Pap-testze dafuZnebuli saSvilosnos yelis kibos skriningi ... · 3 PAP-testze dafuZnebuli saSvilosnos yelis kibos skriningi da diagnostika saSvilosnos yelis kibo aris erT-erTi yvelaze

Pap-testze dafuZnebuli

saSvilosnos yelis kibos

skriningi da diagnostika

klinikuri praqtikis erovnuli rekomendacia / klinikuri mdgomareobis marTvis saxelmwifo standarti

(gaidlaini/protokoli)

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klinikuri praqtikis erovnuli rekomendacia (gaidlaini) `Pap-testze dafuZnebuli saSvilosnos yelis kibos skriningi da diagnostika~ miRebulia klinikuri praqtikis erovnuli rekomendaciebis (gaidlainebi) da daavadebaTa marTvis saxelmwifo standartebis (protokolebi) SemuSavebis, Sefasebis da danergvis erovnuli sabWos 2009 wlis 30 dekembris #2 sxdomaze da damtkicebulia saqarTvelos Sromis, janmrTelobisa da socialuri dacvis ministris 2010 wlis 14 maisis #131/o brZanebiT.

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PAP-testze dafuZnebuli saSvilosnos yelis kibos skriningi da diagnostika

saSvilosnos yelis kibo aris erT-erTi yvelaze gavrcelebuli onkologiuri daavadeba, rogorc saqarTveloSi, ise mTels msoflioSi. is mniSvnelovan problemas uqmnis, erTi mxriv, qalTa janmrTelobas da sicocxles, xolo meore mxriv, saxelwifos, romelsac aseTi pacientebis samkurnalod mniSvnelovani finansuri rezervebi esaWiroeba.

sabednierod, saSvilosnos yelis kibo ganekuTvneba iseT daavadebaTa ricxvs, romelic eqvemdebareba prevencias, adreul diagnostikasa da mkurnalobas. am garemoebas ukve oTxi aTeuli welia warmatebiT iyeneben sxvadasxva qveynebi saSvilosnos yelis kibos skriningis programebis SemuSavebasa da danergvisaTvis. am gamocdilebis safuZvelze bevr qveyanaSi Seiqmna erovnuli saxelmZRvaneloEB/gaidlainebi, xolo 2003 wels evropis 13 qveyanam SeTanxmebulad SeimuSava “saSvilosnos yelis kibos skriningis xarisxis uzrunvelyofis evropuli gaidlaini”. am gaidlainis meore, Sesworebuli da Sevsebuli gamocema 2008 wels evropis sabWom daamtkica sarekomendaciod wevri qveynebisaTvis.

saqarTveloSi saSvilosnos yelis kibos skriningi organizebuli saxelwifo programis saxiT 2008 wels daiwyo q. TbilisSi. am programisaTvis specialurad Seqmnilma “erovnulma skrining centrma” (direqtori profesiri r. RvamiCava), gaeros mosaxleobis fondis saqarTvelos ofisma (UNFPA, xelmZRvaneli T. xomasuriZe) da “saqarTvelos saSvilosnos yelis paTologiis da kolposkopiis sazogadoebam”, saqarTvelos pirveli ledis _ sandra e. rulovsis patronaJiT gaswia didi mosamzadebeli samuSao samedicino personalis SerCevis, momzadebis da treningis mizniT. specialurad iqna momzadebuli saSvilosnos yelis kibos skriningis TiToeuli etapis amsaxveli saxelmZRvanelo masalebi. maqsimalurad iqna gaziarebuli UNFPA-s TanadafinansebiT Catarebuli “kibos kvlevis saerTaSoriso saagentos” IARC-is (lioni, safrangeTi), “aleqsandre naTiSvilis morfologiis institutis” da “onkologiis nacionaluri centris” 2007 w kvlevis “adamianis papilomavirusis gavrceleba Tbilisi mosaxleobaSi” Sedegebi.

saSvilosnos yelis kibos skriningis erovnuli programis erTi wlis Sedegebis analizma da programis saqarTveloSi gavrcobis gadawyvetilebam uCvena iseTi detaluri gaidlainis Sedgenis mizanSewoniloba, sadac gaTvaliswinebuli iqneboda aramarto zemoT xsenebuli evropis e.w. “konsensus gaidlaini”, aramed calkeuli qveynebis, maT Soris aSS-is Sesabamisi gaidlainebic.

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gamoyenebuli Semoklebebi

AGC _ atipiuri jirkvlovani ujredebi (epiTeliocitebi) AGUS _ atipiuri jirkvlovani epiTeliocitebi ganusazRvreli (ucnobi, dauzustebeli) mniSvnelobis atipiiT AIS _ adenocarcioma in situ ASC – atipiuri brtyeli ujredebi (epiTeliocitebi) ASC-H _ atipiuri brtyeli epiTeliocitebi HSIL-is gamoricxvis SeuZleblobiT ASC-US _ atipiuri brtyeli epiTeliocitebi ganusazRvreli (ucnobi, dauzustebeli) mniSvnelobis atipiiT CGIN_ cerviqsuli jirkvlovani intraepiTeliuri neoplazia CIN _ cerviqsuli intraepiTeliuri neoplazia CIS _ karcinoma in situ ECC _ endocerviqsuli gamofxeka, kiuretaJi HPV _ adamianis papilomavirusi HSIL _ maRali xarisxis brtyelujredovani intraepiTeliuri dazianeba LEEP _ maryuJiT eleqtroqirurgiuli eqscizios procedura LLETZ _ maryuJiT transformaciis zonis farTe eqscizio LSIL _ dabali xarisxis brtyelujredovani intraepiTeliuri dazianeba Pap-testi _ saSvilosnos yelis paTologiaTa citologiuri diagnostika dafuZnebuli papanikolaus meTodze SCJ _ sazRvari saSvilosnos yelis lorwovani garsis brtyel da cilindrul epiTeliumebs Soris _ gardamavali zona SIL _ brtyelujredovani intraepiTeliuri dazianeba TBS _ betesdas sistema, saSvilosnos yelis lorwovani garsis cvlilebebis citologiuri Sefasebis sistema (klasifikacia) TZ _ transformaciis zona WHO _ msoflio jandacvis organizacia

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Sesavali

skriningi aris inglisuri sityva, romelic “gamoxSirvas” niSnavs. zogadad skriningi aris jandacvis sistemis strategia, romlis drosac garkveuli asakis klinikurad janmrTel mosaxleobaSi xdeba risk jgufis gamovlena, da am jgufis gaRrmavebuli gamokvleva ama Tu im avadmyofobis aRmosaCenad. kibos skriningis mTavar mizans warmoadgens aRniSnuli daavadebis sikvdilobis maCveneblis Semcireba. saSvilosnos yelis skriningis mizans warmoadgens agreTve invaziuri dazianebis avadobis maCveneblis Semcireba, vinaidan skriningiT SesaZlebelia kiboswinare dazianebaTa aRmoCena da mkurnaloba.

amJamad dagrovilia sakmao masala, romelic miuTiTebs, rom saSvilosnos yelis kibos skrinings SeuZlia Seamciros avadobisa da sikvdilobis maCveneblebi (Hakama, 1982; Hakama et al., 1986; Laara et al., 1987; Sankila et al., 2000; IARC, 2005).

maRali efeqturobis misaRwevad skriningi sasurvelia tardebodes mxolod organizebul pirobebSi (European Commission, 2003; Council of the European Union, 2003). saSvilosnos yelis kibos skrining-programa unda efuZnebodes gansazRvrul meTods _ skrining tests, samizne asakobrivi jgufebis gamoyofas da paTologiis ararsebobis skrining-negatiur SemTxvevaSi skrining-intervalis gansazRvras; skrining-pozitiuri qalebisTvis gansazRvruli gaRrmavebuli kvlevis, samomavlo dakvirvebisa da samkurnalo strategiis arsebobas. skriningis meTodi sasurvelia, iTvaliswinebdes samizne populaciaSi arsebul sxvadasxva risks, daavadebis etiologiis da mimdinareobis Taviseburebebs, romelic xasiaTdeba sakmaod gaxangrZlivebuli preklinikuri periodiTa da kiboswinare dazianebebis ukuganviTarebis realuri SesaZleblobiT. garda amisa, srulyofilad dagegmil skrining-programa yvela etapze unda iyos uzrunvelyofili xarisxis kontroliT.

skriningis procesis efeqturobis maCveneblebis uwyveti monitoringisaTvis aucilebelia populaciaze dafuZnebuli sainformacio sistema, romelic uzrunvelyofs individualuri monacemebis registraciisa da urTierTkavSiris damyarebas populaciis monacemTa bazas, skriningis kartotekasa da kiboTi gamowveuli sikvdilobis SemTxvevebs Soris. aseTi kompiuterizebuli sainformacio sistema mniSvnelovan instruments warmoadgens skrining programis marTvisa da misi efeqturobisa da Sedegebis mecnieruli SefasebisaTvis. aseTi programa saSualebas aZlevs procesSi monawile da/an dainteresebul pirebs _ jandacvis profesionalebs da mmarTvel struqturebs _ awarmoon skriningis monitoringi, iqonion dazustebuli informacia skriningis msvlelobaSi an mogvianebiT (skriningis Semdeg) aRmoCenili invaziuri kibos Sesaxeb.

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1. zogadi nawili

ukanaskneli 60 wlis ganmavlobaSi papanikolaus testi (Pap testi) gamoiyeneba saSvilosnos yelis kiboswinare dazianebebisa da brtyeli epiTeliumis invaziuri kibos adreuli gamovlenis mizniT, Civilebis armqone qalebSi. aRniSnuli testi gulisxmobs saSvilosnos yelis epiTeliumis ujredebis nimuSis aRebas da mikroskopis qveS maT morfologiur gamokvlevas paTologiis aRmosaCenad. gamovlenili citologiuri paTologiis simZimidan gamomdinare, qali saWiroebs SemdgomSi ganmeorebiT citologiur da/an kolposkopiur da histologiur gamokvlevas, ris Sedegadac, SesaZloa, savaldebulo gaxdes mkurnaloba.

saSvilosnos yelis kibos organizebuli skrining-programebi arsebobs msoflios mraval qveyanaSi. Tumca skriningis dagegmvisa da

ganxorcielebis meTodebi gansxvavdeba sxvadasxva qveynebSi (Linos Riza, 2000; Anttila et al, 2004; IARC, 2005). isini emsaxurebian daavadebis adreuli gamovlenis gaumjobesebas da jandacvis xarjTefeqturobis gazrdas. (van Bailegooijen et al., 2000; Miller, 2002).

skriningis araefeqturobis mizezi SeiZleba iyos: (1) skrining-testebis fsevdo-optimaluri gavrceleba, rodesac maRalia Sefardeba absoluturad gamoukvlevel da regularulad dakvirvebis qveS myof qalebs Soris (im SemTxvevebis CaTvliT, rodesac gamokvleva tardeba usargeblod mokle intervalebSi, magaliTad, maSinac, rodesac dasmulia diagnozi _ janmrTeli) da (2) skriningis fsevdo-optimaluri profesionaluri xarisxi da normebi.

1.1. saSvlosnos yelis kiboTi gamowveuli avadoba da sikvdiloba

saSvilosnos yelis kibo aris qalebSi erT-erTi yvelaze gavrcelebuli daavadeba msoflioSi da ikavebs meore adgils ZuZus kibos Semdeg, rogorc avadobis, ise sikvdilobis maCveneblebiT. yovelwliurad msoflioSi 450 000 qali avaddeba saSvilosnos yelis kiboTi da maTi 80% ganviTarebadi qveynebis macxovrebelia.

saSvilosnos yelis kibo seriozuli problemaa evropisTvisac sadac yovelwliurad diagnostirebulia saSvilosnos yelis kibos daaxloebiT 52 000 axali SemTxveva, xolo 27 000 qali kvdeba aRniSnuli daavadebiT (Artyn et al., 2007a & b; Boyle & Ferlay2005);

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naxati 1. saSvilosnos yelis kibos avadobis maCvenebeli msoflioSi (Schiffman and Castle, NEJM, 2005)

naxati 2. saSvilosnos yelis kibos sikvdilobis maCvenebeli. ( Arbyn et al., 2007)

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1.2. risk-faqtorebi

saSvilosnos yelis kibos SemTxvevaTa 99%, iseve rogorc misi kiboswinare daavadebebi dakavSirebulia adamianis papilomavirusul infeqciasTan (HPV), romelic miekuTvneba asimptomur, sqesobrivi gziT gadamdeb yvelaze ufro gavrcelebul infeqciebs (Walboomers et al 1999). seqsualurad aqtiuri qalebis 50-75% sicocxleSi erTxel mainc inficirdeba HPV-iT (Koutsky 1997, Crum et al 2003). infeqciis piki modis mozardebze da adreuli reproduqciuli asakis qalebze (16-30 weli). kibos ganviTarebis riski HPV-infeqciis pirobebSi 15-150 jer metia arainficirebul populaciasTan SedarebiT (IARC, 2005). saSvilosnos yelis kibo warmoadgens am infeqciis iSviaT (2-5%) da mogvianebiT garTulebas.

