28 neoplasia epitelial cervical2014 dra chavez.pptx
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8/17/2019 28 NEOPLASIA EPITELIAL CERVICAL2014 DRA CHAVEZ.pptx
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NeoplasiaIntraepitelial
CervicalDRA JENNY CHAVEZ
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NEOPLASIA INTRAEPITELIAL DELCERVIX
DEFINICION
NIC. Son cambios neoplsicos !"e estn
con#na$os al Epitelio s"per#cial sin invasi%n
$el estroma.
Se consi$era a las lesiones preneoplsicas
$el c"ello "terino& con $iversos 'ra$os $e
anomal(as $e $i)erenciaci%n * ma$"raci%n
cel"lar en el espesor $el epitelio cervical
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Prepuberal Adolescencia Embarazo Perimenopausia Senectud
MOVIMIENTOS DE LA UNIÓN ESAMOOLUMNA!
• SON AM"IOS #ISIOLÓ$IOS
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NIC - anatomía
Cuello: epiteliocilíndrico
Exocervix: epitelioescamoso
Unión escamocolumnar: contiene delos dos epitelios.
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+icroanatom(aEXOCERVIX, Seno "ro'enital
CUBIERTO POR EPITELIO ESCAMOSO
ANATOMÍA
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Epit!io E"to"#$i"a!Zona Ba%a!Pa#a&a%a!
Int#m'iaCon'n%a"i(n%)p#*"ia!
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ANATOMÍA
+icroanatom(aENDOCERVIX - CONDCTOCERVICAL,
CUBIERTO POR EPITELIO CILINDRICO+
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UEATUAL
UEO!I$INAL
El epitelio metapl%sico es el sitio de ori&en del au
Epitelio escamosoori&inal
Epiteliocil'ndrico
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PER,IL CLINICOC"ello "terino accesible al e/amen )(sico& cel"lar* tis"lar .
Inicio 'ra$"al .
Asintomtico.
Detectable en )orma preco0.
Se p"e$e re$"cir la mortali$a$ por cncer $ec"ello "terino con "n pro'rama $e $etecci%ncitol%'ica * en proporci%n a la poblaci%ne/plora$a.
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,ACTORES DE RIESO1en2ticos.Socioecon%micos
3bitosFrmacosInm"nitarios
Pari$a$Se/"ales
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,a"to#% ' #i%.o,a"to#% .n/ti"o%
,a"to#% %o"io"on(mi"o%
H0&ito%1 a!"o2o!3 ta&a"o
,4#ma"o%1 a"o3 'iti!ti!&%t#o!
,a"to#% inm)nita#io%
m)!tipa#i'a'
,a"to#% %5)a!%6n7+t#an%m+%5)a!8
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,a"to#% ' #i%.o #!a"iona'o% "on
!a %5)a!i'a'P#"o"i'a' n ! "omin9o ' !a% #!+
P#im# m&a#a9o m): ;o$n
M<!tip!% "ompa=#o% %5)a!%
,a"to# ma%")!ino
In7""ion% ' t#an%mi%i(n %5)a!1 T#i"omonia%i%3%>*!i%3"!ami'ia%3$i#)% '! 2#p%?3VPH+
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4IOLO15A DELVIRSVir"s $e AND& $e la )amilia $e papovavir"s
Necesitan $e "na cel"la para replicarse
Tienen "na caps"la * "na parte central
S" estr"ct"ra le permite permanecer latente
Resiste la $esecaci%n
E/isten ms $e 677 tipos& menos $e la mita$p"e$en ser onco'enos
Se les clasi#can en $e ba8o& mo$era$o * alto
ries'o.
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La in)ecci%n viral tienetres )ases
() De reposo poca capacidad de in*ectar +portador sano,
-) Producti.a altamente in*ectante
/) Trans*ormante +induce a cancer,
Los vir"s se $ia'nostican ,
4iolo'(a molec"lar 9 PCR * Capt"ra $e :ibri$os;
biopsia
colposcop(a
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IVP3
Latente Sub-clinica Clinica
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Ri%.o on"o./ni"o ' !o%
VPHRi%.o &a;o1@333?33
Ri%.o int#m'io133333?
