Precancerous diseases of the female genital organs. Topic: Background and precancerous diseases
Lecture 13.
Topic: Background and precancerous diseases
Female genital organs.
Plan.
1. Background and precancerous diseases of the cervix.
2. Hyperplastic processes of the endometrium.
3. Precancerous diseases of the ovaries.
4. Precancerous diseases of the external genitalia.
RELEVANCE OF THE TOPIC
The problem of prevention and early diagnosis of cancer of the female genital organs is very relevant due to the fact that in the last 10 years the incidence of cancer has increased several times, and the age of patients diagnosed for the first time has become 10 years younger. The development of malignant tumors of the female genital organs, as a rule, is preceded by various pathological conditions against which they arise. Diagnosis of background and precancerous diseases and their timely treatment are reliable measures for cancer prevention.
Midwives independently conduct preventive examinations of the female population at first aid stations, examination rooms, etc. Therefore, it is very important to study this topic and understand that diagnosis of precancerous conditions leads to cure and recovery of patients in 98-100% of cases.
BACKGROUND AND PRE-CANCEROR DISEASES OF THE FEMALE GENITAL ORGANS
Background- pathological conditions, congenital or acquired, against which precancer and cancer occur.
Precancer - conditions that are characterized by a long course of the dystrophic process, with a tendency to malignancy. The concept of “precancer” includes a complex of clinical and morphological signs:
- clinical- 1. duration of the dystrophic process;
2. has a tendency to malignancy.
- morphological- 1. atypical proliferation of the epithelium;
2. focal proliferations.
Not every precancer turns into cancer. These conditions can exist for a long time without developing into cancer. In other cases, the transition to cancer occurs quickly. Timely treatment of precancerous conditions is a good prevention of cancer.
Background processes of the cervix.
1. true erosion;
2. ectopia or pseudo-erosion;
3. ectropion (may be eroded);
4. polyp c.c.s.m.;
5. leukoplakia;
6. erythroplakia.
True erosion - defect of the epithelial cover (explain the mechanism of its formation). Rarely occurs, because overlaps due to multilayered squamous epithelium advancing from the periphery or due to metaplasia, i.e. transformation of reserve cells into multilayered squamous epithelium. Regenerates within 1-3 weeks. But this is dangerous because precancer (dysplasia) occurs against the background of metaplasia.
In the mirrors - a rich red color, the surface of the erosion is smooth, it can be around the external pharynx, more often on the upper lip, it bleeds.
Ectopia- displacement of the columnar epithelium of the cervical canal to the vaginal part of the sh.m. Externally, ectopia resembles raspberries and red caviar. Causes- during puberty due to an increase in the production of sex hormones (congenital), after childbirth. It is observed in 10-18% of gynecological patients. Upon examination, the mirrors reveal a bright red velvety surface that is easily injured.
Ectropion - occurs as a result of deep disruption of the sh.m. after a deep rupture during childbirth and abortion. The scars that form deform the cervix, the mucous membrane of the cervical canal turns outward and the canal gapes.
It can be considered the main background for the development of precancer. When examined in the mirror, the mucous membrane is bright red, protrudes into the vagina, and scars from a former rupture are visible. If you bring the front and back lips closer together, the protrusion will disappear.
Polyp c.k.sh.m. - occurs as a result of chronic diseases of the cervix. More often there are mucous membranes, single and multiple, red and pink. If covered with columnar epithelium, it has a papillary surface.
Distractoses- this is a violation of the physiological process of keratinization of the epithelial layer.
Leukoplakia - has the appearance of white spots, sometimes dense plaques, tightly fused to the underlying tissue.
Erythroplakia - areas of thinned epithelium (atrophy of the mucous membrane), through which the vascular network is visible (hence the red spots).
Precancerous process-dysplasia.
The concept of “precancerous conditions of the cervix” has undergone significant revision in recent years. This term denotes changes in the cervix, which are observed during cytological or histological examination of its areas.
Dysplasia- This is atypia of the cervical epithelium, which is characterized by intense proliferation of atypical cells. 3 degrees - mild, moderate and severe. Moderate and severe often degenerates into cancer (20-30%). That. dysplasia is a borderline condition and has the ability to degenerate into cancer. They are not revealed when examined in mirrors.
Vaginal leukoplakia
Dystrophic changes in the vaginal mucosa, developing against the background of mild chronic inflammation, helminthic infestation, diabetes, and hormonal disorders.The disease manifests itself in the form of slightly raised plaques or white spots of varying sizes in the area of the labia, clitoris or perineum.
Kraurosis of the vulva
The disease develops against the background of mild chronic inflammation, helminthic infestation, diabetes, and hormonal disorders. There is wrinkling and atrophy of the external genital organs, thinning of their mucous membrane, which takes on the appearance of parchment paper, narrowing of the entrance to the vagina, and atrophy of the hair follicles.Vaginal papillomas
Papillary growths in the vaginal area, non-bleeding, soft. Sometimes multiple growths may appear. The cause of the disease is chronic inflammatory processes of the female genital organs, panillomovirus.Cervical diseases
Predisposing factors for the development of precancerous diseases and cervical cancer are early onset of sexual activity (15-18 years); sexual activity with multiple sexual partners, extramarital contacts; first pregnancy and childbirth before age 20 or after age 28; a large number of abortions (5 or more, especially out-of-hospital); chronic inflammation of the vagina and cervix (especially chronic trichomoniasis).A special risk group consists of women with pathological processes in the cervix:
Cervical erosion
Sharply defined, devoid of epithelium, bleeding surface. Manifests itself in the form of profuse leucorrhoea, contact bleeding during and after sexual intercourse.Cervical polyp
It is characterized by the presence of an outgrowth of the mucous membrane of the canal or the vaginal part of the cervix. Patients with cervical polyps, as a rule, complain of leucorrhoea, bloody discharge from the genital tract, and pain in the lower abdomen. Cervical polyps are precancerous conditions.However, removal of a polyp is not a radical cure, since it is known that the focus of tumor growth can arise from externally unchanged areas of the mucous membrane of the cervix, which indicates the appearance in all its areas of common prerequisites for the occurrence of both polyps and malignant tumors. Complicating the situation and increasing the risk of tumor degeneration of polyps is concomitant chronic inflammation of the cervix.
