子宫内膜病理.ppt

NewGuidelinesforScreeningandManagementofAbnormalPAPTests,LongwenChen,MD,PhDDirectorofCytopathologyMayoClinicArizona,Goal,ScreeningRoleofHPVtestinginscreeningManagementofAbnormalPapTestsRoleofHPVtestinginmanagement,NewGuidelines,ACOGPracticeBulletinDec20092019Consensusguidelinesforthemanagementofwomenwithabnormalcervicalcancerscreeningtests.ASCCP2019newguidelines,Whatdowewanttoachieve?,Overallgoal:establishabalancebetweenscreeningforpreventionwhileavoidingovertestingandtreatment.“.guidelinesshouldneversubstituteforclinicaljudgment.”AJOGOct2019.p346-355,SCREENING,PAPsmear(tests):ReducedincidenceofcervicalCaby70%inthelast50yAnnualrateofcervicalCa:8/100KwomenNewdxeachyear:13,000Deathsperyear:410050%ofwomendxdwcervicalCahaveneverhadaPap10%notscreenedw/in5yrsAmCASoc.CAFacts2019,SCREENING,IncidenceofinvasivecervicalCa65yoaTakeintoconsiderationpastscreeninghx.,Screening:Whentostop,ACS:at70yoaif3negPAPinthepreceeding10yrs.USPreventiveTaskForce:65yACOG:between6570yoaof3negPapinpreceeding10yrs,wassessmentofriskfactorsannually,SCREENING,Afterhysterectomy:ACS,ACOGIfhystforbenignreasons:STOPRateofVAIN:0.12%.NocasesofcancerIfforCIN:annualuntil3normalRateofVAIN:1.7%.1caseofcancerBJOG.2019:113:1354.N=6000post-hyst)IfforcervicalCA:surveillanceindefinitely,Screening:roleofHPVtesting,High-riskHPVtestandcytologyFDAapprovedinwomenover30yoaIfbothnegative:99%negpredictivevalueArchPathLabMed2019;127:959-968:Colpo,MANAGEMENTOFABNORMALPAP,I.AtypicalSquamousCellsA.ASC-US(undeterminedsignificance)riskforinvasiveCalow(:colposcopy,ManagementofASCUSwomen,MANAGEMENTOFABNORMALPAPI.ASCUS,Specialcases:Adolescents:repeatPapat12mosIfASCUSagain:colpoNOHPVtestingPostmenopausal:topicalestrogenbeforerepeatingcytology,ManagementofyoungerwomenwithASC-USorLSIL,MANAGEMENTOFABNORMALPAPII.AGC,AtypicalglandularcellsAGC,nototherwisespecified(endocervical,endometrial)AGS,favorneoplasiaEndocervical,adenocarcinoma-in-situ(AIS),InitialmanagementofAGC,SubsequentmanagementofAGC,MANAGEMENTOFABNORMALPAPII.AGC,RiskforCIN:9-54%RiskforAIS:0-8%RiskforinvasivecervicalCa:3-17%Wrightetal,JAMA2019:287:2120-2129,MANAGEMENTOFABNORMALPAPII.AGC,AGC-NOS:colpo,EMBx,ECC,HPVIfallneg:co-test3ylaterAGC-favorneoplasia:colpo,EMBx,ECC,HPV,ultrasoundIfallneg:performdxcexcisionalprocedure(coldknifecone)If+CIN,AIS:manageperdx,AGC:followup,RepeatPapandHPVat6mos:ifHPV+12mos:ifHPV-Ifbothneg:routinescreeningIf+:colpo,MANAGEMENTOFABNORMALPAPIII.LGSIL,RiskforCIN2,3:12-16%+HPVin80%HPVtestnotuseful(ALTS-LGSILtrial),MANAGEMENTOFABNORMALPAPIII.LGSIL,COLPOSatisfactory/+lesionSatisfactory/nolesionUnsatisfactory/nolesion,ECCAcceptablePreferredPreferred,ManagementofLSIL,MANAGEMENTOFABNORMALPAPIII.LGSIL,LSILwith+HPVornoHPV-Colpo,ECC+CIN2,3:manageperdiagnosis+CIN1,-CIN:repeatcytologyin6and12mosORHPVtestin12mos,LSILwithnegativeHPV-co-testin1yASCor+HPV:ColpoAllnegative:repeatco-test3y,ALTS-LGSILPost-ColpoFUAJOG2019;188:1401-5,Specialpopulations:LGSIL,Adolescents:RepeatPapat12mosIf+again:colpoHPVtestingNOTrecommended,Specialcases:LGSIL,Postmenopausal:optionsreflextestingRepeatPapat6and12moscolpoPregnantColposcopyNOECC,MANAGEMENTOFABNORMALPAPIV.ASC-H,RiskforCIN2,3:33-56%:identifiedwcolpo6477%:identifiedwloopexcisionRiskforinvasivecervicalCa:1%ReflexHPVtesting:Notindicated,butaredoneinsomeinstitutions.Hasvalueinolderwomen?,ManagementofASC-H,ManagementofyoungerwomenwithASC-HorHSIL,ColpoHGSIL,ColpoHGSIL,CIN3,MANAGEMENTOFABNORMALPAPV.HGSIL,RiskforCIN2,3:53-66%:identifiedwcolpo8497%:identifiedwloopexcisionRiskforinvasivecervicalCa:1-2%Intermediatetriage(HPVtestingorrepeatPap):INAPPROPRIATE,ManagementofHSIL,MANAGEMENTFORABNORMALPAPIV.HGSIL,ColpoandECCIfunsatisfactorycolpo,and/orsatisfactorycolpoandnolesionidentified:reviewmaterial(ifunchanged,performdiagnosticexcisionalprocedure),HGSIL,Immediateloopexcision(exceptforadolescents/pregnant),orColpowECCFollowup:Repeatcytologyat6and12mos,Specialcases:HGSIL,Adolescents:ColpoandrepeatPapq6mos,until2negIfCIN2,3persistsx24mos:loopPregnant:Colpo,noECCExcisiononlyifsuspiciousforCARepeatPapat6wkspostpartum,Managementofbiopsy-confir