amJamad identificirebulia HPV-is 100-mde tipi, maT Soris 30-mde aris tropuli genitaluri traqtis mimarT. saSvilosnos yelis kibos SesaZlo ganviTarebis gaTvaliswinebiT ansxvaveben HPV virusis maRali da dabali riskis tipebs. dabali riskis tipebia: HPV 6, 11, 42, 43, 44 da sxva romelTac SeuZliaT gamoiwvion genitaluri kondilomebis da CIN 1 ganviTareba. maRali riskis tipebs miekuTvneba 13 tipi _ HPV 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68. maT Soris yvelaze ufro onkoagresiulia HPV 16 da HPV 18 tipebi. maTi xangrZlivi persistenciis dros SesaZloa ganviTardes CIN1, CIN2,3 da saSvilosnos yelis kibo.

arsebobs agreTve mTeli rigi sxva risk-faqtorebisa an ko-faqtorebisa, rogoricaa nikotinis moxmareba (rac met sigarets moixmars dReSi qali, miT maRalia saSvilosnos yelis kibos ganviTarebis riski) (IARC press 2004), hormonuli kontracepcia (rac ufro xangrZlivad gamoiyeneba hormonuli kontracepcia, miT ufro maRalia riski; magaliTad, misi 10-wliani gamoyeneba aormagebs saSvilonos yelis kibos ganviTarebis risks) (Congliano et al 2005), mSobiarobaTa raodenoba (Tu aRemateba 5-s) (rac meti drouli mSobiaroba aqvs qals da rac mcirea asaki pirveli mSobiarobis dros, miT ufro momatebulia riski.) (Int J Cancer 2006;119); genitaluri infeqciebi, rogoricaa martivi herpesvirusis tipi 2, qlamidiozi (Chlamydia trachomatis) (Smith et al 2004, Castle et al 2003), imunosupresuli mdgomareoba – organoTa transplatacia da HIV (adamianis imunodeficitis virusi) infeqcia (Palefsky et al 2003).

epidemiologiur da virusologiur kvlevaTa safuZvelze gamovlinda, rom HPV-infeqcia xasiaTdeba rogorc SeZenis, ise spontanuri gankurnebis sakmaod maRali albaTobiT (IARC, 2005). HPV-is SeZenis yvelaze mniSvnelovan faqtorebs warmoadgens sqesobrivi cxovrebis dawyebis asaki da sicocxlis ganmavlobaSi qalis an masTan kavSirSi myofi mamakacis sqesobrivi partniorebis raodenoba. zogierT kvlevaSi naCvenebia HPV-inficirebis mimarT ”kondomis” proteqtoruli unari, Tumca kvlevaTa umravlesoba ver avlens aRniSnuli meTodis mniSvnelovan damcav funqcias. arsebobs sxvadasxva mizezi, romlebic abaTilebs ”kondomis” damcav funqcias, maT Soris, araswori da/an araTanmimidevruli gamoyeneba, aseve is faqtic, rom

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HPV-infeqcia SeiZleba arsebobdes genitaluri epiTeliumis gacilebiT ufro farTo ubnebSi, vidre dafarulia kondomiT (Rousseau et al., 2003).

1.3. saSvilosnos yelis kibos ganviTarebis Sesaxeb

gadawyvetileba skriningis asakobrivi jgufisa da skriningis intervalis Taobaze moiTxovs informacias specifikuri asakobrivi periodisa da invaziis gamovlenisaTvis saWiro drois im monakveTis Taobaze, romlis ganmavlobaSic xdeba kiboswinare dazianebaTa aRmoCena. amJamad cxadia, rom aRniSnul dazianebaTa didi nawili, gansakuTrebiT msubuqi displazia (CIN 1), rogorc wesi ar progresirebs da spontanurad ganicdis regress. Ōstor-is (1993) mier Catarebul kvlevaSi gamovlinda, rom CIN 1 da CIN 2 dazianebis mxolod Zalze mcire nawilma (Sesabamisad 1% da 5%) SeiZleba miaRwios invaziuri kibos mdgomareobas aranamkurnaleb SemTxvevebSi, maSin rodesac CIN 3 dazianebis SemTxvevaSi es maCvenebeli Seadgens 12%-ze mets (ix. cxrili #1).

britanuli kolumbiis (kanada) skrining programis monacemebis kvlevam uCvena, rom kiboswinare dazianebaTa regresis sixSire klebulobs asakis matebasTan erTad: 84%-dan 18-34 wlis asakobrivi jgufisTvis 40%-mde 35

welze ufrosi asakobrivi jgufisTvis (van Oortmanssen Habbema, 1991). progresirebis savaraudo maCvenebeli Seadgenda, Sesabamisad, 16% da 60%. gansxvaveba dabali da maRali xarisxis dazianebebs Soris dafiqsirebuli ar yofila. igive provinciaSi SedarebiT adre Catarebuli kvlevis monacemebiT, nebismieri xarisxis displaziis progresirebis mosalodneli sixSire meryeobs 19-38% farglebSi (Boyes et al., 1982; IARC, 2005). fineTSi Catarebul kvlevaSi maRali xarisxis displaziisa da karcinoma in situ-s kombinaciis invaziur kiboSi progresirebis mosalodneli sixSire Seadgens

28-39%-s (Hakama Räsänen-Virtanen,1976). aRniSnuli efuZneboda 30-50 wlis asakobriv jgufSi 3,5 wlis ganmavlobaSi regularuli dakvirvebis pirobebSi dagrovili SemTxvevebis SedarebiT analizs.

cerviqsuli intraepiTeliuri dazianebis aRmoCenis Semdgom kibos

ganviTarebis Taobaze Gustafsson & Adami-sa (1989) da van Oortmanssen Habbema-s (1991) mier erTmaneTisagan damoukideblad Catarebuli skriningebis monacemebis safuZvelze navaraudevia, rom intraepiTeliuri dazianebidan invaziuri kibos Camoyalibebamde arsebuli periodis xangrZlivoba saSualod Seadgens 12 wels. amasTanave, kiboswinare dazianebis invaziur dazianebaSi gadazrdis saSualo xangrZlivobad mkurnalobis ararsebobis pirobebSi miCneulia 10 weli (variaciiT 5-dan 15 wlamde farglebSi) (Luthra et al., 1987; Syrjänen, 1996). Tumca progresis periodi zogjer SeiZleba aRematebodes 50 welsac ki. swored amgvarad xdeba kibos gamovlena sakmaod asakovan qalebSi (75 wels zemoT).

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cxrili #1

kiboswinare dazianebebis savaraudo ukuganviTareba / persistencia / progresirebis monacemebi

dazianebis simZime

ukuganviTareba progresireba progresireba CIN 3-mde

progresireba invaziur kibomde

CIN 1 60% 30% 10% 1% CIN 2 40% 40% 20% 5% CIN 3 33% < 55% _ > 12%

citologiuri skriningis qmediTunarianobisa da efeqturobis mtkice-bulebebi

Pap-testiT skriningi arasodes yofila Sefasebuli randomizebul kvlevebSi. miuxedavad amisa, kvlevebidan miRebuli mtkicebulebebi misi efeqturobis Taobaze eWvs ar badebs (Hakama & Räsänen-Virtnen, 1976; Johannesson et al., 1982;Berrino et al., 1984; Hakama et al., 1986; Lynge, 2000; IARC, 2005, (Clarke & Anderson, 1979; Nieminen et al., 1999; Zappa & Ciatto, 2000).

yvelaze sarwmuno mtkicebulebebidan nawili efuZneba IARC-is multicentrul kvlevas, sadac individualuri skrininguli anamnezi dakavSirebuli iyo kibos dafiqsirebis monacemebTan (Hakama et al., 1986). kvlevis masala moicavs rogorc kohorutuli, aseve SemTxveva-kontrolis kvlevebs.

1.4. samizne asakobrivi jgufebi

progresirebadi dazianebis gamovlenis TvalsazrisiT Pap-testis aReba ufro efeqturia 35-dan 64 wlamde asakobriv jgufSi (ix. cxrili #2).

axali programis dagegmvisas mniSvnelovania skriningis dawyeba 5 wliT adre im asakTan SedarebiT, rodesac saSvilosnos yelis kibos avadobis mrudi piks aRwevs (WHO, 1986). rogorc skandinaviis qveynebSi kibos sixSiris matebis fonze gamoikveTa, yvela asakobrivi jgufi rodi saWiroebs dauyovnebliv dafarvas; programa SeiZleba dawyebuli iyos asimetriulad sakmaod mcire asakobriv jgufSi. maRali dafarva sasurvelia ganxorcieldes ZiriTad samizne jgufebSi (ix. cxrili #2).

ar arsebobs Camoyalibebuli mtkicebuleba skriningis Sewyvetis asakobrivi periodis Taobaze. sxvadasxva kvlevebi aCvenebs maRali xarisxis dazianebaTa gamovlenis dabal maCvenebels skriningSi xangrZlivad monawile 40 wlis zeviT asakobriv jgufSi. rekomendebulia kvlevebis Catareba sikvdilianobis maCvenebelTa gamoyenebiT. Tumca, rutinuli skriningis asaks gadacilebul qalebs, visac arasodes miuRia monawileoba skrininigSi, sasurvelia, mieceT skrinigSi monawileobis ufleba minimum 2 negatiuri Sedegis miRebamde.

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cxrili #2 diferencirebuli skriningis politikis efeqturoba

saSvilosnos yelis brtyelujredovani invaziuri karcinomis sixSiris Semcirebis procentuli maCvenebeli (IARC, 1986).

(cxrili moicavs qalebs romlebsac skriningiT gamouvlindaT negatiuri Sedegi da romelTac warsulSi hqondaT sul mcire erTi negatiuri Sedegi).

skriningis jeradoba

asakobrivi jgufebi

SemTxvevebis Semcireba (%)

Pap-testebis raodenoba erT qalze

weliwadSi erTxel 20-64 93 45 3 weliwadSi erTxel 20-64 91 15 3 weliwadSi erTxel 25-64 90 13 3 weliwadSi erTxel 35-64 78 10 5 weliwadSi erTxel 20-64 84 9 5 weliwadSi erTxel 25-64 82 8 5 weliwadSi erTxel 35-64 70 6 10 weliwadSi erTxel 25-64 64 5

1.5. skrining intervali

IARC-is mier Catarebuli klinikuri multicentruli kvlevebis (1986) monacemebze dayrdnobiT, brtyelujrdovani karcinomis 93% SeiZleba iyos Tavidan acilebuli yovelwliuri skriningiT, 91% _ skriningiT yovel 3 weliwadSi erTxel, da 84% _ skriningiT yovel 5 weliwadSi erTxel (ix. cxrili #2).

cxrilSi #3-Si warmodgenilia niderlandebSi (van den Akker-van Marle et al., 2003) da britaneTSi (Sasieni et al., 2003) Catarebuli bolodroindeli 2 kvlevis Sedegebi saSvilosnos yelis invaziuri kibos riskis Taobaze skriningulad negatiur qalTa Soris. Sasieni-s monacemebze dayrdnobiT britaneTSi SemuSavebul iqna rekomendaciebi 25-49 wlis askobriv jgufSi 3-wliani SualedebiT, xolo 50-64 wlis asakobriv jgufSi 5-wliani SualedebiT skriningis Taobaze, romelic dRemde sruldeba.

1.6. skriningis modelebi

saSvilosnos yelis kibos avadobisa da sikvdilianobis maCvenebelTa gamoyenebiT warmoebulma kvlevebma gamoavlina organizebuli skrininguli aqtivobis efeqturoba saSvilosnos yelis kiboTi avadobis Semcirebis TvalsazrisiT (Hakama Rsnen-irtanen, 1976; Johannesson et al., 1982; Magnus et al., 1987; Lynge, 2002). britaneTSi kvlevebis safuZvelze aseve naCvenebi iyo organizebuli skriningis efeqturoba. iq citologiuri skriningi danergili iyo 1960 wlidan, magram organizebuli saxe gamoZaxebis sistemis da xarisxis kontrolis SeqmniT miiRo 1988 wels. wina wlebSi yovelwliuri Semcireba saSvilosnos yelis kibos avadobis da sikvdilobis maCveneblebis

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ar aRemateboda 1-2%-s, maSin, rodesac 1988 wlidan am maCveneblebis Secireba 7%-s aRwevs. (Sasieni et al., 1995; Quinn et al., 1999; Sasieni & Adams, 1999; Peto et al., 2004; Bray et al., 2005; IARC, 2005).

fineTSi Catarebulma kvlevam gamoavlina, rom organizebul skrining-programaSi monawileobis pirobebSi efeqti TiTqmis 2-jer aRemateba oportunistul (spontanur) skriningSi monawileobis efeqturobas (Sesabamisad, 75% da 43% _ Nieminen et 1999).

