LESI PRAKANKER SERVIKS

Dr. dr. Brahmana Askandar, SpOG (K.Onk)

Divisi Onkologi GinekologiDept. Obstetri Ginekologi

FK Unair / RSU Dr. Soetomo

Lesi Pra Kanker Serviks (Mulut Rahim)

• Istilah lain : Displasia• Biasanya tanpa keluhan• Diagnosis dengan menggunakan pap smear• Merupakan suatu perjalanan sel mulut rahim sebelum

menjadi ganas (kanker serviks)• Berbeda dengan kanker serviks• Kesembuhan baik

NATURAL HISTORYCERVICAL CANCER

NORMAL CIN I CIN II CIN III STAGE 0 INVASIVE

PRA - CANCER CANCER 15 % 30 % 45 %

40 % 20 %

Low grade SIL High grade SIL IDENTIFIED by METHODE VIA

Infeksi HPV Kronis

Perkembangan Terminologi Hasil Tes PapPerkembangan Terminologi Hasil Tes Pap

1943 Papanicolaou 1953 Displasia - Karsinoma Insitu (Reagan) 1967 Neoplasia Intraepitel Serviks (Richart RM) 1988 The Bethesda System 1990 Modifikasi Neoplasia Intraepitel Serviks 1990 British Society for Clinical Cytology 1991 The Bethesda System 2001 The Bethesda System

Kelas I : Tidak ditemukan sel atipik atau sel abnormal

Kelas II : Sitologi atipik tetapi tidak ditemukan keganasan

Kelas III : Sitologi sugestif tetapi tidak konklusif keganasan

Kelas IV : Sitologi sangat sugestif keganasan

Kelas V : Sitologi konklusif keganasan

KLASIFIKASI PAPANICOLAOU

Klasifikasi Papanicolaou

Sistem ini telah banyak ditinggalkan,karena:• Tidak mencerminkan pengertian neoplasia serviks/

vagina• Tidak mempunyai padanan dengan terminologi

histopatologi• Tidak mencantumkan diagnosis non kanker• Tidak menggambarkan interpretasi yang seragam• Tidak menunjukan suatu pernyataan diagnosis

Sistem Cervical Intraepithelial Neoplasia

NIS / CIN 1 sesuai displasia ringan NIS / CIN 2 sesuai displasia sedang NIS / CIN 3 sesuai displasia berat dan karsinoma insitu

Lesi Pra-Kanker Serviks(Bacaan Sistem Bethesda)

• Low grade squamous intraepithelial lesion (LSIL) :- CIN I- HPV Infection

• High grade squamous intraepithelial lesion (HSIL) - CIN II- CIN III- Ca In situ

Bethesda System

Padanan dari klasifikasi

Class I Class II Class III Class IV Class V

Normal InflamMild Mod Sev

CISCancer

D y s p l a s i a

Normal AtypiaCIN I CIN II

CIN III CancerK o i l o c y t o s i s

WNLBenignCellular

Changes

ASCUS

LGSIL HGSIL HGSIL Carcinoma

NEGATIFAS

CUSLGSIL HGSIL HGSIL Carcinoma

Serviks Normal

Lesi Pra Kanker Serviks

Diagnosis Lesi Prakanker

• Inspeksi visual dengan asam asetat (IVA)Pemeriksaan paling sederhanaDilakukan di daerah tanpa fasilitas pap smear

• Pap smear : Dilakukan pada setiap wanita yang sudah menikah (paling lambat 3 tahun) Dilakukan 1x/tahun atau sesuai hasil

• Tes HPV (Hybrid Capture II) Bila hasil pap smear ASCUS atau bila px menghendaki

• Kolposkopi Semua pap smear abnormal harus dilakukan kolposkopi

I V A (Inspeksi Visual Asam Asetat)

Sankaranarayanan dkk (Thailand)Efektif, aman, praktis, murahTidak invasifOleh dokter – bidan - paramedis

Tes IVA

Cara pemeriksaan untuk Tes IVA :• Pasien dalam posisi litotomi.• Spekulum dipasang.• Serviks ditampakkan dan dibersihkan dari lendir.• Serviks dibasahi permukaannya dengan asam asetat

5%, selanjutnya diamati dengan penerangan lampu 100 watt.

