mr.sc. Ovanin - Rakić Ana, dr.med.
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1 Citološka klasifikacija i n t r a e p i t e l n i h lezija vrata maternice mr.sc. Ovanin - Rakić Ana, dr.med otvoren prvi laboratorij za ginekološku citologiju u Hrvatskoj u Petrovoj 1954 Papanicolaou-ova numerička klasifikacija 1968 modifikacija Papanicolaou-ove klasifikacije dodavanjem dijagnoza sukladnih histološkom nazivlju 1990 nova klasifikacija Zagreb 1990 modifikacija The 1988 Bethesda System 2002 Zagreb 2002 modifikacija Zagreb 1990 i NCI Bethesda 2001 Zagreb 2002 Ovanin-Rakić, Pajtler, Stanković i sur 1
2 Pločasti epitel 1954 Papanicolaou n u m e r i č k a I - V 2
3 1968 Zagreb Audy, Ivić Singer modifikacija klasifikacije po Papanicolaou predviđanje numerička + histološke dijagnoze Promjene nazivlja i klasifikacije intraepitelnih lezija pločastog epitela Wien Richart, Barron Dysplasia levis Richart Bethesda Dysplasia levis Dysplasia media Dysplasia gravis Carcinoma in situ Dysplasia media CIN I CIN CIN II III CIN IV Dysplasia gravis CIN I CIN II CIN III SIL SIL I II CIN - cervikalna intraepitelna neoplazija ( Bethesda 1973 ) Carcinoma in situ SIL - skvamozna intraepitelna lezija 3
4 Bethesda 1988 Squamous Cells Atypical squamous cells of undetermined significance ( ASCUS ) Squamous intraepithelial lesions ( SIL ) Low - grade SIL HPV associated changes, mild dysplasia / CIN 1 High - grade SIL moderate dysplasia / CIN 2 severe dysplasia / CIN 3 carcinoma in situ / CIS Sporne točke Bethesd ethesde 1988 Raspoložive metode liječenja u nas kasnih 80-tih s mogućim posljedicama za SIL Dvije reprodukciju skupine Modifikacija DM Bethesda 1988 SIL visokog Zagreb stupnja 1990 (u primjeni od 1993.) DM Dysplasia media Squamous cell carcinoma Bethesda 1988 Squamous Cells Zagreb 1990* Skvamozne stanice Atypical squamous cells Abnormalne skvamozne stanice neodređenog of undetermined significance ( ASCUS ) značaja aja Squamous intraepithelial lesions ( SIL ) Low - grade SIL HPV associated changes, mild dysplasia / CIN 1 High - grade SIL moderate dysplasia / CIN 2 severe dysplasia / CIN 3 carcinoma in situ / CIS Squamous cell carcinoma Skvamozne intraepitelne lezije ( S I L ) Dysplasia levis Dysplasia media Dysplasia gravis Carcinoma in situ CIN I CIN II CIN III Plus promjene povezane s HPV Carcinoma planocellulare SIL niskog stupnja SIL visokog stupnja * Audy-Jurkovi Jurković, Singer, Pajtler et al 4
5 ASCUS Atipične skvamozne stanice neodređenog značenja Abnormalnosti stanice koje su izrazitije od onih kod reaktivnih promjena,a kvantitativno i kvalitativno su nedovoljne za dijagnozu skvamoznih intraepitelnih lezija Kurman, Solomon 1994 Bethesda 2001 Squamous Cell Atypical squamous cells ( ASC ) of undetermined significance ( ASC - US ) cannot exclude HSIL ( ASC - H ) Squamous intraepithelial lesions ( SIL ) ASC -US ASC-HPočetna invazija? Low-grade squamous intraepithelial lesion ( LSIL ) HPV, mild dysplasia / CIN 1 High-grade grade squamous