Background and pre-cancerous diseases. Precancerous diseases of the female genital organs

Lecture 13

Topic: Background and precancerous diseases

Female reproductive 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 genital organs.

RELEVANCE OF THE TOPIC

The problem of prevention and early diagnosis of oncological diseases 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 with newly diagnosed diagnoses 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 occur. 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 FAPs, examination rooms, etc. Therefore, it is very important to study this topic and understand that the diagnosis of precancerous conditions leads to the cure and recovery of patients in 98-100% of cases.

BACKGROUND AND PRECANCER 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, tending to malignancy. The concept of "precancer" includes a complex of clinical and morphological features:

- clinical- 1. the 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 turning 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.k.sh.m.;

5. leukoplakia;

6. erythroplakia.

True erosion - defect of the epithelial cover (tell the mechanism of its formation). It is rare, because. overlaps due to the stratified squamous epithelium advancing from the periphery or due to metaplasia, i.e. transformation of reserve cells into stratified 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 erosion surface is smooth, it can be around the external pharynx, more often on the upper lip, it bleeds.

Ectopia- displacement of the cylindrical epithelium of the cervical canal to the vaginal part of the sh.m. Outwardly, ectopias are similar to raspberries, red caviar. The reasons- at puberty due to an increase in the production of sex hormones (congenital), after childbirth. It is observed in 10-18% of gynecological patients. When viewed in the mirrors, a bright red velvety surface is found, which is easily injured.

Ectropion - arises as a result of a deep violation of sh.m. after a deep rupture during childbirth, abortion. Forming scars deform the cervix, there is an eversion of the mucous membrane of the cervical canal to the outside and gaping of the canal s.m.

It can be considered the main background for the development of precancer. When viewed in the mirrors, the mucous membrane is bright red, protrudes into the vagina, scars of the former gap are visible. If you bring the front and back lips together, the protrusion will disappear.

Polyp ts.k.sh.m. - occurs as a result of chronic diseases of the cervix. More often there are mucous, single and multiple, red and pink. If covered with columnar epithelium, it has a papillary surface.

Dystractoses- 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 soldered to the underlying tissue.

Erythroplakia - areas of thinned epithelium (atrophy of the mucous membrane), through which the vascular network is visible (therefore, the spots are red).

precancerous dysplasia process.

The concept of "precancerous conditions of the cervix" has undergone significant revision in recent years. This term denotes a change in sh.m., which, during a cytological or histological examination of its sections.

Dysplasia- This is atypia of the epithelium of the cervix, which is characterized by intensive 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 visible when viewed in mirrors.

Among gynecological diseases in women of reproductive age, pathology of the cervix occurs in 10-15% of cases. Cervical cancer is currently the most common oncological disease of the female genital organs. It makes up about 12% of all malignant tumors detected in women.

There is a certain staging and staging of pathological processes of the cervix in the development of carcinogenesis. There are background and precancerous diseases, in situ cancer and advanced cervical cancer.

Background are called diseases and changes in the vaginal part of the cervix, in which the normoplasia of the epithelium is preserved, i.e. there is a correct mitotic division of epithelial cells, their differentiation, maturation, exfoliation. These diseases include: pseudo-erosion, ectropion, polyp, endometriosis, leukoplakia, erythroplakia, papilloma, cervicitis, true erosion.

To precancerous conditions of the cervix include epithelial dysplasia - pathological processes in which hyperplasia, proliferation, impaired differentiation, maturation and rejection of epithelial cells are noted.

Etiopathogenesis of diseases of the cervix

Precancer, and subsequently cervical cancer, are formed against the background of benign disorders of the stratified squamous epithelium (ectopia, metaplasia). This becomes possible due to the bipotent properties of reserve cells, which can transform into both squamous and prismatic epithelium.

ectopia columnar epithelium develops in two ways:

1) the formation of cylindrical epithelium from reserve cells on the surface of the cervix (the main path for the development of ectopia);
2) replacement of erosion of the squamous epithelium of inflammatory or traumatic origin with a single-layer cylindrical epithelium originating from the cervical canal (a secondary path for the development of ectopia).

Metaplasia- the process of transformation of reserve cells into squamous epithelium. Squamous metaplasia is associated with the proliferation of reserve cells, which are a necessary factor for malignant transformation. The formation of precancer (dysplasia) leads to the overlap of the cylindrical epithelium with a flat one.

Factors in the development of background and precancerous diseases of the cervix

1. Inflammatory diseases of the genitals cause necrobiosis of the stratified squamous epithelium of the cervix and its desquamation, followed by the formation of eroded areas on it, the healing of which occurs due to the growth of the cylindrical epithelium from the cervical canal, which is not characteristic of the vaginal environment. Pseudo-erosion is formed in this zone. Subsequently, the columnar epithelium is replaced by stratified squamous epithelium.

Of particular importance in the occurrence of cervical dysplasia belongs to the human papillomavirus (HPV).

It penetrates into the basal cells of the epithelium through microtraumas formed during sexual intercourse. The DNA of the virus enters the cell after the shedding of the protein shell and enters the cell nucleus. Being in the basal layer in a small number of copies, the DNA of the virus is not detected (latent period). With further expression of the virus, a subclinical and then a clinical stage of the disease develops. The characteristic cytopathic effect of HPV - koilocytosis - occurs in the surface layers of the epithelium, while the nucleus takes on an irregular shape and becomes hyperchromic due to the accumulation of virions in it, vacuoles appear in the cytoplasm.

Currently, more than 100 different types of HPV have been identified, of which 30 infect the human genital tract. Among the types of HPV infection, there are groups of different oncological risk. So, HPV types 6, 11, 40, 42, 43, 44 and 61 are classified as low oncological risk; to medium risk - 30, 33, 35, 39, 45, 52, 56, 58; to high risk - 16, 18 and 31 types of the virus.

In infected cells, the viral genome can exist in 2 forms: episomal (outside chromosomes) and integrated into the cellular genome. For benign lesions, an episomal form is characteristic, for carcinomas - integration into the genome of a cancer cell. The episomal phase is required for virus replication and virion assembly. This phase is characterized histologically as mild cervical intraepithelial neoplasia (CIN-1). The appearance of aneuploidy, cellular atypia, cytological activity correspond to moderate and severe cervical intraepithelial neoplasia (CIN-2 and CIN-3).

The combination of HIV infection and HPV increases the risk of malignancy. In addition, the synergism of the herpes simplex virus, chlamydia and CMV can contribute to the occurrence of cervical dysplasia.

2. Traumatic injuries of the cervix that arose after childbirth or abortion (a predisposing factor is a violation of trophism and innervation of tissues), as well as barrier contraceptives and vaginal tampons such as "Tampax".
3. Hormonal disorders(increased gonadotropic function, shifts in estrogen metabolism with a predominance of estradiol, an increase in oxygenated forms of 17-ketosteroids).
4. immune disorders(an increase in the level of cytotoxic T-lymphocytes, a decrease in the number of Langerhans cells in the cervix. The degree of dysplasia is proportional to the level of immunosuppression).
5. sexual activity(early onset of sexual activity and a large number of sexual partners).
6. Involutive (age-related) changes in the genital organs, as well as a decrease in the body's resistance, metabolic features and hormonal disorders.
7. COC use with a high content of gestagens.
8. Smoking(the risk of the disease increases with the number of cigarettes per day and the duration of smoking).
9. hereditary factor: the risk of cervical cancer in women with a burdened family history.

Classification of diseases of the cervix

(E.V. Kokhanevich, 1997 with additions and changes)

I. Benign background processes:

A. Dishormonal processes:
1. Ectopic columnar epithelium (endocervicosis, glandular erosion, pseudo-erosion): simple, proliferating, epidermis.
2. Polyps (benign polyp-like growths): simple; proliferating; epidermis.
3. Benign transformation zone: unfinished and finished.
4. Papillomas.
5. Endometriosis of the cervix.
B. Post-traumatic processes:
1. Ruptures of the cervix.
2. Ectropion.
3. Cicatricial changes in the cervix.
4. Cervico-vaginal fistulas.

B. Inflammatory processes:
1. True erosion.
2. Cervicitis (exo- and endocervicitis): acute and chronic.

II. Precancerous conditions:

A. Dysplasia.
1. Simple leukoplakia.
2. Fields of dysplasia:
metallized prismatic epithelium.
3. Papillary transformation zone:
stratified squamous epithelium;
metaplastic prismatic epithelium.
4. Precancerous transformation zone.
5. Warts.
6. Precancerous polyps.
B. Leukoplakia with cell atypia.
B. Erythroplakia.
G. Adenomatosis.

III. Cervical cancer

A. Preclinical forms:
1. Proliferating leukoplakia.
2. Fields of atypical epithelium.
3. Papillary transformation zone.
4. Zone of atypical transformation.
5. Zone of atypical vascularization.
6. Cancer in situ (intraepithelial, stage 0).
7. Microcarcinoma (stage I A).
B. Clinical forms of cancer: exo-, endophytic, mixed.

Histological classification of dysplasia (Richart, 1968)

Cervical intraepithelial neoplasia (CIN) is divided into:
♦ CIN I - mild dysplasia;
♦ CIN II - moderate dysplasia;
♦ CIN III - severe dysplasia and pre-invasive cancer.

Clinic of diseases of the cervix

I. Background processes

Erosion is a pathological process on the vaginal part of the cervix, characterized in the initial stage by dystrophy and desquamation of the squamous stratified epithelium (ulceration, erosion) with subsequent development on the eroded surface of the cylindrical epithelium.

Allocate true erosion and pseudo-erosion.

True erosion of the cervix- damage and desquamation of the stratified squamous epithelium of the vaginal part of the cervix around the external os.

According to the etiological principle, the following are distinguished types of true erosion:

1. Inflammatory (as a result of maceration and rejection of the epithelium), more often in reproductive age.
2. Traumatic (injury, for example, vaginal mirrors), more often in postmenopausal age.
3. Post-burn (after rejection of the scab as a result of chemo-, electro- or cryotherapy), more often in reproductive age.
4. Trophic (with uterine prolapse, after radiation therapy), more often in postmenopausal age.
5. Cancer (during the decay of a cancerous tumor of the cervical cancer), more often in postmenopausal age.
6. Syphilitic - more often in reproductive age.