• Setelah 1-2 menit dilihat perubahan yang terjadi pada serviks:

Hasil :- Negatif gambaran putih –- Positif gambaran putih +

Gambaran Visual dengan Aplikasi Asam Asetat pada Lesi Prakanker

Sebelum pemberian asam asetat Setelah pemberian asam asetat

Alur Penatalaksanan Kasus dengan IVA Positif

IVA Positif

Biopsi terarah-PA

Kolposkopi

Lesi PositifLesi Negatif

Pemeriksaan rutin

Gambar Lesi Pra Kanker

Low grade SIL Low grade SIL

Gambar Lesi Pra Kanker

High grade SIL High Grade SIL

Low grade SIL High Grade SIL

Low grade SIL Kanker Invasif

Pemeriksaan Biopsi

Dilakukan bila dijumpai mass/benjolan di serviks

mANAGEMENT

Management of ASCUS

• ASCUS may be managed by referral to immediate colposcopy, by repeat Pap smear, or by HPV testing.

• Reflex HPV testing when ASCUS is derived from liquid based

cytology has advantage– ASCUS (+) & HPV + Colposcopy– ASCUS (+) & HPV - Repeat Pap test 12 mos

ASCUS MANAGEMENT

Management of Screen Positives

• Initial management of all other Pap abnormalities is by immediate referral to colposcopy

• Finding of atypical squamous cells cannot rule out high-grade (ASC-H), atypical glandular cells (AGC), LGSIL, and high-grade intraepithelial lesions (HGSIL)

Pengobatan Tahap Pra Kanker

• Pengobatan pada tahap pra kanker memberikan hasil yang sangat memuaskan (Oleh karena itu penting melakukan deteksi dini)

• LSIL (CIN I) : Masih bisa dilakukan hanya pengamatan ulangPengamatan pap smear ulang 6 bulan

Krioterapi/Kauter / LEEP

• HSIL (CIN II – III) : Harus dilakukan tindakanCauter / LEEPKonisasi(pengambilan sebagian cervix dg pisau)Histerektomi (Bila usia cukup dan anak cukup)

LSIL MANAGEMENT

HSIL

• Cervical intraepithelial neoplasia (CIN) 2 and 3 are managed in the same way because histologic distinction between the two grades of CIN is poorly reproducible 

• High risk of progression of both CIN 2 and 3 prompt treatment is recommended

• The exceptions to this are pregnant women, who should undergo an excisional procedure only if invasive disease is suspected,

The Fact of CIN 2,3

• For CIN 2 lesions, it appears that 40 to 58 percent of lesions will regress if left untreated, while 22 percent progress to CIN 3 and 5 percent progress to invasive cancer

• For CIN 3, the estimated spontaneous regression rate is 32 to 47 percent, with 12 to 40 percent progressing to invasive cancer if untreated 

Obstet Gynecol. 2009;113(1):18.Br J Cancer. 2003;89(6):1062.

Br J Cancer. 2003;89(6):1062.

HSIL MANAGEMENT

HSIL IN YOUNG WOMEN

ABNORMAL SMEAR IN PREGNANT WOMEN• Pregnant women with cervical intraepithelial

neoplasia 1 (CIN 1) should not undergo cervical excision or ablation

• The patient should be reevaluated six weeks postpartum and managed based on those results

ABNORMAL SMEAR IN PREGNANT WOMEN• A diagnostic excisional procedure is

performed only if invasive disease is suspected

• For pregnant women with CIN 2,3, if invasive disease is not suspected – Follow up

Follow up of HSIL in Pregnant Women

• Repeat evaluation with cytology and colposcopy during the pregnancy, but not more often than every 12 weeks

• Alternatively, reevaluation may be deferred until six weeks postpartum

Hysterectomy

• Hysterectomy is not a first line treatment for CIN.

• Hysterectomy is a reasonable option only for women with CIN 2,3 who have a positive conization margin, who have completed childbearing

Krioterapi

LEEP

LEEP

KONISASI

KONISASI

Summary and Recommendation• For most women with CIN 1, observation is suggested with

cervical cancer screening tests rather than treatment (grade 2c)

• CIN 2,3 is associated with a high risk of cervical cancer. 5% of CIN 2 lesions and 12 to 40 percent of CIN 3 lesions will progress to cervical cancer. 

• For most women with CIN 2,3, we recommend treatment rather than observation (grade 1b)

Uptodate.com

Summary and Recommendation

• Observation with cytology and colposcopy is reasonable for women who are planning future childbearing and are able to comply with long-term testing.

• Treatment is deferred for pregnant women, unless invasive disease is suspected.