Tumca arsebobs zogierTi qveynis gamocdileba, sadac oportunistuli skriningis pirobebSi, agreTve gamovlinda saSvilosnos yelis kiboTi avadobis da sikvdilobis maCveneblebis mniSvnelovani _ 10-60%-iani _ Semcireba (Anttila & Laara, 2000; IARC,2005).

cxrili #3 saSvilosnos yelis invaziuri karcinomis ganviTarebis SedarebiTi riski skrinigulad negatiur da skrinigis gareSe SemTxvevebSi niderlandebisa (van den Akker-van Marle et al., 2003) da britaneTSi (Sasieni et al., 2003) Catarebuli kvlevebis magaliTze

qveynebi da kvlevebi dro skriningis dawyebidan

niderlandebi (van den Akker-van Marle ME et al., 2003)

35-64 wlis asakobrivi

jgufi RR (95% CI)

0-6 Tve 0,12 (0,08-0,17) 7-12 Tve 0,06 (0,93-0,10) 1-2 weli 0,08 (0,06-0,12) 2-4 weli 0,15 (0,11-0,19) 4-6 weli 0,20 (0,14-0,29) 6-10 weli 0,18 (0,11-0,30) gaerTianebuli samefo (Sasieni et al., 2003)

20-29 wlis asakobrivi jgufi RO

(95% CI)


(95% CI)


(95% CI) 0-18 Tve 0,24 (0,16-0,37) 0,12 (0,08-0,18) 0,13 (0,08-0,22) 18-30 Tve 0,33 (0,21-0,51) 0,14 (0,08-0,22) 0,13 (0,07-0,23) 30-42 Tve 0,67 (0,43-1,04) 0,25 (0,16-0,40) 0,15 (0,08-0,26) 42-54 Tve 1,06 (0,65-1,72) 0,30 (0,18-0,50) 0,18 (0,09-0,34) 54-66 Tve 1,40 (0,75-2,62) 0,61 (0,34-1,09) 0.28 (0,14-0,57) 66-78 Tve 1.86 (0,88-3,93) 0,72 (0,36-1,43) 0,33 (0,14-0,79) > 6 weli 2,37 (1,16-4.85) 0,69 (0,36-1,34) 0,55 (0,27-1,10)

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2. saSvilosnos yelis skriningis organizeba

2.1. skriningis politikis ganmsazRvreli principebi

gadawyvetileba skrining-programis Catarebis Taobaze

saSvilosnos yelis kibos skriningis dagegmvisaTvis sasurvelia arsebobdes Sesabamisi kulturuli (erovnuli) garemo da saxelwifos politikuri neba (Miller., 1992; WHO, 2002). programa saWiroebs saTanado saxsrebiT uzrunvelyofas, da rac mniSvnelovania, integracias jandacvis sistemaSi.

mrval evropul qveyanaSi saSvilosnos yelis kibos da kiboswina daavadebebis adreuli gamovlena xorcieldeba sxvadasxva gziT, ase magaliTad: qalis piradi surviliT Catarebuli testirebiT (oportunistuli skriningi) an dedaTa janmrTelobis dacvis programis an jandacvis sxva programebis komponentis saxiT. naklebad sarwmunoa martivi fondebis saSualebiT srulyofili skriningis politikis da programis qmediTunarianobis uzrunvelyofa. organizebuli skriningis zogadi principebis SemoRebis paralelurad mTavrobam minimumamde unda daiyvanos arasaWiro (usargeblo) Pap-testebis daniSvnis SesaZlebloba.

2.2. saSvilosnos yelis kibos skriningis evropuli politika

saSvilosnos yelis kibos organizebuli skrining programebis ganxorcieleba rekomendebulia evropis sabWos (2003) mier. sabWos rekomendaciebze dayrdnobiT, saSvilosnos yelis kibos skrining programebis sistematuri ganxorcieleba moiTxovs mowveva/gamoZaxebis sistemis organizebas skriningis yvela donis xarisxis kontroliT, aseve diagnostikis, mkurnalobisa da gamojanmrTelebis Semdgomi dakvirvebis mtkicebulebebze dafuZnebuli gaidlainebiT uzrunvelyofas. organizebuli skrining programis CatarebisaTvis aseve saWiroa centralizebuli monacemTa bazis arseboba. evropis sabWos rekomendaciebi moicavs konkretul miTiTebebs registraciis, monitoringisa da Sefasebis, treiningis, skriningSi monawile pirTa informirebisa da axali skrinig testebis danergvis sakiTxebze. mraval qveyanaSi evropuli rekomendaciebi dRemde ar aris gatarebuli (Anttila et al., 2004; IARC, 2005).

saSvilosnos yelis skriningi rekomendebulia 25 an 30 wlis asakidan 60 an 65 wlis asakamde (Advisory Committee on Cancer Prevention, 2000; Coleman et al., 1993); sabWos rekomendaciiT, skriningi dawyebuli unda iyos arauadres 20 wlis da araugvianes 30 wlis asakisa. aRniSnul rekomendaciebSi ar arsebobs konkretuli miTiTeba skriningis Sewyvetis asakis Taobaze. programis “evropa kibos winaaRmdeg” sakonsultacio komitetis (Advisory Committee) rekomendaciebze dayrdnobiT, zeda asakobrivi sazRvari ar unda Camouvardebodes 60 wels. saSvilosnos yelis kibos skriningis evropis xarisxis uzrunvelyofis gaidlainebis pirvel gamocemaSi skrining programis Casatareblad optimalur populaciad rekomendebuli iyo 25-dan

14

65 wlamde asakobrivi jgufi (Coleman et al., 1993). IARC-is Tanaxmad, testirebiT mudmivad uaryofiTi Sedegis mqone qalebSi skriningi unda Sewydes 65 wlis asakSi (IARC, 2005). evropulma qveynebma aCvena gamoxatuli variabeloba samizne jgufebSi skrining intervalebisa da asakobrivi sazRvrebis TvalsazrisiT (ix. cxrili #4). yovel 3 weliwadze ufro xanmokle intervalebiT skriningi ar aris mizanSewonili mxolod SedarebiT maRali efeqturobisa da ekonomiurobis motiviT. (IARC, 2005). ar arsebobs aSkara mtkicebuleba skriningis dawyebis optimalur asakTan dakavSirebiT. adreuli dasawyisi gamoiwvevs saSvilosnos yelis displaziis bevri iseTi mdgomareobis mkurnalobas, romelic mkurnalobis gareSec ar gadadis saSvilosnos yelis invaziur kiboSi. sakmaod gvianma dasawyisma gardauvlad SeiZleba ganapirobos adreuli invaziuri kibos SemTxvevebis “gaparva”.

sakonsultacio komitetis rekomendaciebSi miTiTebulia, rom saSvilosnos yelis kibos skriningi sasurvelia tardebodes 3-5 weliwadSi erTxel qveynis materialuri da adamianuri resursebidan gamomdinare. sicocxlis manZilze aRebuli Pap-testebis didi raodenobis SemTxvevaSi matulobs arasaWiro (usargeblo) mkurnalobaTa ricxvi. SezRuduli pirobebis SemTxvevaSi 5 weliwadSi erTxel Catarebul maRalxarisxian, srulfasovan skrinings upiratesoba eniWeba 3 weliwadSi erTxel mcire populaciis dafarviT Catarebul skriningTan SedarebiT.

cxrili #4

evropis zogierT qveyanaSi 1995 wels saSvilosnos yelis kibos rekomendirebuli skrining politikis farglebSi 100000 mosaxleze sikvdilianobis saSualo

maCvenebeli asakobrivi jgufebis mixedviT

saSvilosnos yelis kiboTi gamowveuli sikvdilianoba (1995)

samizne asakobrivi jgufebi

skrinig intervali (wlebSi)

Pap-testebis raodenoba sicocxlis manZilze

saxelwifo programaSi monawile populaciis raodenoba (%)

3- an 5-wliani SualediT skrining gavliliqalTa raodenoba(%)

avstria 6,3 20+ 1 50+ _ _ belgia 4,6 25-64 3 14 58 78 dania 6,3 23-59 3 13 90 75 fineTi 1,7 30-60 5 7 100 93 safrangeTi 4,6 25-64 3 14 < 5 _ germania 5,5 20+ 1 50+ 90 80 saberZneTi 3,0 25-64 3 14 _ _ irlandia 4,6 25-60 5 8 _ _ italia 3,2 25-64 3 14 13 50 luqsenburgi 1,6 15+ 1 55+ _ _ niderlandebi 2,7 30-60 5 7 100 77 portugalia 6,3 20-64 3 16 _ _ espaneTi 3,5 25-65 3 14 _ _ SvedeTi 3,7 23-60 3(e) 14 100 82

britaneTi 5,0 20-64 3 an 5 10-16 100 61

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2.3. jandacvis sistemaSi integracia

saSvilosnos yelis kibos organizebuli skriningi warmoadgens mravalsafexurian process, romelic moicavs Semdeg safexurebs:

samizne populaciis gansazRvra;

saTanado kontigentis mozidva;

Pap-nacxis aReba, Segroveba da laboratoriaSi gadagzavna;

Pap-nacxis Seswavla da daskvnis gaformeba;

normaluri Sedegebis mqone qalebis informireba Semdgomi testirebis TariRTan dakavSirebiT;

aradamakmayofilebeli/araadekvaturi Sedegis mqone qalebis xelmeored gamoZaxeba;

paTologiis mqone qalebze Semdgomi dakvirveba (diagnostikuri procedurebi da mkurnaloba saWiroebisamebr);

programis yvela etapis srulyofili registracia, monitoringi da Sefaseba.

2.4. evropis zogierTi qveynebis skriningis organizebis sistemebi

fineTsa da italiis zogierT regionebSi gamoiyeneba qalebis mowveva/gamoZaxebis sistema (Anttila & Nieminen, 2000; Segnan et al., 2000). fineTSi programa SemoRebuli iyo rodesac oportunistuli (TviTdinebiTi) skrining aqtivoba ar iyo gamoxatuli. samizne populaciis yvela qali programis farglebSi mowveulia Pap-testis asaRebad SeTanxmebul intervalebSi. Pap-testebi damuSavebuli da gaanalizebulia gansazRvrul laboratoriebSi, xarisxis kontrolis pirobebSi. paTologiuri Pap-testis mqone qalebis marTva xdeba gaidlainis Sesabamisad. mimdinareobs skriningis yvela epizodis monitoringi. Sedegebi aisaxeba kibos registrSi. modelis upiratesobas warmoadgens is, rom organizebuli skrining sistema xelmisawvdomia yvela qlisaTvis, xolo am sistemis naklovaneba aris is, rom ikargeba informacia oportunistuli skriningisa.

organizebuli skriningis farglebSi warmoebuli Pap-testebis, kolposkopiuri da histologiuri gamokvlevebis yvela Sedegi, aseve informacia mkurnalobis Sesaxeb registrirebulia.

organizebuli skrining programebi SeiZleba dagegmili iyos niderlandebisa (van Ballegooijen & Hermens, 2000) da britaneTis (Patrick, 2000) msgavsad, sadac gaTvaliswinebulia agreTve spontanurad (oportunistulad) aRebuli Pap-testebis informaciac. aRniSnul qveynebSi xdeba samizne asakobrivi jgufis nebismieri qalis mowveva drois SeTanxmebul periodebSi programis farglebSi ufaso Pap-testis asaRebad (ix. naxati #4). aramonawile qalebis gamovlenas erTiani kompiuteruli bazis daxmarebiT axorcieleben laboratoriebi da xdeba Sexseneba. xorcieldeba skrining procesis yvela safexuris xarisxis kontroli. niderlandebSi qveyanaSi aRebuli nebismieri Pap-testi registrirebulia PALGA-sistemaSi (holandiis

16

paTologiis monacemTa erovnuli baza) Pap-testis aRebis mizezis (skrining programis farglebSi, oportunistuli Pap-testi, ganmeorebiTi Pap-testi), Sedegis, da Semdgom dakvirvebaze rekomendaciebis miTiTebiT. yvela aRniSnuli Pap-testi warmoadgens laboratoriis xarisxis kontrolis obieqts. oportunistuli Pap-testebi ar aris gadaxdiT uzrunvelyofili da aqedan gamomdinare, maTi sixSire klebulobs.

naxati #3

saSvilosnos yelis kibos skriningi fineTis magliTze

britaneTis laboratoriebSi moiTxoven jandacvis marTvis adgilobrivi organizaciis informirebas yvela Pap-testis Sedegebis Taobaze: raTa SemdgomSi Seswordes (Seicvalos) morigi gamoZaxebis TariRi. britaneTSi oportunistuli skriningi maqsimaluradaa SezRuduli.

zogierT qveyanaSi, sadac oportunistuli skriningi ukve farTod aris gavrcelevbuli, iwveven yvela im qals, visac ar hqonia aRebuli Pap-testi gansazRvrul skrining intervalebSi xarjebis dazogvis gamo. daniaSi (Coleman et al., 1993) (ix. naxati #5) da SvedeTSi (Dillner, 2000) mimarTaven aseT mowveva/gamoZaxebis sistemas. skriningis organizaciis aRniSnuli tipi misaRebia im SemTxvevaSi, Tu oportunistuli Pap-testebi eqvemdebareba sistematur xarisxis kontrols; winaaRmdeg SemTxvevaSi is araefeqturia. informacia skriningis asakobriv jgufebsa da skrining intervalebis Taobaze efeqturad unda iqnas miwodebuli yvela qalisaTvis (ara mxolod mowveuli qalebisaTvis) da Pap-testis amRebi pirebisaTvis, raTa SeizRudos Pap-testebis gadaWarbebuli aReba. unda xorcieldebodes programis srulfasovani Sefaseba.

samizne populacia gansazRvrulia mosaxleobis reestris (populaciis centraluri maregistrirebeli organo) mier

yvela qalis mowveva oportunistuli skriningi: informacia ar aris

monawile

normuli Pap-testi

ganmorebiTi skriningi-kvleva 5 wlis Semdeg

aramonawile

paTologiuri Pap-testi

Semdgomi dakvirveba da mkurnaloba

17

safrangeTis zogierT regionebSi mowveva/gamoZaxebis sistema arsebiTad rCeba oportunistuli (ix. naxati #6) (Schaffer et al., 2000). Pap-testebis amRebi pirebi moqmedeben erTiani erovnuli sabWos mier SemuSavebuli skrining politikis farglebSi. yvela Pap-testi registrirebulia _ pacientisa da pap-testis amRebi piris vinaobis, masalis aRebis TariRisa da Sedegis miTiTebiT. yvela laboratoria muSaobs xarisxis dazRveviT da nebismieri Pap-testis Sesaxeb agzavnis monacemebs kompiuterizebul bazaSi. laboratoriebi aRWurvilia registraciis kompiuteruli sistemebiT. Pap-testis Rirebuleba gansazRvrulia kanoniT. Pap-testebis da Semdgomi dakvirvebis Sedegebi eqvemdebareba monitorings. personaluri werilebi egzavneba yvela im qals, visac Pap-testi ar hqonia aRebuli jandacvis sadazRvevo sistemis dafinansebis (romelic faravs populaciis 80%-s) farglebSi 3 wlis ganmavlobaSi. aramonawileebs Sexseneba ar egzavnebaT. vinaidan aRniSnuli sistema dafuZnebulia Pap-testebis amReb pirTa skrining intervalebis dacvis subieqtur (voluntaristul) gadawyvetilebaze, dRemde xdeba sakmaod didi raodenobiT arasaWiro nacxis aReba. Tumca yvela aRebuli Pap-testis xarisxi da Semdgomi dakvirveba kontroldeba: monawileebi imyofebian monitoringis qveS, amasTanave xorcieldeba RonisZiebebi samizne populaciis skriningSi maqsimalurad CarTvisaTvis.