Leukoplakia of the cervix
A spot or large area of whitish color. Patients complain of copious or scanty white discharge.Diseases of the uterine body
Women with early (before 12 years) or late (after 16 years) puberty have a certain predisposition to the occurrence of precancerous diseases and uterine cancer; early (before 40 years) or late (after 50 years) menopause; women who are not sexually active, have not become pregnant, have not given birth, and often suffer from inflammatory diseases of the genital area.It is necessary to take into account heredity, since it has been established that a predisposition to ovulation disorders, obesity, diabetes mellitus and uterine cancer can be inherited.
Predisposing factors include, first of all, ovulation disorders, which cause primary or secondary infertility and are accompanied by the development of endometrial hyperplastic processes.
Polycystic ovary syndrome (Stein-Leventhal syndrome)
This disease is characterized by a long-term high concentration of estrogen in the blood, often leading to the development of hyperplastic processes in the uterus and sometimes to the development of endometrial cancer.Recurrent glandular endometrial hyperplasia
A typical precancerous disease, which manifests itself as irregularities in the menstrual cycle with very heavy periods. Sometimes uterine bleeding or spotting occurs during the intermenstrual period or during menopause.Endometrial polyps
The disease is manifested by long and heavy menstruation, frequent premenstrual bleeding from the genital tract. The causative factors for the occurrence of a pathological process in the endometrium are various kinds of stress, hormonal disorders, chronic inflammatory diseases of the female genital area, and hereditary burden of tumor diseases.Malignant degeneration of polyps is observed against the background of concomitant metabolic disorders, obesity and diabetes. Removal of a polyp is not a radical method of cure, since it is known that the focus of tumor growth can arise from externally unchanged areas of the endometrium, which indicates the appearance in all its areas of the same prerequisites, both for the occurrence of polyps and malignant endometrial tumors.
Uterine fibroids
A benign tumor of the uterus, consisting of muscle and connective tissue elements. In the conditions of modern stressful life, accompanied by excessive stress and toxic environmental influences, the frequency of this disease in women has increased sharply.The causes of the disease are frequent abortions, pathology of the cardiovascular system, liver disease, and hormonal disorders. Oncological alertness is caused by growing fibroids with an increase in myomatous nodes during menopause and menopause.
Obesity and diabetes mellitus are common precursors to uterine cancer. Therefore, identifying and treating not only overt, but also latent diabetes mellitus in women with any of the listed diseases is an important preventive anti-cancer measure.
Ovarian diseases
It is well known that there is a high incidence of malignant and borderline ovarian tumors in women who have previously undergone surgery for benign tumors and tumor-like formations of the ovaries, or after removal of one of the ovaries, when the risk of developing a tumor in the remaining ovary increases. The incidence of malignant ovarian tumors in women who have previously undergone surgery for various gynecological and breast diseases increases sharply.Various long-term changes and irregularities in the menstrual cycle are conditions that precede malignant changes in the ovaries.
An increased risk group includes women who have previously taken hormones for a long time to suppress the estrogenic function of the ovaries.
To date, the most difficult distinction remains between ovarian tumors and inflammatory processes of the uterine appendages. According to various clinics, 3-19% of patients with malignant ovarian tumors are under observation with an erroneous diagnosis of “chronic inflammation of the uterine appendages,” and in 36% of cases, chronic inflammatory processes in the appendages are diseases associated with ovarian tumors. In addition, in some cases, these inflammatory processes play the role of a cause that provokes malignant transformations in benign ovarian tumors.
Benign tumors and tumor-like formations of the ovaries are represented by a large number of different forms. Patients' complaints and symptoms of the disease depend on the size and location of the tumor. Most often, patients complain of changes or disturbances in the menstrual cycle, pain in the lower abdomen, less often in the lower back and rectum, which is often the reason for erroneous treatment “for radiculitis” or “for hemorrhoids”. Large tumors are manifested by the presence of palpable formations of the appendages, pain, and abdominal enlargement. It must be remembered that any benign ovarian tumor can undergo transition to malignant.
A great danger in terms of the occurrence of malignant ovarian tumors is fraught with long-term passive observation of patients for low-symptomatic or asymptomatic uterine fibroids.
Concluding the description of precancerous diseases, it is necessary to note once again that the nature of these diseases does not lie in a local pathological change in any particular area of tissue or organ. The reason for the appearance of precancerous conditions is always hidden more deeply and goes beyond the scope of the individual damaged organ.
Pathological formations in organs or tissues can be compared to the tip of an iceberg, when the bulk of painful changes remain hidden, but the most significant. For this reason, surgical treatment, which eliminates only the visible manifestations of the pathological process, is at least incomplete.
At the same time, precancerous changes in organs and tissues do not necessarily turn into cancer; they are completely reversible with the possibility of partial or complete restoration of the functions of all damaged organs. This is achieved by an integrated approach to the emerging disease with the involvement in treatment of all organs and systems involved in the pathological process, without dividing a single disease with various organ manifestations into separate parts, which, unfortunately, happens with traditional treatment by medical specialists.
It must be remembered that the main factors contributing to the further progression of precancerous changes in tissues include: maintaining a state of chronic inflammation in the altered organs or the pathological focus itself; chronic intoxication due to latent or chronic foci of infections, as well as chronic household or professional toxic exposures; long-term disturbances in the functioning of the endocrine glands with hormonal imbalance and changes in metabolism; chronic stress, depleting the nervous and immune systems.
It becomes clear that treating a precancerous disease is not an easy task, but with a correct assessment of all the changes present in the patient, it is completely solvable. At the same time, the conscious participation and medical discipline of the patient himself is a necessary condition, since any, even the most effective prescriptions and useful advice from a doctor, cannot by themselves cure the patient. His active participation is necessary. When treating a precancerous disease, taking into account its possibility of transition or, conversely, not transitioning into cancer, the patient’s intelligence often becomes a more important factor than his immunity.
