Servikal Premalign Lezyonlar ve Serviks Kanserine Klinik Perspektif İle Yaklaşım
Özet
Bu bölüm, servikal premalign lezyonlar ve serviks kanserine klinik perspektiften kapsamlı bir yaklaşım sunmaktadır. Serviks kanseri büyük ölçüde önlenebilir bir hastalıktır ve bu durum etkin tarama programları ve erken tanı yöntemleri ile sağlanmaktadır. Servikal intraepitelyal neoplaziler, kanser gelişiminin öncül lezyonları olup, doğru tanı ve uygun yönetimi invaziv kanserin önlenmesinde kritik rol oynamaktadır. Yüksek riskli HPV enfeksiyonu temel etyolojik faktördür ve hastalığın patogenezinde E6 ve E7 onkoproteinleri önemli rol oynar. Tarama yöntemleri arasında sitoloji, HPV DNA testleri ve kolposkopi yer alır. Klinik yönetim, lezyon derecesi, hasta yaşı ve fertilite beklentileri gibi faktörlere göre bireyselleştirilir. Düşük dereceli lezyonlarda izlem ön planda iken, yüksek dereceli lezyonlarda eksizyonel tedavi önerilir. Özel hasta gruplarında (gebeler, immünsüprese bireyler) daha dikkatli ve konservatif yaklaşımlar benimsenir. HPV aşılaması hem primer korunmada hem de nükslerin azaltılmasında önemli bir rol oynar. Sonuç olarak, kanıta dayalı yönetim stratejileri serviks kanserine bağlı morbidite ve mortalitenin azaltılmasında etkilidir.
This chapter provides a comprehensive clinical perspective on cervical premalignant lesions and cervical cancer. Cervical cancer is largely preventable due to effective screening programs and advances in early detection methods. Cervical intraepithelial neoplasia represents precursor lesions, and accurate diagnosis combined with appropriate management is essential to prevent progression to invasive disease. High-risk human papillomavirus (HPV) infection is the primary etiological factor, with E6 and E7 oncoproteins playing key roles in carcinogenesis. Screening strategies include cytology, HPV DNA testing, and colposcopy. Clinical management is individualized based on lesion grade, patient age, and fertility considerations. While low-grade lesions are generally managed with observation, high-grade lesions require excisional treatment due to their higher malignant potential. Special populations, such as pregnant and immunocompromised patients, require more cautious and conservative approaches. HPV vaccination plays a crucial role in both primary prevention and reduction of recurrence. In conclusion, evidence-based screening and management strategies significantly reduce the morbidity and mortality associated with cervical cancer.
Referanslar
Montz FJ. Management of high-grade cervical intraepithelial neoplasia and low-grade squamous intraepithelial lesion and potential complications. Clin Obstet Gynecol. 2000;43:394.
Benard VB, Watson M, Castle PE, Saraiya M. Cervical carcinoma rates among young females in the United States. Obstet Gynecol. 2012;120:1117.
Winer RL, Lee SK, Hughes JP, et al. Genital human papillomavirus infection: incidence and risk factors in a cohort of female university students. Am J Epidemiol. 2003;157:218.
Moscicki AB, Hills N, Shiboski S, et al. Risks for incident human papillomavirus infection and low-grade squamous intraepithelial lesion development in young females. JAMA. 2001;285:2995.
Schmeink CE, Massuger LF, Lenselink CH, et al. Prospective follow-up of 2,065 young unscreened women to study human papillomavirus incidence and clearance. Int J Cancer. 2013;133:172.
Gustafsson L, Adami HO. Natural history of cervical neoplasia: consistent results obtained by an identification technique. Br J Cancer. 1989;60:132.
Chan JK, Monk BJ, Brewer C, et al. HPV infection and number of lifetime sexual partners are strong predictors for "natural" regression of CIN 2 and 3. Br J Cancer. 2003;89:1062.
American College of Obstetricians and Gynecologists. ACOG Practice Bulletin no. 66, September 2005. Management of abnormal cervical cytology and histology. Obstet Gynecol. 2005;106:645.
McIndoe WA, McLean MR, Jones RW, Mullins PR. The invasive potential of carcinoma in situ of the cervix. Obstet Gynecol. 1984;64:451.
Peto J, Gilham C, Fletcher O, Matthews FE. The cervical cancer epidemic that screening has prevented in the UK. Lancet. 2004;364:249.
McCredie MR, Sharples KJ, Paul C, et al. Natural history of cervical neoplasia and risk of invasive cancer in women with cervical intraepithelial neoplasia 3: a retrospective cohort study. Lancet Oncol. 2008;9:425.
Tainio K, Athanasiou A, Tikkinen KAO, et al. Clinical course of untreated cervical intraepithelial neoplasia grade 2 under active surveillance: systematic review and meta-analysis. BMJ. 2018;360:k499.
Leung SOA, Vitonis A, Feldman S. Yield of loop electrosurgical excision procedure (LEEP) among patients with and without known high-grade cervical dysplasia. Gynecol Oncol. 2020.
