Squamous metaplasia of the cervix: what is it and how to treat it. What is squamous metaplasia Cervicitis squamous metaplasia of glandular epithelium

Metaplasia. The essence of metaplasia is that cambial cells of tissues under unusual conditions begin to differentiate into structures that are not characteristic of a given organ, i.e. one differentiated tissue is replaced by another differentiated one. At the same time, metaplastic tissue and its cells do not have signs of atypia, and metaplasia itself is reversible, which characterizes it, unlike dysplasia, as a benign process. Metaplasia is usually a response to damaging influences and allows the tissue to survive in unfavorable conditions. For example, the appearance of phylogenetically more ancient intestinal epithelium in the stomach is regarded as an adaptive mechanism in response to infection of the stomach with H. pylori.

It is generally accepted that in most cases there is no direct connection between metaplasia and cancer. However, in metaplastic foci, signs of neoplastic development - dysplasia - may subsequently appear, which constitutes an increased risk of cancer. From these positions, metaplasia is usually considered as a background condition.

Dysplasia . According to WHO experts, precancerous changes include dysplasia, which is characterized by insufficient and incomplete differentiation of stem cells and impaired coordination between cell proliferation and maturation. In most organs, dysplasia develops against the background of previous hyperplasia associated with chronic inflammation or dyshormonal disorders, but it can also occur de novo, those. immediately as such.

The term “dysplasia” refers to deviations from the normal structure of the entire tissue complex (and not just the appearance of cells with signs of cellular atypia).

In all organs, with epithelial dysplasia, an expansion of the germinal zones is always observed, accompanied by a violation of the histostructure and proliferation of cambial, immature cells with varying degrees of atypia. Based on this, WHO experts defined epithelial dysplasia as a triad: 1) cellular atypia; 2) impaired cell differentiation; 3) violation of tissue architectonics.

In normal epithelium there is a clear stratification, i.e. the cells are arranged in ordered layers, and the germinal zone - the basal layer of epithelial cells - is of insignificant width.

For grade I dysplasia the epithelium differs from normal only in the tendency to proliferation of the basal layer of cells (i.e., expansion of the germinal zone), and the cells only show signs of atypia. Epithelial cells begin to lose their polar orientation in the architectonics of the integumentary layer, which leads to a change in stratification.

With II degree dysplasia proliferating basal cells occupy more than half the height of the epithelial layer, cell atypia is observed mainly in its middle layers, i.e. stratification is aggravated and the epithelium in such foci acquires a multirow-multilayered structure. Ill degree of dysplasia characterized by the replacement of immature cells from the basal layer of almost the entire epithelial layer. Only in its upper row are mature cells preserved. Pathological mitoses are observed. Cellular atypia increases, the stratified epithelium loses its zonal structure, acquiring “architectonic anarchy.” The disruption of cell stratification and the transformation of the epithelium into a multi-row, multi-layered layer progresses. The basement membrane is preserved. These changes are close to the level of carcinoma in situ,

With dysplasia, distinct changes in the activity of all regulators of intercellular relationships are detected: adhesive molecules and their receptors, growth factors, proto-oncogenes and oncoproteins produced by them. Moreover, genetic rearrangements can significantly precede morphological changes and serve as early signs of pretumor changes. Over time, dysplasia can regress, be stable, or progress. The dynamics of the morphological manifestations of epithelial dysplasia largely depend on the degree of severity and duration of its existence. A low degree of dysplasia has virtually nothing to do with cancer. The reverse development of mild and moderate dysplasia is observed everywhere. Therefore, grade I-II dysplasia is often classified as an optional precancer.

Stages of tumor formation : 1) hyperplasia ≫ 2) benign tumors ≫ 3) dysplasia ≫ 4) cancer in situ ≫ 5) invasive cancer. Often in this chain one of the links may be missing, most often the second. This chain of successive changes is also called morphological continuum.

The term “early cancer” was first proposed for gastric cancer. Later, the main criteria for early cancer of any location were formulated. Basically, it is a well-differentiated tumor in

within T1, most often with an exophytic form of growth, without regional and distant metastases, that is, this is cancer that does not extend beyond the mucous membrane, epidermis of the skin, or other tissue on which it arose. In practice, the tumor should not extend beyond T1NOMO.

Early cancer is a clinical and morphological concept, based on a careful study of operational data and the removed specimen. The exact characteristics of early cancer depend on the organ affected, but The main symptom of early cancer is that the tumor is limited to the mucous membrane. For some

localizations (mucous membranes of the lips and oral cavity, esophagus, larynx, bronchi, cervix, etc.) early cancer is carcinoma in situ. For cancer of internal organs lined with glandular epithelium (stomach, intestines, endometrium) and parenchymal organs (breast, thyroid, prostate gland, etc.), the concept of “early cancer” may be somewhat broader and may not coincide with the concept of “carcinoma in situ” due to features of the architectonics of the mucous membranes of these organs. In principle, early cancer could be called stage I of the disease - a tumor within the parenchyma of an organ without metastases. However, due to the lack of uniformity in the biological behavior of neoplasms of different localizations, as well as the difference in diagnostic capabilities, the term “early cancer” must be clarified in each specific situation. In one case it may be only carcinoma in situ, in another - minimal or small cancer without metastases, in the third - T1N0M0.