2.5. samizne populaciis, jandacvis sferos Sesabamisi profesionalebisa da kvlevis meTodebis gansazRvra

programis ganxorcielebamde savaldebuloa samizne populaciis sworad SerCeva. aucilebelia samizne populaciis aRwera da masSi mimdinare skrining aqtivobis mimoxilva. warmatebuli programis gasaxorcieleblad savaldebuloa adekvaturi resursebiT, rogorc momsaxure personaliT, aseve kvlevis meTodebiT uzrunvelyofa, agreTve saTanado infrastruqturis arseboba.

jandacvis sistemebis mravalferovnebisa da calkeul qveyvebSi specifiur garemoebaTa arsebobis gamo, ararealuria evropis qveynebSi xarisxiani skriningis organizebis erTiani gegmis SemuSaveba, Tumca miRebulia e.w. SeTanxmebuli gaidlainebi (Consesus guidlines) zogierT sakvanZo sakiTxebze. sazogadod mniSvnelovania yvela qveyanaSi xorcieldebodes skrining programa, magram nacionaluri marTvis principebis SemuSavebiT.

2.6. samizne populaciis gansazRvra da aRwera

rogogrc zemoT aRiniSna, savaldebuloa zustad ganisazRvros samizne populacia da programis ganxorcielebis areali. administraciuli centris mier unda ganisazRvros erTiani skrining procesisTvis aucilebeli yvela resursi. im SemTxvevebSi, rodesac saresurso baza ar aris srulyofili calkeul konkretul ubnebSi, srulyofili diagnostirebisa da mkurnalobis mizniT didi centrebi SeiZleba moemsaxuros ramodemine ubans adaptirebuli sakomunikacio sistemis saSualebiT. Znelia adekvaturi

18

Sefasebis uzrunvelyofa, rodesac Pap-testebi aRebulia an mowodebulia didi raodenobiT, an biofsiuri masala aRebulia gansazRvruli samizne geografiuli arealis farglebs gareT. migraciis maRali sixSire garkveul problemebs uqmnis srulyofili statistikis warmoebas. amis gamo sasurvelia populaciis mdgradoba. sasurvelia moxdes migraciis dokumentacia da axali misamarTebis mudmivi xelaxali registracia. optimaluri administraciuli efeqturobisa da statistikuri stabilurobis misaRwevad teritoriuli erTeulebi dakompleqtebuli unda iyos aranakleb 250000 mudmivi mcxovrebiT.

19

naxati #4

saSvilosnos yelis kibos skriningi niderlandebis magaliTze


permanentulad aramonawileTa ganacxadebis gauqmeba

yvela darCenili (monawile) qalis mowveva

oportunistuli skriningi PALGA-

sistemaSi arsebuli Canawerebis mixedviT

monawile aramonawile

normuli Pap-testi


gamoucxadebloba ar gamoexmaura 6

TveSi

gamocxadda

ganmeorebiTi skrinigi 5 weliwadSi

Semdgomi dakvirveba da mkurnaloba

Sexseneba aramudmivi mizezi

mudmivi mizezi

Sexseneba

monacemTa bazaSi Setanil iqnas aramonawilis statusiT

20

naxati #5

saSvilosnos yelis kibos skriningi daniis magaliTze

samizne populacia

paTologiis registracia: ukanaskneli Pap-testis mqone/armqone qalTa

gamovlena

aramonawiled gamocxadeba

bolo 3 weliwadSi aRebuli Pap-testebi

bolo 3 weliwadSi auRebeli Pap-testebi

gamoZaxeba ar xdeba gamoZaxeba

monawileebi aramonawileebi ganacxadis

gareSe

momavalSi monawileobaze uaris ganacxadi


dakvirveba da/an

mkurnaloba

normuli, an Tu adre ar iyo Pap-testi regirstrirebuli, gamoZaxeba 3 wlis Semdeg

Sexseneba

aramonawileebi ganacxadis

gareSe

monawileebi momavalSi monawileobaze uaris ganacxadi

zemoaRniSnulis msgavsad

Sexseneba, adgilobrivi

kanonmdeblobis Sesabamisad

21

naxati #6

saSvilosnos yelis kibos skriningi elzasis regionis (safrangeTi)

magaliTze


Ria mowveva ojaxis eqimis an ginekologis mier

janmrTelobis dazRvevis furceli: 2 wlis manZilze Pap-testis anazRaurebis gareSe

mowveva

skriningis registracia: yvela Pap-testi aRebulia samizne populaciaSi

aramonawileebi

normuli Pap-testi paTologiuri Pap-testi

ganmeorebiTi skriningi 3 weliwadSi

Semdgomi dakvirveba da mkurnaloba (kolposkopiuri, histologiuri gamokvlevisa da mkurnalobis

Sedegebis registracia)

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2.7. jandacvis sferos saTanado profesiuli kadrebisa da aRWurvilobis gansazRvra

jandacvis menejmentis specialistebi

jandacvis sferos specialistebi unda darwmunebuli iyon imaSi, rom programa uzrunvelyofili iqneba populaciaze dafuZnebuli sainformacio sistemiT da iwarmoebs skrining procesis TiToeuli safexuris monitoringi. isini unda iyvnen pasuxismgeblebi, rogorc monacemTa Segrovebaze da monitoringze, ise skriningis procesSi aRmocenebuli problemis gadawyvetis uzrunvelyofaze. sazogadoebrivi jandacvis specialistebi unda flobdnen epidemiologiis, statistikisa da komunikaciis safuZvlebs. sasurvelia gaTvaliswinebuli iyos skrining programebis monitoringisa da Sefasebis evropuli saswavlo kursebis moTxovnebi.

Pap-testis amRebi pirebi da aRebis pirobebi

TiToeuli qveynis jandacvis sistemisa da kulturis Taviseburebebidan gamomdinare, Pap-testis aRebis procesSi SesaZlebelia CarTuli iyvnen jandacvis sxvadasxva profesionalebi, ase magaliTad eqimebi, eqTnebi an laborantebi. amJamad daniasa da niderlandebSi Pap-testis amReb ZiriTad pirebs warmoadgenen zogadi profilis eqimebi. fineTSi, SvedeTSi, italiasa da saberZneTSi zogierT pilotur proeqtSi msgavs saqmianobas axorcieleben bebia-qalebi an laboratoriis eqTnebi. didi britaneTis gamocdileba adasturebs, rom eqTnebs SeuZliaT sakmaod kargad ganaxorcielon aRniSnuli manipulacia. avstriaSi, belgiaSi, germaniasa da safrangeTSi Pap-testis aReba umeteswilad xdeba ginekologebis mier.

TiToeul qveyanaSi sasurvelia Catardes Pap-testis amRebi personalis minimaluri treiningi _ evropuli gaidlainebis Sesabamisad. Pap-testis amRebma pirebma unda icodnen qalis genitaluri sistemis anatomia, Pap-testis paTologiuri Sedegis SemTxvevaSi paTologiis marTvisa da populaciis masiuri skriningis ZiriTadi aspeqtebi; savaldebulod unda flobdnen saSoSi sarkis Cadgmis teqnikas (saSvilosnos yelis vizualizaciis mizniT) da gacnobierebuli hqondeT transformaciis zonis tipis gansazRvris mniSvneloba. aseve sasurvelia, SeeZloT saSvilosnos yelis nacxis aRwerilobis swori interpretacia.

mniSvnelovania, rom qalebi kmayofilebas gamoTqvamdnen SeTavazebul momsaxurebaze. Pap-testis aRebamde sasurvelia saTanado pirobebis _ myudro garemos, Tbili da damamSvidebeli atmosferos uzrunvelyofa, raTa qalebma Tavi igrZnon maqsimalurad komfortulad.

citologiuri diagnostikis laboratoriebi

citologiuri diagnostikis gaidlainebi saSvilosnos yelis skriningisa da momsaxure personalisTvis (citoteqnikosebi da citopaTologebi) profesiuli uzrunvelyofis sakiTxebze aRwerilia me-6-e TavSi.

23

diagnostikuri da samkurnalo centrebi

mniSnelovania, rom gaRrmavebuli gamokvleva _ kolposkopia tardebodes profesionali kolposkopistis mier. skriningi ar iqneba efeqturi, Tu paTologiuri Pap-testis Semdeg ar moxdeba saSvilosnos yelis dazianebaTa saTanado Sefaseba da marTva. kolposkopiis erovnul kolposkopiur asociacias sasurvelia hqondes mowodebuli gaidlainebis Sesabamisi saswavlo kursi kolposkopiaSi.

sainformacio samsaxurisa da ofisis momsaxure personali

sainformacio samsaxurisa da ofisis momsaxure personals unda hqondeT gacnobierebuli konfidencialobisa da pacientebis detaluri monacemebis sworad registraciis mniSvneloba.

zogadi profilis eqimebis monawileoba

zogadi profilis eqimebma romc ar awarmoon Pap-testebis aReba, isini mainc mniSvnelovan rols TamaSoben skrining programaSi da amdenad, unda icodnen programis struqtura, kerZod, gamoZaxebis sqemis niuansebi. maT SeuZliaT konsultacia gauwion skriningis Taobaze im qalebs, romelTac aRar aqvT kavSiri qalTa konsultaciebTan da ojaxis dagegmvis samsaxurebTan. niderlandebisa da britaneTis gamocdileba uCvenebs zemoaRniSnuli kuTxiT zogadi profilis eqimebis muSaobis efeqturobas. zogadi profilis eqimebma TiToeul SemTxvevaSi unda moiTxovon informacia wina Pap-testis Catarebis TariRisa da Sedegebis Taobaze, raTa ganisazRvros morigi Pap-testis aRebis vadebi. zogadi profilis eqimebma sasurvelia Seinaxon maTi pacientebis Pap-testebis yvela Sedegis aslebi.

zogadi profilis eqimebs aseve gacnobierebuli unda hqondeT, rom sikvdilobis maCvenebeli warmoadgens skrining programebis Sefasebis erT-erT mniSvnelovan kriteriums. maT unda icodnen, rom saWiroa gardacvalebis mizezis sworad dokumentireba: ar SeiZleba iyos dafiqsirebuli termini “saSvilosnos kibo”, yovelTvis unda iyos miTiTebuli kibos specifiuri lokalizacia _ endometriumis an saSvilosnos yelis.

2.8. programis koordinacia

skriningi warmoadgens process eqTnebis, bebiaqalebis, citologebis, paTologebis, ginekologebis, zogadi profilis eqimebisa, sazogadoebrivi jandacvis specialistebis da sainformacio samsaxuris monawileobiT. yvela es specialisti saWiroebs urTierTSeTanxmebul muSaobas. unda Seiqmnas komiteti, romelic iqneba dakompleqtebuli yvela aRniSnuli specialistiT, romelic unda awarmoebdes skriningis monitorings erovnuli politikis da gaidlainebis Sesabamisad. komitetis Tavmjdomared unda iqnas daniSnuli programis pasuxismgebeli menejeri.

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Tavmjdomares ekisreba profesiuli pasuxismgebloba organizaciul, xarisxis dacvis, Sefasebis, masmediasTan urTierTobis da misT. sakiTxebSi; mas SeiZleba esaWiroebodes damxmare pirebi Tavisi funqciebis srulyofilad gansaxorcieleblad. programis menejeri unda flobdes aucilebel resursebs da avtoritets programaSi monawile yvela profesionalis koordinirebuli muSaobisa da komitetis gadawyvetilebaTa realizaciis uzrunvelsayofad. nebismier SemTxvevaSi sasurvelia konsensusis miRweva skrining procesis yvela monawiles Soris.