A.N. Gritsai, Doctor of Medical Sciences, Senior Researcher,
gynecological department
PRE-TUMOR DISEASES
FEMALE GENITAL ORGANS
VULVA
Etiology
Background diseases of the vulva are characterized by clinical and histological manifestations, expressed in dystrophic changes in the tissue of this organ. Their occurrence is associated with various metabolic and neuroendocrine disorders due to aging processes and changes in hormonal levels or viral infection.
Of great interest are chronic viral diseases of the vulva, the most common manifestation of which are genital warts (HPV 6 and 11), which are multiple warty lesions of the skin and mucous membrane. The disease is often combined with the presence of sexually transmitted infections. Rapidly progressing condylomas are classified as verrucous cancer. Prolonged existence of human papillomavirus infection can lead to true vulvar dysplasia and cancer.
Classification
Dystrophic changes in the vulva include: vulvar kraurosis, leukoplakia and atrophic vulvitis.
According to modern terminology, there are: lichen sclerosus or lichen (vulvar kraurosis), squamous cell hyperplasia (vulvar leukoplakia) and other dermatoses. Clinically, these processes have similar clinical manifestations. The frequency of these diseases ranges from 1 in 300 to 1 in 1000 women and occurs mainly in peri- or postmenopausal age. Possible causes of the disease are autoimmune and dyshormonal disorders. Recently, this pathology has been increasingly detected in patients of reproductive age and in 70% is combined with infectious agents of a specific and nonspecific nature.
Clinic
Initial manifestations of dystrophy, such as hyperemia, swelling of the vulva with vulvodynia, gradually turn into lichenification of the vulva - dryness of the upper layers, their wrinkling and peeling. Subsequently, the tissue begins to change at deeper levels and acquires a whitish color. These processes are reversible with adequate treatment directed against the cause that caused this condition. Otherwise, lichen sclerosus develops over the entire surface of the vulva with damage to the deep layers and a sharp thinning of the surface. The labia decrease in size, vulvodynia is a constant concern, the greatest discomfort is observed at night. Over time, foci of hyperplastic dystrophy appear on the affected tissue of the vulva in the form of hyperkeratotic plaques, merging into large layers, often tearing off themselves, forming erosive surfaces.
Diagnostics
It is carried out comprehensively and includes: visual examination, vulvoscopy, cytological and necessarily histological examination of the affected surface.
Lichen sclerosus and squamous cell hyperplasia can be combined with each other, in which case the risk of cellular atypia and its progression to cancer increases. The probability of malignancy for each disease is relatively small (up to 5%).
Treatment
It involves a set of measures: anti-inflammatory, sedatives, antihistamines, multivitamins, corticosteroids, physiotherapy using laser and magnetic effects. In the presence of a viral lesion of the vulva, antiviral and immunomodulatory treatment is carried out, followed by surgical removal of the lesion; in this case, various physical methods of conservative surgery are used.
PRE-CANCER DISEASES OF THE VULVA
Etiology
The cause of the development of dysplastic changes in the integumentary epithelium of the vulva is considered to be a local viral infection caused by papillomavirus, especially HPV 16. In 60%, the accompanying factor is smoking. An increase in incidence in young patients has been established. The average age of onset of the disease has decreased from 55 to 35 years. In almost 50% of cases, damage to the vulva is combined with similar or more severe dysplastic changes in the epithelium of the cervix, as well as with genital warts. If left untreated, the process progresses to invasive cancer, usually within 10 years; spontaneous regression of the pathological process is possible, especially during pregnancy. The incidence of the disease is 0.53 per 100 thousand women.
Dysplasia is a morphological diagnosis, characterized by disruption of cell differentiation processes. There are mild (VINI), moderate (VINII) and severe degrees (VINIII) of dysplasia. In mild cases, changes are observed only in the lower third of the epithelial layer; in severe cases, they occupy the entire layer, and keratinization and mitoses are observed in the most superficial cells.
Clinic
In 60% of patients, dysplasia is asymptomatic. In 30%, clinical manifestations are very varied. Papular lesions are often found, raised above the skin and having a scaly surface, in appearance resembling flat condylomas or weeping with the appearance of moist erythema. Leukoplakia is often detected. VINI is often represented by a subclinical picture of human papillomavirus infection. In patients with clinical complaints (itching - in almost 75% of cases, pain in the vulva, anus, vagina) signs of VINII or VINIII are usually found, the lesion may be one or more.
Diagnostics
It is considered mandatory to conduct a histological examination of the biopsy specimen.
Treatment
The treatment method depends on the patient’s age, the degree of dysplasia and the number of lesions. At a young age, preference is given to more gentle surgical methods in the form of excision of the pathological focus, chemical coagulation, ablation using a carbon dioxide laser, cryodestruction, and radiosurgery. For small and multiple lesions, preference is given to laser vaporization. For large and multiple lesions, stage-by-stage re-excision of the lesions is performed. Superficial vulvectomy is performed in cases where the risk of invasion is high, that is, in middle and older age, as well as with extensive lesions and recurrent dysplasia. Complete excision makes it possible to definitively determine the extent of possible invasion and should be carried out within a minimum of 8 mm of healthy tissue.
CERVIX
Background processes of the cervix among gynecological diseases in women of reproductive age are 10-15.7%. Background diseases are observed in 80-90% of cases of all cervical pathology, respectively, 10-20% are precancerous and malignant diseases of this organ. The incidence of malignancy of precancerous lesions of the cervix is 6-29%.
Background diseases include true erosions, ectopia, endometriosis, cervicitis, condylomatosis, papillomatosis, deciduosis, ectropion. Pretumor lesions include squamous cell hyperplasia and dysplasia.
Etiology
Of the etiological factors for the occurrence of background and precancerous diseases of the cervix, the following are considered the main ones:
Inflammatory diseases of the cervix, vagina and uterus caused by various microbial, viral factors and their combination;
Dishormonal disorders;
Mechanical injuries;
A combination of these reasons.