Small cancer is an invasive cancer, the smallest tumor (usually 1 cm in diameter), confidently determined by clinical research methods.

The term “early” implies a certain stage of malignancy, when the tumor is localized, there are no metastases, and a favorable outcome of radical treatment can be predicted with great certainty.

For example, carcinoma in situ of the stomach, which is an example of early cancer, can occupy an area of ​​up to 10-12 cm in diameter; metastases, as a rule, are absent, long-term results of treatment are the most favorable. On the other hand, very small stomach cancer can have invasive properties and be a source of extensive metastases (lympho- and hematogenous).

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

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

Background are called diseases and changes in the vaginal part of the cervix, in which normoplasia of the epithelium persists, i.e. correct mitotic division of epithelial cells occurs, 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 cervical diseases

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 turn into both squamous and prismatic epithelium.

Ectopia columnar epithelium develops in two ways:

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

Metaplasia- the process of transforming 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) is caused by the overlap of the cylindrical epithelium with flat epithelium.

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 with the subsequent formation of eroded areas on it, the healing of which occurs due to the growth of columnar epithelium from the cervical canal, which is not typical for the vaginal eco-environment. Pseudo-erosion forms in this zone. Subsequently, the columnar epithelium is replaced by stratified squamous epithelium.

The human papillomavirus (HPV) plays a particularly important role in the occurrence of cervical dysplasia.

It penetrates into the basal cells of the epithelium through microtraumas formed during sexual intercourse. The viral DNA enters the cell after shedding its 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 (latency period). With further expression of the virus, the subclinical and then clinical stages of the disease develop. 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 hyperchromatic due to the accumulation of virions in it, and 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, groups of different cancer risks are distinguished. Thus, low cancer risk includes HPV types 6, 11, 40, 42, 43, 44 and 61; to average risk - 30, 33, 35, 39, 45, 52, 56, 58; to high risk - 16, 18 and 31 types of virus.

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

The combination of HIV infection and HPV increases the risk of malignancy. In addition, the occurrence of cervical dysplasia can be promoted by the synergy of the herpes simplex virus, chlamydia and CMV.

2. Traumatic injuries to the cervix arising after childbirth or abortion (the predisposing factor is a violation of the trophism and innervation of tissues), as well as barrier contraceptives and vaginal tampons such as Tampax.
3. Hormonal disorders(increased gonadotropic function, changes in estrogen metabolism with a predominance of estradiol, an increase in oxygenated forms of 17-ketosteroids).
4. Immune disorders(increased level of cytotoxic T-lymphocytes, decreased 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 characteristics and hormonal disorders.
7. Use of COCs with a high content of gestagens.
8. Smoking(the risk of disease increases with the number of cigarettes per day and duration of smoking).
9. Hereditary factor: risk of cervical cancer in women with a family history.

Classification of cervical diseases

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

I. Benign background processes:

A. Dishormonal processes:
1. Ectopia of columnar epithelium (endocervicosis, glandular erosion, pseudo-erosion): simple, proliferating, epidermalizing.
2. Polyps (benign polyp-like growths): simple; proliferating; epidermising.
3. Benign transformation zone: unfinished and completed.
4. Papillomas.
5. Cervical endometriosis.
B. Post-traumatic processes:
1. Cervical ruptures.
2. Ectropion.
3. Cicatricial changes in the cervix.
4. Cervicovaginal fistulas.

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

II. Precancerous conditions:

A. Dysplasia.
1. Simple leukoplakia.
2. Dysplasia fields:
metallized prismatic epithelium.
3. Papillary transformation zone:
multilayer squamous epithelium;
metaplastic prismatic epithelium.
4. Pretumor transformation zone.
5. Condylomas.
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.

Cervical Disease Clinic

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 squamous multilayer epithelium (ulceration, erosion), followed by the development of columnar epithelium on the eroded surface.

There are true erosion and pseudo-erosion.

True cervical erosion- 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 during reproductive age.
2. Traumatic (injury, for example, from vaginal specula), more often in postmenopausal age.
3. Post-burn (after rejection of the scab as a result of chemotherapy, electrical or cryotherapy), more often in reproductive age.
4. Trophic (with uterine prolapse, after radiation therapy), more often in postmenopausal age.
5. Cancerous (with the disintegration of a cancerous tumor of the cervix), more often in postmenopausal age.
6. Syphilitic - more often in reproductive age.

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

During colposcopy, true erosion is defined as an epithelial defect with exposed subepithelial stroma, with the bottom below the level of stratified squamous epithelium, and the edges are clear. After using a 3% acetic acid solution, the bottom of the 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 epithelial cover at the border with true multilayered squamous epithelium. Fibrin deposits and blood are visible on the surface of this pathological area. In the subepthelial connective tissue, the inflammatory process, leukocyte infiltration are expressed, dilated capillaries, hemorrhages, and tissue edema are detected.