When viewed in mirrors with the naked eye, erosion has a bright red color, bleeds easily. In addition to syphilitic, trophic and cancerous erosion, all other species quickly undergo epidermization and, after 1-2 weeks, are covered with stratified squamous epithelium.

In colposcopy, true erosion is defined as a defect in the epithelium with exposed subepithelial stroma, with the bottom below the level of stratified squamous epithelium, the edges are clear. After applying a 3% solution of acetic acid, the bottom of true erosion turns pale, when using Lugol's solution, the bottom does not perceive color, only the surrounding stratified squamous epithelium is stained. Histological examination reveals the absence of an epithelial cover on the border with a true stratified squamous epithelium. On the surface of this pathological area, fibrin deposits and blood are visible. In the subepthelial connective tissue, an inflammatory process, leukocyte infiltration are expressed, dilated capillaries, hemorrhages, tissue edema are detected.

True erosion refers to short-term processes: there are no more than 1-2 weeks, and it turns into pseudo-erosion.

Pseudo-erosion (endocervicosis) of the cervix- replacement of stratified squamous, cylindrical epithelium outward from the transitional zone between them in various previous pathological processes. In the absence of the latter, this phenomenon is called ectopia.

Types of pseudo-erosion:

1. Progressive - the formation of glandular structures on the surface and in the depths of the cervix. The neck increases due to the growth of the cylindrical epithelium and glands of the mucous membranes of the cervical canal, as well as as a result of reserve cell hyperplasia. The process is characterized by the formation of cysts in the glands of pseudo-erosion, changes in the cervix are manifested by an increase in size, lymphocytic infiltration, and proliferation of connective tissue.

2. Stationary - the second phase of pseudo-erosion, during which part of the eroded glands remains under the growing stratified squamous epithelium and turns into retention cysts (naboth cysts), which are single or multiple, their diameter is 3-5 mm.

3. Healing (epidermis) - after the treatment of inflammatory processes, the elimination of hormonal disorders. The healing process occurs in the reverse order: the columnar epithelium is replaced by a stratified squamous epithelium formed from reserve cells. Cylindrical pseudo-erosion epithelium undergoes dystrophy followed by desquamation. Pseudo-erosion disappears with complete rejection of the cylindrical epithelium with the formation of glandular structures. But often cystic formations remain. Cysts come in various sizes: from 2-3 mm to 1-2 cm, due to this, the cervix is ​​\u200b\u200bdeformed and enlarged. When the squamous epithelium is replaced by a cylindrical epithelium, phenomena of indirect metaplasia (differentiation) of reserve cells into cells of stratified squamous epithelium are observed. In this case, keratinization of the mature metaplastic epithelium occurs in the form of keratosis (complete keratinization of cells, without nuclei with the formation of a keratohyalin layer), parakeratosis (incomplete keratinization of cells without a keratohyalin layer, but with nuclei), hyperkeratosis (excessive keratinization of the epithelium).

Polyps of the cervix- this is an overgrowth of the mucous membrane of the cervical canal in the form of a leg with a connective tissue rod covered with a stratified squamous or cylindrical epithelium with glandular structures in the thickness.

Types of polyps:

1. Simple polyps - glandular or glandular-fibrous formations without proliferative changes.
2. Adenomatous polyps - glandular structures with proliferative activity, having a focal or diffuse character.

Microscopy of polyps: structures of small size (from 2 to 40 mm in diameter), oval or round in shape, with a smooth surface, hanging into the vagina on a thin base. Polyps have a dark pink hue, soft or dense consistency (depending on the content of fibrous tissue). The surface of polyps may be covered with stratified or columnar epithelium. In the first case, the polyp has a smooth surface with open ducts of the glands and tree-like branching vessels, in the second - a papillary surface.
During proliferation, increased growth of the polyp is observed, and during epidermization, the glandular structures are covered with stratified squamous epithelium and growth stops. Polyps with dysplasia are precancerous conditions.

Clinical picture: The occurrence of complaints and objective signs of the pathological process depend on concomitant diseases of the genital organs. In polyps of the endocervix, squamous metaplasia (indirect metaplasia of the reserve cells of the columnar epithelium) often occurs. Secondary changes include circulatory disorders (without an inflammatory reaction), accompanied by edema of the stroma and congestion in the vessels. In the presence of secondary changes, there may be sanious discharge.

Benign transformation zone (zone of benign metaplasia)- transformation of prismatic epithelium (PE) into stratified squamous (squamous) epithelium (MSE).

The transformation zone is formed at the site of the former ectopic PE as a result of regeneration and epidermization processes. The regeneration process occurs only after the destruction of the ectopia within the normal squamous epithelium. More often, PE replacement is carried out by epidermization. In this case, the stratified squamous epithelium is formed from reserve cells located between the basement membrane and the ectopic PE. Under the influence of an acidic environment in the vagina, reserve cells will turn into immature, and later - into a functionally complete stratified squamous epithelium.

With colposcopy, a complete and unfinished transformation zone is distinguished.

Unfinished transformation zone. With extended colpocervicoscopy, white or white-pink spots with a smooth relief are found (PE cells in the process of metaplasia acquire the structure of MSE cells, while maintaining the mucus-producing function). The localization of the spots is different - in the center or along the periphery of the ectopia, i.e. on its border with the ITU. Foci of metaplastic epithelium can take the form of stripes, "tongues", "continents". In the zone of foci of metaplastic epithelium, the excretory ducts of functioning glands are often preserved. Tree-like branching blood vessels may be observed. As metaplasia progresses, the areas of ectopic PE decrease, and a continuous zone of MSE is determined on the cervix. When lubricated with Lugol's solution, the unfinished transformation zone is weakly and unevenly stained ("marble pattern").

Finished transformation zone- this is the mucous membrane of the cervix, covered with MSE and single or multiple retention cysts. The MSE blocks the exit of the secret of the gland and creates tension in the cyst, as a result, the surface wall is raised above the epithelium surrounding the gland. The color of retention cysts depends on the nature of their contents - from blue to yellow-green. The colpocervicoscopic picture before and after exposure to acetic acid does not change, since there are no mucus-producing cells in the integumentary epithelium, and the vessels of the retention cysts do not contain a muscle layer, therefore they do not react to acid. The epithelium with the Schiller test is stained more evenly than with an incomplete transformation zone. Unfinished and finished transformation zones can be combined.

Papilloma- focal proliferation of stratified squamous epithelium with keratinization phenomena. A relatively rare form of damage to the cervix. When viewed with the help of mirrors on the vaginal part, papillomatous growths in the form of rosettes are determined, outwardly similar to an exophytic form of cancer. Papilloma may be pink or whitish in color, clearly delimited from the surrounding tissue.

With a colposcopic picture, a large number of tree-like branching vessels are determined on its surface. When a 3% solution of acetic acid is applied to the papilloma, the vessels spasm and the papillae turn pale. Does not stain with Lugol's solution. Papillomas relatively often undergo malignant transformation. Morphological examination allows you to establish the correct diagnosis.

Endometriosis of the cervix. As a result of traumatization of the mucous membrane of the cervix during examination or treatment, conditions arise for the implantation of endometrial cells. They, multiplying, form foci of subepithelial endometriosis.

Colposcopic picture: dark red or cyanotic, limited, somewhat elevated formations of various sizes and shapes. Histological examination revealed glandular structures of the endometrium, hemorrhages and small cell infiltration of the surrounding connective tissue.

Eroded ectropion- eversion of the mucous membrane of the cervix, characterized by the presence of pseudo-erosion and cicatricial deformity of the cervix.

The etiological factor is the expansion of the cervical canal and traumatization of the cervix (after childbirth, abortion).

Pathogenesis: when the lateral walls of the cervix are traumatized, the circular muscles are damaged, which leads to eversion of the walls and exposure of the mucous membrane of the cervical canal, which resembles pseudo-erosion. In this case, the boundary between the stratified squamous epithelium and the cylindrical epithelium of the cervix is ​​violated. There is metaplasia (replacement) of the cylindrical epithelium on the walls of the cervical canal by a multilayered flat one. The cervix is ​​hypertrophied and undergoes glandular cystic degeneration.

Along with these processes, there is an proliferation of connective tissue and the formation of cicatricial deformity of the cervix. Patients complain mainly of leucorrhea, pain in the lower back and lower abdomen, menstrual dysfunction in the form of menorrhagia, caused by concomitant, as a rule, chronic endocervicitis and endomyometritis.

cervicitis- an inflammatory process of the mucous membrane of the cervical canal (section 2.3.4), which leads to hypertrophy of its cellular elements, and in some cases to metaplasia.

II. Precancerous conditions

Dysplasia- pronounced proliferation of the atypical epithelium of the cervix with a violation of its "layering" without involvement of the stroma and surface epithelium in the process. Dysplasia is the most common form of morphological precancer of the cervix. The frequency of transition of dysplasia to preinvasive carcinomas is 40-64%. In 15% of patients, against the background of dysplasia, microcarcinoma develops.

Dysplasia is characterized by acanthosis, hyperkeratosis, parakeratosis, increased mitotic activity, cell structure disorders (nuclear polymorphism, changes in the nuclear-cytoplasmic ratio with an increase in the first, vacuolization, pathological mitoses).

Dysplasia is manifested by intensive cell proliferation with the appearance of atypia in them, especially nuclei, without involvement of the surface epithelium in the process.

Depending on the intensity of cell proliferation and the severity of cellular and structural atypia in the epithelial layer, namely in the lower third or in more superficial sections, there are mild, moderate and severe dysplasia (cervical intraepithelial neoplasia - CIN-I, CIN-II, CIN-III ).

At mild dysplasia there is hyperplasia of the basal and parabasal layers (up to U3 thickness of the epithelial layer), cellular and nuclear polymorphism, impaired mitotic activity.