Currently, more than 100 different types of HPV have been identified, of which 30 infect the genital tract. Among the types of HPV infections, groups of different oncogenic risk are distinguished. Thus, HPV 6 is considered to be at low cancer risk; eleven; 40; 42; 43; 44 and 61 types, to average risk – 30; 33; 35; 39; 45; 52; 56; 58, high risk – 16; 18; 31. In morphological manifestation 11; 39; 42; 44; 53; 59; HPV types 62 and 66 are associated with low-grade squamous intraepithelial lesions; 16; 51; 52; 58 – with high-grade squamous intraepithelial lesions, 16; 18; 31; 51; 52; 58 – with squamous cell cancer; Types 16 and 18 – with adenocarcinoma. Varying degrees of susceptibility of the cervical epithelium to viral damage are associated with genetic predisposition. Gene discovered in the human genome p53, which is responsible for suppressing tumor growth.
The combination of HPV with other risk factors can significantly increase the incidence of cervical pathology. The risk of the disease increases with frequent and prolonged smoking, with long-term use of hormonal contraceptives (more than 12 years), with the use of an IUD (more than 5 years), with frequent changes of sexual partners, a low social standard of living, and a large number of abortions and childbirths.
Classifications
Modern classifications of pathological changes in the cervix are based on histological examination data, as well as on the results of colpocervicoscopy, and there are practically no old terms in them. In the 2nd edition of the histological classification of tumors (HCT) of the female reproductive system (1996), in addition to benign and malignant tumors, the section “Epithelial tumors and associated lesions” presents data on squamous and glandular neoplasms.
Squamous cell formations include: papilloma, condyloma acuminata with morphological signs of human papillomavirus infection (PVI), squamous metaplasia and metaplasia of the transitional cell type, squamous atypia of undetermined significance observed in cells during cervicitis and reparative processes, low severity of intraepithelial squamous cell damage (LSIL), including cervical intraepithelial neoplasia CINI and/or human papillomavirus, high severity intraepithelial squamous cell lesion (HSIL), including moderate and severe degrees of dysplasia CIN II and CIN III and squamous cell carcinoma.
Classification of background diseases,
precancerous conditions of the cervix(Yakovleva I.A., Kukute B.G., 1979)
|
Background processes |
Precancerous processes |
|
A. Hyperplastic, associated with hormonal imbalance 1. Endocervicosis: proliferative healing 2. Polyps: proliferative epidermalizing 3. Papillomas 4. Simple leukoplakia 5. Endometriosis B. Inflammatory: true erosion cervicitis B. Post-traumatic ruptures: ectropion scar changes cervicovaginal fistulas |
A. Dysplasia that occurs on an unchanged neck or in the area of background processes: mild, severe B. Leukoplakia with cell atypia B. Erythroplakia G. Adenomatosis |
In this classification, dysplastic changes (cervical intraepithelial neoplasia - CIN) are grouped under the name squamous intraepithelial lesions of varying severity (LSIL, HSIL). It should be noted that CIN I degree of severity is synonymous with mild dysplasia, CIN II degree - moderate, the concept of CIN III severity is used to designate both severe dysplasia and preinvasive carcinoma. To designate leukoplakia with atypia, which in the domestic literature is classified as a precancerous lesion, the term dysplasia with keratinization is used abroad.
Clinic
All changes in the cervix are associated either with age-related hormonal changes, or with hormonal imbalance and immune status, or with the influence of external factors: infection, chemical, physical, traumatic damage during childbirth or as a result of therapeutic measures.
BACKGROUND PROCESSES OF THE CERVIX
Classification of cervical ectopia (Rudakova E.B., 1996)
Types: Forms:
1. Congenital 1. Uncomplicated
2. Acquired 2. Complicated
3. Recurrent
CERVICAL ECTOPIA
The prevalence of this pathology in women is extremely high (38.8%), including in 49.2% of gynecological patients; it is most often detected in nulliparous women under the age of 25 years (from 54.25 to 90% of cases). Currently, there are 3 types of ectopia (Rudakova E.B. 1999, 2001): congenital is detected in 11.3% of women, acquired - in 65.6% and recurrent - in 23.1%, as well as 2 clinical forms: complicated in 82.3% and uncomplicated in 17.6%. Complicated forms of ectopia include its combination with a violation of the epithelial-stromal relationship (ectropion) with inflammatory processes of the cervix and vagina, with other background, as well as precancerous processes (polyp, squamous hyperplasia).
Cervicitis - total inflammation of the cervix, including the mucous membrane of the vaginal part of the cervix (ectocervicitis and endocervicitis). Cervicitis is one of the main causes of cervical ectopia, which is combined with it in 67.7% of cases. However, the existence of an independent disease is also possible. The cause of the development of this pathology is specific and nonspecific infectious agents.
Polyp - This is the growth of the mucous membrane of the cervical canal. Detection frequency is 1-14% of patients. This pathology occurs at any age; it is combined with ectopia in 2.8% of cases.
Cervical endometriosis often combined with other forms of endometriosis. Most often, this condition of the cervix occurs after diathermocoagulation, and occurs in 0.8-17.8% of cases.
Cervical erosion - This is the rejection of the epithelium as a result of inflammation, disruption of trophic processes, chemical exposure, and diathermocoagulation. The absence of the integumentary epithelium is usually short-term and therefore, as a disease itself, is rare.
Clinic
With uncomplicated background processes, patients do not present specific complaints. However, in the presence of inflammatory processes on the part of the appendages, uterus, or the actual addition of a specific and/or nonspecific infection of the cervix, patients note leucorrhoea of a pathological nature, burning, itching, pain, and postcoital bleeding. When examined in mirrors, background processes have a clearly defined pattern and are easily diagnosed.