True erosion is a short-term process: it lasts no more than 1-2 weeks and turns into pseudo-erosion.

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

Types of pseudo-erosions:

1. Progressive - the formation of glandular structures on the surface and in the depths of the cervix. The cervix enlarges due to the proliferation of columnar 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 pseudoerosion glands; 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 (Nabothian cysts), which can be single or multiple, their diameter is 3-5 mm.

3. Healing (epidermising) - after treatment of inflammatory processes, elimination of hormonal disorders. The healing process occurs in the reverse order: the columnar epithelium is replaced by stratified squamous epithelium, formed from reserve cells. The columnar epithelium of pseudoerosion undergoes degeneration followed by desquamation. Pseudo-erosion disappears with complete rejection of the columnar 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 ​​deformed and enlarged. When squamous epithelium is replaced by columnar epithelium, phenomena of indirect metaplasia (differentiation) of reserve cells into cells of multilayered 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 keratohyaline layer), parakeratosis (incomplete keratinization of cells without a keratohyaline layer, but with nuclei), hyperkeratosis (excessive keratinization of the epithelium).

Cervical polyps- this is a growth of the mucous membrane of the cervical canal in the form of a stalk with a connective tissue rod covered with multilayered squamous or columnar 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 nature.

Microscopy of polyps: small structures (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 tint, soft or dense consistency (depending on the content of fibrous tissue). The surface of polyps can be covered with stratified or columnar epithelium. In the first case, the polyp has a smooth surface with open gland ducts and tree-like branching vessels, in the second - a papillary surface.
With proliferation, increased growth of the polyp is observed, and with epidermization, the glandular structures overlap 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 endocervical polyps, squamous metaplasia (indirect metaplasia of columnar epithelial reserve cells) often occurs. Secondary changes include circulatory disorders (without an inflammatory reaction), accompanied by edema of the stroma and congestion in the vessels. If there are secondary changes, there may be bloody discharge.

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

The transformation zone is formed at the site of the former ectopic PE as a result of the processes of regeneration and epidermization. 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, multilayered 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 functionally complete multilayered squamous epithelium.

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

Unfinished transformation zone. Extended colpocervicoscopy reveals white or white-pink spots with a smooth relief (PE cells, in the process of metaplasia, acquire the structure of MSE cells, maintaining their mucus-producing function). The localization of spots is different - in the center or along the periphery of the ectopia, i.e. at its border with ITU. Foci of metaplastic epithelium can take the form of stripes, “tongues,” and “continents.” In the area 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, areas of ectopic PE decrease, and a continuous zone of MSE is determined on the cervix. When smeared with Lugol's solution, the unfinished transformation zone is weakly and unevenly colored (“marble pattern”).

Completed transformation zone- this is the mucous membrane of the cervix, covered with MSE and single or multiple retention cysts. MSE blocks the exit of gland secretions and creates tension in the cyst, as a result of which 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 retention cysts do not contain a muscle layer, and therefore do not react to acid. The epithelium with the Schiller test is stained more evenly than with the unfinished transformation zone. Unfinished and completed transformation zones can be combined.

Papilloma- focal proliferation of stratified squamous epithelium with keratinization phenomena. A relatively rare form of cervical lesions. When examined with the help of speculum, papillomatous growths in the form of rosettes are determined on the vaginal part, which are externally similar to the exophytic form of cancer. Papilloma can be pink or whitish in color, clearly demarcated from the surrounding tissue.

A colposcopic picture reveals a large number of tree-like branching vessels on its surface. When a 3% acetic acid solution 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.

Cervical endometriosis. As a result of trauma to the mucous membrane of the cervix during examination or treatment, conditions arise for the implantation of endometrial cells. They multiply and form foci of subepithelial endometriosis.

Colposcopic picture: dark red or bluish, limited, somewhat elevated formations of various sizes and shapes. Histological examination reveals 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 deformation of the cervix.

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

Pathogenesis: when the lateral walls of the cervix are injured, 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 columnar epithelium of the cervix is ​​disrupted. Metaplasia (replacement) of the columnar epithelium on the walls of the cervical canal occurs with multilayered squamous epithelium. The cervix hypertrophies and undergoes glandular cystic degeneration.

Along with these processes, the growth of connective tissue and the formation of cicatricial deformation of the cervix occurs. Patients complain mainly of leucorrhoea, pain in the lower back and lower abdomen, menstrual dysfunction in the form of menorrhagia, caused by concomitant, usually chronic endocervicitis and endomyometritis.

Cervicitis- 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 atypical epithelium of the cervix with a violation of its “layering” without involving 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 carcinoma is 40-64%. In 15% of patients, microcarcinoma develops against the background of dysplasia.

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

Dysplasia is manifested by intense proliferation of cells with the appearance of atypia, especially nuclei, without involving 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, mild, moderate and severe dysplasia is distinguished (cervical intraepithelial neoplasia - CIN-I, CIN-II, CIN-III ).

