武功密笈

小黃藏書

1. Cytology Classification:

Bethesda System	Dysplasia/CIN System	Papanicolaou System
Within normal limit	Normal	I
Infection (organism should be specified)	Inflammatory atypia (organism)	II
Reactive and reparative changes
Squamous cell abnormalities ASCUS 　 　 LSIL 　 　 　 　 　 HSIL 　 　 Squamous cell carcinoma	Squamous atypia 　 HPV atypia 　 Mild dysplasia 　 Moderate dysplasia 　 Severe dysplasia 　 Carcinoma in situ 　 Squamous cell carcinoma	IIR 　 　 CIN 1 　 CIN 2 III 　 　 CIN 3 IV 　 　 V

v ASCUS: Atypical Squamous Cells of Undetermined Significance

v LSIL: Low-grade Squamous Intraepithelial Lesion

v HSIL: High-grade Squamous Intraepithelial Lesion

v HPV atypia º Koilocytosis

2. Diagnosis:

1. The Pap Test:

À Patients should be adviced:

not to douche for 48 hours before test

not to use vaginal creams for 1 week before test

to abstain from coitus for 24 hours before test

Á Four major factors causing sampling error:

improper collection, poor transfer from collecting device to slide,

air drying, contamination with lubricant

 Evaluation of the Abnormal Pap Smear: (Figure 16.9, p461)

G ASCUS: 2 alternatives

ã destruction of abnormal transformation zone, 或

ã Pap at the interval of 3-6 months (under the request of the patient)

< If a lesion persists more than 2 years, treatment should be recommended

because of the diminished likelihood of spontaneous regression.

ã destruction of abnormal transformation zone, 或

ã Pap at the interval of 3-6 months (under the request of the patient)

< If a lesion persists more than 2 years, treatment should be recommended

because of the diminished likelihood of spontaneous regression.

G LSIL:

- Colposcopy is generally preferable to performed to determine whether a lesion is

present.

- If LSIL is confirmed by histology, depending on the patient’s choice, ablation or

Pap at a interval of 4-6 months both make sense.

< If a lesion persists more than 1 years, treatment should be recommended.

G HSIL:

- colposcopy and directed biopsy

- Ablative therapy should be performed once HSIL is confirmed by colposcopy and

directed biopsy.

1. Colposcopy:

À Procedures:

Position the patient Ø Bringing the colposcope into position Ø Insert the speculum

Ø Expose the cervix Ø Repeat the pap, if necessary

Ø Cleanse the cervix with cotton swabs Ø Examine the cervix with the colposcope

Ø Apply acetic acid Ø Examine the columnar villi Ø Look for acetowhite epithelium

Ø Look for punctation and mosaic Ø Look for the external border of acetowhite lesions

Ø Look for the internal border of the acetowhite lesions

Ø Reexamine the cervix with the green filter Ø Ask three questions

Ø Colpophotography may be performed

Ø Perform the ECC under direct colposcopic vision

Ø Perform colposcopically directed biopsy of the most sever area

Ø Apply Monsel’s solution or silver nitrate for hemostasis

Ø Document the colposcopic findings.

Á Abnormal Findings:

¥ Leukoplakia:

¥ Acetowhite Epithelium:

¥ Punctation:

¥ Mosaic:

¥ Atypical Vascular Pattern:

1. Human Papillomavirus Typing:
2. Cervicography:

1. Treatment:

1. Methods:

- surgical excision, cryosurgery, laser vaporization, loop electrosurgical excision, etc.

2. Loop Electrosurgical Excision:

- Loop electrosurgical excision should not be used prior to identification of an intraepithelial

lesion that requires treatment.

- Power source (electrosurgical generator): 35-55 watts

Electrofulguration with ball electrode: 50-60 watts

z If too much electrofulguration occurs, the patient will develop an eschar with more discharge

and the risk of infection and late bleeding will be higher.

- Complications: hemorrhage (intraoperative or postoperative), and cervical stenosis.

3. Conization:

- Indications:

? Limits of the lesion cannot be visualized with colposcopy.

‚ The SCJ is not seen at colposcopy.

ƒ Endocervical curettage histologic findings are positive for CIN 2 or CIN 3.

„ There is a lack of correlation between cytology, biopsy, and colposcopy results.

… Microinvasion is suspected based on biopsy, colposcopy, or cytology results.

† The colposcopist is unable to rule out invasive cancer.

4. Hysterectomy:

- too radical for treatment of CIN

- Indications:

? Microinvasion

‚ Cervical intraepithelial neoplasia at limits of conization specimen

ƒ Poor compliance with follow-up

„ Other GYN problems, eg. fibroids, etc.

… Cancerphobia

　

• asymptomatic:
• often accompanying active HPV infection

è vulvar warts, odoriforous vaginal discharge from vaginal warts

• often accompanying CIN

1. Screening:

• for women with positive CIN,

è Colposcopic examination for possible VAIN lesions

1. Diagnosis:

• Colposcopic examination and directed biopsy

1. Treatment:

1. VAIN 1/HPV infection: no treatment required
2. VAIN 2: ablation therapy
3. VAIN 3:

- Small lesions: excision

- Lesion occupying the entire vagina: total vaginectomy with a split-thickness skin graft

　

1. Classification:

Nonneoplastic epithelial disorders of skin and mucosa: Lichen sclerosus (lichen sclerosis et atrophicus) Squamous hyperplasia (formerly hyperplastic dystrophy) Other dermatoses

Mixed nonneoplastic and neoplastic epithelial disorders

Intraepithelial neoplasia: Squamous intraepithelial neoplasia VIN 1 VIN 2 VIN 3 (severe dysplasia or carcinoma in situ) Nonsquamous intraepithelial neoplasia Paget’s disease Tumors of melanocytes, noninvasive

Invasive tumors

2. Vulvar Intraepithelial Neoplasia (VIN):

1. Grading:

VIN 1: mild dysplasia

VIN 2: moderate dysplasia

VIN 3: severe dysplasia or carcinoma in situ

2. Treatment:

- simple excision, laser ablation, or superficial vulvectomy with or without STSG

- for extensive and recurrent VIN: superficial vulvectomy with or without STSG

1. Paget’s Disease of the Vulva:

(extramammary Paget’s disease of the vulva, adenocarcinoma in situ)

1. Clinical Features:

- pruritus, vulvar soreness, eczematoid appearance

- 30% patient with second synchronous or metachronous primary neoplasm:

eg. cervical cancer, colon cancer, rectal cancer, bladder cancer, gallbladder cancer, and

breast cancer.

2. Treatment:

- The underlying dermis should be removed for adequate histologic evaluation.

- If underlying invasive carcinoma is present,

Ö radical vulvectomy and at least an ipsilateral inguinal-femoral lymphadenectomy

- for recurrent disease: surgical excision (Recurrent lesions are almost always in situ.)