Average degree of dysplasia characterized by damage to the U3-2/3 thickness of the stratified squamous epithelium. In this case, the affected part of the epithelium is represented by elongated, oval cells, closely adjacent to each other. Mitoses are visible, including pathological ones. A slight nuclear-cytoplasmic shift is characteristic: the nuclei are large, the rough structure of chromatin.

At severe dysplasia hyperplastic cells of the basal and parabasal layers occupy more than 2/3 of the epithelial layer. The nuclei are large, oval or elongated, hyperchromic, there are mitoses. There is a pronounced polymorphism of the nucleus, a nuclear-cytoplasmic shift, binuclear cells, sometimes giant cells with a large nucleus can be seen in smears. Cells maintain clear boundaries.

Dysplasia can occur with the progression of changes (an increase in atypical cells in the lower layers of the epithelium), stabilization of the process or its regression (pushing out pathological cells due to the growth of normal epithelium).

Simple leukoplakia - pathological process of keratinization of stratified squamous epithelium. This pathology occurs during one of the stages of pseudo-erosion. The development of hyperkeratosis, parakeratosis, acanthosis is noted, keratinization of intermediate cells and perivascular subepithelial infiltrates from histiocytes and plasma cells occur.

Histological picture: simple leukoplakia has the appearance of a white spot, soldered to the underlying tissue.

The surface is rough, folded or scaly with horny overlays. The fields of leukoplakia are flat, convex, trough-shaped, represented by yellowish or whitish areas, divided by vessels into polygons, which forms a honeycomb pattern. Leukoplakia cells do not contain glycogen. With a warty form, beards filled with keratinized masses form on the surface of leukoplakia, the epithelium thickens due to proliferation and expansion of the basal layer (basal cell hyperreactivity); there is a disorderly arrangement of basal cells with atypia.

During a gynecological examination, leukoplakia is determined in the form of dense plaques against the background of an unchanged mucous membrane with mildly pronounced cervical hypertrophy.

Fields of dysplasia are defined as white polygon areas separated by red borders.

There are fields of hyperplasia of the MSE and fields of metaplasia of the PE.

ITU hyperplasia fields occur against the background of "false erosions" or in the cervical canal in the presence of prolonged chronic inflammation. The foci have clear boundaries, do not change under the influence of acetic acid, Sample

Schiller negative. With this pathology, a single-phase basal temperature, or two-phase, with a shortened luteal phase, is determined. Fields of MSE hyperplasia are not amenable to conventional anti-inflammatory therapy, and are prone to relapse after diathermoexcision.

PE metaplasia fields are determined only after a long (within 30-40 s) exposure to ectocervix acetic acid; 1-1.5 minutes after the cessation of the action of the acid, the colposcopic picture of metaplasia disappears. This is due to the mucus-producing ability of metaplastic PE: under the influence of acid, intracellular mucus coagulates, giving the epithelium a white color; during cellular secretion, the pathological focus again acquires a pink color. This pathology is less dangerous in terms of malignancy than the fields of ITU hyperplasia.

papillary transformation zone.

Colpocervicoscopic picture: white or pale pink spots with red monomorphic (they have the same shape, size, location level) blotches and smooth relief.

It distinguishes two types of papillary transformation zone:
♦ papillary zone of hyperplasia of the MSE - macroscopic examination of the cervix is ​​not changed; determined foci of pathology during colposcopy do not respond to acetic acid; Schiller's test is negative;
♦ papillary zone of PE metaplasia - determined only after prolonged exposure to acetic acid; Schiller's test is negative.

Precancerous transformation zone has the appearance of white monomorphic rims around the excretory ducts of the glands, determined after prolonged exposure to acetic acid. Schiller's test is negative. The foci of this pathology are characterized by hyperplasia and dysplasia of metaplastic epithelium with signs of cell atypia. They are localized on the cervix and in the cervical canal, next to the areas of the zone of incomplete benign transformation, fields of dysplasia, ectopic PE.

Cervical warts - abnormal growths of stratified squamous epithelium in the form of acanthosis (immersion of keratinizing epithelial islets into the underlying tissue between the connective tissue papillae) with elongated papillae.

Etiology: herpes virus type 2, human papillomavirus infection.

Colposcopic signs of flat warts can be: aceto-white epithelium, leukoplakia, punctuation, mosaic, "pearl" surface after treatment with acetic acid.
Histological picture: squamous metaplasia with the presence of specific cells - koilocytes with altered nuclei (enlarged or reduced) and perinuclear vacuolization or pushing the cell plasma to the membrane, koilocytes are located in the middle and superficial layers of the epithelium.

Precancerous polyps . With colpooscopy, various types of epithelial dysplasia are determined.

Histologically, focal or diffuse proliferation of stratified squamous and/or metaplastic epithelium is detected.

erythroplakia - a pathological process of the mucous membrane, in which there is a significant thinning of the epithelial cover with symptoms of dyskeratosis. Atrophy of the superficial and intermediate layers of squamous stratified epithelium is noted, which is accompanied by hyperplasia of the basal and parabasal layers with atypia of cellular elements.

Clinically manifests as bright red areas with clear but irregular borders surrounded by normal mucosa.

III. Cervical cancer

Proliferating leukoplakia localized in the ectocervix zone.

White bumpy foci with clear boundaries are determined, rising above the surface of the epithelium.

A characteristic sign of malignancy is polymorphism of epithelial and vascular formations (different shape, size, height, color of the integumentary epithelium - milky white with gray and yellow tints or with vitreous transparency, the structure of connective tissue and vascular components). The vascular pattern is not defined. Schiller's test is negative.

Fields of atypical epithelium- polymorphic epithelial foci, delimited by sinuous intersecting red pink lines, with clear boundaries. Epithelial areas are distinguished by concavity of the relief. They are localized mainly on the vaginal part of the cervix.

Papillary zone of atypical epithelium- polymorphic foci are localized in the area of ​​the external pharynx of the cervical canal. Colposcopically, atypical epithelium is defined as unevenly thickened endophytically growing layers of white or white-yellow color.

Zone of atypical transformation represented by the presence of polymorphic epithelial "rims" around the openings of the ducts of the glands. Adaptive vascular hypertrophy is characteristic - tree-like branching of vessels that do not disappear under the influence of acetic acid.

Area of ​​atypical vascularization. Atypical vascular growths are the only manifestation of this pathology. They are characterized by: the absence of visible anastomoses, uneven expansion, lack of response to vasoconstrictor substances. The boundaries of this zone are determined only during the Schiller test (the epithelium with atypical vessels is not stained).

Preinvasive cervical cancer(intraepithelial carcinoma, cancer in situ). The preinvasive stage of cancer is characterized by malignant transformation of the epithelium in the absence of the ability to metastasize and infiltrative growth.

The predominant localization is the border between the stratified squamous and cylindrical epithelium (in young women - the area of ​​​​the external pharynx; pre- and post-menopausal periods - the cervical canal).

Depending on the structural features of the cells, two forms of cancer in situ are distinguished - differentiated and undifferentiated. In the differentiated form of cancer, the cells have the ability to mature; the undifferentiated form is characterized by the absence of signs of stratification in the epithelial layer.

Patients report pain in the lower abdomen, leucorrhoea, bloody discharge from the genital tract.

Microinvasive cervical cancer (microcarcinoma)- a relatively compensated and slightly aggressive form of the tumor, which occupies an intermediate position between intraepithelial and invasive cancer.

Microcarcinoma is a preclinical form of a malignant process and therefore does not have specific clinical signs.

Invasive cervical cancer. The main symptoms are pain, bleeding, leucorrhoea. Pain is localized in the sacrum, lower back, rectum and lower abdomen. With advanced cervical cancer with damage to the parametric tissue of the pelvic lymph nodes, pain can radiate to the thigh.

Bleeding from the genital tract occurs as a result of damage to easily injured small vessels of the tumor.

The whites are serous or bloody in nature, often with an unpleasant odor. The appearance of leucorrhoea is due to the opening of the lymphatic vessels during the collapse of the tumor.

With the transition of cancer to the bladder, frequent urination and frequent urination are observed. Compression of the ureter leads to the formation of hydro- and pyonephrosis, and later to uremia. When a tumor of the rectum is affected, constipation occurs, mucus and blood appear in the feces, and vaginal-rectal fistulas form.

Diagnosis of background and precancerous diseases of the cervix

I. Basic methods of examination.

1.Anamnesis and gynecological examination. During a visual examination, attention is paid to the surface of the cervix, color, relief, shape of the external pharynx, the nature of the secretion of the cervical canal and vagina, various pathological conditions (ruptures, ectopia, eversion of the mucous membrane of the cervical canal, tumor, etc.). Conduct a bimanual study.

2. Clinical and laboratory examination: complete blood count, blood glucose test, RW, HIV, HbsAg, urinalysis, biochemical blood test, coagulogram.

Z. Cytological research method(staining according to Romanovsky-Giemsa, Pappenheim, Papanicolaou, fluorescent microscopy) is a method for the early diagnosis of precancerous conditions and cervical cancer.

It consists in microscopic examination of smears obtained from the surface of the cervix. The material is obtained from 3 sites: from the surface of the vaginal part of the cervix, from the site at the border of the squamous stratified epithelium with the mucous membrane of the cervical canal and from the lower third of the endocervix and is separately applied to clean glass slides in a thin even layer. Examine native smears or study stained smears. When stained according to Papanicolaou, the smear is preliminarily fixed in a mixture of Nikiforov, consisting of equal parts of 95% ethyl alcohol and ether, for 30 minutes; the term for sending the smear to the laboratory is no more than 15 days. They also stain according to Romanovsky-Giemsa, Pappenheim.

Cytological classification of cervical smears according to Papanicolaou (PAP-smear test)

1st class - no atypical cells, normal cytological picture;
2nd class - a change in cellular elements due to an inflammatory process in the vagina and (or) cervix;
3rd class - there are single cells with altered ratios of the nucleus and cytoplasm;
4th class - individual cells are found with signs of malignancy (enlarged nuclei, basophilic cytoplasm, cell atypia);
Grade 5 - there are numerous atypical cells in the smear.
Fluorescence microscopy is based on the affinity of acridine orange for cellular DNA and RNA. Glow range from yellow-green to orange-red (cancer cells) color.