At mild dysplasia hyperplasia of the basal and parabasal layers (up to 3 thickness of the epithelial layer), cellular and nuclear polymorphism, and impaired mitotic activity are observed.

Moderate degree of dysplasia characterized by damage to U3-2/3 thickness of 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 chromatin structure is rough.

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, hyperchromatic, there are mitoses. There is pronounced polymorphism of the nucleus, nuclear-cytoplasmic shift, binucleate cells, sometimes giant cells with a large nucleus can be seen in smears. Cells maintain clear boundaries.

Dysplasia can occur with 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 of histiocytes and plasma cells occur.

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

The surface is rough, folded or scaly with horny overlays. The fields of leukoplakia are flat, convex, trough-shaped, with yellowish or whitish areas divided by vessels into polygons, which forms a honeycomb pattern. Leukoplakia cells do not contain glycogen. In the 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 random arrangement of basal cells with symptoms of atypia.

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

Dysplasia fields are defined as white polygonal areas separated by red borders.

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

MSE hyperplasia fields occur against the background of “false erosions” or in the cervical canal in the presence of long-term chronic inflammation. The lesions have clear boundaries and do not change under the influence of acetic acid, Test

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

Fields of PE metaplasia determined only after prolonged (30-40 s) exposure of the ectocervix to acetic acid; 1-1.5 minutes after the cessation 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 MSE hyperplasia.

Papillary transformation zone.

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

There are two types of papillary transformation zone:
♦ papillary zone of MSE hyperplasia - macroscopy of the cervix is ​​not changed; identified foci of pathology during colposcopy do not respond to acetic acid; Schiller test is negative;
♦ papillary zone of PE metaplasia - determined only after prolonged exposure to acetic acid; Schiller test is negative.

Pretumor transformation zone has the appearance of white monomorphic rims around the excretory ducts of the glands, determined after prolonged exposure to acetic acid. The Schiller test is negative. 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, near areas of the zone of incomplete benign transformation, fields of dysplasia, and ectopic PE.

Cervical condylomas - abnormal growths of stratified squamous epithelium of the acanthosis type (immersion of keratinizing epithelial islands into the underlying tissue between the connective tissue papillae) with elongated papillae.

Etiology: herpes virus type 2, human papillomavirus infection.

Colposcopic signs of flat condylomas can be: aceto-white epithelium, leukoplakia, punctation, mosaic, “pearly” surface after treatment with acetic acid.
Histological picture: squamous metaplasia with the presence of specific cells - koilocytes with altered nuclei (enlarged or decreased) and perinuclear vacuolization or displacement of the cell plasma to the membrane; koilocytes are located in the middle and superficial layers of the epithelium.

Precancerous polyps . Colposcopy reveals various types of epithelial dysplasia.

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

Erythroplakia - a pathological process of the mucous membrane, in which a significant thinning of the epithelial cover occurs with the phenomena of dyskeratosis. There is atrophy of the surface and intermediate layers of squamous multilayer epithelium, which is accompanied by hyperplasia of the basal and parabasal layers with atypia of cellular elements.

Clinically, it appears as bright red areas with clear but irregular borders surrounded by normal mucosa.

III. Cervical cancer

Proliferating leukoplakia localized in the ectocervix area.

White lumpy lesions with clear boundaries are identified, rising above the surface of the epithelium.

A characteristic sign of malignancy is polymorphism of epithelial and vascular formations (various shapes, sizes, heights, color of the integumentary epithelium - milky white with gray and yellow shades or with glassy transparency, the structure of connective tissue and vascular components). The vascular pattern is not defined. The Schiller test is negative.

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

Papillary zone of atypical epithelium- polymorphic lesions are localized in the area of ​​the external os of the cervical canal. Colposcopically, atypical epithelium is determined in the form of 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 gland ducts. Adaptive vascular hypertrophy is characteristic - tree-like branching of blood vessels that does not disappear under the influence of acetic acid.

Zone of atypical vascularization. Atypical vascular proliferations are the only manifestation of this pathology. They are characterized by: absence of visible anastomoses, uneven expansion, lack of response to vasoconstrictors. The boundaries of this zone are determined only by performing the Schiller test (the epithelium with atypical vessels is not stained).

Preinvasive cervical cancer(intraepithelial carcinoma, carcinoma 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 stratified squamous and cylindrical epithelium (in young women - the area of ​​the external pharynx; in 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, cells have the ability to mature; the undifferentiated form is characterized by the absence of signs of layering in the epithelial layer.

Patients note pain in the lower abdomen, leucorrhoea, and 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. The 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 tumor vessels.

Leucorrhoea is serous or bloody in nature, often with an unpleasant odor. The appearance of leucorrhoea is caused by the opening of lymphatic vessels during the disintegration of the tumor.

When cancer spreads to the bladder, frequent urge and increased urination are observed. Compression of the ureter leads to the formation of hydro- and pyonephrosis, and subsequently to uremia. When a tumor affects the rectum, constipation occurs, mucus and blood appear in the stool, and vaginal-rectal fistulas are formed.

