広汎性子宮全摘出術の実際

子宮頸癌Ⅲb期と診断。術前動注化学療法（NAC）にてⅠb期相当にdown staging、また卵巣腫瘍合併例であったため開腹術施行。

HPVタイピング検査を行う場合の管理指針

組織診断でCIN1、2と判定された患者において、HPVハイリスク型といわれているHPV16、18、31、33、35、45、52、58の8種類が検出される場合には、厳重な経過観察が推奨される。
子宮頸癌発症のリスクは検出されるHPVのタイプによって異なるので、CIN1/2患者のフォローアップにおいてHPVタイピング検査の結果はリスク評価に有用と考えられる。浸潤癌からの検出頻度が高いHPV16、18、31、33、35、45、52、58のタイプはハイリスクの群として厳重にフォローアップし、場合によっては治療を行う。

Management of Women with Atypical Squamous Cells of Undetermined Significance (ASC-US) （意義不明な異型扁平上皮細胞[ASC-US]を有する女性の管理方針）

ASC-US例にはハイリスクHPV検査が第1に勧められる。しかしながら何らかの理由でハイリスクHPV検査を実施できない場合には、ただちにコルポスコープを行い、異常があれば生検をするか、あるいは6カ月後と12カ月後に細胞診を再検査する。ASC-USかつハイリスクHPV陽性例には、ただちにコルポスコピー下に生検を行う。
 
参考文献：
  1. Wright TC Jr, et al. 2006 consensus guidelines for the management of women with abnormal cervical cancer screening tests. Am J Obstet Gynecol. 2007 Oct;197(4):346-55. doi: 10.1016/j.ajog.2007.07.047. PMID: 17904957.
  1. 日本産科婦人科学会/日本産婦人科医会編集・監修：産婦人科診療ガイドライン 婦人科外来編2020、p34 図1
出典
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1: 著者提供

妊婦細胞診異常の取り扱い方針

妊娠中の子宮頸部細胞診異常例にはコルポスコープ検査を実施し、異常所見を認めた場合は狙い組織診を実施する。中等度異形成以下の所見の場合は引き続き細胞診の経過観察をし、CIN3以上の病変については進行癌を疑う所見がない場合は1カ月ごとに細胞診コルポスコープ検査でフォローアップする。進行癌が疑われる場合は円錐切除などで診断確定後、胎児の発育状況に応じて最終治療方針を決定する。
 
参考文献：
石井賢治、工藤一弥、菊池義公ほか：妊婦の頸部細胞診異常の取り扱いについて. 日臨細胞誌　1994；33(3)：p475, 図1
出典
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1: 著者提供

ベセスダシステム2001細胞診結果とその取扱い

*腺異型として記載されているが、ベセスダシステムでは上皮内腺癌を想定していることから、変更して記載した。

典型的症例：CIN3症例

病　歴：36歳　2回経妊2回経産婦。子宮頸がん集団検診にて細胞診異常を指摘され来院。
診　察：コルポスコピーで子宮腟部後唇に広範な白色上皮。
診　断のためのテストとその結果：細胞診判定はHSIL、生検組織診判定はCIN3。
治　療：子宮頸部レーザー円錐切除術施行。
転　帰：軽快退院
コメント：細胞診、コルポスコピー、組織診3者併用診でCIN3と診断した場合は円錐切除が推奨される。

典型的症例：浸潤癌症例

病　歴：57歳　5回経妊3回経産婦。接触出血を主訴として来院。
診　察：子宮頸部に肉眼浸潤癌。
診断のためのテストとその結果：細胞診判定はSCC、生検組織診判定は扁平上皮癌。両側傍結合織には抵抗を触れず子宮頸癌ⅠB2期と診断。
治　療：広汎子宮全摘出術施行。
転　帰：軽快退院

子宮頸部狙い生検の実際

生検法の実際は、まず細胞を採取し、次にコルポスコピーを行い、その最強病変部位から狙い組織診を行う。生検部位に迷う場合は、酢酸加工の影響が低下したときに異常所見として残っている部分から採取するのも一方法である。採取器具は先端に刃のついたいわゆるパンチを用いる。先端の刃の部分が丸く浅いもの、三角形で深いものなど多種ある。よく切れる刃であれば通常器具による差はないが、前者のほうが出血は少ない。組織採取にあたっては、子宮腟部に先端が開いた状態でパンチを押し当て、それから先端を閉じて組織片を切り取る。その際パンチの刃が子宮腟部の表面で滑ってしまい、思うような大きさの組織片が取れないことがあるが、意識的に刃を押しつけるようにすれば失敗は少ない。生検後の出血部位の止血は、通常はタンポンによる圧迫のみで十分であるが、出血が強度な場合は適宜縫合、焼灼、止血剤（アルギン酸ナトリウムやトロンビン沫など）散布を行う。

