Precancerous conditions in gynecology

Precancerous disease is a preinvasive intraepithelial lesion that has the same etiopathology as invasive cancer. It is still progressing and threatening to develop into invasive cancer, which lasts for about 10-15 years.

Precancerous lesions are asymptomatic, do not cause metastases, and when completely removed, the disease is completely cured.

Anatomical division of precancerous lesions
Precancerous lesions of the lower genital tract and precancerous lesions of the endometrium are distinguished anatomically.

The precancerous lesions of the lower genital tract include:

precancerous lesions of the vulva precancerous lesions of the vagina, precancerous lesions of the cervix, precancerous lesions of the anus

Histological division
There are two types of epithelium physiologically in the genitals: stratified squamous epithelium on the vulva (horned) and vagina (non-horned) and single-row cylindrical epithelium of the endometrium. Precancerous lesions can arise from both types of epithelium.

Both occur on the cervix with an interface in the form of a transformational metaplastic zone (squamous-colonary junction).

The epithelium in the metaplastic zone is the most sensitive to precancerous lesions due to remodeling. For this reason, squamous cell epithelial precancerous lesions are also more common.

Causes and risk factors
In precancerous lesions of the vulva, vagina and cervix, chronic oncogenic papillomavirus infection (18 different types) is usually the cause. 70% of oncogenic HPV infections are caused by HPV-16 or HPV-18. The infection alone is not enough, usually atypical cells are removed by the immune system. Risk factors for precancerous lesions are smoking, immunosuppression, immunoncompetence, sexually transmitted diseases (especially chlamydia and HSV-2), promiscuity (defined as more than 6 life partners), early coitarché [1].

Endometrial precancerous lesions are caused by hyperestrinism. This can be absolute (normal progestogen levels and high estrogens) or relative (normal estrogen levels and low progestogens).

Precancerous screening

 * Colposcopy (called vulvoscopy in the vulva) - a colposcope device is used, which is structurally a telescope, not a microscope, as is sometimes stated.
 * Cytology
 * HPV typing

Cervical precancerous lesions
This is a very sophisticated issue with the best developed screening system, so a separate article discusses this topic.

Precancerous disease of the vulva
There are two types of vulvar intraepithelial neoplasia (VIN):


 * usual VIN (uVIN) - lesions more common and with a better prognosis, caused by HPV infection,
 * differentiated VIN (dVIN) - less common lesions that are not caused by HPV infection, have a mutated p53 gene, have a worse prognosis.

(Previously, a distinction was made between VIN I, which today no longer belongs to VIN, VIN II and VIN III, which is synonymous with 'in situ' carcinoma.)

Other precancerous lesions include:
 * extramammary form Pagett's disease,
 * premature -in diagnosis there is used rule A ( asymmetry ), B ( border ), C ( color ), D ( diameter ), E ( evolution ).

It is necessary to differentiate psoriasis and lichen lesions differentially. Biopsy is an essential method in diagnosis, the samples are easily biopsically accessible and any suspected lesion should be histologically examined

Vaginal precancerous lesions
Vaginal intraepithelial neoplasia (VaIN) occurs most often in patients after hysterectomy (90%), especially in the surgical stump. There may also be co-occurrence on the cervix and vagina. In 80%, lesions occur in the proximal third.

Endometrial precancerous lesions
Atypical hyperplasia, which is a precancerous adenocarcinoma, can occur in the endometrium and can be either simplex or complex and with or without atypia. Another precancerous disease is carcinoma in situ, which is less common and occurs in the atrophic mucosa.

Treatment of precancerous lesions
In general, you can choose a conservative, ie wait-and-see approach (few times), or an active approach. The active approach includes either destructive methods for pathological tissue that are no longer used (cryoablation, laser vaporization) or ablative methods. In the case of the vulva, it is laser-skinning or excision, in the case of the vagina a partial or total collectectomy, in the case of the endometrium a hysterectomy with adnexectomy, in the case of the cervix a cylindrical dissection or conization (cold-knife, LEEP or laser-ablation).

For endometrial precancerous lesions in women of childbearing potential who wish to become pregnant, gestagen therapy may be indicated. For vaginal and vulvar lesions caused by HPV, treatment with Imiquimod (immunomodulatory cream) may be appropriate in some cases.

Related articles

 * Malignant tumors in gynecology
 * Treatment of precancerous lesions of gynecological tumors
 * Prevention of gynecological tumors
 * Cervical precancerous lesions
 * Precancerous conditions in dermatology