Diagnosis of background and precancerous diseases of the cervix

I. Basic examination methods.

1.History 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.). A bimanual examination is performed.

2. Clinical and laboratory examination: general blood test, blood test for glucose, RW, HIV, HbsAg, general urine test, biochemical blood test, coagulogram.

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

It consists of a microscopic examination of smears obtained from the surface of the cervix. The material is obtained from 3 areas: from the surface of the vaginal part of the cervix, from the area 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 separately applied to clean glass slides in a thin, even layer. Examine native smears or study stained smears. When using Papanicolaou staining, the smear is pre-fixed in Nikiforov’s mixture, consisting of equal parts of 95% ethyl alcohol and ether, for 30 minutes; The period for sending a smear to the laboratory is no more than 15 days. Staining is also carried out according to Romanovsky-Giemsa and Pappenheim.

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

1st class - no atypical cells, normal cytological picture;
2nd class - changes in cellular elements are caused by 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 with signs of malignancy are detected (enlarged nuclei, basophilic cytoplasm, cell atypia);
Grade 5 - the smear contains numerous atypical cells.
Fluorescence microscopy is based on the affinity of acridine orange for cellular DNA and RNA. The glow ranges from yellow-green to orange-red (cancer cells).

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

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

Normal mucosa is pink in color with a smooth shiny surface. Subepithelial vessels are not identified. After treatment with a 3% solution of acetic acid, the unchanged epithelium becomes pale in 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-layer columnar epithelium is presented as a smooth, distinct line. The Schiller test is based on the ability of normal epithelium to change color under the influence of iodine to dark brown, depending on the glycogen content in the epithelial cells. Normally, there is a uniform brown coloration. Iodine-negative areas indicate a sharp decrease in glycogen in the cells of the integumentary epithelium of the cervix.

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

Transformation zone:
a) unfinished - tongue-shaped areas and/or individual islands of immature squamous epithelium with a smooth surface and the mouths of the excretory ducts of open glands in the form of dark dots and fragments of ectopia surrounding the external pharynx. When performing the Schiller test, 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 tint. Vessels contract under the influence of acetic acid.

True erosion - the bottom has a homogeneous red color.

Polyps. Columnar epithelium is characterized by a papillary structure; when the glandular growths of the polyp are covered by flat epithelium, its surface is smooth. Polyps are not stained with Lugol's solution.

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

Punctuation (precision). Corresponds to the old term "base of leukoplakia". A simple base 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 a background of whitish proliferating epithelium. Polymorphic dark red dots are identified. Both forms 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). Mosaic is iodine negative.

Papilloma consists of individual papillae, in which vascular loops are identified. The vessels are evenly distributed, shaped like kidneys. When papilloma is treated with a 3% acetic acid solution, the vessels contract and the mucous membrane 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 and do not anastomose with each other. After treatment with a 3% acetic acid solution, atypical vessels do not spasm and become more defined.

Colpomicroscopy - intravital histological examination of the vaginal part of the cervix, in which the tissue of the cervix is ​​studied 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 material is collected under the control of a colposcopic examination in the area of ​​severe pathology using a sharp scalpel. The biopsy specimen is preserved in a 10% formalin solution and in this form is sent for histological examination.

II. Additional examination methods.

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

2.Molecular biological diagnostics 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 special feature of PCR is the enzymatic (DNA polymerase) duplication of the pathogen's DNA, which leads to the formation of multiple 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. The reaction is measured using electrophoresis in an agar gel placed in an electric field. A solution of the fluorophore ethidium bromide is introduced into the gel, which stains double-stranded DNA. A positive PCR result is determined by the luminescence band in ultraviolet light.
Ligase chain reaction (LCR). To identify the DNA pathogen, a ligase is used, 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 cross-sectional images 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 with an outer diameter of 2.7 mm and compatible with the working channels of standard endoscopes. OCT of the cervical mucosa 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 cervical mucosa. For OCT, areas with various colposcopic signs are selected, 2-3 repeatable tomograms are obtained from each point, and a control scan of the area of ​​healthy mucosa is required. The total time of 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 border between the upper and lower layers is contrasting, clear, smooth 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 in the lower layer of multiple contrasting, round and/or longitudinal optical structures of low brightness, lymphocytic infiltration of the stroma.

OCT signs of exocervicitis: the image has a contrasting two-layer structure; the height of the top layer has been reduced; a clear and even boundary between the upper and lower layers; the presence in the lower layer of multiple contrasting, round and longitudinal weakly scattering areas of various sizes.

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

OCT signs of cervical cancer: bright image (highly scattered), heterogeneous; the image lacks structure; the signal fades quickly; image depth has been reduced.

Treatment of background and precancerous diseases of the cervix

Therapy for background and precancerous conditions of cervical cancer is carried out in 5 stages.

Stage 1 - etiopathogenetic treatment.

A. Antibacterial and antiviral therapy is carried out for 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 (chapter genitourinary infections).