intraepithelial lesion ( HSIL ) moderate and severe dysplasia, CIS / CIN2, CIN3 with features suspicious for invasion Squamous cell carcinoma Zagreb 2002 * Skvamozne stanice Atipične skvamozne stanice ( ASC ) neodređenog značenja ( ASC - US ) ne može e se isključiti iti HSIL ( ASC - H ) ne može e se isključiti iti invazija Skvamozne intraepitelne lezije ( SIL ) Dysplasia levis CIN 1 Low-grade SIL Dysplasia media CIN 2 Dysplasia gravis High-grade grade SIL Carcinoma in situ CIN 3 Plus promjene povezane s HPV Početna invazija se ne može e isključiti iti Carcinoma planocellulare * Ovanin-Raki Rakić, Pajtler, Stanković et 5
6 Cilindrični ni epitel Bethesda Glandular Cells Presence of endometrial cells in one of the following circumstances Out - of - phase in a menstruating woman In a postmenopausal woman No menstrual history available Atypical glandular cells of undetermined significance (AGCUS) Endometrial Endocervical Not other specified Adenocarcinoma Specify probable site of origin : endocervical, endometrial, extrauterine Not other specified Zagreb (Audy, Singer, Pajtler) Cilindrične stanice Abnormalne cilindrične stanice neodređenog značenja Endometrijske Endocervikalne Neodređenog porijekla Adenocarcinoma Endometrija Endocerviksa Ekstrauterini Neodređenog porijekla 6
7 AGCUS Atipične cilindrične stanice neodređenog značenja Atipija jezgre endometralnih ili endocervikalnih cilindričnih stanica koja je izrazitija od reaktivnih ili reparativnih promjena, a bez jasnih značajki za invazivni adenokarcinom Kurman, Solomon 1994 AGCUS - podjela neklasificirane vjerojatno reaktivne vjerojatno premaligne / maligne Revizija Bethesda 1988,
8 Bethesda 2001 Glandular Cell: Atypical glandular cells (AGC) endocervical cells ( NOS or specify in comments ) endometrial cells ( NOS or specify in comments ) glandular cells ( NOS or specify in comments ) Atypical glandular cells endocervical cells, favor neoplastic glandular cells - NOS, favor neoplastic Endocervical adenocarcinoma in situ (AIS) Adenocarcinoma endocervical, endometrial, extrauterine not otherwise specified ( NOS ) Zagreb 2002 (Ovanin, Pajtler, Stanković i sur.) Glandularne stanice: Atipične glandularne stanice (AGC) Vjerojatno reaktivne promjene Vjerojatno intraepitelna lezija Vjerojatno invazivna lezija Adenocarcinoma in situ (AIS) Adenocarcinoma Porijeklo: Endocervikalne Endometralno Ekstrauterino Neodređeno Zagreb 2002 (Ovanin, Pajtler, Stanković i sur.) Glandularne stanice: Atipične glandularne stanice (AGC) Vjerojatno reaktivne promjene Vjerojatno intraepitelna lezija Vjerojatno invazivna lezija Adenocarcinoma in situ (AIS) Adenocarcinoma Porijeklo: Endocervikalne Endometralno Ekstrauterino Neodređeno BROJ ABNORMALNIH STANICA TIP DESKVAMACIJE JEZGRA - oblik, veličina, kromatin nukleoli, mitoze POZADINA RAZMAZA 8