PRE-CANCEROR CONDITIONS OF THE CERVIX
Leukoplakia is a pathology of the cervix, which in 31.6% of cases is associated with the occurrence of dysplasia and malignant transformation of stratified squamous epithelium against the background of dyskeratosis. The frequency of this disease is 1.1%, in the structure of cervical pathology it is 5.2% and 80% of all precancerous pathology of the cervix. The following forms of leukoplakia are distinguished:
1. Colposcopic form (silent iodine-negative zones);
2. Clinically expressed forms: simple leukoplakia, warty leukoplakia, base of leukoplakia, leukoplakia fields.
Dysplasia- histological diagnosis, expressed in flattening of tissue of a regressive type, associated with a decrease in differentiation. Dysplasia can occur on unchanged mucosa, or can accompany any of the underlying conditions of the cervix. Dysplasia can also be a disease itself, or it can precede and/or accompany cancer. The frequency of detection of dysplasia during medical examinations is 0.2-2.2%. Diagnostic criteria for cervical dysplasia include disruption of the epithelial structure, cell polymorphism, nuclear hyperchromia, and an increase in the number of mitoses. The more mitoses and the more pronounced cell polymorphism, the more severe the dysplasia. If the described changes are found only in the lower third of the epithelial layer, they speak of mild dysplasia; if they are detected in the lower and middle thirds, they speak of moderate dysplasia; if they involve the entire thickness of the epithelium, they speak of severe dysplasia.
Diagnostics
The main methods for diagnosing any pathological conditions of the cervix are examination in mirrors, simple and extended colposcopy, assessment of vaginal microbiocenosis with active HPV typing, cytological examination of fingerprint smears (the so-called Pap smears) and targeted biopsy followed by histological examination. Diagnostic signs are compared, and treatment tactics are selected.
Treatment
Treatment involves following the main steps.
Stage I - vaginal sanitation. The duration of treatment depends on the number of combined infectious agents and is carried out in a complex manner with the inclusion of etiotropic antibacterial, immunomodulatory, and enzyme drugs.
Stage II - local treatment of the cervix. For background diseases of the cervix and CIN I-II in nulliparous women, it is possible to use gentle methods of physical influence - cryodestruction, laser vaporization, radiosurgical treatment. For recurrent ectopia in women who have given birth, ectropion, CIN II-III, preference is given to cone-shaped excision of the cervix, which is carried out using laser, radio, and surgical methods. Surgical treatment in the scope of hysterectomy for CIN III is performed: in perimenopausal age, in combination with other background gynecological pathology and in the absence of technical conditions for performing cone-shaped excision of the cervix.
Stage III - correction of vaginal microbiocenosis of hormonal and immune background, stimulation of reparative processes of the cervix and vagina.
BODY OF THE UTERUS
Uterine fibroids (MM)- one of the most common gynecological diseases. Among outpatient gynecological patients, MM occurs in 10-12%, in inpatients 17%, among the total number of operated patients from 35 to 50%. The detection rate of this pathology during medical examinations is 8-9%. In 53.3-63.5%, MM is detected at the age of 40-50 years, 15-17% at the age of 30-40 years. It is more common (60.1%) among women with mental work and residents of large cities than among women with physical work and those living in rural areas (9.4%).
Classification
MM is a benign tumor of muscle and connective tissue elements. EAT. Vikhlyaeva and L.N. Vasilevskaya (1981) recommended the following names for MM depending on the predominance of muscle or connective tissue. Subserous nodes should be called fibromyomas, because. the ratio of parenchyma to stroma is 1:3, that is, the connective tissue component predominates, intramural and submuscular nodes - fibroids or leiomyomas, where the ratio is 2:1 or 3:1. Statistics on the location of the nodes are as follows: subserous nodes are detected from 12.3 to 16.8%, interstitial or intramural - in 43% of cases, submucosal - from 8.1 to 28%. Myomatous nodes develop in 92-97% of the body of the uterus and only 8-5% in the cervix. In 3.5-5% of cases, an interligamentous location of the node is possible. Multiple MM is observed in 85%, and a combination of interstitial and subserous nodes is observed in 82.9%.
Etiology and pathogenesis
The occurrence of MM is facilitated by disturbances of endocrine homeostasis in the links of the hypothalamus-pituitary-ovaries-uterus chain. These disorders may be based on hereditary predisposition, inflammatory or atrophic changes, ovarian dysfunction, endocrinopathies, and somatic diseases. There are primary hormonal disorders due to infantilism, primary endocrine infertility, dyshormonal disorders in the peripubertal period and secondary hormonal disorders against the background of an altered neuromuscular receptor apparatus of the myometrium (abortion, intrauterine interventions of a different nature, complications of childbirth, chronic inflammatory processes).
The opinion accepted in the recent past about the leading role of hyperestrogenism in the pathogenesis of MM has now been revised. Almost 70% of patients have an ovulatory, unchanged menstrual cycle. In contrast to previously existing assumptions about the main role of estrogens in the growth and proliferation of MM, the modern concept is characterized by the establishment of a key role not only of estrogens, but, to a greater extent, of progesterone. G.A. Savitsky et al. (1985) revealed that the content of estrogen and progesterone in the vessels of the uterus is higher than in the peripheral blood (the phenomenon of local hyperhormonemia). The implementation of exo- and endogenous hormonal influence in the MM tissue is ensured by the presence in it of a specific receptor protein that is related to estrogen (ER) or progesterone (RP). So Yu.D. Landechowski et al. (1995) it was found that 50-60% of MM nodes are both ER+ and ER+, and 25-30% ER+ and ER–. In this case, given the leading role of progesterone in the pathogenesis of MM, it is suggested that there is RP dysfunction, abnormalities in the structure of receptors or mutant forms. Steroid hormones realize differentiation and proliferation of tissues at the local cellular level. Among the factors of intercellular interaction, germ factors play an important role. In MM, the following have been studied and compared with the clinical picture: insulin-like, epidermal, vascular endothelial growth factors, platelet growth factor, fibroblasts, tumor necrosis factor, interferon-2, interleukin-1, endothelin-1. All factors except interferon-2 stimulate cell growth. Modern studies of the pathobiology of MM pay close attention to the study of proliferative potential, apoptosis, angiogenesis during tumor growth and development and are carried out at the molecular genetic level. According to preliminary data, the most common cytogenetic abnormalities in MM are: translocation within or deletion of chromosome 7, translocation involving chromosome 12, especially chromosome 14, and structural aberrations of chromosome 6. Aberrations have also been described for chromosomes 1, 3, 4, 9 and 10. More pronounced, but similar changes occur in the study of patients with uterine sarcomas.