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

In women of reproductive age, estrogen-gestagen drugs 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 ethinyl estradiol and 75 mcg gesto-den);
femodene (ethinyl estradiol - 30 mcg, gestodene - 75 mcg);
rigevidon (150 mcg levonorgestrel and 30 mcg ethinyl estradiol);
mersilon (desogestrel - 150 mcg, ethinyl estradiol 20 mcg).
Gestagens are prescribed from the 16th to the 25th day of the menstrual cycle:
progesterone 1 ml of 2.5% solution IM daily;
17-OPK1 ml 12.5% ​​solution IM once;
duphaston (dydrogesterone) 10-20 mg per day;
norethisterone (Norkolut) 0.005-0.01 g per day;
pregnin 0.02 g 2 times a day, sublingually;
organametril (linestrol) 0.005 g per day;
utrozhestan 200-300 mg per day (1 capsule in the morning and 1-2 capsules in the evening an hour after meals).
For age-related vulvar dystrophy, estriol preparations are used:
estriol 4-8 mg 1 time/day. for 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: apply fluorocort (triamcinolone acetate), 5 g of ointment in a thin layer to the affected area, 3 times a day.
B. Immunomodulators (see Appendix 3). D. Desensitizing drugs:
astemizole 1 tablet. (0.01 g) 1 time/day;
tavegil (clemastine) 1 tablet. (0.001 g) 2 times/day;
Avil (pheniramine) 1 tablet. (0.025 g) 2-3 times/day;
Zyrtec (cetirizine) 1 tablet. (0.01 g) 1 time/day;
Claritin (loratadine) 1 tablet. (0.01 g) 1 time/day. D. Vitamin therapy:
vitamin B1 0.002 g 3 times a day;
vitamin B6 1 ml 5% solution IM;
ascorbic acid 200 mg/day;
rutin 0.02 g 3 times/day;
tocopherol acetate 1 capsule (100 mg) 2 times a day.

Stage 2 - correction of disorders of the vaginal biocenosis.

The vagina is sanitized with antibacterial drugs, followed by 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 - orally 3-5 doses 2 times a day;
lyophilized culture of lactic acid bacteria, 4-6 doses 2 times a day, for 3-4 weeks;
colibacterin 2-4 doses 3-4 times/day. an hour before meals, 4-6 weeks;
lactovit 1 capsule 2 times a day;
hilak 20-40 drops 3 times a day. with a small amount of liquid;
bifiform 1 capsule 2 times a day, 15-30 days.

Stage 3 - surgical treatment

Includes the following methods:

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

II. Radical surgical intervention: 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 (layer-by-layer) diathermocoagulation. At the site of exposure to electric current, an ulcer develops, which is then covered with normal epithelium. In this way, pseudo-erosion and various deformations of the cervix are treated. The operation is performed in the luteal phase of the cycle. After surgery, antibacterial ointments are applied to the cervix.

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

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

Negative aspects: a painful procedure, often the scab disappears on the 7-10th day and bleeding appears; a scar is formed, along which a gap may occur during childbirth; there is no material for histological examination.

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

Advantages of the method: non-traumatic, bloodless, faster healing without rough scars, reduced incidence of complications, ease of use, safety for the patient and medical staff, possibility of use in an outpatient setting.

Indications: benign pathological processes of CIM (ectopia of columnar epithelium of a post-traumatic nature, benign transformation zone - completed and unfinished, subepithelial endometriosis); precancerous processes of cervical cancer (simple leukoplakia, fields of dysplasia, papillary zone of dysplasia, precancerous zone of transformation); condylomas and polyps of the cervix.

Contraindications: concomitant acute infectious diseases; acute and subacute inflammatory diseases of the internal genital organs; purity of vaginal flora III-IV degree; venereal diseases; true CMM erosion; 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 cervical canal is not observed, and recovery occurs faster than with other methods of physical destruction of the cervical tumor. 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 area, which facilitates subsequent endoscopic control.

Indications: background diseases of the cervix (pseudo-erosion, eroded ectropion, common form of simple leukoplakia, endometriosis, condylomas, polyps, retention cysts); precancerous processes (leukoplakia with atypia, erythroplakia, grade I-III dysplasia); pre-invasive cervical cancer localized on the vaginal part; recurrent forms of diseases with ineffective 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 on the cervix, 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 does not occur, the erosion site is re-treated twice with control after 4 weeks. Vagotil (polycresulene) - 36% solution, 2-3 times a week, apply a tampon to the area of ​​erosion for three minutes, number of procedures 10-12.

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

Indications: combination of benign and/or precancerous processes of the cervix with hypertrophy and deformation; the presence of dysplasia in patients who previously underwent destruction of the cervix, 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 that extends to the fornix and vaginal walls; significant post-traumatic deformation of the cervix, extending to the vaginal vault; severe somatic diseases.

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

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

6. Amputation of the cervix (carried out for severe dysplasia).

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

8. Hysterectomy

Indications: CIN-III with localization in the cervical canal; technical impossibility of performing electrical excision 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.