4.Colposcopy(examination of the ectocervix) and cervicoscopy(examination of the endocervix). Simple colposcopy - examination of the cervix after removal of discharge from its surface without the use of medications. A simple colposcopy performed at the beginning of the study is indicative.

Extended colposcopy carried out after applying to the vaginal part of the cervix 3% solution of acetic acid or 2% Lugol's solution, hematoxylin, adrenaline.

Normal pink mucosa with a smooth shiny surface. Subepithelial vessels are not defined. After treatment with a 3% solution of acetic acid, the unchanged epithelium acquires a pale color, when applying 2% Lugol's solution (Schiller's test), the surface of the vaginal part of the cervix evenly turns dark brown. The border between stratified squamous and single-layered columnar epithelium is presented as a smooth, distinct line. Schiller's test is based on the ability of normal epithelium to change color under the influence of iodine to dark brown, depending on the content of glycogen in epithelial cells. Normally, a uniform brown coloration is noted. Iodine-negative areas indicate a sharp decrease in glycogen in the cells of the integumentary epithelium of the cervix.

Ectopic columnar epithelium defined as a cluster-shaped cluster of bright red globular or oblong papillae. When 3% acetic acid is applied to the surface of an ectopia, the papillae turn pale, acquire a glassy appearance and resemble bunches of grapes.

Transformation Zone:
a) incomplete - tongue-shaped areas and / or separate islands of immature squamous epithelium with a smooth surface and the orifices of the excretory ducts of open glands in the form of dark dots and fragments of ectopia surrounding the external pharynx. During the Schiller test, the immature poorly differentiated squamous epithelium does not turn brown;
b) complete - the surface of the vaginal part of the cervix is ​​completely covered with stratified squamous epithelium, on which open glands and retention cysts are revealed in the form of vesicles with a yellowish tinge. Vessels contract under the action of acetic acid.

True erosion - the bottom has a homogeneous red color.

Polyps. The cylindrical epithelium is characterized by a papillary structure, when the glandular growths of the polyp are overlapped by a flat epithelium, its surface is smooth. Polyps do not stain with Lugol's solution.

Leukoplakia. The surface of whitish plaques (keratinization areas) is rough, folded or scaly, their contours are clear. Under the influence of a 3% solution of acetic acid, the structure of leukoplakia does not change; during the Schiller test, iodine-negative areas are formed.

Punctuation (punctuation). Corresponds to the old term "basis of leukoplakia". The simple basis of leukoplakia is defined as dark red, small monomorphic dots located against the background of delimited whitish or light yellow areas that do not rise above the level of the integumentary epithelium of the vaginal part of the cervix. The papillary base of leukoplakia rises above the surface of the cervix and has a papillary structure against the background of a whitish proliferating epithelium. Polymorphic dark red dots are identified. Both bases of leukoplakia are iodine-negative.

Mosaic (fields). It is represented by whitish or yellowish areas of irregular polygonal shape, separated by thin red borders (filaments of capillaries). The mosaic is iodine-negative.

Papilloma consists of separate papillae, in which vascular loops are determined. Vessels are evenly distributed, shaped like kidneys. When papilloma is treated with a 3% solution of acetic acid, the vessels contract, the mucosa turns pale. Papilloma is not stained with Lugol's solution.

Atypical transformation zone- the presence of a typical transformation zone in combination with leukoplakia, mosaic, puncture and atypical vessels.

Atypical vessels- randomly located vessels that have a bizarre shape, non-anastomosing with each other. After treatment with a 3% solution of acetic acid, atypical vessels do not spasm, they become more defined.

Colpomicroscopy - intravital histological examination of the vaginal part of the cervix, in which the tissue of the cervix is ​​examined in incident light under a magnification of 160-280 times with staining of the vaginal part of the cervix with a 0.1% aqueous solution of hematoxylin.

5.Histological examination. The sampling of the material is carried out under the control of colposcopic examination in the area of ​​severe pathology with a sharp scalpel. The biopsy is kept in 10% formalin solution and sent for histological examination in this form.

II. Additional methods of examination.

1. Bacterioscopic and bacteriological examination of the separated cervical canal and vagina.

2.Molecular biological diagnosis of genital infections.

Polymerase chain reaction (PCR). The method is based on the selective addition of nucleotides to the complementary region of the target DNA. A feature of PCR is enzymatic (DNA polymerase) duplication of the pathogen's DNA, which leads to the formation of many copies. The reaction solution contains nucleoside phosphates, from which DNA segments are built, as well as a PCR buffer. The reactions take place in thermal cyclers with automatic temperature changes. Accounting for the reaction is carried out using electrophoresis in agar gel placed in an electric field. A solution of ethidium bromide fluorophore is introduced into the gel, which stains double-stranded DNA. A positive PCR result is counted by the band of luminescence in ultraviolet light.
Ligas chain reaction (LCR). A ligase is used to identify the pathogen DNA, and the results are recorded using an additional immunoluminescent reaction.

Z. Hormonal study of gonadotropic hormones of the pituitary gland and sex hormones.

4. Ultrasound examination of the pelvic organs.

5. Research with radioactive phosphorus. The method is based on the property of phosphorus to accumulate in areas of intense cell proliferation.

6. Optical coherence tomography (OCT) is a new method for obtaining a cross-sectional image of the internal microstructure of biological tissues in the near infrared range with a high level of resolution.

For OCT examination of the cervix, a compact portable optical tomograph is used, equipped with a universal microprobe having an outer diameter of 2.7 mm and compatible with the working channels of standard endoscopes. OCT of the mucous membrane of the cervix is ​​performed during a standard gynecological examination. The optical probe of the tomograph under the control of a colposcope is brought directly to the surface of the mucous membrane of the cervix. For OCT, areas with various colposcopic signs are selected, 2-3 repeated tomograms are obtained from each point, and a control scan of a healthy mucosal area is mandatory. The total time of the tomographic examination is 10-20 minutes.

OCT signs of unchanged cervical mucosa: structural optical image with 2 control horizontally oriented layers and a smooth, continuous border between them. The upper layer corresponds to the stratified squamous epithelium, the lower layer corresponds to the connective tissue stroma. The boundary between the upper and lower layers is contrasting, clear, even and continuous.

OCT signs of endocervicitis: atrophy of the epithelium in the form of a decrease in the height of the upper layer on tomograms, hypervascularization of the stroma - the appearance of multiple contrasting, rounded and/or longitudinal optical structures of low brightness in the lower layer, lymphocytic infiltration of the stroma.

OCT signs of exocervicitis: the image has a contrasting two-layer structure; lowered the height of the top layer; a clear and even border between the upper and lower layers; the presence in the lower layer of multiple contrasting, rounded and longitudinal weakly scattering regions of various sizes.

OCT signs of true erosion: absence of two contrast layers; uniform, structureless bright image;

OCT - signs of cervical cancer: bright image (strongly scattered), inhomogeneous; the image is devoid of structure; the signal fades quickly; reduced image depth.

Treatment of background and precancerous diseases of the cervix

The therapy of background and precancerous conditions of CC is carried out in 5 stages.

Stage 1 - etiopathogenetic treatment.

A. Antibacterial and antiviral therapy is carried out with clinical and laboratory signs of an inflammatory process in the vagina and cervix. Particular attention should be paid to the treatment of STIs, which is carried out depending on the specific pathogen identified (head genitourinary infections).

B. Hormone therapy is carried out when an ectopic cylindrical epithelium of a dyshormonal nature is detected using COCs. With concomitant hormone-dependent gynecological diseases (endometriosis, uterine fibroids), treatment is carried out according to the nosological form.

In women of reproductive age, estrogen-progestin preparations are used from the 5th to the 25th day of the menstrual cycle, followed by a seven-day break:
marvelon (desogestrel 150 mcg, ethinyl estradiol - 30 mcg);
logest (20 mcg of ethinyl estradiol and 75 mcg of gestodene);
femoden (ethinylestradiol - 30 mcg, gestodene - 75 mcg);
rigevidon (150 mcg levonorgestrel and 30 mcg ethinyl estradiol);
mersilon (desogestrel - 150 mcg, ethinylestradiol 20 mcg).
Gestagens are prescribed from the 16th to the 25th day of the menstrual cycle:
progesterone 1 ml 2.5% solution i / m daily;
17-OPK1 ml 12.5% ​​solution i / m once;
dufaston (dydrogesterone) 10-20 mg per day;
norethisterone (norkolut) 0.005-0.01 g per day;
pregnin 0.02 g 2 times / day, sublingually;
orgametril (linestrol) 0.005 g per day;
utrozhestan 200-300 mg per day (1 capsule in the morning and 1-2 capsules in the evening one hour after meals).
With age-related dystrophy of the vulva, estriol preparations are used:
estriol 4-8 mg 1 time / day. within 2-3 weeks, then the dose is gradually reduced to 1-2 mg per day;
ovestin 4-8 mg (4-8 tablets) for 2-3 weeks, then the dose is gradually reduced to 0.25-2 mg per day.
Estrogens are combined with corticosteroids in the form of ointments: Fluorocort (triamcinolone acetate), 5 g of ointment, apply a thin layer to the affected area, 3 times / day.
B. Immunomodulators (see Appendix 3). D. Desensitizing drugs:
astemizole 1 tab. (0.01 g) 1 time / day;
tavegil (clemastine) 1 tab. (0.001 g) 2 times / day;
avil (pheniramine) 1 tab. (0.025 g) 2-3 times / day;
zyrtec (cetirizine) 1 tab. (0.01 g) 1 time / day;
claritin (loratadine) 1 tab. (0.01 g) 1 time / day. D. Vitamin therapy:
vitamin B1 0.002 g 3 times / day;
vitamin B6 1 ml 5% solution i/m;
ascorbic acid 200 mg / day;
rutin 0.02 g 3 times / day;
tocopherol acetate 1 capsule (100 mg) 2 times / day.