Perkins RB, Guido RS, Castle PE, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines for Abnormal Cervical Cancer Screening Tests and Cancer Precursors. J Low Genit Tract Dis. 2020;24:102.
Egemen D, Cheung LC, Chen X, et al. Risk Estimates Supporting the 2019 ASCCP Risk-Based Management Consensus Guidelines. J Low Genit Tract Dis. 2020;24:132.
Castle PE, Schiffman M, Wheeler CM, Solomon D. Evidence for frequent regression of cervical intraepithelial neoplasia-grade 2. Obstet Gynecol. 2009;113:18.
Moscicki AB, Schiffman M, Burchell A, et al. Updating the natural history of human papillomavirus and anogenital cancers. Vaccine. 2012;30(Suppl 5):F24.
McAllum B, Sykes PH, Sadler L, et al. Is the treatment of CIN 2 always necessary in women under 25 years old? Am J Obstet Gynecol. 2011;205:478.e1.
Herbert A, Holdsworth G, Kubba A. Why young women should be screened for cervical cancer: the difference between CIN2 and CIN3. Int J Cancer. 2010;126:2256.
Lichter K, Krause D, Xu J, et al. Adjuvant Human Papillomavirus Vaccine to Reduce Recurrent Cervical Dysplasia in Unvaccinated Women: A Systematic Review and Meta-analysis. Obstet Gynecol. 2020;135:1070.
Kapp P, Schmucker C, Siemens W, et al. Human papillomavirus (HPV) vaccination in women after conisation. Cochrane Database Syst Rev. 2025;9:CD016121.
Harrison R, Huh W. Occupational Exposure to Human Papillomavirus and Vaccination for Health Care Workers. Obstet Gynecol. 2020;136:663.
ASCCP. HPV Vaccine Member Announcement. Available from: https://www.asccp.org/Assets/d3abdb05-25c5-4e58-9cec-05c11fb2b920/63717787631000000/hpv-vaccine-member-announcment-02-19-20-pdf. Accessed September 28, 2020.
Bray F, Laversanne M, Sung H, et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2024;74:229.
Walboomers JM, Jacobs MV, Manos MM, et al. Human papillomavirus is a necessary cause of invasive cervical cancer worldwide. J Pathol. 1999;189:12.
Ries LAG, Melbert D, Krapcho M, et al. SEER Cancer Statistics Review, 1975-2004. National Cancer Institute; Bethesda, MD; 2007.
Bader AA, Winter R, Haas J, Tamussino KF. Where to look for the sentinel lymph node in cervical cancer. Am J Obstet Gynecol. 2007;197:678.e1.
Wenzel HHB, Van Kol KGG, Nijman HW, et al. Cervical cancer with <5 mm depth of invasion and >7mm horizontal spread- Is lymph node assessment only required in patients with LVSI? Gynecol Oncol. 2020;158:282.
Park JY, Kim DY, Kim JH, et al. Outcomes after radical hysterectomy according to tumor size divided by 2 cm interval in patients with early cervical cancer. Ann Oncol. 2011;22:59.
Perez CA, Grigsby PW, Camel HM, et al. Irradiation alone or combined with surgery in stage IB, IIA, and IIB carcinoma of uterine cervix: update of a nonrandomized comparison. Int J Radiat Oncol Biol Phys. 1995;31:703.
Elit L, Fyles AW, Devries MC, et al. Follow-up for women after treatment for cervical cancer: a systematic review. Gynecol Oncol. 2009;114:528.
Salani R, Backes FJ, Fung MF, et al. Posttreatment surveillance and diagnosis of recurrence in women with gynecologic malignancies: Society of Gynecologic Oncologists recommendations. Am J Obstet Gynecol. 2011;204:466.
Referanslar
Montz FJ. Management of high-grade cervical intraepithelial neoplasia and low-grade squamous intraepithelial lesion and potential complications. Clin Obstet Gynecol. 2000;43:394.
Benard VB, Watson M, Castle PE, Saraiya M. Cervical carcinoma rates among young females in the United States. Obstet Gynecol. 2012;120:1117.
Winer RL, Lee SK, Hughes JP, et al. Genital human papillomavirus infection: incidence and risk factors in a cohort of female university students. Am J Epidemiol. 2003;157:218.
Moscicki AB, Hills N, Shiboski S, et al. Risks for incident human papillomavirus infection and low-grade squamous intraepithelial lesion development in young females. JAMA. 2001;285:2995.
Schmeink CE, Massuger LF, Lenselink CH, et al. Prospective follow-up of 2,065 young unscreened women to study human papillomavirus incidence and clearance. Int J Cancer. 2013;133:172.
Gustafsson L, Adami HO. Natural history of cervical neoplasia: consistent results obtained by an identification technique. Br J Cancer. 1989;60:132.
Chan JK, Monk BJ, Brewer C, et al. HPV infection and number of lifetime sexual partners are strong predictors for "natural" regression of CIN 2 and 3. Br J Cancer. 2003;89:1062.