Stage 4 - postoperative therapy, correction of existing disorders

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

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

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

After radical treatment of precancerous processes, bacterioscopic, colpocervicoscopic and cytological monitoring is mandatory (after 1-2-6 months and a year). They are removed from the register only after receiving the appropriate 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 for managing patients with various forms of background and precancerous diseases of the cervix

Ectopia of columnar epithelium of post-traumatic origin

For ectopic columnar epithelium of dyshormonal origin without concomitant gynecological pathology, three-phase oral contraceptives are prescribed. If there is no effect, cryo- or laser destruction or chemical coagulation is indicated.

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

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

In case of dysplasia, the treatment method is chosen taking into account the results of complex clinical-endoscopic, cytological, bacterioscopic, bacteriological studies of the cervical canal and morphological examination of targeted biopsy material, as well as hormonal levels. Research results 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, treatment of dysplasia of metaplastic epithelium must begin with sanitation of the vagina and cervix.

In case of dysplasia of the cervical epithelium (CIN I-P), in the absence of cicatricial deformation, cryo- or laser destruction is performed; in the presence of cicatricial deformation, diathermo-conization is performed.

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

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

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

Preinvasive cervical cancer. The method of choice is cone-shaped electroexcision. Indications for hysterectomy: age over 50 years; predominant localization of the tumor in the cervical canal; common anaplastic variant with ingrowth into the glands; the absence in the preparation removed during the previous conization of areas free of tumor cells; impossibility of wide excision; combination of pre-invasive 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 hysterectomy; if there are contraindications to surgery, intracavitary y-therapy is used.

Invasive cervical cancer:

Stage I - combined treatment in two options: 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 surgery, combined radiation therapy (external and intracavitary irradiation) is used.
Stage II - in most cases, a combined radiation 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 for radical surgery.
Stage III - radiation therapy in combination with restorative and detoxification treatment.
Stage IV - symptomatic treatment.

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Squamous metaplasia(squamous metaplasia) is a normal physiological process in which columnar epithelium is covered or replaced by stratified squamous epithelium. It usually occurs in the ectopic area, but can also occur in the cervical canal and on the surface of polyps. The course and nature of this process depend on a number of factors, such as hormonal stimulation, pH of the vaginal environment, infections, etc.

Squamous metaplasia begins with the appearance under the CE of a layer of subcylindrical reserve cells capable of proliferation and hyperplasia, which in recent years have been called stem cells. The origin of these cells is still unclear. There is a version that metaplasia can also arise as a result of the activity of mononuclear cells - derivatives of the stroma.

The formation of MPE occurs as a result of the growth and differentiation of reserve cells. The proliferation of the latter is accompanied by the development of immature and subsequently mature squamous metaplasia.

Metaplastic epithelium(ME) histologically represents incompletely differentiated squamous epithelium of varying degrees of maturity, sometimes located directly on the columnar epithelium, the cells of which gradually degenerate.
Cells in immature squamous metaplasia are smaller, do not contain glycogen, and are immunohistochemically characterized by the characteristics of endocervical (presence of mucin) and squamous (intermediate filament keratins) epithelium. On the outer surface of the immature metaplastic epithelium, cells of the endocervical type are sometimes preserved.

Immature metaplasia. Hematoxylin and eosin staining

Mature metaplasia

Intermediate stages of metaplasia

Along with the terms “immature” and “mature” squamous metaplasia, the term “atypical metaplastic epithelium” (squamous metaplasia with cell atypia) is used, the cellular elements of which are characterized by variability in the shape and size of the nuclei, the content of chromatin in them, and the presence of nucleoli.

Intensive proliferation of reserve cells, localization of the latter in endocervical-type crypts can sometimes raise suspicion of an early stage of squamous cell carcinoma. However, the absence of polymorphism, hyperchromic cell nuclei and single mitoses make it possible to exclude the diagnosis of a malignant lesion.

The process of metaplasia can lead to the appearance of epithelia of various types, including atypical. The interpretation of the epithelium at various stages of its formation is complex and ambiguous even for histologists. The process of identifying such epithelium colposcopically seems even more difficult.

Metaplastic epithelium- the main substrate for the colposcopic concept of “transformation zone”.

The colposcopic manifestation of normal metaplasia is the normal transformation zone (NT). Metaplastic epithelium of varying degrees of maturity covers the pseudoglands, which remain open for some time. When the opening of the pseudogland is closed, secretions begin to accumulate inside it (closed glands). Over time, this secretion stretches the gland, causing vasodilation and perifocal inflammation, and Nabothian cysts appear, or, in other words, retention cysts. The entire process stimulates vascular proliferation. Metaplastic epithelium represents the main morphological substrate for the transformation zone on the cervix. ST in combination with ectopia occurs in many young women of reproductive age.

As a rule, ST is a physiological benign process. However, according to a number of researchers, the MPE formed after transformation differs in biological properties from the primary MPE and, under certain conditions, can serve as a basis for the development of a malignant process. In any case, the CT is an area vulnerable to any external influence, especially to HPV, therefore, in 90% of cases, it is in the transformation zone, especially in the presence of immature epithelium, that cervical neoplasia develops. Immature metaplasia can easily be mistaken for CIN by a colposcopist. Fully mature metaplastic epithelium is practically indistinguishable in appearance from the original (natural) stratified squamous epithelium.