2nd stage - correction of violations of the vaginal biocenosis.

The vagina is sanitized with antibacterial drugs, followed by the restoration of its biocenosis (chapter "Colpitis"). For a sustainable effect, it is necessary to simultaneously restore the biocenosis of not only the vagina, but also the intestines:
bificol - inside 3-5 doses 2 times / day;
lyophilized culture of lactic acid bacteria, 4-6 doses 2 times / day, for 3-4 weeks;
colibacterin 2-4 doses 3-4 times / day. one hour before meals, 4-6 weeks;
lactovit 1 capsule 2 times / day;
hilak 20-40 drops 3 times / day. with a small amount of liquid;
bifiform 1 capsule 2 times / day, 15-30 days.

3rd stage - surgical treatment

Includes the following methods:

I. Local destruction: diathermosurgical method, cryodestruction, laser destruction, chemical destruction.

II. Radical surgery: excision of the cervix, amputation of the cervix, reconstructive plastic method, hysterectomy.

1. Diathermocoagulation - destruction by electric current. It can be monoactive (with one electrode), bipolar (with two electrodes combined into one bipolar) and bioactive (in an electrolyte solution). There are superficial and deep (layered) diathermocoagulation. An ulcer develops at the site of exposure to an electric current, which is then covered with normal epithelium. Thus, pseudo-erosion and various deformations of the CMM are treated. The operation is carried out in the luteal phase of the cycle. After the operation, antibiotic ointments are applied to the cervix.

Indications: benign background processes without severe deformation and hypertrophy of the cervix.

Contraindications: acute and subacute inflammatory diseases of the female genital organs; active genital tuberculosis, cyclic spotting from the genital tract; benign background processes in combination with severe deformity and hypertrophy of the cervix, especially in women over 40 years of age.

Negative sides: a painful procedure, often the scab disappears on the 7-10th day and bleeding appears; a scar is formed along which a gap in childbirth can go; no material for histological examination.

2. Cryodestruction - the use of low temperatures that cause necrosis of pathological tissues. The cold agent is liquid nitrogen. There are the following varieties of this method:
♦ cryocoagulation (cryoconization);
♦ cryolaser therapy - cryotherapy (first stage) and action with a helium-neon laser after 3 days (second stage);
♦ combined cryodestruction (cryolaser therapy and cryoultrasound therapy). Cryodestruction is carried out in the first phase of the cycle. Apply one-, two-, and three-stage freezing with exposure from 3 to 8-10 minutes.

Advantages of the method: atraumatic, bloodless, faster healing without rough scars, reduced complication rate, ease of use, safety for the patient and medical staff, the possibility of using on an outpatient basis.

Indications: benign pathological processes of CIM (ectopic columnar epithelium of a post-traumatic nature, benign transformation zone - complete and incomplete, subepithelial endometriosis); precancerous processes of cervical cancer (simple leukoplakia, dysplasia fields, papillary dysplasia zone, pretumor transformation zone); condylomas and polyps of CMM.

Contraindications: concomitant acute infectious diseases; acute and subacute inflammatory diseases of the internal genital organs; purity of the vaginal flora III-IV degree; venereal diseases; true erosion of CMM; tumors of the female genital organs with suspected malignancy; severe somatic diseases in the stage of decompensation.

3. Laser destruction (vaporization). High-energy lasers are used: carbon dioxide, argon, neon, ruby.

Advantages of the method: tissue necrosis is minimal, stenosis of the cervix canal is not observed, and recovery occurs sooner than with other methods of physical destruction of the cervix. The positive side of laser treatment is the absence of inflammatory complications and bleeding. Unlike electrocoagulation and cryodestruction, after laser treatment of dysplasia, the junction between the squamous and columnar epithelium does not move into the cervical canal, but remains in the ectocervix, which facilitates subsequent endoscopic control.

Indications: background diseases of the cervix (pseudo-erosion, eroded ectropion, a common form of simple leukoplakia, endometriosis, warts, polyps, retention cysts); precancerous processes (leukoplakia with atypia, erythroplakia, stage I-III dysplasia); preinvasive cervical cancer with localization on the vaginal part; recurrent forms of diseases with the ineffectiveness of conservative treatment and other types of destruction.

Contraindications: acute inflammatory diseases of any localization; malignant diseases; spread of the pathological process up to 2/3 of the length of the cervical canal; pathological discharge from the genital tract.

Disadvantages of the method: pain during laser treatment is more pronounced, the failure rate in the treatment of dysplasia is slightly higher than with cryodestruction, the probability of recurrence of the process reaches 20%.

Laser treatment is a more complex and expensive method compared to cryodestruction.

4. Chemical destruction. For the treatment of benign processes in CMM, nulliparous women are successfully used Solkovagin - an aqueous solution that contains nitric, acetic, oxalic acids and zinc citrate, which is used to treat erosion; control after 3-5 days. If healing has not occurred, the site of erosion is treated twice again with a control after 4 weeks. Vagotil (polycresulen) - 36% solution, 2-3 times a week, apply a swab to the area of ​​erosion for three minutes, the number of procedures is 10-12.

5. Diathermoelectroexcision (conization) - electrosurgical cone-shaped excision of pathologically altered cervical tissue in the form of a cone, the top of which faces the internal pharynx. Complications are identical to those in diathermocoagulation, but are characterized by a greater degree of severity. If bleeding occurs at the time of surgery, ligatures are applied. Used to treat ectropion, leukoplakia, dysplasia.

Indications: a combination of benign and / or precancerous processes of the cervix with hypertrophy and deformation; the presence of dysplasia in patients who have previously undergone cervical destruction, which caused a displacement of the transformation zone into the cervical canal, or this displacement is due to the woman's age (after 40 years); relapses of dysplasia after electrocoagulation, cryodestruction, laser vaporization; intracervical localization of dysplasia; severe form of dysplasia.

Contraindications: inflammatory processes of the female genital organs; damage to the cervix, which pass to the vault and walls of the vagina; significant post-traumatic deformity of the cervix, extending to the vaginal vault; severe somatic diseases.

Advantages of the method: radical removal of pathologically altered cervix tissues within healthy tissues, the possibility of a thorough histological examination of the removed preparation.

Complications: bleeding, menstrual irregularities, endometriosis, shortening of the cervix and cervical canal, metaplasia.

6. Amputation of the cervix (carried out with a severe degree of dysplasia).

7. Reconstructive-plastic method - restores the normal anatomical structure of the cervix, helps to maintain the menstrual cycle.

8. Hysterectomy

Indications: CIN-III with localization in the cervical canal; technical impossibility of performing electroexcision due to anatomical features; combination with uterine fibroids or ovarian tumors; relapses after cryotherapy or laser therapy.

When the process spreads to the vaginal vaults, extirpation of the uterus from the upper 1/3 of the vagina is indicated.

4th stage - postoperative therapy, correction of existing disorders

At this stage, the vagina and CMM are treated with antiseptics and antibiotics.

Stage 5 - medical examination and rehabilitation (assessment of the general condition, menstrual function, immune homeostasis)

Removed from the dispensary for benign (background) pathological processes 1-2 years after treatment. For control, colpocervicoscopy, cytology and bacterioscopy are performed.

After radical treatment of precancerous processes, bacterioscopic, colpocervicoscopic and cytological control is mandatory (after 1-2-6 months and a year). They are removed from the register only after receiving the relevant results of endoscopic and cytological studies 2 years after treatment, since relapses of dysplasia are observed mainly at the end of the 1st and 2nd year of observation.

Clinical tactics of managing patients with various forms of background and precancerous diseases of the cervix

Ectopic columnar epithelium of post-traumatic origin

With ectopia of the cylindrical epithelium of dyshormonal genesis without concomitant gynecological pathology, three-phase oral contraceptives are prescribed. In the absence of effect, cryo- or laser destruction, chemical coagulation are indicated.

Benign polypoid growths are an indication for diagnostic curettage, polypectomy.

With exo- and endocervicitis, etiotropic therapy (antibacterial, antiprotozoal, antimycotic, antiviral) is carried out, depending on the type of pathogen.

In case of dysplasia, the treatment method is chosen taking into account the results of a comprehensive clinical and endoscopic, cytological, bacterioscopic, bacteriological examination of the cervical canal and morphological examination of the targeted biopsy material, as well as hormonal levels. The results of studies indicate that dysplasia of metaplastic epithelium, which in the form of fields, papillary zone and pretumor transformation is determined against the background of endocervicosis, is caused by infection. Therefore, the treatment of metaplastic epithelium dysplasia must begin with the sanitation of the vagina and cervix.

In case of dysplasia of the epithelium of the cervix (CIN І-P), in the absence of cicatricial deformity, cryo- or laser destruction is performed, in the presence of cicatricial deformity, diathermo-conization is performed.

With simple leukoplakia, hormonal disorders are corrected; if it is ineffective, laser or cryodestruction, diathermocoagulation is indicated.

With condylomatosis, a viral infection (human papillomavirus) is usually detected, which is confirmed by the presence of koilocytic atypia in a cervical smear. Treatment should be combined: general (immunomodulators), etiotropic and local, aimed at the destruction of the focus. The destruction of the focus can be carried out using podofilin or solcoderm, applied topically, as well as by cryogenic or laser methods, using diathermoexcision.

Dysplasia of the stratified squamous epithelium (leukoplakia, fields and papillary transformation zone) in most cases develops against the background of hormonal disorders (hyperproduction of estrogen, anovulatory menstrual cycle, insufficiency of the second phase). Therefore, a positive effect is possible with a combination of CO2 - laser destruction, cryodestruction or electroexcision with hormone therapy. The dose and its regimen depend on the age, MC, concomitant diseases of the patient.

Preinvasive cervical cancer. The method of choice is cone-shaped electroexcision. Indications for extirpation of the uterus: age over 50 years; primary localization of the tumor in the cervical canal; a common anaplastic variant with ingrowth into the glands; the absence in the preparation, removed during the previous conization, of areas free from tumor cells; the impossibility of carrying out a wide excision; a combination of preinvasive cancer with other diseases of the genital organs requiring surgical intervention; tumor recurrence.