Clinic
Clinical manifestations of the disease are mainly determined by the size, quantity, location and growth rate of myomatous formations. With slow growth and small-sized formations, the disease is asymptomatic (42%).
With an increase in the growth of nodes, the main clinical manifestation is various disorders of menstrual function from hyperpolymenorrhea to menometrorrhagia (75%). Most of all, this symptom is characteristic of the submucosal and interstitial location of MM.
Pain syndrome was noted in 21-56% of cases. The pain can be acute or chronic. Acute pain is a sign of urgent clinical situations: necrosis or torsion of a tumor node. Clinically, hyperthermia, symptoms of peritoneal irritation, and leukocytosis are additionally detected. Constant pain is a sign of rapid tumor growth or its interligamentous location. Cramping pain is characteristic of a “nascent” submucous node.
With significant sizes of MM, a symptom of compression of adjacent organs appears (14-25%). 10% of patients complain of dysuric disorders; the interligamentous location of nodes can cause ascending pyelonephritis and hydronephrosis. Compression of the sciatic nerve contributes to the appearance of radicular pain. Compression of the rectum leads to constipation.
Sometimes the only clinical manifestation of MM may be pathological profuse watery leucorrhoea. With necrosis of the mucous membrane of the submucosal nodes, leucorrhoea acquires a foul odor.
Diagnostics
Diagnosis, as a rule, is not difficult and includes comparison of medical history, patient complaints, bimanual palpation, ultrasound examination, uterine probing, and separate diagnostic curettage. In some cases, CT, MRI, angiography, cystoscopy, and sigmoidoscopy are performed. The entire diagnostic algorithm is aimed at clarifying the size of the tumor, its location, the condition of the myomatous nodes, the nature of the disorders of neighboring organs and the combination of fibroids with other background, precancerous or oncological pathology.
The long-term existence of MM and impaired vascularization of tumor nodes can lead to the following secondary dystrophic and degenerative changes occurring in myomatous nodes - swelling of the MM node. The nodes are soft, pale in color when cut, with fluid sweating and the formation of cavities. Such MMs are called cystic - necrosis of MM nodes. There are dry, wet and red necrosis. With dry necrosis, tissue shrinks with areas of necrosis; such changes occur in patients during the menopausal period. With wet necrosis, tissue softening and the formation of cavities filled with necrotic masses are noted. Red necrosis (hemorrhagic infarction) is more common in patients during pregnancy. The node becomes full-blooded, with a violation of the structure, the veins of the node are thrombosed.
Infection, suppuration, abscessation of nodes:
Salt deposition in MM:
Node atrophy:
An important point in the diagnosis of MM is its combination with other gynecological diseases. During a comprehensive examination of the endometrium in MM, glandular cystic endometrial hyperplasia was observed in 4% of cases, basal hyperplasia
zia - in 3.6%, atypical and focal adenomatosis - in 1.8%, polyps - in 10% of cases. According to some observations, detection of endometrial pathology is possible in 26.8% of cases.
According to Ya.V. Bokhman (1987) atypical hyperplasia was noted in 5.5%, endometrial cancer - in 1.6% of cases in patients with MM, in 47.7% of patients with EC concomitant MM was detected. At the Jena University Clinic, during an examination of patients with MM, ER was found in 5.2%; a similar number of patients with MM (6.7%) were identified during surgery for cervical cancer.
The commonality of the pathogenesis of MM and a number of malignant diseases makes it possible to identify patients with MM as a high-risk group for the development of malignant tumors. This determines a more active tactic for identifying this pathology with the exclusion of endometrial pathology, emphasizing the feasibility and need for corrective neoadjuvant measures and the timeliness of surgical treatment.
Treatment
The choice of treatment method and treatment regimen are determined taking into account the main diagnostic features of the development of MM.
Conservative treatment of MM is carried out if the size of the tumor does not exceed 12 weeks of pregnancy and if the tumor is located interstitially or subserosally. In this case, it is advisable to prescribe a set of therapeutic measures, including: regulation of wakefulness and sleep; sedatives, antidepressants; vitamin therapy with the maximum combination of vitamins E, A, C; symptomatic hemostatic and antianemic therapy, immunomodulatory drugs, herbal medicine, spa treatment. Taking into account the pathogenetic aspects, hormonal therapy is given one of the main places in this complex. Currently, the following are recommended for use in the treatment of MM: gestagens (Norkolut, Depo-Provera, Provera, Dufoston), combined estrogen-gestagens (Marvelon, Femoden, Silest), antigonadotropic drugs (Danazol), analogues of gonadotropin-releasing hormones (Zoladex, Buserelin -Depot, Naforelin). Hormone therapy can be carried out as a step to further surgical treatment, as well as after performing a conservative myomectomy.
The main treatment method for MM is surgery (from 52% to 94% of cases).
Indications for surgical treatment:
disorders of the menstrual-ovarian cycle and ineffectiveness of conservative treatment;
rapid tumor growth;
dysfunction of neighboring organs.
radical,
semi-radical,
conservative.
Radical operations are considered interventions in the amount of hysterectomy, supravaginal amputation of the uterus. Semi-radical include defundation, high amputation of the uterus, conservative - myomectomy, enucleation of nodes, removal of a submucosal node.
BACKGROUND AND PRE-CANCERUS DISEASES OF THE UTERUS BODY
Hyperplastic processes of the endometrium are diseases defined exclusively at the morphological level, which are the result of hormonal disorders in perimenopausal patients. The frequency of this condition among various hyperplastic processes ranges from 5.8 to 6.2%, and 10-12.4% develop into cancer.
Classification
The WHO histological classification identifies 3 main types of hyperplastic processes in the endometrium: endometrial polyps (glandular, glandular-fibrous, fibrous polyps), endometrial hyperplasia (glandular, glandular-cystic hyperplasia) and atypical endometrial hyperplasia.
