your own health!
You can undergo an examination by a gynecologist, pass all the necessary tests, do a PAP test and, if necessary, undergo treatment for detected precancerous diseases at the Israeli Oncological Hospital LISOD. The best gynecological oncologists will give detailed advice based on the test results and prescribe effective treatment.
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