9 Zagreb 2002 (Ovanin, Pajtler, Stanković i sur.) Glandularne stanice: Atipične glandularne stanice (AGC) Vjerojatno reaktivne promjene Vjerojatno intraepitelna lezija Vjerojatno invazivna lezija Adenocarcinoma in situ (AIS) Adenocarcinoma Porijeklo: Endocervikalne Endometralno Ekstrauterino Neodređeno Zagreb 2002 (Ovanin, Pajtler, Stanković i sur.) Glandularne stanice: Atipične glandularne stanice (AGC) Vjerojatno reaktivne promjene Vjerojatno intraepitelna lezija Vjerojatno invazivna lezija Adenocarcinoma in situ (AIS) Adenocarcinoma Porijeklo: Endocervikalne Endometralno Ekstrauterino Neodređeno 9
10 Zagreb 2002 (Ovanin, Pajtler, Stanković i sur.) Glandularne stanice: Atipične glandularne stanice (AGC) Vjerojatno reaktivne promjene Vjerojatno intraepitelna lezija Vjerojatno invazivna lezija Adenocarcinoma in situ (AIS) Adenocarcinoma Porijeklo: Endocervikalne Endometralno Ekstrauterino Neodređeno ADENOCa -diferencijalna dijagnoza REPARATORNI EPITEL POSTRADIJACIJSKE PROMJENE DECIDUALNA REAKCIJA PROMJENE KOD IUD a KARCINOM ( nekeratinizirani pločasti, anaplastični, endometralni, metastatski) ENDOCERVICITIS MIKROGLANDULARNA HIPERPLAZIJA TUBARNA METAPLAZIJA (endometrioidni tip) UZORAK UZET ČETKICOM NAKON KONIZACIJE ( BETTENDORF U.; BOON ME; SUURMEIJER g. ) 10
11 Z a k lj u č a k CIN II ( DM ) izdvajanjem iz HSIL u Zagreb 1990 i 2002 drugačiji dg.- th. postupnik ASC i AGC podjela na tri podskupine kraći i adekvatniji put do konačne dijagnoze AIS uvršten u klasifikaciju kao zasebna dijagnoza Zagreb 1990 i 2002 jedinstvene klasifikacije za cijelu Hrvatsku Prevalencija i histološka provjera atipičnih stanica (ASC i AGC) Barišić Ana, dr.med 11
12 Prevalencija (%) ASC AGC Dozvoljena * 5 1,8 KB Osijek, KB Rijeka, KBC Zagreb Petrova III / ,09-7,3 0,06-1,6 KBC Zagreb Petrova ( 2005.god.) 6,50 1,63 Literatura ** 1,0-10,32 0,11-2,10 * Kurman, Solomon 1994 ** Davey i sur 1996, Bergeron i sur 2000, Ferreccio i sur 2003, Chhieng i sur 2004, Kennedy i sur 1996, Korn i sur 1998, Manetta i sur 1999, Burja i sur. 1999, Histološka provjera - teža a lezija ( % ) ASC AGC CIN 2/3 intraepitelne 9,8-34,9-88 % pločasti epitel (skvamozne ili glandularne) 0,1-1,7 % invazija invazivne 4-12,7 invazija - 97% cilindrični epitel ( pretežno endometralni ) Solomon i sur 2001 Eltabbakh Eddy i sur i 1997 sur 2000, Soofer, Sidawy 2000, Eddy i sur 1997, De Simone i sur,
13 Zavod za ginekološku citologiju Petrova (2005. god VCE obrisaka) ASC (1803/ 6,50%) ASC-US (1511/ 5,45%) ASC-H (246/ 0,88%) ASC-inv? (46/ 0,17%) H I S T O L O Š K A P R O V J E R A 1 /0,06% 14 /5,69% CIN I ASC-H (11) ASC-H + ACG II/III (3) CIN II 2 CIN III 8 CIM 1 0 / 0% CIN III + AIS 2 Carcinoma Adenosquamosum (biopsija) 1 (Planocelulare trajni PHD) Zavod za ginekološku citologiju Petrova (2005. god VCE obrisaka) AGC (450/ 1,63%) H I S T O L O Š K A P R O V J E R A vjerojatno reaktivno (362/ 1,31%) vjerojatno intraepitelno (63/ 0,23%) 4 /6,35% Intraepitelne lezije 100% (4) CIN III, AIS 2 AIS 1 CIN III 1 vjerojatno invazivna (25/ 0,09%) 5 /20,0% Invazivne lezije 100% (5) AC endometrija 3 AC cerviksa 1 IC početna inv. 1 13
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