2.9. infrastruqtura

saWiroa adekvaturi sainformacio sistemis arseboba. pirvelad aucileblobas warmoadgens samizne populaciis TiToeul wevrze monacemTa ganaxlebis furclis arseboba.

2.10. mowveva/gamoZaxebis sistema

saWiroa administraciul monacemTa bazis Seqmna, romelSic Seyvanil iqneba detaluri informacia samizne populaciis TiToeuli qalis Sesaxeb, maT Soris saxeli da gvari, dabadebis TariRi, janmrTelobisa da socialuri dacvis RonisZiebaTa gatarebis SemTxvevebi, piradi eqimis monacemebi (aseTis arsebobis SemTxvevaSi) da sakontaqto misamarTi.

populaciis registracia savaldebuloa, rom mudmivad axldebodes mosaxleobis migraciis, piradi monacemebis detalebis cvlilebaTa gaTvaliswinebiT. im qveynebSi, sadac populaciis aRmweri samsaxuri dafuZnebulia mcire zomis administraciul ubnebze, mniSvnelovania urTierTkavSiri aRmwer pirTa Soris.

Sromisuunaro qalebi sasurvelia, ar iyvnen gamoricxulni saSvilosnos yelis skriningidan, vinaidan isini xasiaTdebian Tanabari riskiT populaciis danarCen nawilTan mimarTebaSi. mniSvnelovania samizne populaciaSi iseTi subpopulaciebis specialuri saWiroebebis Sefaseba, rogoricaa eTnikuri da emigrantTa umciresobebi, gansxvavebuli kulturisa da religiis Taviseburebebi.

mizanSewonilia, gamoyofili iyos Semdegi specifiuri jgufebi:

qalebi, visac arasodes hqoniaT sqesobrivi aqtivoba, xasiaTdebian saSvilosnos yelis kibos ganviTarebis dabali riskiT. Tumca, gansakuTrebiT axalgazrda qalTa Soris, aRniSnulma mdgomareobam SesaZloa ganicados cvlileba. amdenad, umjobesia yvela qalis mowveva skrining programaSi, maTi seqsualuri gamocdilebisgan damoukideblad.

histereqtomiis Semdeg qalebi SesaZloa gamoeTiSon skrinings, Tu qirurgiuli Careva ar ukavSirdeboda saSvilosnos yelis neoplazias. amasTanave qalebi, visac nawarmoebi hqondaT subtotaluri histereqtomia (saSvilosnos supravaginuri amputacia saSvilosnos yelis amokveTis gareSe), unda agrZelebdnen monawileobas skrining programaSi.

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2.11. rogor unda ganisazRvros samizne populacia da moxdes misi dafarvis uzrunvelyofa

skrining programis warmatebis ZiriTad winapirobas warmoadgens samizne populaciaSi Seyvanil qalTa realuri skriningis uzrunvelyofa. Tumca, gansakuTrebuli Zalisxmevaa saWiro skriningSi iseTi qalebis mosawvevad, romelTac arasodes miuRiaT monawileoba msgavs RonisZiebebSi.

2.12. winaaRmdegobebi (barierebi)

skriningSi monawile qalTa kontigentis gansazRvra asocirdeba iseT parametrebTan, rogoricaa asaki, socialur-ekonomikuri da ojaxuri mdgomareoba. adgilobriv pirobebze dayrdnobiT, martoxela qalebi, eTnikur umciresobaTa warmomadgenlebi, da dabali social-ekonomikuri statusis mqone qalebi SeiZleba naklebad aRmoCndnen CarTulni skrining programaSi (Arbyn et al., 1997; IARC, 2005). xSirad maT warsulSi ar CatarebiaT Pap-testi, Tumca uaric ar ganucxadebiaT jandacvis struqturebTan urTierTobaze. personaluri gamoZaxebis samsaxuri aRmoCnda maRalefeqturi aseTi jgufebis dafarvis TvalsazrisiT (Ronca et al., 1991; IARC, 2005).

skriningSi aramonawile pirebi xasiaTdebian avadobisa da sikvdilobis SedarebiT maRali riskiT. Sromisuunaro qalebi xSirad eTiSebian saSvilosnos yelis skrinings, rodesac jer kidev gaaCniaT populaciis darCenili nawilisTvis damaxasiaTebeli tolfasi riskis. ase, magaliTad, paraplegiis mqone qalebi xSirad seqsualurad ufro aqtiurebi arian maTi invalidobis gamomwvevi travmis winamorbed periodTan SedarebiT, xolo sxvadasxva fsiqiuri darRvevebis mqone qalebi zogjer, SesaZloa, intensiur mowevas uxamebdnen seqsualur aqtivobas.

SiSi ginekologiuri gamokvlevebis mimarT, SiSi kibos mimarT, socialuri warmomavloba, nerviuloba Pap-testis amRebi piris sqesis gamo, meTodisadmi undobloba, skrining momsaxurebis adreul gamocdilebasTan, da sazogadod, jandacvis sistemasTan dakavSirebuli diskomforti _ es aris is winaaRmdegobebi, romelTa Secvlac rTulia da romlebic ganpirobebulia qveynis eTnokulturiTa da socialuri TaviseburebebiT. am ukanasknelTa daZlevisaTvis saWiroa piradi kontaqti, msjeloba, axsna, garCeva individualur Sexvedrebze. igive SeiZleba iTqvas potenciur dabrkolebebze, rogorebicaa manZili klinikebamde da lodinis xangrZlivoba, rac aseve aqveiTebs momsaxurebis xelmisawvdomobas. testisa da/an konsultaciis Tanxa aseve SeiZleba warmoadgenes damatebiT dabrkolebas.

2.13. Tanxmobis mopovebis gazrdis meTodebi

rekomendebulia miRweul iqnas srulyofili saSualo riskis mqone populaciis monawileoba skriningSi. naCvenebia, rom sakmaod efeqturia individualuri mosawvevebis sistema. qalebis piradi eqimebis saxeliT gagzavnili mosawvevebma SeiZleba ganapirobebos Tanxmobis SedarebiT

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maRali sixSire (Ronco et al., 1997; Segnan et al., 1998). arsebobs utyuari mtkicebulebebi, rom qalTa umravlesobaSi Pap-testis paTologiuri Sedegi iwvevs uaryofiT fsiqologiur efeqts, ramac SeiZleba gamoiwvios uaryofiTi damokidebuleba skriningis gagrZelebisa da Semdgomi dakvirvebis mimarT (IARC, 2005).

britaneTSi, 1988 welTan SedarebiT, rodesac populaciis dafarva Seadgenda 25% da warmoebda miznobrivi gadaxda, gamoZaxeba-gamocxadebis kompiuterizebuli sistemis SemoRebis kvaldakval, 1993 wlidan popoulaciis dafarva gaizarda da narCundeba 80%-ze maRali maCvenebliT.

2.14. skriningis Rirebuleba

evropis qveynebSi, organizebuli skrinigi, Cveulebriv ufasoa (Anttia et al., 2004). oportunistuli skriningis Rirebuleba srulad an nawilobriv ifareba jandacvis individualurad dazRvevis xarjze. Tu skriningi ar aris ufaso, an srulyofilad dafaruli sadazRvevo organizaciis mier, sasurvelia gadaxdisuunaro qalebs gaewios daxmareba. mniSvnelovania, rom oportunistuli skrinigi qalebisaTvis ar aris populaciaze dafuZnebul programebTan SedarebiT ufro iafi, rac gaTvaliswinebuli unda iyos sadazRvevo kompaniebis mier.

2.15. skriningi saqarTveloSi

saqarTveloSi, iseve rogorc msoflios sxva qveynebSi, saSvilosnos yelis kibo ikavebs qalebSi meore adgils avadobis da sikvdilobis maCveneblebiT ZuZus kibos Semdeg. amasTanave ukanasknel wlebSi es maCveneblebi matulobs.

naxati #7. saSvilosnos yelis kibos avadobis maCvenebeli (n/100 000) saqarTveloSi (1999-2006 wlis maCveneblebi eyrdnoba saxelmwifo statistikis departamentis monacemebs, 2007 wlis maCvenebeli _ erovnuli onkologiuri centris statistikis monacemebs)

0

2

4

6

8

10

12

14

16

18

1999 2000 2001 2002 2003 2004 2005 2006 2007

9,8

7,9

10,711,2

12,513,3

14,5 14,1

16,2

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aRsaniSnavia, rom saSvilosnos yelis kibos axladgamovlenili SemTxvevevbis TiTqmis 50% warmoadgens daavadebis II-IV stadias, rodesac mkurnalobis efeqturoba mcirea da prognozulad Zalzed arakeTilsaimedo.

saqarTveloSi, kerZod TbilisSi 2008 wlidan saSvilosnos yelis kibos skriningis piloturi programis implementacia efuZneba gamarTuli Pap-laboratoriebis da Pap-diagnostikis gamocdilebis, garkveuli adamianuri da materialuri resursebis da, rac mTavaria, politikuri nebis arsebobas.

naxati #8

saSvilosnos yelis kibos skriningi saqarTveloSi (Tbilisi)

saqarTveloSi skriningi amJamad emyareba masmediiTa da reklamiT mowveul qalTa momarTvianobas. gansazRvrulia samizne populacia _ 25-60 w. asakobrivi jgufiT, xolo skrining intervalad miRebulia 3 weli, Pap testireba da atipiuri Pap testis mqone qalebis gaRrmavebuli gamokvleva (kolposkopia, biofsia, histologiuri gamokvleva) mosaxleobisaTvis ufasoa (ifareba municipaluri biujetiT da UNFPA fondidan). mwiri materialuri resursis gamo jerjerobiT ver ifareba gamovlenili kiboswinare daavadebebis mkurnalobis xarjebi.

momavalSi, dagegmilia skriningis organizebul meTodze gadasvla, rac iTvaliswinebs mosaxleobis reestris bazaze dafuZnebul kompiuterizebul mowveva/gamoZaxebas.

gamoyenebuli literatura

1. Clarke E.A. & Anderson T.W. (1979). Does screening by "Pap" smears help prevent cervical cancer? A case-control study. Lancet 2: 1-4.

2. Coleman D., Day N., Douglas G., Farmery E., Lynge E., Philip J., & Segnan N. (1993). European Guidelines for Quality Assurance in Cervical Cancer Screening. Europe against cancer programme.Eur J Cancer 29A Suppl 4: S1-S38.

samizne populaciis mowveva masmediiT

monawileebi

normuli Pap-testi paTolgiuri Pap-testi

skriningi 3 wlis Semdeg gaRrmavebuli kvleva, dakvirveba da/an mkurnaloba

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3. Comber H. & Gavin A. (2004). Recent trends in cervical cancer mortality in Britain and Ireland: the case for population-based cervical cancer screening. Br. J. Cancer 91: 1902-1904.

4. Council of the European Union (2003). Council Recommendation of 2 December 2003 on cancer screening (2003/878/EC). Off. J. Eur. Union L 327/34-38.

5. Davies P., Arbyn M., Dillner J., Kitchener H., Ronco G., & Hakama M. (2006). A report on the current status of European research on the use of human papillomavirus testing for primary cervical cancer screening. Int. J. Cancer 118: 791-796.

6. Dickman P.W., Hakulinen T., Luostarinen T., Pukkala E., Sankila R., Soderman B., & Teppo L. (1999). Survival of cancer patients in Finland 1955-1994. Acta Oncol. 38 Suppl. 12: 1-103.

7. Dillner J. (2000). Cervical cancer screening in Sweden. Eur J Cancer 36: 2255-2259. 8. Engeland A., Haldorsen T., Tretli S., Hakulinen T., Hцrte L.G., Luostarinen T., Magnus K.,

Schou G., Sigvaldason H., Storm H.H., Tulinius H., & Vaittinen P. (1993). Prediction of cancer incidence in the Nordic countries up to the years 2000 and 2010. A collaborative study of the Five Nordic Cancer Registries. APMIS Suppl 38: 1-124.

9. European Commission (2003). Proposal for a Council Recommendation on Cancer Screening (presented by the Commission). Brussels, 5.5.2003. C0M(2003) 230 final. 2003/0093 (CNS), 1-21.

10. Goldie S.J. (2002). Health economics and cervical cancer prevention: a global perspective. Virus Res. 89: 301-309.

11. Gornall R.J., Boyd I.E., Manolitsas T., & Herbert A. (2000). Interval cervical cancer following treatment for cervical intraepithelial neoplasia. Int. J. Gynecol. Cancer 10: 198-202.

12. Hakama M., Miller A.B., & Day N.E. (1986). Screening for cancer of the uterine cervix. From the IARC Working Group on Cervical Cancer Screening and the UICC Project Group on the Evaluation of Screening Programmes for Cancer. IARC Sci. Publ. , 1-315.

13. Hristova L. & Hakama M. (1997). Effect of screening for cancer in the Nordic countries on deaths, cost and quality of life up to the year 2017. Acta Oncol. 36 Suppl 9: 1-60.

14. IARC (2005). Cervix Cancer Screening. IARC Handbooks of Cancer Prevention. Vol. 10. IARCPress, Lyon

15. Insinga R.P.,Glass A.G., & Brenda B.R. (2004). Diagnoses and outcomes in cervical cancer screening: a population-based study. Am. J. Obstet. Gynecol. 191: 105-113.

