KURSUS

1. LESI PRAKANKER SERVIKS
Dr. dr. Brahmana Askandar, SpOG (K.Onk)
Divisi Onkologi Ginekologi
Dept. Obstetri Ginekologi
FK Unair / RSU Dr. Soetomo

2. 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

3. NATURAL HISTORY
CERVICAL 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. Bethesda System

10. Padanan dari klasifikasi
Class I Class II Class III Class IV Class V
Normal Inflam
Mild Mod Sev
CIS
Cancer
D y s p l a s i a
Normal Atypia
CIN I CIN II
CIN III Cancer
K o i l o c y t o s i s
WNL
Benign
Cellular
Changes
AS
CUS
LGSIL HGSIL HGSIL Carcinoma
NEGATIF
AS
CUS
LGSIL HGSIL HGSIL Carcinoma

11. Serviks Normal

12. Lesi Pra Kanker Serviks

13. Diagnosis Lesi Prakanker
• Inspeksi visual dengan asam asetat (IVA)
Pemeriksaan paling sederhana
Dilakukan 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

14. I V A
(Inspeksi Visual Asam Asetat)
Sankaranarayanan dkk (Thailand)
Efektif, aman, praktis, murah
Tidak invasif
Oleh dokter – bidan - paramedis

15. 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 +

16. Gambaran Visual dengan Aplikasi Asam
Asetat pada Lesi Prakanker
Sebelum pemberian asam asetat Setelah pemberian asam asetat

17. Alur Penatalaksanan
Kasus dengan IVA Positif
IVA Positif
Biopsi terarah-
PA
Kolposkopi
Lesi PositifLesi Negatif
Pemeriksaan
rutin

18. Gambar Lesi Pra Kanker
Low grade SIL Low grade SIL

19. Gambar Lesi Pra Kanker
High grade SIL High Grade SIL

20. Low grade SIL High Grade SIL

21. Low grade SIL Kanker Invasif

22. Pemeriksaan Biopsi
Dilakukan bila dijumpai mass/benjolan di serviks

23. mANAGEMENT

24. 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

25. ASCUS MANAGEMENT

26. 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)

27. 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 ulang
Pengamatan  pap smear ulang 6 bulan
Krioterapi/Kauter / LEEP
• HSIL (CIN II – III) :
Harus dilakukan tindakan
Cauter / LEEP
Konisasi(pengambilan sebagian cervix dg pisau)
Histerektomi (Bila usia cukup dan anak cukup)

28. LSIL MANAGEMENT

29. 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,

30. 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.

31. HSIL MANAGEMENT

32. HSIL IN YOUNG WOMEN

33. 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

34. 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

35. 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

36. 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

37. Krioterapi

38. LEEP

39. LEEP

40. KONISASI

41. KONISASI

42. 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

43. 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.