G.M. Savelyeva et al. (1980) proposed a clinical and morphological classification of endometrial precancer:
1. Adenomatosis and adenomatous polyps;
2. Glandular hyperplasia in combination with hypothalamic and neurometabolic endocrine disorders at any age;
3. Recurrent glandular hyperplasia of the endometrium, especially in perimenopausal age.
Etiology, pathogenesis
In the development of this pathological condition, particular importance is given to concomitant somatic pathology (functional state of the liver, thyroid gland, pancreas, cardiovascular system, excess weight), as well as changes in the ovaries. All these conditions lead to absolute or relative hyperestrogenism. In this case, all hyperplastic processes have disturbances in both central and peripheral hormonal components. However, during background processes they affect the pituitary profile to a lesser extent, changing only the functional activity of the ovarian tissue. In precancerous conditions, persistent hypergonadopropism is determined, which persists until deep menopause.
Clinic
For a long time, this disease can be asymptomatic and is often detected in combination with other gynecological pathologies (uterine fibroids, endometriosis, functional ovarian cysts).
The main symptoms, as a rule, are bloody discharge from the genital tract that appears during menopause, or any menstrual dysfunction from hyperpolymenorrhea to menometrorrhagia in patients of the reproductive period.
Diagnostics
The main diagnostic method is histological examination of the endometrium. Material for research can be obtained by aspiration biopsy or by separate diagnostic curettage of the uterus with hysteroscopy. Recently, great importance has been given to the role of ultrasound in the diagnosis of hyperplastic processes. However, the accuracy of this method is not high enough (up to 88%). The capabilities of this method increase significantly when using color Doppler mapping (CDC), which allows one to determine the nature of changes in the endometrium based on the characteristics of blood flow. It is generally accepted that endometrial thickness up to 5.5 mm (with individual values from 1 to 44 mm) determines the benign nature of the lesion, and for malignant processes - 24 mm (from 7-56 mm). When examining endometrial vessels, a significantly higher number of signals in the color flow mode is observed in endometrial cancer than in hyperplastic processes (87 and 34%). According to L.A. Ashrafyan et al. (2003) this method in its improved version is suitable for screening endometrial pathology.
Treatment
Considering the nature of pathogenetic changes, treatment should be carried out comprehensively, including correction of somatic, background gynecological pathology, hormonal and surgical effects.
Priority in the treatment regimen is determined by the histological structure of hyperplastic processes.
Hormonal therapy is indicated in cases of glandular endometrial hyperplasia. In this case, a wide arsenal of drugs is used depending on the patient’s age: gestagens (Norkolut, Depo-Provera, Provera, Dufoston), combined estrogen-gestagens (Marvelon, Femoden, Silest), antigonadotropic drugs (Danazol), analogues of gonadotropin-releasing hormone ( Zoladex, Buserelin-Depot, Naforelin).
After 3 months of treatment, the effectiveness of this treatment is determined (repeated endometrial biopsy).
For endometrial polyposis, “minor” surgical techniques are used: separate diagnostic curettage with hysterectomy; in case of relapses of the disease,
niya - ablation of the endometrium.
For atypical hyperplasia, treatment tactics are determined by the age of the patient. In postmenopausal age, preference is given to the surgical method involving extirpation of the uterus and appendages.
Hormone therapy may be prescribed as a neoadjuvant step. This method is also preferable when hyperplastic processes are combined with other gynecological surgical pathology and hormone therapy is ineffective.
For patients of reproductive age, indications and methods for treating atypical hyperplasia using only hormone therapy have been developed. Norkolut, Depo-Provera, Provera, Duphoston, antigonadotropic drugs (Danazol), analogues of gonadotropin-releasing hormone (Zoladex, Buserelin-Depot, Naforelin) are used. Treatment continues for up to 12 months with a control biopsy every 3 months of treatment.
In perimenopausal patients with dysfunctional uterine bleeding, with severe somatic pathology, preference is given to the use of microinvasive surgical interventions: combined diathermy (loop diathermy in combination with roller diathermy), resection (diathermy with a loop only), roller diathermy, laser ablation (using laser energy) , radiofrequency ablation (using radiofrequency exposure) and cryoablation (using cryotechniques). The effectiveness of these methods is significantly higher than surgical ablation (80-90%), and the combination with hormone therapy helps achieve amenorrhea in 70% of patients.
Precancerous diseases can be facultative or obligate. Obligate precancer is an early oncological pathology, which over time tends to develop into cancer. In contrast, facultative precancerous diseases do not always develop into cancer, but require very careful monitoring. Moreover, the longer the treatment of an optional precancerous condition is delayed, the higher the likelihood of developing a malignant tumor. Find out in the article which ailments are classified as precancerous conditions.
Precancerous diseases: types and causes of development
The presence of a precancerous background does not at all indicate that it will absolutely turn into cancer. Thus, precancerous diseases turn into malignant ones only in 0.1–5% of cases. Diseases that fall under the category of precancerous include almost all chronic inflammatory processes.
- precancerous diseases of the gastrointestinal tract;
- precancerous skin diseases;
- precancerous diseases of the genital organs in women.
Precancerous diseases of the gastrointestinal tract
The probable cause of cancer development is chronic gastritis, especially its anacid form. Atrophic gastritis poses a great danger; in this case, the incidence of cancer is 13%.
Menetrier's disease (tumor-stimulating gastritis) is also a precancerous disease - this disease is the cause of stomach cancer in 8-40% of cases.
The likelihood of a gastric ulcer becoming malignant depends on its size and location. The risk increases if the ulcer diameter exceeds 2 cm.
Pre-tumor pathology of the stomach includes gastric polyps, especially the group of adenomatous diseases more than 2 cm - here the possibility of transition to a malignant state is 75%.
Diffuse polyposis is an obligate precancer - in almost 100% of cases this precancerous disease develops into cancer. This disease is transmitted genetically and degeneration into a malignant state occurs at a young age.
Crohn's disease and ulcerative colitis are facultative precancers and are subject to conservative treatment.
Precancerous skin diseases
The following can degenerate into malignant tumors:
- nevi;
- chronic radiation damage to the skin;
- late radiation dermatitis;
- actinic keratoses;
- senile keratoses and atrophies;
- trophic ulcers, chronic ulcerative and vegetative pyoderma, which exist for a long time;
- ulcerative and wart form of lichen planus;
- cicatricial changes in the skin in areas of erythematous and tuberculous lupus
- bordered precancerous hyperkeratosis of the red border of the lips, keloids.