16. Nieminen P., Kallio M., Anttila A., & Hakama M. (1999). Organised vs. spontaneous Pap-smear screening for cervical cancer: A case-control study. Int. J. Cancer 83: 55-58.

17. Nieminen P., Kotaniemi L., Hakama M., Tarkkanen J., Martikainen J., Toivonen T., Ikkala J., Luostarinen T., & Anttila A. (2005). A randomised public-health trial on automation-assisted screening for cervical cancer in Finland: performance with 470,000 invitations. Int. J. Cancer 115: 307-311.

18. Nygard J.F., Skare G.B., & Thoresen S.O. (2002). The cervical cancer screening programme in Norway, 1992-2000: changes in Pap smear coverage and incidence of cervical cancer. J Med Screen. 9: 86-91.

19. Ostor A.G. (1993). Natural history of cervical intraepithelial neoplasia: a critical review. Int. J. Gynecol. Pathol. 12: 186-192.

20. Parkin DM, Bray F, Ferlay J, Pisani P. (2005) Global cancer statistics 2002. CA Cancer J. Clin. 55:74- 108.

21. Patnick J. (2000). Cervical cancer screening in England. Eur J Cancer 36: 2205-2208. 22. Peto J., Gilham C., Fletcher O., & Matthews F.E. (2004). The cervical cancer epidemic that

screening has prevented in the UK. Lancet 364: 249-256. 23. Quinn M., Babb P., & Jones J. (1999). Effect of Screening on Incidence and Mortality from

Cancer of the Cervix in England: Evaluation Based on Routinely Collected Statistics. BMJ 318: 904-908.

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24. Ronco G., Pilutti S., Patriarca S., Montanari G., Ghiringhello B., Volante R., Giordano L., Zanetti R., Mancini E., & Segnan N. (2005). Impact of the introduction of organised screening for cervical cancer in Turin, Italy: cancer incidence by screening history 1992-98. Br. J. Cancer 93: 376-378.

25. Ronco G., Segnan N., & Ponti A. (1991). Who has Pap tests? Variables associated with the use of Pap tests in absence of screening programmes. Int J Epidemiol 20: 349-353.

26. Rousseau A., Bohet P., MerliЉre J., Treppoz H., Heules-Bernin B., & Ancelle-Park R. (2002). Evaluation du dйpistage organisй‚ et du dйpistage individuel du cancer du col de l'utйrus: utilitй‚ des donnйes de l'Assurance maladie. Bull. Epidemiol. Hebdom. 19: 81-84.

27. Salomon J.A., Weinstein M.C., & Goldie S.J. (2004). Taking account of future technology in cost effectiveness analysis. BMJ 329: 733-736.

28. Sankila R., Demaret E., Hakama M., Lynge E., Schouten L.J., & Parkin D.M. (2000). Evaluation and monitoring of screening programmes, Office for Official Publications of the European Communities edn.

29. Sant M., Aareleid T., Berrino F., Bielska L.M., Carli P.M., Faivre J., Grosclaude P., Hedelin G., Matsuda T., Moller H., Moller T., Verdecchia A., Capocaccia R., Gatta G., Micheli A., Santaquilani M.,

30. Roazzi P., & Lisi D. (2003). EUROCARE-3: survival of cancer patients diagnosed 1990-94-results and commentary. Ann.Oncol. 14 Suppl. 5: V61-V118.

31. Sasieni P. & Adams J. (1999). Effect of screening on cervical cancer mortality in England and Wales: analysis of trends with an age period cohort model. BMJ 318: 1244-1245.

32. Sasieni P., Adams J., & Cuzick J. (2003). Benefit of cervical screening at different ages: evidence from the UK audit of screening histories. Br. J. Cancer 89: 88-93.

33. Sasieni P.D., Cuzick J., Lynch-Farmery E.L., & National Co-ordinating Network for Cervical Screening Working Group (1996). Estimating the efficacy of screening by auditing smear histories of women with and without cervical cancer. Br. J. Cancer 73: 1001-1005.

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35. Segnan N., Ronco G., & Ciatto S. (2000). Cervical cancer screening in Italy. Eur J Cancer 36: 2235- 2239.

36. Sherlaw-Johnson C. & Philips Z. (2004). An evaluation of liquid-based cytology and human papillomavirus testing within the UK cervical cancer screening programme. Br. J. Cancer 91: 84-91.

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38. Storm H., Buiatti E., Hakulinen T., & Ziegler H. (2004). Guidelines on confidentiality in populationbased cancer registration in the European Union. Lyon 1-20.

39. Syrjдnen K.J. (1996). Spontaneous evolution of intraepithelial lesions according to the grade and type of the implicated human papillomavirus (HPV). Eur. J. Obstet. Gynecol. Reprod. Biol. 65: 45- 53.

40. Tyczynski, J.E., Dйmaret, E., and Parkin, D.M. (2003) Standards and Guidelines for Cancer Registration in Europe. IARC Technical Publications, no.40. Lyon: IARCPress.

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42. van Ballegooijen M., Habbema J.D., van Oortmarssen G.J., Koopmanschap M.A., Lubbe J.T., & van Agt H.M. (1992). Preventive Pap-smears: balancing costs, risks and benefits. Br. J. Cancer 65: 930- 933.

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43. van Ballegooijen M. & Hermens R. (2000). Cervical cancer screening in the Netherlands. Eur J Cancer 36: 2244-2246.

44. van Ballegooijen M., Koopmanschap M.A., van Oortmarssen G.J., Habbema J.D.F., Lubbe Th.N., & van Agt H.M. (1990). Diagnostic and treatment procedures induced by cervical cancer screening. Eur J Cancer 26: 941-945

45. van Ballegooijen M., van den Akker van Marle M.E., Patnick J., Lynge E., Arbyn M., Anttila A., Ronco G., & Habbema D.F. (2000). Overview of important cervical cancer screening process values in EUcountries, and tentative predictions of the corresponding effectiveness and cost-effectiveness. Eur J Cancer 36: 2177-2188.

46. van den Akker van Marle M.E., van Ballegooijen M., van Oortmarssen G.J., Boer R., & Habbema J.D.F. (2002). Cost-effectiveness of cervical cancer screening: comparison of screening policies. J. Natl. Cancer Inst. 94: 193-204.

47. van den Akker-van Marle ME, van Ballegooijen M., & Habbema J.D. (2003a). Low risk of cervical cancer during a long period after negative screening in the Netherlands. Br. J. Cancer 88: 1054- 1057.

48. van Oortmarssen G.J. & Habbema J.D. (1991). Epidemiological evidence for age-dependent regression of pre- invasive cervical cancer. Br. J. Cancer 64: 559-565.

49. Walter S.D., Clarke E.A., Hatcher J., & Stitt L.W. (1988). A comparison of physician and patient reports of Pap smear histories. J Clin Epidemiol 41: 401-410.

50. WHO (1986). Control of cancer of the cervix uteri. A WHO meeting. Bull WHO 64: 607-618. 51. WHO (2002). National Cancer Control Programmes. Policies and Managerial Guidelines, 2nd

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53. L.J. & Parkin D.M.), pp. 99-118. Europe Against Cancer Programme, Brussels, Luxemburg.

3. saSvilosnos yelis rutinuli citologiuri gamokvleva _

Pap testireba

3.1. rutinuli citologiuri gamokvleva

saSvilosnos yelis zedapiridan (eqtocerviqsi) da saSvilosnos yelis arxidan (endocerviqsi) ujredebis aReba xdeba specialuri masalis asaRebi instrumentebiT. ujredebis gadatana sasagne minaze xdeba pirdapir an specialur Txevad garemoSi moTavsebis Semdeg. mikroskopuli SefasebisaTvis aucilebelia ujrdebis SeRebva, ris Semdegac xdeba maTi mikroskopuli analizi.

SeuiaraRebeli normaluri Tvalis optikuri garCevisunarianobaa 100 μm, xolo birTvis saSualo zoma ki 10μm. amgvarad, birTvis vizualizaciisaTvis saWiro minimaluri gadidebaa X10, Tumca am gadidebaze SeuZlebelia birTvis detalebis garCeva. skrininguli mizniT gamoiyeneba 10 jer gamadidebeli obieqtivi da 10-iani okulari. am gadidebaze SesaZlebelia birTvis ZiriTadi maxasiaTeblebis (zoma da kontrastuloba) garCeva,

31

Tumca struqturuli garCevisunarianoba sakmaod dabalia. mxedvelobis centrSi dafiqsirebis Semdegac ki. ginekologiur citologiaSi mcire gadideba gamoiyeneba mxolod orientaciisaTvis, da ara gamosakvlevi mizniT. obieqtebis detaluri Seswavla xdeba ufro did (25x da 40x) gadidebaze.

minis daTvaliereba iwyeba misi kididan. erTi mxedvelobis velis daTvalierebis Semdeg damTvalierebeli gadadis Semdeg mxedvelobis velze sasasagne magidis swrafi moZraobiT. es procesi - monacvleobiTi moZraoba da SeCereba grZeldeba erTi da imave mimarTulebiT sanam ar mivaRwevT safari minis mopirdapire kides. Semdeg damkvirvebeli gadadis momijnave paralelur xazze da mihyveba mas mopirdapire mimarTulebiT, sanam ar moxdeba mTeli minis daTvaliereba. es aris minis daTvalierebis e.w. "meandriseuli" forma.

minis moZraobisas erTi mxedvelobis velidan meoreSi gadasvla xdeba daaxloebiT 180 mlwm-Si. am drois ganmavlobaSi ar xdeba gamosaxulebis fokusireba centraluri mxedvelobiT. axali mxedvelobis velis aRqma xdeba latenturi periodis dros periferiuli mxedvelobiT. Tu saeWvo ubnis aRmoCena ar moxdeba daaxloebiT 230 mlwm-Si, sasagne magidis moZraobiT gadavdivarT Semdeg mxedvelobis velSi. saeWvo ubnis aRmoCenisas xdeba misi fokusireba centraluri mxedvelobiT (Tvalis e.w. sakaduri (naxtomiseburi) moZraobiT). Semdeg isev vamoZravebT sasagne magidas da vaTvalierebT Semdege mxedvelobis vels.

citoteqnologi, romelsac sWirdeba saSualod 5 wuTi erT minaze da erTi wuTi dokumentaciaze, SeZlebs naxos 10 SemTxveva erT saaTSi da 60 SemTxveva dReSi, Tu 6 saaTs gaatarebs mikroskopTan. am droidan erTi saaTi eTmoba pacientis dokumentebis wakiTxvasa da formebis Sevsebas.

rutinuli citologia warmoadgens standartul meTods saSvilosnos yelis pirveladi gamokvlevisaTvis. ganmeorebiTi Pap nacxi gamoiyeneba winaswarSerCeuli samizne populaciis gamokvlevis mizniT, dabali xarisxis citologiuri paTologiebis SemTxvevaSi da rogorc Semdgomi meTvalyureobis meTodi, mkurnalobis Semdeg citologiuri nacxis xarisxis Sefaseba warmoadgens Pap diagnostikis ZiriTad komponents.

3.2. siTxeze dafuZnebuli citologia

Txel-nacxiani, igive siTxeze dafuZnebuli citologia (LBC - Liquid Based Cytology) iyenebs ujreduli masalis sasagne minaze gadatanis axal teqnologias. masalis asaRebad rekomendebulia cerviqsuli funji, Tumca SesaZlebelia endocerviqsis plastikuri wkiris gamoyeneba cakle an endocerviqsul braSTan kombinaciaSi. am dros ar xdeba masalis minaze gaTxapvna, rogorc rutinuli citologiuri nacxis SemTxvevaSi. masalis asaRebi instrumenti aRebul masalasTan erTad gadaitaneba specialur konteinerSi, romelic Seicavs aseve specialur satransporto siTxes. konteineri Semdeg igzavneba Sesabamisad aRWurvil laboratoriaSi. 50-ian wlebSi ganviTarda ramodenime komerciuli sistema, maT Soris ThinPrep(Cytyc,

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Boxborough, MA, USA) da BD SurePathTM B(formerly, AutoCyte PREP, BD Diagnostics,

Diagnostic Systems - TriPath USA) sistemebi yvelaze kargadaa cnobili. ThinPrep-2000 an ufro metad avtomatizebuli ThinPrep -3000 procesoriT, xdeba siTxis aspiracia specialuri membranis gavliT romelic akavebs ujredul masalas. es ujreduli masala Semdeg gadaitaneba minaze ujredebis Zalian Txeli fenis saxiT, romelsac xSirad ujredebis monoSres uwodeben. BD SurePathTM-iT Segrovebuli ujreduli masala gaivlis e.w. Cell EnrichmentTM - ujredebis gamdidrebis process. am dros xdeba gadamfaravi ujreduli masalis da detritis (sisxli, lorwo da anTebiTi ujredebi) moSoreba. amerikis FDA-s mier rekomendebulia mxolod ThinPrep da BD SurePathTM. Tumca xdeba sxva siTxeze dafuZlebuli iseTi teqnologiebis gamoyenebac, rogoricaa: CYTOscreen System� (Seroa), Turbitec� (Labonord), PapSpin� (Shandon), Cytoslide� (Menarini), da SpinThin® (Shandon). bolo dromde FDA-s mier rekomendebuli iyo mxolod ThinPrep, LSIL da HSIL -is gamovlenis ufro maRali albaTobis gamo, rac rutinul citologiasTan SedarebiT amcirebda araadeqvaturi nacxebis ricxvs, 2003 wels FDA-m gamosca rekomendacia BD SurePath gamoyenebaze HSIL- is maRali albaTobiT gamovlenis mizniT.