Ri%.o a!to1 @3F33@+
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PRORESION E HISTORIA
NATURALNasiell9>@<=;Displasia leve a normal >@B
Displasia leve persistente @@B
Displasia leve a severa 6>B
Displasia mo$ a normal B
Displasia mo$ a severa 7BDisplasia severa persistente 6>B
Lenta pro'resi%n $e NIC a Cncer
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E$o!)"i(n Nat)#a! ' !a En7#m'a'
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Vacunas contra el VP0
Vacuna Tetra.alente1 VP0 23((3(2 4 (5
Nombre comercial 1 $ardasil
Vacuna "i.alente1 VP01 (2 4 (5
Nombre comercial1 er.ari6
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M/to'o% ' Dt""i(nCito!o.ía $a.ina!
Co!po%"opia
T%t ' %"2i!!#
Biop%ia
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PAPANICOLAOU
o#. N+ Papani"o!ao) n?F 2i9o !a o&%#$a"i(nin"i'nta! ' G) n
5tn'i'o% ' "/!)!a% toma'a%' !a $a.ina n ! 2)manop)'n o&%#$a#% "/!)!a%'#i$a'a% '! ")!!o )t#ino+
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NIC
PAPANICOLAOU -P#pa#a"i(n ' pa"int -o&tn"i(n ' m)%t#a
•Citoespatula de Zsalay
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CITOLOIA+2to$o $e e/ploraci%n bsica!"e nos a*"$a a,
D/ prec%0 $e cncer cervico"terinoA*"$a a la valoraci%n :ormonalD/ $e cervicova'initis
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"E#$%$S %E %E#ECC&$'• Citolo'(a c2rvico<va'inal
e/)oliativa+ E% !a int#p#ta"i(n '!a% "/!)!a% G) % 2a!!an '%"ama'o!i&#mnt ' !a% %)p#*"i%pit!ia!% o G) % 2an #mo$i'o a
t#a$/% ' )n #a%pa'o '! 0#a "/#$i"o-$a.ina!+
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!otaci7n sua.ede /2893 iniciandoa las / de la car%tula
los diestros
!otaci7n sua.edel cepillo3 (589
:7mo ;acer la toma<
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Laminilla1 un tercio paraidenti*icaci7n
Dos tercios para elmaterial
:7mo ;acer el *rotis<
Toma 4 preparaci7n del *rotis en = se&undos
>ona de identi*icaci7n 4 manipulaci7n
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RECOMENDACIONES PARA TOMA DE
CITOLOIADebe e)ect"arse en b"enas con$iciones
9)ase estro'2nica;.
No reali0ar tacto va'inal.
Intro$"cir el esp2c"lo sin l"bricante.
Tratar in)ecciones previamente.
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RECOMENDACIONES A LA
PACIENTENo $"c:as va'inales @ :rs. previas a la
m"estra.
No relaciones se/"ales @ :rs previas.
No me$icamentos va'inales, %v"los&
cremas o 8aleas& = :rs previas.
No toma $e citolo'(a en per(o$omenstr"al.
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RECOMENDACIONES PARA TOMA
DE CITOLOIAE/ten$i$o #no para )cil lect"ra.
Fi8aci%n rpi$a para evitar $esecaci%n.
No e)ect"ar biopsia va'inal& cervicales oen$ometriales ni e/tirpaci%n $e p%lipos
antes $e la toma $el PAP
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,ACTORES UE PRODUCENERRORR"o!""i(n inap#opia'a+ T#an%7#n"ia '*"int '%' ! 'i%po%iti$o
' #"o!""i(n 2a"ia !a !amini!!a+
S"a'o a! ai#+Contamina"i(n "on !)&#i"ant+
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C!a%i*"a"ion '! #po#t
'! PapClasi#caci%n 'eneral
Dnt#o ' !ímit% no#ma!%
Cam&io% "!)!a#% &ni.no%
Ano#ma!i'a' ' "/!)!a% pit!ia!%
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SISTEMA BETHESDA ?TIPO DE ESPECI+EN.
