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| Management of AGUS Pap Smears - 2001 |
Conference Report
Autumn in New York 2001: Controversies in Gynecology
November 12-13, 2001
Montefiore Medical Center, Bronx, NY
Mark D. Levie, MD
ztaženo z www.medscape.com
Management of AGUS Pap Smears
Atypical glandular cells of undetermined significance (AGUS) was the term initially used in the Bethesda System to describe cells with either endometrial or endocervical differentiation, displaying nuclear atypia that exceeds obvious reactive or reparative changes, but lacking the unequivocal features of invasive adenocarcinoma.[7] This descriptive diagnosis, unlike the ASCUS diagnosis, is seldom used. The incidence of ASCUS Pap smears ranges from 3% to 10%, whereas AGUS Pap smears comprise only 0.1% to 0.7% of all Pap smears obtained.[19]
Several issues have been raised concerning the AGUS diagnosis. Unlike ASCUS Pap smears, which are seldom associated with invasive disease (0.1% to 0.2%), AGUS Pap smears have a significant association with invasive disease (5% to 7%). Because of the similarity in terminology and the markedly different management needed for these 2 diagnoses, Bethesda 2001[20]has proposed the removal of the term as 1 of the 5 main subdivisions in the glandular cell section of epithelial abnormalities. In the new system, cells would be reported as "atypical" and characterized, if possible, as endocervical or endometrial in origin. In addition, 2 other main categories, "atypical glandular endocervical cells, favor neoplasia" and "endocervical adenocarcinoma in situ" would be added to the glandular cell section.
There are many benign sources for a Pap smear diagnosed as AGUS. The most common etiologies are endometrial polyps, endocervical polyps, and microglandular hyperplasia. Other sources for this diagnosis are the presence of an intrauterine device, previous conization, tubal metaplasia, inflammatory changes, Arias-Stella reaction, and pregnancy-associated changes.
AGUS and Preinvasive/Invasive Cancer
Currently, the diagnosis of AGUS is divided into several subtypes. Dr. Gary Goldberg, Professor of Obstetrics and Gynecology, Albert Einstein College of Medicine, presented a review of the literature regarding the significance of AGUS and each subtype. He pointed out that most series in the literature are very small as a result of the relative infrequency of the diagnosis.
The first subtype is "AGUS, favor reactive changes." Within this category, approximately 25% of patients will have preinvasive disease. The pathology of these preinvasive lesions in most cases is actually SILs that are not glandular in origin. Fewer than 2% of patients with this subtype have invasive disease. "AGUS, not otherwise specified" is the next subtype, and in this group approximately 26% have preinvasive disease and 6% have invasive disease. The last subtype of AGUS is the category that is the most worrisome, "AGUS, favor neoplasia." Approximately 40% of patients with this diagnosis will have preinvasive disease, and as many as 25% will have invasive disease. The majority of invasive cancers detected in this group are endometrial in origin, with a minority being adenocarcinoma of the cervix. Although most of the preinvasive lesions in this group are squamous in origin, adenocarcinoma in situ (AIS) is noted in approximately 14% of patients.
Management of AGUS Pap Smears
All patients with AGUS Pap smears require the same basic workup. Colposcopy is the backbone for detecting most abnormalities that may yield an AGUS Pap. Because most of the abnormalities are squamous in origin (SIL), these should be relatively routine to recognize and biopsy as needed. Attention must also be paid to the entire vagina to avoid missing any lesions within this area. Endocervical curettage must be done, even if the endocervical canal looks normal through the colposcope. Adenocarcinoma of the cervix and AIS may be difficult to recognize on colposcopy for several reasons. First, clinicians are less familiar with the appearance of glandular disease, as they are rare compared with squamous lesions. Second, these lesions may be small, high up in the endocervical canal, and may be located at the base of glands not visualized during colposcopy.
Koonings and associates[21] considered the importance of age when evaluating an AGUS Pap smear. They noted that older patients (> 50 years) have lower odds of high-grade cervical dysplasia and higher odds of uterine cancer. The researchers concluded that patients older than 45 years require endometrial biopsies for the workup of an AGUS Pap. Geir and colleagues,[22] even more cautious, recommend endometrial sampling in all patients older than 35 years of age.
If the above evaluation is negative, it is important to review the slides with the cytologist to ensure a proper diagnosis was made. Follow-up Pap smears every 4 months until 4 negative Pap smears are obtained is the protocol outlined by Dr. Goldberg. If repeat cytology remains abnormal, further workup, including pelvic ultrasound and cervical conization, is warranted, as long as colposcopy, endocervical curettage, and endometrial biopsy are all negative. Although rare, extragenital malignancies such as breast and ovarian cancer have been detected in patients with AGUS Pap smears.
Conclusions
The most important point brought out at the conference was that a diagnosis of AGUS is truly a significant finding; 1 in 3 women have a significant abnormality, and there is a 1 in 10 chance of their having cancer.[21] The change in the Bethesda terminology should serve to trigger physicians to conduct an extensive evaluation and avoid treating this finding with only a repeat Pap smear as is done with an ASCUS Pap.
Kompendium/Onkogynekologie/: Management of AGUS Pap Smears - 2001
Napsáno dne Saturday, 22. December 2001 @ 18:45:54 CET | | | |