3.3. siTxeze dafuZnebuli citologiis gamoyenebis mizanSewoniloba

siTxeze dafuZnebuli citologiuri meTodebis pirveli upiratesobaa, rom am dros TiTqmis yvela ujredi gadaitaneba siTxeSi, maSin rodesac rutinuli nacxis nawili rCeba masalis asaReb instrumentze (Rubio, 1977). ujredebis siTxeSi gadatana zrdis nacxis reprezentatulobas (Hutchinson et al., 1994). ThinPrep da SurePath sistemebis mier xdeba ujredebis wriuli fenis Seqmna romelic Seicavs saSualod 50,000 - 75,000 ujreds, maSin rodesac rutinuli nacxi Cveulebriv Seicavs 100,000 - 250,000 ujreds. siTxeze dafuZnebuli citologiuri masalis dros aRiniSneba optimaluri fiqsacia. meores mxriv Secvlili foni saWiroebs citopaTologis Sesabamis momzadebas da adaptacias (Austin & Ramzy, 1998). eriTrocitebi, lorwos didi nawili iSleba da leikocitebi ufro Tanabradaa ganawilebuli. epiTeliuri fragmentebi romelTa interpretacia gaZnelebulia rutinul nacxSi, siTxeze dafuZnebuli citologiis dros Cveulebriv eqvedebareba daSlas, maSin rodesac diagnostikurad Rirebuli cilindruli an metaplaziuri ujredebis jgufebi rCeba TiTqmis ucvleli saxiT. aseTi saxis nacxis daTvaliereba mikroskopSi gacilebiT komfortulia da Sesabamisad aadvilebs citologiuri struqturebis Sefasebas (Linder& Zahniser, 1997; Austin & Ramzy, 1998). garda amisa, darCenili siTxidan SesaZlebelia damatebiTi nacxis momzadeba damatebiTi gamokvlevebisTvis (mag: adamianis papilomavirusis dnm-is an qlamidiis gamovlena), nacxis asaRebad qalis ganmeorebiTi moyvanis gareSe (Sherman et al., 1997; Ferenczy & Franco, 1997). Txelnacxiani citologia ufro mosaxerxebelia avtomatizebuli skriningisaTvis. mniSvnelovani dabrkolebaa meTodis maRali TviTRirebuleba. sxvadasxva kvlevebiT naCvenebia rom HSIL-is gamovlenis albaToba erTi da igivea, rogorc siTxeze dafuZnebuli, ise rutinuli citologiuri meTodebis dros, Tumca zogierTi kvlevis mixedviT naCvenebia

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LSIL da HSIL is gamovlenis ufro maRali albaToba siTxeze dafuZnebuli citologiiT. saerTo jamSi ar arsebobs maRali sarwmunoebis mtkicebuleba siTxeze dafuZnebuli citologiis ufro maRali efeqturobis Taobaze maRali xarisxis intraepiTeluri dazianebebis gamovlenisaTvis.

3.4. citologiuri nacxis xarisxi

adeqvaturobis TBS kriteriumi

The Bethesda sistemis (TBS) (1988w.) ZiriTad inovacias warmoadgenda masalis adeqvaturobis Sefaseba. Tavdapirvelad mowodebuli iyo adeqvaturobis sami kategoria: damakmayofilebeli, damakmayofilebeli magram SezRuduli diagnostikuri SesaZleblobiT da aradamakmayofilebeli. meore kategoria gamoiyeneba ZiriTadad im nacxebisaTvis romlebic ar Seicaven endocerviqsul an metaplaziur ujredebs (transformaciuli zonidan masalis aRebis maCvenebeli), an nawilobriv anTebiTi nacxebisaTvis. Tumca es kategoria amoRebul iqna betesdas bolo klasifikaciaSi (2006), ris Semdegac klinicisti valdebuli iyo aeRo ganmeorebiTi nacxi. sadReisod, garda ZiriTadi diagnozisa da masalis aRwerilobisa, diagnozis formaSi unda aRiniSnos 10-ze naklebi endocerviqsuli ujredis an anTebiTi eqsudatis arseboba, romelic faravs ujredebis 75%-ze naklebs. aradamakmayofileblad iTvleba nacxi romelic Seicavs mxolod cilindrul ujredebs brtyeli epiTeliocitebis gareSe. am SemTxvevaSi klinicistma unda moiTxovos ganmeorebiTi nacxis aReba. aradamakmayofilebeli nacxis SemTxvevaSi, aucilebelia mizezis miTiTeba, da agreTve aucilebelia transformaciuli zonidan masalis aRebis Sesaxeb informaciis miTiTeba.

ujreduloba

TBS-is mixedviT rutinuli citologiuri nacxi unda Seicavdes sul mcire 8000-12000 brtyel epiTeliocits (Solomon et al., 2002). ujredebis raodenobis gansazRvra xdeba zogadi principiT da ara TiToeuli ujredis daTvlis gziT. TBS-sSi mocemulia cnobili raodenobis ujredebis Semcveli mxedvelobis velebis suraTebi e.w. "reference images" (Solomon & Nayer, 2004).

mwiria mtkicebulebiTi medicinis monacemebi adeqvaturi rutinuli Pap nacxis Sesaxeb. didi britaneTis organzebuli skrininguli programa emyareboda koncefcias, rom cerviqsis nacxi unda Seicavdes kargad vizualizebad ujredul masalas, romelic faravs sasagne minis erT mesameds mainc. (BSCC Editorial, 1990). TBS-is kriteriumiT siTxeze dafuZnebuli citologiuri nacxi unda Seicavdes sul mcire 5,000 ujreds (Solomon et al., 2002). rekomendebulia ujredulobis gansazRvra preparatis centraluri nawilis 10 didi gadidebis mxdevelobis velis SefasebiT. cnobisTvis 5000 ujredi uTanabrdeba daaxloebiT 3,8 ujreds 40X gadidebaze Thin prep-isaTvis da 9.0-s (40X) Sure path-isaTvis. am gamoTvlebis detalebi da ilusrtaciebi mocemulia "The Bethesda System for Reporting Cervical Cytology:Definitions, Criteria and Explanatory Notes” (Solomon & Nayer 2004). minimaluri

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ujredulobis kriteriumad miRebulia nacxSi 5000 ujredis arseboba (Geyer et al., 2000; Studeman et al., 2003). Solomon-isa da TanaavtorTa mixedviT saWiroa axali kvlevebi ujredulobis gansazRvris da misi mgrZnobelobis Seswavlis mizniT nebismieri tipis preparatisaTvis. did britaneTSi, siTxeze dafuZnebuli citologiis gamoyenebam Seamcira araadeqvaturi nacxebis raodenoba, Tumca jer kidev ar arsebobs sabolood SeTanxmebuli kriteriumebi masalis adeqvaturobis gansazRvrisaTvis (National Institute for Clinical Excellence (NICE), 2003).

e.w. gadamfaravi faqtorebi da sxva kriteriumebi

sxva mizezebi, ris gamoc SeuZlebelia nacxis interpretacia mocemulia 1991 gamocemul TBS-Si (Luff & et al, 1992). aradamakmayofileblad unda CaiTvalos nacxi, romlis ujredebis 75%-ze metis vizualizacia SeuZlebelia sisxliT gadafarvis, anTebis an gaSrobis artefaqtis gamo, agreTve nacxebi romelic laboratoriaSi movida gatexili miniT an pacientis saidentifikacio nomris gareSe.

masalis aReba transformaciis zonidan

miuxedavad imisa, rom jvaredini kvlevebi mudmivad uCveneben citologiuri paTologiebis gamovlenis ufro maRal albaTobas im rutinul nacxebSi, romlebic Seicavs transformaciuli zonis komponents, (Elias et al., 1983; Vooijs et al., 1985; Killough et al., 1988; Boon & Suurmeijer, 1993), grZelvadiani kvlevebiT ar aris dadasturebuli maRali xarisxis avTvisebiani dazianebebis gamovlenis ufro maRali albaToba analogiuri tipis nacxebSi (Elias et al., 1983; Vooijs et al., 1985; Killough et al., 1988; Boon & Suurmeijer, 1993). am mizezis gamo transformaciuli zonis komponentis ar arseboba ar SeiZleba gamoyenebuli iqnas erTaderT kriteriumad nacxis aradamakmayofileblad miCnevisaTvis.

naCvenebia, rom qalebi aradamakmayofilebeli nacxebiT, imyofebian maRali xarisxis dazianebis gamovlenis ufro maRali riskis qveS, vidre negatiuri nacxis mqone qalebi (Ransdell et al.,1997; Nygard et al., 2004). ujreduli preparatebi ar miiCneva "aradamakmayofileblad", rodesac SesaZlebelia epiTeliur ujredovani paTologiis amocnoba, im SemTxvevaSic ki rodesac nacxis xarisxi dabalia (Luff et al., 1992).

rekomendacia

rogorc minimumi, TBS kriteriumebi rutinuli nacxebisaTvis da LBC unda iqnas gamoyenebuli, Tu masala CaiTvleba araadeqvaturad. amasTanave, araadeqvaturobis mizezi miTiTebuli unda iyos citologiuri diagnozis formaSi. qali aradamakmayofilebeli nacxiT unda iqnas dabarebuli ganmeorebiT testirebaze da unda moxdes SemTxvevis monitoringi. qali unda mowveul iqnas ganmeorebiT, Tu axali nacxis aReba ar moxda Tavis droze. sasurvelia, yovelTvis mieTiTos tranformaciuli zonidan masalis aRebis Taobaze.

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3.5. saSvilosnos yelidan masalis aReba da adeqvaturi Pap-nacxis momzadeba

saSvilosnos yelidan masalis sworad aReba Sesabamisi aRWurvilobiT, mniSvnelovnad aadvilebs Pap-testis Sefasebas. arasworad aRebuli nacxi cru pozitiuri da cru negatiuri Sedegebis ZiriTadi mizezia.

aRWurviloba, SesaZleblobebi

skrining programaSi erTvebian klinikurad janmrTeli qalebi. mniSvnelovania maTi damokidebuleba momsaxureobisadmi: arian isini kmayofilebi, Tu aRar Caitareben skrinings an sakontrolo tests. sanam nacxi aiReba, masalis aRebisTvis unda iyos konfidencialuri, mSvidi atmosfero. saSvilosnos yelis daTvaliereba unda xdebodes marTvadi Suqis gamoyenebiT.

xelsawyoebi unda momzaddes gasinjvamde, rom pacientma rac SeiZleba naklebi xani dahyos ginekologiur savarZelze, arakomfortul poziciaSi. gamosayenebeli aRWurviloba moicavs xelTaTmanebs, sarkeebs, masalis asaReb nivTebs, sasagne minebs, fiqsators, fanqars.

maqsimalurad unda Semcirdes drois intervali masalis aRebasa da dafiqsirebas Soris. amisaTvis fiqsatori TavRia da ukve Semowmebuli unda iyos. sasterilizacio saSualebebis da narCenebis gadayra unda moxdes masalis aRebis Semdeg.

aseve sasurvelia, pacientisaTvis xelmisawvdomi iyos sada, sasaubro eniT dawerili broSurebi, raTa pacientma moaxerxos damoukidebladac miiRos informacia sxvadasxva mosalodneli Sedegebis Sesaxeb. klinikuri monacenebis anketa unda Seivsos sworad, saTanadod.

saSvilosnos yelis skriningis CatarebisaTvis ukuCvenebas warmoadgens: totaluri histereqtomia, yelis amputacia (Tu operacia Catarda cerviqsis dazianebis gamo, vaginaluri nacxi unda gakeTdes rekomendebuli sixSiriT), kiboze eWvis arseboba da yelis areSi makroskopiulad gamoxatuli dazianeba. am ukanasknelis arsebobis SemTxvevaSi sasurvelia pacienti gaigzavnos kolposkopiur gamokvlevaze da/an biofsiaze.

masalis adekvaturi ujredulobis xelSemSleli faqtorebi: 1. menstruacia, sisxlisdena; 2. vaginaluri anTeba/infeqcia; 3. seqsualuri urTierToba nacxis aRebamde 24 saaTis ganmavlobaSi; 4. mZime genitaluri atrofia (gviani menopauza); 5. orsuloba, mSobiarobis Semdgomi periodi da laqtacia; 6. fizikuri manipulaciebi an qimiuri gaRizianeba, rogoricaa: winaswari

vaginaluri gamokvleva, madezinfeqciebeli nivTierebebis (siTxeebis) gamoyeneba, zeTovani saSualebebi, vaginaluri wamlebi, gamorecxvebi an spermiciduli saSualebebi (nacxis aRebamde 24 saaTis ganmavlobaSi), wina nacxis aReba 3 kviramde drois intervalSi, saSvilosnos yelis operacia 3 Tvemde drois intervalSi;

7. radioTerapia.