ADECACIDAD DEL ESPECI+EN. Satis)actorio para eval"aci%n Insatis)actorio para eval"aci%n.
CATE1ORIACION 1ENERAL Ne'ativo para lesi%n intraepitelial o
mali'ni$a$ Anormali$a$es $e c2l"las epiteliales
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C!a%i*"a"ion '! #po#t '! Pap
S"#ciencia $e la m"estra
Sati%7a"to#ia pa#a !a $a!o#a"i(n
Sati%7a"to#ia pa#a !a $a!o#a"i(n p#o !imita'a
Po"o %ati%7a"to#ia pa#a !a $a!o#a"i(n
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ANORMALIDADES DE CELULAS
ESCAMOSAS...ASC 9c2l"las $e si'ni#ca$o
in$etermina$o;ASC<SASC<3
LEI41
LEIA1Carcinoma $e c2l"las escamosas.
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ANORMALIDADES DE CELULAS
LANDULARESA1C 9cel"las 'lan$"lares at(picas;A1C<NOS
A1C )avorece neoplasia
A$enocarcinoma en$ocervical in sit"a$enocarcinoma
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DIANOSTICOS DESCRIPTIVOSAnormali$a$es $e c2l"las epiteliales• C/!)!a% %"amo%a% 1
o Atípi"a% ' impo#tan"ia in't#mina'a
o L%i(n int#apit!ia! %"amo%a ' .#a'o &a;o
o L%i(n int#apit!ia! %"amo%a ' .#a'o a!to
o Ca#"inoma ' "/!)!a% %"amo%a%C/!)!a%.!an')!a#%
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DIANOSTICOS DESCRIPTIVOS• C2l"las en$ometriales
o C/!)!a% atípi"a% ' impo#tan"iain't#mina'a
o A'no"a#"inoma n'o"#$i"a!
o
A'no"a#"inoma n'omt#ia!o A'no"a#"inoma 5t#a)t#ino
• Ot#a% nop!a%ia% ma!i.na%
DIANOSTICOS DESCRIPTIVOS
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DIANOSTICOS DESCRIPTIVOS
Cambios cel"lares beni'nos
• In7""i(n
• Cam&io% #a"ti$o% a%o"ia'o% a1
--Inama"i(n--At#o*a "on inama"i(n--Ra'ia"i(n--Di%po%iti$o int#a)t#ino
--Ot#o%
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CLASI,ICACIONClasiicación$"S
Clasiicación(ic)art
Clasiicación*et)esda
%isplasia leve C&' 1 S&L ba+o ,rado
%isplasiamoderada
C&' && S&L alto ,rado
%isplasia rave C&' &&& S&L alto ,rado
Carcinoma in s C&' &&& Sil alto ,rado
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CLASI,ICACION RICHARTNIC I Displasia leve
NIC II Displasia mo$era$a
NIC IIIDisplasia severa
Carcinoma in sit"
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CLASI,ICACION OMSDisplasia leve
Displasia mo$era$a
Displasia severa
Carcinoma in sit"
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Co!po%"opia
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NIC
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INDICACIONES DE LACOLPOSCOPIA• Citolo'(as Anormales
• Est"$io D/. en pctes sintomaticas
• Apreciaci%n $e la resp"esta a laestim"laci%n con estr%'eno
• Control $e Nic en el embara0o
• InGamaciones severas rec"rrentes oresistentes al tratamiento
• D/. De in)ecciones virales
• D/. De patolo'(a V"lvar 9 V"lvoscop(a ;• D/. De patolo'(a peniana 9 Peniscop(a ;
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COLPOSCOPIA SATIS,ACTORIA6. Vis"ali0ar la 0ona $e trans)ormaci%ncompletamente.