Precancerous Dubreuil's melanosis, pigmented actinic keratoses, and epidermal-dermal border nevus have a high tendency to become malignant.
In 5-6% of cases, carcinomas develop from scars resulting from burns. Benign epithelial tumors that tend to become malignant are cutaneous horn (12-20% of cases) and keratoacanthoma (17.5%).
Although the likelihood that warts and papillomas will develop into malignant changes is quite low, there are still a number of cases where cancer develops from them.
Precancerous diseases of the female genital organs
The cervix is most often affected, followed by the ovaries in second place, followed by the vagina and external genitalia. At the same time, cervical polyps rarely degenerate into cancer, as they are accompanied by bloody discharge, which is why they are quickly diagnosed and promptly removed.
Erosion can be present in a woman for months or even years and not manifest itself in any way. If cervical erosion exists for a long time and is not treated, it can cause the development of a tumor. The main cause of cervical and uterine cancer is the human papilloma virus.
Ovarian cysts in the early stages in women are asymptomatic and can only be detected during a gynecological examination. Any recognized cyst must be removed.
Vaginal cancer develops due to leukoplakia. In women who neglect hygiene, leukoplakias turn into ulcers, which in the future can become the basis for the development of cancer. In advanced stages, treatment is difficult, especially if you refuse regular medical examination. It should be borne in mind that vaginal cancer is more dangerous than cervical cancer, therefore all chronic diseases of the vagina must be treated in a hospital setting.
Cancer is often the cause of a negligent attitude towards one’s health, and in many cases it is possible to prevent its development through regular examinations with doctors. To prevent such an outcome, you should be especially attentive to any deterioration in your health and visit specialists in a timely manner.
These include:
Leukoplakia
Bowen's disease
Paget's disease
Leukoplakia– it is characterized by proliferation of multilayered squamous epithelium and disruption of its differentiation and maturation – para- and hyperkeratosis, acanthosis without pronounced cellular and nuclear polymorphism, disruption of the basement membrane. Round cell infiltration is noted in the underlying basement membrane.
Macroscopically
Leukoplakia manifests itself in the form of dry plaques of a whitish or yellow color with a pearlescent sheen, slightly rising above the mucous membrane.
Located tumor in a limited area. Most often in the area of the labia minora and around the clitoris. As the tumor progresses, it thickens and ulcerates.
Colposcopic picture
with leukoplakia the following: the keratinized surface is slightly transparent, looks like a simple “white spot” or like a white bumpy surface, devoid of blood vessels, Schiller’s test is negative.
Krauroz
– with it, atrophy of the papillary and reticular layers of the skin, death of elastic fibers and hyalinization of connective tissue are noted. First, the epidermis hypertrophies (with symptoms of acanthosis and inflammatory infiltration of the underlying connective tissue), then the skin of the labia atrophies.
During colposcopy detect pronounced telangiectasia. The skin and mucous membrane of the external genitalia are atrophic, fragile, easily wounded, depigmented, the entrance to the vagina is narrowed. The Schiller test is negative or weakly positive.
A targeted biopsy, cytological examination of scrapings from the affected surface, and taking smears - fingerprints - are performed.
Leukoplakia and kraurosis accompanied by itching and burning, which leads to skin injury, secondary infection and the development of vulvitis.
In 20% of cases, cancer of the external genitalia may develop.
Treatment
consists in prescribing a set of means:
1. Desenbilizing and sedative therapy
2. Compliance with the work and rest regime
3. Gymnastic exercises
4. Elimination of spices and alcoholic beverages
To relieve itching, 10% anesthetic and 2% diphenhydramine ointments, 2% resorcinol lotions, novocaine blockades of the pudendal nerve, or surgical denervation are used locally.
If conservative therapy is successful, vulvectomy or radiation therapy is indicated.
Bowen's disease occurs with symptoms of hyperkeratosis and acanthosis.
Clinically, flat or raised spots with clear edges and infiltration of the underlying tissues are determined.
Paget's disease- peculiar large light cells appear in the epidermis. Clinically, isolated bright red, sharply limited eczema-like spots with a granular surface are identified. The skin around the spots is infiltrated.
Invasive cancer often develops against the background of Bowen and Paget's disease.
Treatment– surgical (vulvectomy).
Condylomas of the vulva
Genital condylomas of the genital area are warty growths covered with stratified squamous epithelium. It is transmitted sexually, manifests itself with itching and pain, and occurs at a young age. Diagnosed upon examination.
Treatment is local (local) and systemic.
Dysplasia (atypical hyperplasia) of the vulva
– atypia of the multilayered epithelium of the vulva without spreading, local and diffuse forms are distinguished; depending on the atypia of epithelial cells, weak, moderate and severe degrees of dysplasia are distinguished.
Malignant tumors of the external genitalia
Cancer of the external genitalia
– in the structure of tumor diseases of the female genital organs, it ranks fourth after cancer of the cervix, uterine body and ovaries, accounting for 3-8%. It is more common in women aged 60-70 years, combined with diabetes mellitus, obesity and other endocrine diseases.
Etiology and pathogenesis Vulvar cancer has not been studied enough. The cause of the development of dysplastic changes in the integumentary epithelium of the vulva is considered to be a local viral infection. 50% of cases of vulvar cancer are preceded by precancerous diseases (atrophic vulvitis, leukoplakia, kraurosis).
In 60% of cases, the tumor is localized in the area of the labia majora and minora and the perineum, in 30% - the clitoris, urethra and ducts of the large glands of the vestibule; may be symmetrical. Mostly there are squamous keratinizing or non-keratinizing forms, less often - poorly differentiated or glandular. There are exophytic, nodular, ulcerative and infiltrative forms of the tumor.
The tumor spreads along its length, often obscuring the site of its primary localization and involving in the process the lower third of the vagina, the tissue of the ischeorectal and obturator zones. The most aggressive course is characterized by tumors localized to the clitoral region, which is due to the abundant blood supply and characteristics of lymphatic drainage.