子宮頸部レーザー円錐切除術（Nd・YAGレーザー）の実際

レーザーにはCO2, Nd・YAG, KTP・YAGなどの種類がある。CO2レーザーは蒸散能に優れ切除時間が速いが、YAGレーザーに比べて凝固、止血能は劣る。YAGレーザーは接触照射であり操作が容易である。コールドナイフと比較したレーザー円錐切除の利点としては、①術中術後の出血量が非常に少ないこと、②病巣の遺残が疑われる場合でも容易に蒸散を加えることができ、かつ腟壁の病変やskip lesionにも蒸散の併用により保存的治療が可能であること、③術後にコルポ診上UCFとなる症例がコールドナイフよりも生じにくく、外来での経過観察がしやすいこと――などが挙げられる。また、CINの治癒率に関しても、諸家により症例の選択や方法が異なるものの、おおむね100%近い成績が報告されている。

クリニカルパス

クリニカルパス

子宮頸部細胞診後に精密検査としてのコルポスコピー・生検を行う場合は？

組織診で確認されたCIN1/2の管理・治療は？

子宮頸部円錐切除術の低侵襲代用法としてのLEEP、レーザー蒸散術はどのような場合に行うか？

HPVワクチン接種の対象は？

ハイリスクHPV検査はどのような場合に使うか？

Management of Women with Atypical Squamous Cells: Cannot Exclude High-grade SIL（高悪性度SILを除外できない異型扁平上皮細胞[ASC-H]を有する女性の管理方針）

ASC-H症例の取扱い―ASCCP（米国コルポスコピー子宮頸部病理学会）のガイドライン―（原図は英文）
出典
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1: 2001 Consensus Guidelines for the management of women with cervical cytological abnormalities.
著者: Wright TC Jr, Cox JT, Massad LS, Twiggs LB, Wilkinson EJ; ASCCP-Sponsored Consensus Conference.
雑誌名: JAMA. 2002 Apr 24;287(16):2120-9. doi: 10.1001/jama.287.16.2120.
Abstract/Text: OBJECTIVE: To provide evidence-based consensus guidelines for the management of women with cervical cytological abnormalities and cervical cancer precursors.
PARTICIPANTS: A panel of 121 experts in the diagnosis and management of cervical cancer precursors, including representatives from 29 professional organizations, federal agencies, and national and international health organizations, were invited to participate in a consensus conference sponsored by the American Society for Colposcopy and Cervical Pathology (ASCCP).
EVIDENCE AND CONSENSUS PROCESS: Guidelines for the management of women with cervical cytological abnormalities were developed through a multistep process. Starting 6 months before the conference, working groups developed draft management guidelines based on formal literature reviews of English-language articles published in 1988-2001, as well as input from the professional community at large, obtained using interactive Internet-based bulletin boards. On September 6-8, 2001, the ASCCP Consensus Conference was held in Bethesda, Md. Guidelines with supporting evidence were presented and underwent discussion, revision, and voting.
CONCLUSIONS: Management of women with atypical squamous cells (ASC) depends on whether the Papanicolaou test is subcategorized as of undetermined significance (ASC-US) or as cannot exclude high-grade squamous intraepithelial lesion (HSIL) (ASC-H). Women with ASC-US should be managed using a program of 2 repeat cytology tests, immediate colposcopy, or DNA testing for high-risk types of human papillomavirus (HPV). Testing for HPV DNA is the preferred approach when liquid-based cytology is used for screening. In most instances, women with ASC-H, low-grade squamous intraepithelial lesion, HSIL, and atypical glandular cells should be referred for immediate colposcopic evaluation.
JAMA. 2002 Apr 24;287(16):2120-9. doi: 10.1001/jama.287.16.2120.