Microinvasive cervical cancer. The method of choice in the treatment of microcarcinoma is extrafascial extirpation of the uterus, in the presence of contraindications to surgical intervention - intracavitary y-therapy.

Invasive cervical cancer:

Stage I - combined treatment in two versions: remote or intracavitary irradiation followed by extended extirpation of the uterus with appendages or extended extirpation of the uterus followed by remote y-therapy. If there are contraindications to surgical intervention - combined radiation therapy (remote and intracavitary irradiation).
Stage II - in most cases, a combined beam method is used; surgical treatment is indicated for those patients in whom radiation therapy cannot be carried out in full, and the degree of local spread of the tumor allows radical surgery.
Stage III - radiation therapy in combination with restorative and detoxification treatment.
IV stage - symptomatic treatment.

- a group of congenital and acquired pathological conditions that precede the development of oncological lesions, but not always transforming into a malignant tumor. May be optional or obligatory. The group of precancers includes a large number of diseases of an inflammatory, non-inflammatory and dystrophic nature, malformations, age-related changes and benign neoplasia. It is diagnosed on the basis of clinical, laboratory and instrumental studies. Treatment tactics and malignancy prevention measures are determined by the type and localization of the pathological process.

Precancer - changes in organs and tissues, accompanied by an increased likelihood of developing malignant neoplasms. Their presence does not mean mandatory transformation into cancer, malignancy is observed in only 0.5-1% of patients suffering from various forms of precancer. The study of this group of diseases began in 1896, when the dermatologist Dubreuil proposed to consider keratoses as pathological conditions preceding skin cancer. Subsequently, the theory of precancers became the subject of research by doctors of various specialties, which led to the formation of an integral concept that takes into account the clinical, genetic and morphological aspects of the formation of cancerous tumors.

The modern version of this concept is based on the idea that malignant neoplasia almost never occurs in healthy tissue. Each type of cancer has its own precancer. In the process of transformation from healthy tissue to a malignant tumor, cells go through certain intermediate stages, and these stages can be distinguished by studying the morphological structure of the affected area. Scientists have been able to identify precancers for many cancers of various localizations. At the same time, the precursors of other groups of oncological lesions remain unidentified in most cases. Treatment of precancerous processes is carried out by specialists in the field of oncology, dermatology, gastroenterology, pulmonology, gynecology, mammology and other fields of medicine.

Classification of precancers

There are two types of precancers: facultative (with a low probability of malignancy) and obligate (degenerate into cancer in the absence of treatment). Experts consider these pathological processes as two initial stages of cancer morphogenesis. The third stage is non-invasive cancer (carcinoma in situ), the fourth stage is early invasive cancer. The third and fourth stages are considered as the initial stages of the development of a malignant neoplasm and are not included in the group of precancers.

Taking into account localizations, the following types of precancers are distinguished:

• Skin precancers: Paget's disease, Bowen's dyskeratosis, xeroderma pigmentosa, cutaneous horn, senile keratosis, radiation dermatitis, long-term fistulas, post-traumatic and trophic ulcers, post-burn scars, skin lesions in SLE, syphilis and tuberculosis, congenital malformations and acquired skin diseases.
• Precancers of the red border of the lips: dyskeratosis, papillomas.
• Precancers of the oral mucosa: fissures, ulcers, leukokeratosis.
• Precancers of the nasopharynx and larynx Key words: papillomas, dyskeratosis, basal fibroid, chondroma, adenoma, contact fibroma.
• Precancers of the mammary gland: nodular and diffuse dishormonal hyperplasia.
• Precancers of the female genital organs: hyperkeratosis, erosion and polyps of the cervix, endometrial hyperplasia, endometrial polyps, adenomatosis, cystic mole, some ovarian cystomas.
• Precancers of the gastrointestinal tract: post-burn scars of the esophagus, leukoplakia of the esophagus, gastritis, gastric ulcer, adenomatous polyps of the esophagus, stomach and intestines, ulcerative colitis, fistulas and fissures of the anus, scars of various localization.
• Precancers of the liver and biliary tract: cirrhosis, cholelithiasis, hepatoma.
• Precancers of the urinary tract, testicles and prostate: leukoplakia of the bladder mucosa, papillomas, adenomas, cryptorchidism, prostatic hyperplasia, teratoid testicular tumors, specific lesions of the epididymis in gonorrhea and tuberculosis.

Facultative precancers are chronic diseases and conditions with a relatively low risk of malignancy. Such pathological processes are accompanied by tissue dystrophy and atrophy, as well as disruption of cell regeneration processes with the formation of areas of cell hyperplasia and metaplasia, which can subsequently become a source of a malignant tumor. The group of facultative precancers includes chronic nonspecific and specific inflammatory processes, including esophagitis, atrophic gastritis, gastric ulcer, ulcerative colitis, cervical erosion and many other diseases. In addition, this group includes some developmental anomalies, age-related changes and benign neoplasia.

Obligate precancers are considered as pathological conditions that, if left untreated, sooner or later transform into cancer. The probability of malignancy in such lesions is higher than in facultative precancers. Most obligate precancers are due to hereditary factors. These diseases include adenomatous polyps of the stomach, Bowen's dermatosis, xeroderma pigmentosa, familial polyposis of the large intestine, etc. the level of maturity with a predominance of less specialized forms) and a violation of the architectonics of tissues (a change in the normal structure, the appearance of areas of asymmetry, atypical relative positions of cells, etc.).

Specialists usually distinguish three degrees of dysplasia in precancer: mild, moderate and severe. The main criterion that determines the degree of dysplasia is the level of cell atypia. The progression of dysplasia is accompanied by an increase in cellular polymorphism, an increase in nuclei, the appearance of hyperchromia, and an increase in the number of mitoses. The appearance of areas of dysplasia in precancer does not necessarily result in the formation of a clone of malignant cells. Stabilization of the process, a decrease or increase in the severity of pathological changes are possible. The more pronounced dysplasia, the higher the likelihood of malignancy.

Precancerous conditions (precancerous)

Skin precancers

Precancerous skin diseases are a widespread and well-studied group of precancers. The leading place in the list of factors provoking such pathological conditions is occupied by adverse meteorological effects, primarily excessive insolation. In addition, high humidity, wind and low ambient temperatures matter. Skin precancers can be triggered by prolonged contact with chemical carcinogens, including tar, arsenic, and lubricants. Radiation dermatitis occurs when a high dose of ionizing radiation is received. The cause of trophic ulcers is circulatory disorders. Post-traumatic ulcers can form at the site of extensive purulent wounds. Unfavorable heredity plays an important role in the development of some diseases.

The risk of malignancy of keratoacanthoma is about 18%, skin horn - from 12 to 20%, post-burn skin lesions - 5-6%. The diagnosis of precancer of the skin is made taking into account the data of the anamnesis and external examination. If necessary, take material for cytological examination. Treatment usually consists of excising the affected tissue. Surgical removal, cryodestruction, laser therapy, diathermocoagulation are possible. Some precancers require therapy for the underlying disease, dressings, skin grafting, etc. Prevention consists in minimizing harmful effects, observing safety rules when working with chemical carcinogens, and timely and adequate treatment of traumatic injuries and inflammatory skin diseases. Patients at risk should be regularly examined by a dermatologist.

Precancers of the gastrointestinal tract

Precancers of the gastrointestinal tract include a large number of chronic diseases of the gastrointestinal tract. The most important are atrophic gastritis, tumor-stimulating gastritis (Monetrier's disease), gastric ulcer, adenomatous polyps of the stomach and intestines, Crohn's disease and ulcerative colitis. The reasons for the development of precancers can vary. Important factors are unfavorable heredity, Helicobacter pylori infection, eating disorders (irregular meals, consumption of spicy, fatty, fried foods) and autoimmune disorders.

The probability of malignancy of precancers of the gastrointestinal tract varies significantly. With familial polyposis of the colon, malignancy is observed in 100% of cases, with large adenomatous polyps of the stomach - in 75% of cases, with Monetrier's disease - in 8-40% of cases, with atrophic gastritis - in 13% of cases. In stomach ulcers, the prognosis depends on the size and location of the ulcer. Large ulcers are malignant more often than small ones. With the defeat of the greater curvature (very rare localization of the ulcer), malignant degeneration is observed in 100% of patients.

The leading role in the diagnosis is usually played by endoscopic methods of research. During gastroscopy and colonoscopy, the doctor evaluates the size, location and nature of the precancer and performs an endoscopic biopsy. The tactics of treatment is determined by the type of pathological process. Patients are prescribed a special diet, conservative therapy is carried out. At a high risk of malignancy, surgical excision of precancers is performed. Preventive measures include adherence to a diet, timely treatment of exacerbations, correction of immune disorders, early identification of persons with a hereditary predisposition, regular examinations by a gastroenterologist in combination with instrumental studies.

Precancers of the female reproductive system

In the group of precancerous diseases of the female reproductive system, experts combine precancers of the female genital organs and mammary glands. Among the risk factors for the development of precancers, researchers indicate unfavorable heredity, age-related metabolic and endocrine disorders, early onset of sexual activity, numerous births and abortions, lack of childbirth, sexually transmitted diseases, some viral infections (human papillomavirus, herpesvirus type 2), smoking, use chemical contraceptives and occupational hazards.

When diagnosing precancer, data from a gynecological examination, colposcopy, hysteroscopy, ultrasound of the pelvic organs, Schiller test, examination of cervical scrapings, mammography, histological examination and other methods are taken into account. Treatment may include diet, physiotherapy, hormonal drugs, antipruritic and antimicrobial agents, etc. Chemical coagulation, diathermocoagulation, radiodestruction, cryosurgery, and traditional surgical techniques are used to remove various types of precancer. Indications for surgery and the scope of intervention are determined individually, taking into account the history of the disease, the risk of malignant transformation, the age of the patient and other factors.

