Význam vyšetrenia krčku maternice u žien po HPV očkovaní. Ctirad Mokráš
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1 Význam vyšetrenia krčku maternice u žien po HPV očkovaní. Ctirad Mokráš
2 Carcinoma cervicis uteri Morbidita 600 Mortalita 200 Ca.cervicis uteri je druhou najčastejšou gynekolog.malignitou vo svete / treťou na Slovensku/.
3 Polovicu Nobelovej ceny získal Harald zur Hausen z Nemeckého ústavu pre výskum rakoviny v Heidelbergu za objav ľudských papillomových vírusov, ktoré sú príčinou rakoviny krčku maternice. Druhá polovica patrí spoločne Francoise Barréovej-Sinoussiovej z Pasteurovho ústavu v Paríži a Lucovi Montagnierovi zo Svetovej nadácie pre výskum a prevenciu AIDS z rovnakého ústavu.
4 Etiológia Vírusové HPV Enviromentálne a exogénne kofaktory fajčenie HAK parita a sexuálne chovanie partnerského páru Chlamýdia trachomatis, Herpes simplex, HIV Faktory zo strany hostiteľa imunosupresíva genetické a imunolog.faktory
5 Rakovina krčku maternice súvisiaca HPV typmi s jednotlivými 10% 7,3% 3% 4% 5% 14,1% 57,6% HPV 16 HPV 18 HPV 45 HPV 31 HPV 33 HPV neg All other HPV types Munoz et al, NEJM 2003
6 Mechanizmus prenosu a nákazy HPV Pohlavný styk Počas pohlavného styku 1 Genitálno genitálny, manuálno genitálny, orálne genitálny kontakt 2 4 Genitálna infekcia HPV u panien je zriedkavá, ale môže byť následkom sexuálneho kontaktu bez penetrácie. 2 Správne používanie kondómu môže napomôcť znížiť riziko, ale nechráni plne pred infekciou. 5 Nepohlavné spôsoby Od matky na novorodenca (vertikálny prenos) 6 Kontaminovanými predmetmi (napr. spodné prádlo, chirurgické rukavice, kliešte na biopsiu) 7,8 Hypotetické, ale nie sú dobre zdokumentované; vyskytnú sa zriedkavo Väčšina infikovaných jedincov nevie, že sú infikovaní a nevedome môžu roznášať vírus. 9 8
7 Spektrum zmien v epitely krčku maternice spôsobených infekciou HPV 1 Normálny krčok maternice HPV infekcia / CIN* 1 CIN 2 / CIN 3 / rakovina krčka ka maternice *CIN = cervikálna intraepiteliálna neoplázia 1. Adapted from Goodman A, Wilbur DC. N Engl J Med. 2003;349: Copyright 2003 Massachusetts Medical Society. All rights reserved. Adapted with permission.
8 Kumulatívne riziko infekcie HPV (%) Kumulatívne riziko akejkoľvek HPV infekcie u žien podľa veku*, Východisková hodnota veku N= Roky *V skupine kolumbijských žien 1. Prebraté z Muñoz N, Méndez F, Posso H, et al. J Infect Dis. 2004;190: Publikované s dovolením The University of Chicago Press. Copyright 2004 by the Infectious Diseases Society of America. Všetky práva vyhradené.
9 Prevalence of Cervical Neoplasia (%) Prevalencie cervikálnych SIL a rakoviny krčka maternice podľa veku*,1 6,0% 5,0% 4,0% LSIL HSIL Karcinóm 3,0% 2,0% 1,0% 0,0% < Vek (roky) SIL squamózna intraepiteliálna lézia *Štúdia uskutočnená vo vidieckej Kostarike (N=9175) 1. Herrero R, Hildesheim A, Bratti C, et al. Population-based study of human papillomavirus infection and cervical neoplasia in rural Costa Rica. J Natl Cancer Inst. 2000;92: Prebraté so súhlasom z Oxford University Press.
10 % spojitosti s určitými HPV typmi HPV a rakovina: všeobecný obraz cervix vulv.lézie penis análny oro-faryng. hrtan 15
11 Preventívne vyšetrenie v gynekológii 1x za 12 mesiacov / kolpo, OC,TVS/ od 18.r.života 1.OC ster v 24.roku života
12 Očkovanie Vďaka dôslednej vakcinácii ustúpili niektoré ochorenia /pravé kiahne, detská obrna, záškrt, tetanus/. Priaznivá situácia vo výskyte nebezpečných inf.chorôb vďaka očkovaniu dáva priestor na úvahy, že tieto choroby už nie sú hrozbou. Pozitívny trend si časť verejnosti vysvetľuje tak, že vakcinácia nie je potrebná. Narastajúce aktivity odporcov očkovania. Šírenie pochybností o účinnosti očkovania je však nebezpečné.
13 Cervarix < Silgard 6,11 6,11,16,18
14 Súvisiace prípady SILGARD je účinný proti léziám spojeným s HPV typmi 6/11/16/ SILGARD Placebo % Účinnosť 99% Účinnosť n=7 863 n=7 863 n= n=7 900 CIN (any grade) or AIS External Genital Lesions* *Genitálne bradavice, VIN 1, VaIN 1.
15 D.T.1988
16 D.T.1988 Cytol.: NILM Histol.: NILM
17 K.J. 1990
18 K.J.1990 Cytol.: 7/2015 NILM výrazné zápalové pozadie Histol.: 9/2016 knips v mikroúseku CIN II
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20 Zhrnutie Kolposkop.nález u očkovanej pacientky je naskôr dielom HPV LR. V druhom prípade ide síce o HG léziu/cin II/, ale nie typom HPV, proti ktorému bola pac.očkovaná. Z uvedeného vyplýva, že aj napriek dokázanému protektívnemu účinku vakcíny, toto očkovanie pacientku od prevent.vyšetrenia neoslobodzuje.
21
22 Ďakujem, že ste ma počúvali.
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