Management of Women with Atypical Glandular Cells (AGC) （異型腺細胞[AGC]を有する女性の管理方針）

AGC症例の取扱い―ASCCP（米国コルポスコピー子宮頸部病理学会）のガイドライン―（原図は英文）
出典
imgimg
1: 2001 Consensus Guidelines for the management of women with cervical cytological abnormalities.
著者: Wright TC Jr, Cox JT, Massad LS, Twiggs LB, Wilkinson EJ; ASCCP-Sponsored Consensus Conference.
雑誌名: JAMA. 2002 Apr 24;287(16):2120-9. doi: 10.1001/jama.287.16.2120.
Abstract/Text: OBJECTIVE: To provide evidence-based consensus guidelines for the management of women with cervical cytological abnormalities and cervical cancer precursors.
PARTICIPANTS: A panel of 121 experts in the diagnosis and management of cervical cancer precursors, including representatives from 29 professional organizations, federal agencies, and national and international health organizations, were invited to participate in a consensus conference sponsored by the American Society for Colposcopy and Cervical Pathology (ASCCP).
EVIDENCE AND CONSENSUS PROCESS: Guidelines for the management of women with cervical cytological abnormalities were developed through a multistep process. Starting 6 months before the conference, working groups developed draft management guidelines based on formal literature reviews of English-language articles published in 1988-2001, as well as input from the professional community at large, obtained using interactive Internet-based bulletin boards. On September 6-8, 2001, the ASCCP Consensus Conference was held in Bethesda, Md. Guidelines with supporting evidence were presented and underwent discussion, revision, and voting.
CONCLUSIONS: Management of women with atypical squamous cells (ASC) depends on whether the Papanicolaou test is subcategorized as of undetermined significance (ASC-US) or as cannot exclude high-grade squamous intraepithelial lesion (HSIL) (ASC-H). Women with ASC-US should be managed using a program of 2 repeat cytology tests, immediate colposcopy, or DNA testing for high-risk types of human papillomavirus (HPV). Testing for HPV DNA is the preferred approach when liquid-based cytology is used for screening. In most instances, women with ASC-H, low-grade squamous intraepithelial lesion, HSIL, and atypical glandular cells should be referred for immediate colposcopic evaluation.
JAMA. 2002 Apr 24;287(16):2120-9. doi: 10.1001/jama.287.16.2120.

Management of Women with Low-grade Squamous Intraepithelial Lesions (LSIL)（低悪性度扁平上皮内病変[LSIL]を有する女性の管理方針）

LSIL症例の取扱い―ASCCP（米国コルポスコピー子宮頸部病理学会）のガイドライン―（原図は英文）
妊婦の場合はコルポスコピーの実施時期は分娩後に延期することも許容される。
 
参考文献：
  1. 日本産科婦人科学会/日本産婦人科医会：産婦人科診療ガイドライン 婦人科外来編 2023.
  1. Massad LS, Einstein MH, Huh WK, Katki HA, Kinney WK, Schiffman M, Solomon D, Wentzensen N, Lawson HW, 2012 ASCCP Consensus Guidelines Conference. 2012 updated consensus guidelines for the management of abnormal cervical cancer screening tests and cancer precursors. Obstet Gynecol [Internet]. 2013 Apr [cited 2019 Feb 21];121(4):829–46. Available from: http://insights.ovid.com/crossref?an=00006250-201304000-00019 PMID: 23635684
  1. Practice Bulletin No. 140: management of abnormal cervical cancer screening test results and cervical cancer precursors. Obstet Gynecol [Internet]. Obstet Gynecol; 2013 Dec [cited 2023 Dec 12];122(6):1338–1366. Available from: https://pubmed.ncbi.nlm.nih.gov/24264713/ PMID: 24264713
  1. Bentley J, Bertrand M, Brydon L, Gagné H, Hauck B, Mayrand MH, McFaul S, Power P, Schepansky A, Straszak-Suri M, Colgan T, Geldenhuys L, Heywood M, Howlett R, Kapusta L, Kupets R, Murphy J, Nation J, Senikas V, Shier M. Colposcopic management of abnormal cervical cytology and histology. J Obstet Gynaecol Can [Internet]. J Obstet Gynaecol Can; 2012 [cited 2023 Dec 12];34(12):1188–1202. Available from: https://pubmed.ncbi.nlm.nih.gov/23231803/ PMID: 23231803
  1. Hunter MI, Monk BJ, Tewari KS. Cervical neoplasia in pregnancy. Part 1: screening and management of preinvasive disease. Am J Obstet Gynecol [Internet]. Am J Obstet Gynecol; 2008 Jul [cited 2023 Dec 12];199(1):3–9. Available from: https://pubmed.ncbi.nlm.nih.gov/18585520/ PMID: 18585520
出典
imgimg
1: 2001 Consensus Guidelines for the management of women with cervical cytological abnormalities.
著者: Wright TC Jr, Cox JT, Massad LS, Twiggs LB, Wilkinson EJ; ASCCP-Sponsored Consensus Conference.
雑誌名: JAMA. 2002 Apr 24;287(16):2120-9. doi: 10.1001/jama.287.16.2120.
Abstract/Text: OBJECTIVE: To provide evidence-based consensus guidelines for the management of women with cervical cytological abnormalities and cervical cancer precursors.
PARTICIPANTS: A panel of 121 experts in the diagnosis and management of cervical cancer precursors, including representatives from 29 professional organizations, federal agencies, and national and international health organizations, were invited to participate in a consensus conference sponsored by the American Society for Colposcopy and Cervical Pathology (ASCCP).
EVIDENCE AND CONSENSUS PROCESS: Guidelines for the management of women with cervical cytological abnormalities were developed through a multistep process. Starting 6 months before the conference, working groups developed draft management guidelines based on formal literature reviews of English-language articles published in 1988-2001, as well as input from the professional community at large, obtained using interactive Internet-based bulletin boards. On September 6-8, 2001, the ASCCP Consensus Conference was held in Bethesda, Md. Guidelines with supporting evidence were presented and underwent discussion, revision, and voting.
CONCLUSIONS: Management of women with atypical squamous cells (ASC) depends on whether the Papanicolaou test is subcategorized as of undetermined significance (ASC-US) or as cannot exclude high-grade squamous intraepithelial lesion (HSIL) (ASC-H). Women with ASC-US should be managed using a program of 2 repeat cytology tests, immediate colposcopy, or DNA testing for high-risk types of human papillomavirus (HPV). Testing for HPV DNA is the preferred approach when liquid-based cytology is used for screening. In most instances, women with ASC-H, low-grade squamous intraepithelial lesion, HSIL, and atypical glandular cells should be referred for immediate colposcopic evaluation.
JAMA. 2002 Apr 24;287(16):2120-9. doi: 10.1001/jama.287.16.2120.