American College of Obstetricians and Gynecologists. ACOG Practice Bulletin no. 66, September 2005. Management of abnormal cervical cytology and histology. Obstet Gynecol. 2005;106:645.
McIndoe WA, McLean MR, Jones RW, Mullins PR. The invasive potential of carcinoma in situ of the cervix. Obstet Gynecol. 1984;64:451.
Peto J, Gilham C, Fletcher O, Matthews FE. The cervical cancer epidemic that screening has prevented in the UK. Lancet. 2004;364:249.
McCredie MR, Sharples KJ, Paul C, et al. Natural history of cervical neoplasia and risk of invasive cancer in women with cervical intraepithelial neoplasia 3: a retrospective cohort study. Lancet Oncol. 2008;9:425.
Tainio K, Athanasiou A, Tikkinen KAO, et al. Clinical course of untreated cervical intraepithelial neoplasia grade 2 under active surveillance: systematic review and meta-analysis. BMJ. 2018;360:k499.
Leung SOA, Vitonis A, Feldman S. Yield of loop electrosurgical excision procedure (LEEP) among patients with and without known high-grade cervical dysplasia. Gynecol Oncol. 2020.
Perkins RB, Guido RS, Castle PE, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines for Abnormal Cervical Cancer Screening Tests and Cancer Precursors. J Low Genit Tract Dis. 2020;24:102.
Egemen D, Cheung LC, Chen X, et al. Risk Estimates Supporting the 2019 ASCCP Risk-Based Management Consensus Guidelines. J Low Genit Tract Dis. 2020;24:132.
Castle PE, Schiffman M, Wheeler CM, Solomon D. Evidence for frequent regression of cervical intraepithelial neoplasia-grade 2. Obstet Gynecol. 2009;113:18.
Moscicki AB, Schiffman M, Burchell A, et al. Updating the natural history of human papillomavirus and anogenital cancers. Vaccine. 2012;30(Suppl 5):F24.
McAllum B, Sykes PH, Sadler L, et al. Is the treatment of CIN 2 always necessary in women under 25 years old? Am J Obstet Gynecol. 2011;205:478.e1.
Herbert A, Holdsworth G, Kubba A. Why young women should be screened for cervical cancer: the difference between CIN2 and CIN3. Int J Cancer. 2010;126:2256.
Lichter K, Krause D, Xu J, et al. Adjuvant Human Papillomavirus Vaccine to Reduce Recurrent Cervical Dysplasia in Unvaccinated Women: A Systematic Review and Meta-analysis. Obstet Gynecol. 2020;135:1070.
Kapp P, Schmucker C, Siemens W, et al. Human papillomavirus (HPV) vaccination in women after conisation. Cochrane Database Syst Rev. 2025;9:CD016121.
Harrison R, Huh W. Occupational Exposure to Human Papillomavirus and Vaccination for Health Care Workers. Obstet Gynecol. 2020;136:663.
ASCCP. HPV Vaccine Member Announcement. Available from: https://www.asccp.org/Assets/d3abdb05-25c5-4e58-9cec-05c11fb2b920/63717787631000000/hpv-vaccine-member-announcment-02-19-20-pdf. Accessed September 28, 2020.
Bray F, Laversanne M, Sung H, et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2024;74:229.
Walboomers JM, Jacobs MV, Manos MM, et al. Human papillomavirus is a necessary cause of invasive cervical cancer worldwide. J Pathol. 1999;189:12.
Ries LAG, Melbert D, Krapcho M, et al. SEER Cancer Statistics Review, 1975-2004. National Cancer Institute; Bethesda, MD; 2007.
Bader AA, Winter R, Haas J, Tamussino KF. Where to look for the sentinel lymph node in cervical cancer. Am J Obstet Gynecol. 2007;197:678.e1.
Wenzel HHB, Van Kol KGG, Nijman HW, et al. Cervical cancer with <5 mm depth of invasion and >7mm horizontal spread- Is lymph node assessment only required in patients with LVSI? Gynecol Oncol. 2020;158:282.
Park JY, Kim DY, Kim JH, et al. Outcomes after radical hysterectomy according to tumor size divided by 2 cm interval in patients with early cervical cancer. Ann Oncol. 2011;22:59.
Perez CA, Grigsby PW, Camel HM, et al. Irradiation alone or combined with surgery in stage IB, IIA, and IIB carcinoma of uterine cervix: update of a nonrandomized comparison. Int J Radiat Oncol Biol Phys. 1995;31:703.
Elit L, Fyles AW, Devries MC, et al. Follow-up for women after treatment for cervical cancer: a systematic review. Gynecol Oncol. 2009;114:528.
Salani R, Backes FJ, Fung MF, et al. Posttreatment surveillance and diagnosis of recurrence in women with gynecologic malignancies: Society of Gynecologic Oncologists recommendations. Am J Obstet Gynecol. 2011;204:466.