PRECANCER DISEASES
FEMALE GENITAL ORGANS

VULVA

Etiology

Background diseases of the vulva are characterized by clinical and histological manifestations, expressed in degenerative changes in the tissue of this organ. Their occurrence is associated with various metabolic and neuroendocrine disorders against the background of aging processes and hormonal changes or infection with viruses.

Of great interest are chronic viral diseases of the vulva, the most common manifestation of which are genital warts (HPV 6 and 11), representing multiple warty lesions of the skin and mucous membranes. The disease is often combined with the presence of sexually transmitted infections. Rapidly progressing warts are classified as verrucous cancer. Prolonged existence of human papillomavirus infection can lead to true vulvar dysplasia and cancer.

Classification

Vulvar dystrophic changes 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 a similar clinical manifestation. The frequency of these diseases ranges from 1 in 300 to 1 in 1000 women and occurs mainly in peri- or postmenopausal age. A possible cause of the disease are autoimmune, 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

The 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. In the future, 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 on the entire surface of the vulva with damage to the deep layers and a sharp thinning of the surface. The labia is reduced in size, vulvodynia worries constantly, the greatest discomfort is noted at night. Over time, on the affected tissue of the vulva, foci of hyperplastic dystrophy appear in the form of hyperkeratotic plaques, merging into large layers, often tearing themselves away, 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 of each disease is relatively small (up to 5%).

Treatment

It involves a set of measures: anti-inflammatory, sedative, antihistamine, multivitamin, corticosteroid drugs, physiotherapy using laser and magnetic exposure. 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.

PRECANCER 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%, smoking is an accompanying factor. An increase in morbidity in young patients was established. The average age of onset of the disease has decreased from 55 to 35 years. In almost 50% of cases, the defeat of 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, and spontaneous regression of the pathological process is possible, especially during pregnancy. The frequency of the disease is 0.53 per 100 thousand women.

Dysplasia is a morphological diagnosis, characterized by a violation of the processes of cell differentiation. There are mild (VINI), moderate (VINII) and severe (VINIII) dysplasia. With a mild degree, changes are noted only in the lower third of the epithelial layer, with a severe one, they occupy the entire layer, and keratinization and mitoses are noted in the most superficial cells.

Clinic

In 60% of patients, dysplasia is asymptomatic. In 30%, the clinical manifestations are very diverse. Papular foci are often found, raised above the skin and having a scaly surface, in appearance resembling flat warts or weeping with the appearance of moist erythema. Often leukoplakia is detected. VINI is often represented by a subclinical picture of human papillomavirus infection. Patients with clinical complaints (itching - in almost 75% of cases, pain in the vulva, anus, vagina) usually show signs of VINII or VINIII, the lesion may be one or more.

Diagnostics

It is considered mandatory to conduct a histological examination of the biopsy.

Treatment

The method of treatment correlates with the age of the patient, the degree of dysplasia and the number of lesions. At a young age, preference is given to more gentle methods of surgical treatment in the form of excision of the pathological focus, chemical coagulation, ablation with a carbon dioxide laser, cryodestruction, and radiosurgical exposure. With small and multiple foci, preference is given to laser vaporization. With large and multiple lesions, a phased re-excision of the foci 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 in extensive lesions and recurrence of dysplasia. Complete excision makes it possible to finally determine the degree of possible invasion and should be carried out within healthy tissue of at least 8 mm.

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 pathology of the cervix, respectively, 10-20% are precancerous and malignant diseases of this organ. The frequency of malignancy of precancerous lesions of the cervix is ​​6-29%.

Background diseases include true erosion, ectopia, endometriosis, cervicitis, condylomatosis, papillomatosis, deciduosis, ectropion. Precancerous 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:

1. 
   Inflammatory diseases of the cervix, vagina and uterus caused by various microbial, viral factors and their combination;
2. 
   dishormonal disorders;
3. 
   mechanical injury;
4. 
   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, there are groups of different, oncogenic risk. Thus, HPV 6 is considered to be a low oncological risk; eleven; 40; 42; 43; 44 and 61 types, to the average risk - 30; 33; 35; 39; 45; 52; 56; 58, high risk - 16; eighteen; 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; eighteen; 31; 51; 52; 58 - with squamous cervical cancer; 16 and 18 types - with adenocarcinoma. The varying degree of susceptibility of the cervical epithelium to viral damage is associated with a genetic predisposition. A gene discovered in the human genome p53, which is responsible for the suppression of 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), the use of IUDs (more than 5 years), with frequent changes of sexual partners, a low social standard of living, a large number of abortions and childbirth.

Classifications

Modern classifications of pathological changes in the cervix are based on the data of histological examination, 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 related lesions" presents data on squamous and glandular neoplasms.

Squamous cell formations include: papilloma, genital warts with morphological signs of human papillomavirus infection (PVI), squamous metaplasia and transitional cell metaplasia, squamous atypia of uncertain significance, observed in cells with 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 injury (HSIL), including moderate to severe dysplasia CIN II and CIN III, and squamous cell carcinoma.
Classification of underlying diseases,
precancerous conditions of the cervix(Yakovleva I.A., Kukute B.G., 1979)

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 grade I CIN is synonymous with mild dysplasia, grade II CIN is moderate, and grade III CIN is used to refer to both severe dysplasia and preinvasive carcinoma. To refer to leukoplakia with atypia, which in the domestic literature is referred to 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 a violation of the hormonal balance and immune status, or with the influence of external factors: infection, chemical, physical, traumatic injury during childbirth or as a result of therapeutic measures.

BACKGROUND PROCESSES OF THE CERVIC

Classification of cervical ectopia (Rudakova E.B., 1996)

Types: Shapes:

1. Congenital 1. Uncomplicated

2. Acquired 2. Complicated

3. Recurrent

ECTOPIA OF THE CERVICAL

The prevalence of this pathology in women is extremely high (38.8%), including 49.2% of gynecological patients, most often detected in nulliparous women under the age of 25 (from 54.25 to 90% of cases). Currently, 3 types of ectopia are distinguished (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 epithelial-stromal relationships (ectropion) with inflammatory processes of the cervix and vagina, with other background, as well as precancerous processes (polyps, 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 in 67.7% of cases. However, the existence of an independent disease is also possible. The cause of the development of this pathology are specific and non-specific infectious agents.

Polyp - This is an overgrowth of the mucous membrane of the cervical canal. The detection rate is 1-14% of patients. This pathology occurs at any age, its combination with ectopia is noted in 2.8% of cases.

Endometriosis of the cervix 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, diathermocoagulation. The absence of the integumentary epithelium is usually short-term and therefore, as a disease itself, is rare.

Clinic

With an uncomplicated course of background processes, patients do not present specific complaints. However, in the presence of inflammatory processes on the part of the appendages, the uterus, or the actual attachment of a specific and / or non-specific infection of the cervix, patients report pathological leucorrhoea, burning, itching, pain, postcoital spotting. When viewed in mirrors, background processes have a clearly expressed picture and are well diagnosed.

PRECANCER CERVICAL CONDITIONS

Leukoplakia is a pathology of the cervix, which in 31.6% of cases is associated with the occurrence of dysplasia and malignant transformation of the stratified squamous epithelium against the background of dyskeratosis. The frequency of this disease is 1.1%, in the structure of the pathology of the cervix 5.2% and 80% of the total precancerous pathology of the cervix. There are the following forms of leukoplakia:

1. Colposcopic form (silent iodine-negative zones);

2. Clinically pronounced forms: simple leukoplakia, warty leukoplakia, basis of leukoplakia, leukoplakia fields.

Dysplasia- histological diagnosis, expressed in the flattening of tissue of the regressive type, associated with a decrease in differentiation. Dysplasia can occur on the unchanged mucosa, and can accompany any of the background conditions of the cervix. Dysplasia can also be a disease itself, or it can precede and/or accompany oncological diseases. The frequency of detection of dysplasia during medical examinations is 0.2-2.2%. The diagnostic criteria for cervical dysplasia include a violation of the structure of the epithelium, 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 epithelium, they speak of mild dysplasia, if they are detected in the lower and middle thirds - of moderate dysplasia, if they capture the entire thickness of the epithelium - of severe dysplasia.

Diagnostics

The main methods for diagnosing any pathological conditions of the cervix are examination in the mirrors, simple and extended colposcopy, assessment of vaginal microbiocenosis with active HPV typing, cytological examination of smears - prints (the so-called PAP smears) and targeted biopsy followed by histological examination. Diagnostic signs are compared, and treatment tactics are selected.

Treatment

Treatment involves the implementation of the main stages.

Stage I - sanitation of the vagina. The duration of treatment depends on the number of combined infectious agents and is carried out in a complex with the inclusion of etiotropic antibacterial, immunomodulatory, enzyme preparations.

Stage II - local treatment of the cervix. With background diseases of the cervix and CIN I-II in nulliparous women, it is possible to use sparing methods of physical influence - cryodestruction, laser vaporization, radiosurgical treatment. In case of recurrent ectopia in women giving birth, ectropions, CIN II-III, preference is given to cone-shaped excision of the cervix, which is carried out using a laser, radio, surgical method. 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 the microbiocenosis of the vagina of the hormonal and immune background, stimulation of the reparative processes of the cervix and vagina.

UTERINE BODY

Uterine fibroids (MM)- one of the most common gynecological diseases. Among outpatient gynecological patients, MM occurs in 10-12%, inpatients 17%, among the total number of operated patients from 35 to 50%. The frequency of detection of this pathology during professional 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 of mental labor and residents of large cities than among women of manual labor and 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, tk. the ratio of parenchyma to stroma is 1:3, that is, the connective tissue component predominates, intramural and submuscular nodes are fibroids or leiomyomas, where the ratio is 2:1 or 3:1. Statistical data 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%. Fibroids in 92-97% develop in 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. In 85%, multiple MM is observed, and a combination of interstitial and subserous nodes is observed in 82.9%.