Management of Women with High-grade Squamous Intraepithelial Lesions (HSIL)（高悪性度扁平上皮内病変[HSIL]を有する女性の管理方針）

HSIL症例の取扱い―ASCCP（米国コルポスコピー子宮頸部病理学会）のガイドライン―（原図は英文）
出典
imgimg
1: 2001 Consensus Guidelines for the management of women with cervical cytological abnormalities.
著者: Wright TC Jr, Cox JT, Massad LS, Twiggs LB, Wilkinson EJ; ASCCP-Sponsored Consensus Conference.
雑誌名: JAMA. 2002 Apr 24;287(16):2120-9. doi: 10.1001/jama.287.16.2120.
Abstract/Text: OBJECTIVE: To provide evidence-based consensus guidelines for the management of women with cervical cytological abnormalities and cervical cancer precursors.
PARTICIPANTS: A panel of 121 experts in the diagnosis and management of cervical cancer precursors, including representatives from 29 professional organizations, federal agencies, and national and international health organizations, were invited to participate in a consensus conference sponsored by the American Society for Colposcopy and Cervical Pathology (ASCCP).
EVIDENCE AND CONSENSUS PROCESS: Guidelines for the management of women with cervical cytological abnormalities were developed through a multistep process. Starting 6 months before the conference, working groups developed draft management guidelines based on formal literature reviews of English-language articles published in 1988-2001, as well as input from the professional community at large, obtained using interactive Internet-based bulletin boards. On September 6-8, 2001, the ASCCP Consensus Conference was held in Bethesda, Md. Guidelines with supporting evidence were presented and underwent discussion, revision, and voting.
CONCLUSIONS: Management of women with atypical squamous cells (ASC) depends on whether the Papanicolaou test is subcategorized as of undetermined significance (ASC-US) or as cannot exclude high-grade squamous intraepithelial lesion (HSIL) (ASC-H). Women with ASC-US should be managed using a program of 2 repeat cytology tests, immediate colposcopy, or DNA testing for high-risk types of human papillomavirus (HPV). Testing for HPV DNA is the preferred approach when liquid-based cytology is used for screening. In most instances, women with ASC-H, low-grade squamous intraepithelial lesion, HSIL, and atypical glandular cells should be referred for immediate colposcopic evaluation.
JAMA. 2002 Apr 24;287(16):2120-9. doi: 10.1001/jama.287.16.2120.