@. Vis"ali0aci%n $e la lesi%n en to$a s"e/tensi%n.
. Tomar "n nHmero $e biopsias
representativo.
. "e se realice le'ra$o en$ocervical 9e/eptoen embara0o
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COLPOSCOPIA
NO SATIS,ACTORIADiscrepancia ma*or $e "n 'ra$o
entre, Citolo'(a. Impresi%n Colposc%pica. 4iopsia
Sospec:a $e invasi%n en la citolo'(a o
en la impresi%n colposc%pica pero !"eno se con#rma con la :istolo'(a.
4iopsia NO CONCL-ENTE.
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CONDICIONES PARA EVALUACIKN
COLPOSCOPICA SATIS,ACTORIA6. Colposcop(a satis)actoria
@. "e no e/ista ms $e "n 'ra$o $e$iscrepancia entre,
Citolo'(a. Impresi%n Colposc%pica. 4iopsia.
. Le'ra$o en$ocervical ne'ativo.
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U%o ' 0"i'o a"/ti"o
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Co!po%"opiaEpit!io a"to &!an"o
P)nta'O
Mo%ai"o
L)"op!a%ia
Epit!io :o'o n.ati$o
Va%o% atípi"o%
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U%o '! *!t#o $#'
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U%o ' !).o!
DIA1NJSTICO
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DIA1NJSTICO
BIOPSIA
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L%ion% p#nop!a%i"a%
5o"#$i"a!%DISPLASIA LEVE
P#%n"ia ' "!+ Atípi"a%
P#'i'a ' !a ma')#a"i(n "itop!a%m0ti"a n !t#"io in7#io# '! pit!io+
LEI DE BAJO GRADO(NIC 1)
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DISPLASIA LEVE (NIC 1)
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L%ion% p#nop!a%i"a%
5o"#$i"a!%DISPLASIA +ODERADA
P#o!i7#a"i(n ' "!+ Con n<"!o% atípi"o%
P#'i'a ' ma')#a"i(n "itop!a%m0ti"a G)o")pan "omo m05imo 'o% t#"io% in7#io#%
'! pit!io+
I DE ALTO GRADO (NIC 2)
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DISPLASIA MODERADA (NIC 2)
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L%ion% p#nop!a%i"a%
5o"#$i"a!%DISPLASIA SEVERA - CIS
La p#o!i7#a"i(n ' "!+ Atípi"a% "on p#'i'a' ma')#a"i(n "itop!a%m0ti"a %)p#a !o% 'o%t#"io% in7#io#% '! pit!io
A7"tan'o ! t#"io %)p#io# &inpa#"ia!mnt o &in n %) tota!i'a'6 "a#"inoma in %it) 8+
LEI DE ALTO 1RADO 9NIC ; CARCINO+A IN SIT
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DISPLASIA SEVERA NIC ;
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• TIPO DE LESIJN
• EXTENSIJN DE LA LESIJN
• PARIDAD• EDAD DE LA PACIENTE
•CONFIA4ILIDAD SE1I+IENTO
• E+4ARAO& ESTERILIACIJN& 3IV
ESTRATE1IA DE +ANEKO
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T#ataminto ' !%ion%
p#in$a%o#a% ' "#$i5Ablaci%n,
-- E!"t#o 'iat#mia
-- C#i( "oa.)!a"i(n
-- T#mo "oa.)!a"i(n
-- La%# ' CO?
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T#ataminto ' !%ion%
p#in$a%o#a% ' "#$i5Cir"'ia conserva$ora<<E5ti#pa"i(n ' !a 9ona %"amo"o!)mna#--L0%# ' "o?
--A%a 'iat#mia
Coni9a"ion
Ci#).ía #a'i"a!Hi%t#"tomia a&'omina! tota!