Etiology and pathogenesis

The occurrence of MM is facilitated by disturbances in endocrine homeostasis in the links of the hypothalamus-pituitary gland-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 (abortions, 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 the earlier assumptions about the main role of estrogens in the growth and proliferation of MM, the modern concept is characterized by the establishment of the key role not only of estrogen, but to a greater extent of progesterone. G.A. Savitsky et al. (1985) found 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). Implementation of exogenous and endogenous hormonal influence in the MM tissue is ensured by the presence in it of a specific receptor protein related to estrogens (ER) or progesterone (RP). So Yu.D. Landechovsky et al. (1995) it was found that 50-60% of MM nodes are both RE+ and RP+, and 25-30% RP+ and RE-. In this case, taking into account the leading role of progesterone in the pathogenesis of MM, an assumption is made about the presence of RP dysfunction, anomalies in the structure of receptors, or mutant forms. Steroid hormones realize the differentiation and proliferation of tissues at the local cellular level. Among the factors of intercellular interaction, growth 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, fibroblast growth factor, 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 in the process of tumor growth and development and are carried out at the molecular genetic level. According to preliminary data, the most common cytogenetic disorders in MM are: translocation within or deletion of chromosome 7, translocation involving chromosome 12, especially with chromosome 14, and structural aberrations of chromosome 6. Aberrations are also described for chromosomes 1, 3, 4, 9, and 10. More pronounced, but similar changes occur in the study of patients with uterine sarcomas.

Clinic

The clinical manifestations of the disease are mainly determined by the size, number, location and growth rate of myomatous formations. With slow growth and small lesions, 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 feature is characteristic of the submucosal and interstitial location of the MM.

Pain syndrome was noted in 21-56% of cases. Pain can be acute or chronic. Acute pain is a sign of urgent clinical situations: necrosis or torsion of the tumor node. Clinically, hyperthermia, symptoms of peritoneal irritation, leukocytosis are additionally detected. Constant pain is a sign of the rapid growth of the tumor or its interligamentous location. Cramping pains are characteristic of the "born" submucosal node.

With a significant size of the MM, a symptom of compression of adjacent organs appears (14-25%). 10% of patients complain of dysuric disorders, interligamentous arrangement 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 mucosa of the submucosal nodes, the leucorrhoea acquires a fetid odor.

Diagnostics

Diagnosis, as a rule, is not difficult and includes a comparison of anamnesis data, patient complaints, bimanual palpation, ultrasound, uterine probing, and separate diagnostic curettage. In some cases, CT, MRI, angiography, cystoscopy, sigmoidoscopy are performed. The entire diagnostic algorithm is aimed at determining the size of the tumor, its location, the condition of the myomatous nodes, the nature of violations of neighboring organs and the combination of fibroids with other background, precancerous or oncological pathology.

Long-term existence of MM and impaired vascularization of tumor nodes can lead to the following secondary dystrophic and degenerative changes occurring in the myoma nodes - edema of the MM node. The nodes are soft, pale in color on the cut, with liquid sweating and cavities. Such MM are called cystic - necrosis of MM nodes. There are dry, wet and red necrosis. With dry necrosis, wrinkling of the tissue occurs with areas of necrosis, such changes occur in patients in the menopausal period. With wet necrosis, softening of tissues is noted, the formation of cavities filled with necrotic masses. 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, abscessing of nodes:

• 
  Salt deposition in MM:

• 
  Node atrophy:

An important point in the diagnosis of MM is its combination with other gynecological diseases. In a comprehensive examination of the endometrium in MM, glandular cystic hyperplasia of the endometrium was noted in 4% of cases, basal hyperplasia

According to Ya.V. Bohman (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 RE, concomitant MM was detected. In the clinic of the University of Jena, when examining patients with MM, EC was found in 5.2%, a similar number of patients with MM (6.7%) was detected during surgery for cervical cancer.

The commonality of the processes of pathogenesis of MM and a number of malignant diseases makes it possible to identify patients with MM in a high-risk group for the occurrence of malignant tumors. This determines a more active tactic for the detection of this pathology with the exception of endometrial pathology, emphasizes the expediency and necessity of corrective neoadjuvant measures and the timeliness of surgical treatment.

Treatment

The choice of treatment method, treatment regimens 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 the 12-week pregnancy and if the tumor is interstitial or subserous. In this case, it is advisable to prescribe a complex of therapeutic measures, including: regulation of wakefulness and sleep; sedative, antidepressant drugs; vitamin therapy with the maximum combination of vitamins E, A, C; symptomatic hemostatic and anti-anemic therapy, immunomodulatory drugs, herbal medicine, spa treatment. Taking into account the pathogenetic moments, one of the main places is assigned to hormone therapy in this complex. Currently, the following are recommended for MM therapy: 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 stage for further surgical treatment, as well as after conservative myomectomy.

The main treatment for MM is surgery (52% to 94% of cases).

Indications for surgical treatment:

• 
  violations of the menstrual-ovarian cycle and the ineffectiveness of conservative treatment;
• 
  rapid tumor growth;
• 
  violation of the function 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 the submucosal node.

BACKGROUND AND PRECANCER DISEASES OF THE UTERINE BODY

Hyperplastic processes of the endometrium are diseases that are determined exclusively at the morphological level, which are the result of hormonal disorders in patients of perimenopausal age. The frequency of this condition among various hyperplastic processes ranges from 5.8 to 6.2%, and 10-12.4% turn into cancer.

Classification

The WHO histological classification distinguishes 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 neuroexchange-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, special importance is given to concomitant somatic pathology (functional state of the liver, thyroid gland, pancreas, cardiovascular system, overweight), as well as changes in the ovaries. All these conditions lead to absolute or relative hyperestrogenism. In this case, all hyperplastic processes have disturbances both in the central and peripheral hormonal levels. 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 bleeding from the genital tract that appeared in menopause, or any menstrual dysfunction from hyperpolymenorrhea to menometrorrhagia in patients of the reproductive period.

Diagnostics

The main diagnostic method is the histological examination of the endometrium. Material for research can be obtained with aspiration biopsy or with 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 possibilities of this method increase significantly when using color Doppler mapping (CDM), which makes it possible to determine the nature of changes in the endometrium by the characteristics of the blood flow. It is generally accepted that the thickness of the endometrium up to 5.5 mm (with individual values ​​from 1 to 44 mm) determines the benign nature of the lesion, in malignant processes - 24 mm (from 7-56 mm). In the study of 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 appropriate for screening endometrial pathology.

Treatment

Given the nature of pathogenetic changes, treatment should be carried out in a complex manner, including the correction of somatic, background gynecological pathology, hormonal and surgical effects.

Priority in the treatment regimen is determined by the histological structure of hyperplastic processes.

Hormone therapy is indicated in cases of endometrial glandular hyperplasia. In this case, a wide arsenal of drugs is used depending on the age of the patient: 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 effect is determined (repeated biopsy of the endometrium).

With endometrial polyposis, methods of "small" surgical technique are used: separate diagnostic curettage with hysterectomy, with relapses of the disease

With atypical hyperplasia, the tactics of treatment are determined by the age of the patient. In postmenopausal age, preference is given to the surgical method in the amount of extirpation of the uterus with appendages.

Hormone therapy may be given as a neoadjuvant step. Also, this method is preferable in case of a combination of hyperplastic processes with other gynecological surgical pathology and the ineffectiveness of hormone therapy.

In patients of reproductive age, indications and methods for the treatment of atypical hyperplasia using only hormone therapy have been developed. Norkolut, Depo-Provera, Provera, Dufoston, antigonadotropic drugs (Danazol), analogues of gonadotropin-releasing hormone (Zoladex, Buserelin-Depot, Naforelin) are used. Treatment continues up to 12 months with follow-up biopsy every 3 months of treatment.

In patients of perimenopausal age 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 (loop diathermy only), roller diathermy, laser ablation (using laser energy) , radiofrequency ablation (using radiofrequency exposure) and cryoablation (using cryotechniques). The effectiveness of these methods is much higher than surgical ablation from 80-90%, and the combination with hormone therapy in 70% of patients contributes to the achievement of amenorrhea.

Precancerous diseases are those diseases on the basis of which the occurrence of malignant neoplasms is possible. Precancerous diseases of the external genitalia include leukoplakia and kaurosis.

Leukoplakia- a degenerative disease, as a result of which there is a change in the mucous membrane, accompanied by keratinization of the epithelium.
It is characterized by the appearance in the area of ​​the external genital organs of dry white plaques of various sizes, which are areas of increased keratinization, followed by sclerosis and wrinkling of tissues. In addition to the external genital organs, leukoplakia can be localized in the vagina and on the vaginal part of the cervix.

Caurosis of the vulva- a disease characterized by atrophy of the mucous membrane of the vagina, labia minora and clitoris. It is a process of atrophy, sclerosis. Due to atrophy, sclerosis, wrinkling of the skin and mucous membrane of the external genital organs occurs, the entrance to the vagina narrows narrowly, the skin becomes dry, easily injured. The disease is accompanied by persistent itching in the vulva.

Background diseases of the cervix include:

• pseudo-erosion
• true erosion
• Ectropion
• Polyp
• Leukoplakia
• erythroplakia

pseudo-erosion is the most common underlying disease of the cervix.
Objectively, an easily injured granular or velvety surface is found around the throat of a bright red color. Pseudo-erosion has a characteristic colposcopic picture. Distinguish between congenital pseudo-erosion, which occurs during puberty with an increase in the production of sex hormones, and acquired pseudo-erosion, caused by inflammation or injury of the cervix. Healing of pseudo-erosion occurs due to the overlap of the columnar epithelium with stratified squamous epithelium.

Along with pseudo-erosion, it sometimes occurs true erosion, which is a defect in the stratified squamous epithelium of the vaginal part of the cervix, occurs with diseases of the genital organs.

Polyp of the cervix is a focal mucosal overgrowth with or without an underlying stroma. When examining the cervix, a soft, pinkish mass is found hanging from the cervical canal into the vagina. Muco-bloody discharge is characteristic.

erythroplakia The cervix is ​​​​areas of thinned epithelium, through which the underlying tissue of red color shines through.

Dysplasia of the cervix- morphological changes in the stratified squamous epithelium of the vaginal part of the cervix, which are characterized by intensive proliferation of atypical cells.

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