Congenital transformation zone

Histologically, in VZT thickenings of stromal papillae can be detected, subdividing and branching inside, so colposcopically these areas-fields can appear in the form of a mosaic.

In the layer of keratinized cells with hyperkeratosis and parakeratosis, nuclei may remain, although they become pyknotic and can give a picture of leukoplakia, with thickened areas. Similar conditions are found in virgins and even newborns.

The border, or junction, of VZT with normal MPE is clear, often extending from the exocervix to the vaginal vaults. The absence of glycogen makes this area iodine negative. In practice, it is mistaken for leukoplakia or CIN and is often subjected to repeated ablations, which, it should be noted, are ineffective.

Squamous (squamous) metaplasia is non-cancerous changes in the epithelium of internal organs, which are the body’s protective reaction to the influence of unfavorable factors. Metaplasia is a pathological process in which single-layer cylindrical, prismatic or cuboidal epithelium is replaced by more resilient cells of multilayered squamous epithelium, with or without keratinization. Most often, squamous metaplasia affects the epithelium of the lungs (especially in smokers) and the cervix, but can also affect the mucous membrane of the bladder, intestines, and internal glands.

Mechanism of development of squamous metaplasia

We will consider the development of metaplasia using the example of the mucous membrane of the cervix, where the cylindrical epithelium is replaced by flat epithelium. Metaplastic squamous epithelium develops not from the main mature cells, but from the underlying, so-called reserve cells. That is, under the layer of columnar epithelium, a layer of reserve cells is formed, which gradually grows. Gradually, the upper layer of the columnar epithelium peels off and is replaced. Next comes the stage of immature squamous metaplasia, at which histological studies clearly show the boundaries of groups of reserve cells and several layers of cells are formed, similar to ordinary squamous non-keratinizing epithelium.

At the stage of maturing squamous metaplasia, the cells become increasingly similar to the intermediate cells of the squamous epithelium, and at the stage of mature metaplasia, the epithelium is indistinguishable from the natural surface layer of the squamous epithelium.

Is squamous metaplasia dangerous?

Metaplasia is not a disease, but a variant of the body’s adaptation to physiological or pathological stress factors. In this regard, squamous metaplasia does not have specific signs and is diagnosed only through laboratory tests, through the detection of squamous epithelial cells in smears, sputum, other research material, or during histological examination of tissues.

Most often, metaplasia is formed against the background of chronic inflammatory processes, as well as due to adverse external influences (smoking, working in an unfavorable environment, etc.). Although in itself it is a benign reversible process, long-term exposure to unfavorable factors or lack of treatment for the disease that provoked the changes can subsequently lead to the development of dysplasia and a precancerous condition.

Causes and treatment of squamous metaplasia

The most common type is squamous cell metaplasia of the cervix. It may be a reaction to:

• chronic inflammatory process;
• hormonal imbalances;
• infectious diseases.

Squamous cell metaplasia of the lungs is most often caused by smoking, but can also be triggered by chronic diseases (bronchitis, etc.). Bladder metaplasia is caused by inflammatory processes, and cystitis comes first among the causes.

Since squamous metaplasia is a variant of the body’s adaptive response, it does not require specific treatment as such. After the underlying disease is cured or the stress factor on the body ceases, after some time the epithelium itself returns to normal. For example, to treat squamous metaplasia of the bronchial epithelium caused by smoking, it is enough to give up this habit, and the rest of the treatment will be symptomatic.

First, let's understand the terminology: metaplasia is a change in the properties of a tissue, its acquisition of characteristics of another tissue within the diversity of one germ layer, that is, tissue of the same histiotype. Most often, this phenomenon occurs in epithelial or connective tissue. According to the clinical classification, squamous cell metaplasia of the cervix is ​​a benign process.

Metaplasia of the cervical epithelium occurs for quite a long time during the proliferation and differentiation of new, so-called reserve or. In the cervix, the described process occurs precisely during cell proliferation. Most often, single-layer prismatic epithelial cells (characteristic of the cervical canal) are replaced by multilayer squamous epithelial cells (located in the vagina). Or the creeping of squamous epithelial cells onto cylindrical cells. Normally, there is a visible, clear line between these epithelia.

Causes of cervical metaplasia

Most often, metaplasia is a response to some chronic pathological process, such as inflammation, infection, hormonal changes in the female body, a violation of vaginal pH, or a sign of healing. When the aggressive influence of irritating factors ceases, the tissue returns to its normal morphological structure.

Do not panic prematurely; metaplastic epithelium in itself is not a malignant formation and does not even belong to precancerous conditions. Although it is not a positive process and requires additional examination and clarification of the causative factor. This is like an adaptive reaction of the body to changed conditions, giving a signal about an existing pathological process. After this, individual treatment of cervical metaplasia is required. In any case, this disease requires regular monitoring by the attending physician.