TRATA+IENTO
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TRATA+IENTO
C<DL CRIOTERAPIAELET!OAUT
+&S
CISONO L 7 ?6
0ISTE!ETOM@A
CA+I
CAINV ONCOLO1O
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CRIOTERAPIA
D%t#): pit!io%)p#*"ia! '!
")!!o )t#ino T pa#a '%t#)""i(n
-? - Ca%% mp!a'o%1
o5i'o nit#o%o : CO?
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CRIOTERAPIA. Es el con'elamiento $el c"ello atemperat"ras s"mamente ba8as, >= ba8o ceropara el CO@ * =@ ba8o cero para el NO@. Tienecomo e)ecto con'elar el a'"a intracel"lar * losniveles t%/icos $e M intracel"lar.
Con$iloma plano, 6 ciclo $e min& Ac.Tricloroac2tico al =B&Imi!"imo$ al B& Fl"oracilo
Displasia leve * mo$era$a, @ ciclos $e min.o 6 $e ? min.
EQUIPO PARA CRIOTERAPIA
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EQUIPO PARA CRIOTERAPIA
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CRIOCIRUÍA
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CRIOCIRUÍA
roundidad de acción mm
rea de cristali/ación peri0rica radial 3 a mm
'o adecuada para lesiones !ue aectan endoc0rvix
Un ciclo o dos con duración min con intervalo de 1 min
(eepiteli/ación 4 semanas
Exudado seroso por 5 a 3 semanas
racaso del tratamiento en a 167
SEUIMIENTO NIC TRATADO CON
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SEUIMIENTO NIC TRATADO CONCRIOTERAPIA
CRIOTERAPIA
PAP EN 6 MESES
NORMAL ANORMAL
ECC ANUAL ECC
REFERENCIA A US
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LASER SE DECIDE TRATAMIENTO1
+ S 2a '%"a#ta'o "0n"# in$a%i$o
?+ P)' $#% to'a !a !%i(n
+ R%)!ta'o ' !.#a'o n'o"#$i"a! 6-8+
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USOS DE LASER
#an'% !%ion%
C)!!o )t#ino i##.)!a#3 a%p"to ' &o"a' p%"a'o : %)#"o% p#o7)n'o%
E5tn%i(n ' !a n7#m'a' 2a%ta !a$a.ina o !%ion% %at!it%
L%ion% "on a7""i(n .!an')!a# 5tn%a
CONIZACION
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CONIZACION+
INDICACIONES DE CONIZACION+
+ No po'# $i%)a!i9a# !o% !imit% ' !a !%ion')#ant !a "o!po%"opia+
?+ No % o&%#$a !a )nion %"amo"o!)mna#')#ant !a "o!po%"opia+
+ L.#a'o n'o"#$i"a! 68 pa#a NIC ? :NIC +
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CONIZACION+
. No :a* correlacion entre losres"lta$os $e citolo'ia& biopsia *colposcopia.
. Sospec:a $e microinvasion con base $elos res"lta$os $e biopsia& colposcopia ocitolo'ia.
>. C"an$o no se p"e$e $escartar lapresencia $e Ca invasivo
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Coni9a"ion
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C i i
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Coni9a"ion
LEEP PASO A
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LEEP PASO APASO
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5
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3ISTERECTO+5A.
INDICACIONES,• PARIDAD COMPLETA 6NIC III : CIS8• • MICROINVASIKN
• NIC EN LOS LIMITES DE CONIZACIKN
POSITIVOS A LESIKN
REPORTE DE LESIONES
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REPORTE DE LESIONES
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TRATAMIENTONI I3 II3 III PATOLO$IA$INEOLO$IA
NI I
NI II
NI III
0ISTE!ETOMIA SIN P!EVIOT!ATAMIENTO DEL NI
!IOTE!APIA ( ILO
!IOTE!APIA - ILOS ONPE!IODO DE DES0IELO DE /min)
LEEP
PA!IDAD SATIS#E0A10ISTE!ETOMIA TOTAL)
PA!IDAD INSATIS#E0A ONO DESEA 0ISTE!ETOMIA1