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aucilebelia am faqtorebis gaTvaliswineba da maTi zegavlenis minimumamde dayvana. citologiuri preparatebis xarisxi SeiZleba dabali iyos orsulobis da mSobiarobis Semdgom adreul periodSi, reaqciuli anTebiTi cvlilebebis gamo. amdenad, orsuli qalebisTvis, negatiuri skrining-istoriiT, nacxis aReba sasurvelia gadaidos mSobiarobidan 6-8 kviriT im SemTxvevaSi, Tu bolo nacxi ar aRebula 3 welze meti xnis win da/an Tu skriningis Sedegebi savaraudod ar iqneba informaciuli. Tu bolo nacxi aRmoCnda paTologiuri da SualedSi qali dafexmZimda, maSin sakontrolo nacxis aReba ar unda gadaidos.

qalis momzadeba masalis asaRebad. masalis aReba saSvilosnos yelidan

masalis aRebamde qals unda avuxsnaT, Tu risTvis aris saWiro nacxis aReba da ra Tanxmlebi movlenebi da/an garTulebebia mosalodneli. unda gamovkiTxoT janmrTelobis zogadi mdgomareoba, aqvs Tu ara araregularuli sisxldena, an gamonadeni. unda CavniSnoT bolo mentruaciis TariRi da bolo orsulobis monacemebi. unda avuxsnaT, rom nacxis aradamakmayofilebeli xarisxis SemTxvevaSi, saWiroa gamokvlevis ganmeoreba 3-6 TveSi. pacients sworad unda gavagebinoT citologiuri kvlevis Sedegebi.

rutinuli nacxisTvis, minebi unda dainiSnos fanqriT, garkveviT, minis mqrqal boloze pacientis saidenTifikacio monacemebis (saxeli, nomeri, dabadebis TariRi) CvenebiT. sxva meTodebiT Sesrulebuli moniSvnebi minis damuSavebis dros SeiZleba waiSalos.

savarZelze pacientis maqsimalurad komfirtulad moaTavsebis Semdeg (dorzalur an lateralur poziciaSi), sinaTlis wyaros ise mivmarTavT, rom kargad Candes saSvilosnos yeli. masalis aRebamde ar SeiZleba tamponis gamoyeneba.

sarkis Tbil wyalSi an xelSi GgaTbobis Semdeg, mas vdgamT saSoSi vulvis mwvervalis gayolebaze, naxevrad Seyvanis Semdeg vatrialebT 90°-iT da vxsniT (vaRebT) saSoSi mTlianad ganTavsebis Semdeg. lubrikantebi Cveulebriv saWiro ar aris. aucileblobis SemTxvevaSi gamoiyeneba cota Tbili wyali an wyalSi xsnadi lubrikanti ise, rom ar dabinZurdes saSvilosnos yeli, ramdenadac man SeiZleba daazianos masalis xarisxi. yeli ise unda iqnas dasaTvaliereblad axlos motanili, rom ar Sewuxdes pacienti. unda aRweros saSvilosnos yelis garegnuli mdgomareoba, aqvs Tu ara adgili sxvadasxva paTologiur mdgomareobas, an Tu aRiniSneba saeWvo simptomebi. nacxis aRebamde ar SeiZleba yelis rutinulad gawmenda an tamponis gamoyeneba.

saSvilosnos yelis kiboswinare daavadebebi ZiriTadad aRmocendeba transformaciul zonaSi (TZ), eqtocerviqsis mravalSrian brtyel epiTeliumisa da endocerviqsis cilindrul epiTeliumis mijnaze: amitom, mniSvnelovania ujreduli masala Tavdapirvelad am zonidan iqnes aRebuli. nacxSi metaplaziuri brtyeli ujredebis da endocerviqsuli ujredebis Tanaarseboba niSnavs, rom masala aRebulia transformaciuli zonidan, magram es ar gvaZlevs imis garantias, rom masala aRebulia mTlianad misi

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mimdebare nawilidan. warsulSi endocerviqsuli komponentebis ararseboba, iTvleboda nacxis ganmeorebiT aRebis mizezad. xangrZlivma kvlevebma uCvena, rom pacientebs bolo negatiuri nacxiT, endocerviqsuli ujredebis gareSe ar aqvT cerviqsis Semdgomi dazianebis maRali riski, negatiuri nacxis mqone qalebTan SedarebiT. miuxedavad amisa endocerviqsuli ujredebis da/an metaplaziuri ujredebis arseboba gansazRvravs rom masala aRebulia samizne zonidan.

saSvilosnos yelis skriningi yovelTvis moiTxovs Sesabamisi instrumentebiT aRebul endo- da eqtocerviqsul masalas. transformaciuli zonidan masalis asaRebad gamoiyeneba sxvadasxva tipis xis an plastikuri Spadelebi (naxati #9). Spadelebi wagrZelebuli daboloebebiT, braSebi (mokle jagrisiani endocerviqsuli funjebi) da cocxisebri cerviqsuli funjebi warmoadgens rekomendebul instrumentebs. ganirCeva Spadelebi 2 SesaZlo daboloebiT: Ayre (mokle) daboloeba da Aylesbury (wagrZelebuli) daboloebiT. bambiani daboloebis aplikatorebi aRar gamoiyeneba.

rekomendebulia masalis aRebis 3 meTodi:

1. cerviqsuli funjiT (c) 2. Spadelis da endocerviqsuli funjis kombinaciiT - eqtocerviqsidan da

endocerviqsidan masalis asaRebad (a da b) 3. mxolod wagrZelebulboloiani SpadeliT (a)

naxati #9

dauSvebelia mxolod endocerviqsuli funjis gamoyeneba (b).

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cerviqsuli funji saukeTesoa Tu pacienti fexmZimea da aqvs advilad sisxlmdeni saSvilosnos yeli. kombinirebuli meTodi, endocerviqsuli funjis gamoyenebiT, saukeTesoa Tu cilindrul da brtyel epiTeliumebs Soris sazRvari ganlagebulia endocerviqsul arxSi (xSirad postmenopauzur qalebSi), aseve saSvilosnos yelis operaciis Semdeg, an Tu aris cilindruli epiTeliumis didi zomis eqtopia. zog qveynebSi, magaliTad, did britaneTSi, xmaroben mxolod Spadels.

rutinuli nacxis aReba da damuSaveba

cerviqsuli funji

cerviqsuli funjiT endo- da eqtocerviqsuli ujredebis aReba xdeba erTdroulad: grZeli bususebi iReben masalas endocerviqsidan, mokle bususebi iReben masalas eqtocerviqsidan. funji gverdebze CamoWrilia ise, rom ujredebi aiRos mxolod brunvis saaTis isris mimarTulebiT datrilebisas.

1. funjis grZeli bususebi Tavsdeba endocerviqsul arxSi;

2. funjs vabrunebT 3600-iT xuTjer, saaTis isris mimarTulebiT, cera TiTsa da saCvenebel TiTs Soris, msubuqi zewoliT. Semdeg cerviqsuli funjis orive mxares calcalke minis gaswvriv gadavusvamT minas;

3. nacxs vafiqsirebT dauyovnebliv.

naxati #10

nacxi SeiZleba dafiqsirdes pipetiT an “spreis” saSualebiT, an mTeli mina uSualod moTavsdes fiqsatorian konteinerSi. arCeuli fiqsatori aris 95%-iani eTilis spirti, magram SeiZleba sxva fiqsatorebis gamoyenebac. mina dafiqsirebuli unda iyos sul mcire 10 wuTis ganmavlobaSi. Semdeg amoviRoT fiqsatoridan da SevinaxoT mSralad sasagne minebis yuTSi transportirebisaTvis.

TuUgamoiyeneba “spreiT” SesxurebiT fiqsacia, fiqsatoris Sesxureba unda moxdes minidan 20sm moSorebiT da swori kuTxiT. Tu axlodan SevasxurebT fiqsators, maSin ujredebi gadairecxeba an gaiyineba, Tu daxrilad mivmarTavT Wavls, masalaze agregatebi warmoiqmneba. wveTebis warmoqmnis Tavidan asacileblad ar unda gamoviyenoT bevri fiqsatori. The BSCC (britanuli) gaidlainiT rekomendebulia minis moTavseba horizontalur zedapirze spreiT fiqsaciisTvis, rom Tavidan aviciloT araTanabari

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fiqsacia. unda moxdes swrafi fiqsacia, ramdenime wamSi, rom ar ganviTardes nacxis gaSrobis artefaqtebi.

nacxis dauyovnebeli fiqsacia imitom iZens kritikul mniSvnelobas, rom preparatis Tundac nawilobrivi gaSroba amaxinjebs da cvlis ujredul komponentebs. unda aRiniSnos, rom postmenopauzuri qalebis nacxi da sisxliani nacxebi gansakuTrebiT swrafad Sreba.

naxati #11

Spadelisa da endocerviqsuli funjis kombinacia

nacxis aReba SpadeliT

1. Spadeli daboloebis anatomiuri Tavsebadobis mixedviT unda iqnas SerCeuli. aranamSobiarebi qalisTvis gamoiyeneba Aylesbury daboloeba, namSobiarebisTvis farTo Ayre daboloeba. wagrZelebuli bolo Sedis saSvilosnos yelis arxSi, sanam SigniTa morkaluri zedapiri ar Seexeba saSvilosnos yels;

2. keTdeba erTze meti sruli bruni. saaTis isris mimarTulebiT datrialebisas vaCerebT 9 saaTis poziciaze, Tu sawinaaRmdego mimarTulebiT vabrunebT, maSin vaCerebT 3 saaTis poziciaze, rom afxekili masala darCes horizontalurad mdebare Spadelis zemo zedapirze;

3. Spadelis wveri gamofxeks yelis Sesavals, naklebad gamoSverili nawili ki _ yelis zedapirs. saWiroa, rom sqvamocilindruli (SCJ) are aifxikos ramdenadac SesaZlebelia kargad. Tu aris Zlier gamoxatuli eqtopia, unda Camoifxikos yelis gareTa nawili calke, Ayre Spadelis brtyeli bolos saSualebiT;

4. nacxis aRebis Semdeg dasaSvebia Spadelis gverdze gadadeba da nacxis aRebis proceduris gagrZeleba cerviqsuli funjiT. aRebuli ujreduli masalis gaSrobis saSiSroeba minimaluria, Tu is lorwosTan erTad darCeba Spadelze mcire xniT.

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masalis aReba endocerviqsuli funjiT

endocerviqsuli funjis 2/3 DTavsdeba saSvilosnos yelis arxSi, ise rom distaluri bususebi TvaliT unda Candes. Semdeg funji unda davatrialoT 90°- 1800°-iT.

naxati #12

ujreduli masalis gadatana sasagne minaze

endocerviqsuli braSi yelis arxidan amoRebisTanave, dauyovnebliv unda gadavagoroT (da ara wavusvaT) minis gareTa mesamedze imis sapirispiro mimarTulebiT, ra mimarTulebiTac vatrialebdiT funjs masalis aRebisas. funjis moZraoba unda moxdes erTi mimarTulebiT, (ara zigzagiseburad), zewolis gareSe, rom miviRoT Txeli da Tanabari nacxi. Semdeg SpadeliT aRebuli masala rac SeiZleba swrafad unda wavusvaT minis Sua mesamedze. mWidro sigrZivi moZraoba uzrunvelyofs masalis gadasvlas Spadelis orive zedapiridan sasagne minaze.

SeiZleba, funjis masala gadavitanoT minis zeda naxevarze sigrZivad, xolo Spadelis masala minis qveda naxevrze, aseve sigrZivad.

Semdeg vaxdenT nacxis dauyovnebel fiqsacias zemoT aRwerili erT-erTi meTodiT. radganac endocerviqsuli ujredebi Sreba Zalian swrafad, fiqsatoris dawveTeba sasagne minaze ujreduli masalis wasmamde SeiZleba dagvexmaros swraf da xarisxian fiqsaciaSi.

naxati #13

Tu nacxis amRebi gamoucdelia, misTvis sirTules warmoadgens ori nacxis

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ganTavseba erT minaze da orive masalis adeqvaturi fiqsacia pirveli masalis gamoSrobamde. aseT situaciaSi ufro advilia endocerviqsuli da eqtocerviqsuli masalis wasma 2 minaze cal-calke, aseT SemTxvevaSi jer fiqsirdeba Spadelis masala da mxolod amis Semdeg gadavdivarT funjiT masalis aRebaze.

masalis aReba mxolod grZel boloiani SpadeliT

mesame arCevani aris ujredebis aReba eqto- da endocerviqsidan mxolod grZelTaviani Spadelis saSualebiT. Spadelis erTi mxaris masala gadaitaneba minis Ezeda naxevaris sigrZeze, meore mxaris masala ki, minis qveda naxevris sigrZeze. es meTodi gamoiyeneba inglisSi.

siTxeze dafuZnebuli citologiuri testi

siTxeze dafuZnebuli citologiuri testisaTvis masala aiReba zustad iseve, rogorc es xdeba rutinuli Pap-testis dros, magram gamoiyeneba mxolod plastikuri xelsawyoebi.

naxati #14

nacxis swrafi fiqsaciis aucileblobis gamo, sarke rCeba Cadgmuli. amis mizezs winaswar uxsnian pacients, sanam mina momzaddeba da dafiqsirdeba. sarke ukan gamogvaqvs neli moZraobiT, gaSlil mdgomareobaSi, sanam yeli ar ganTavisufldeba. sarke SeiZleba daiketos bolomde gamoRebis Semdeg.

proceduris damTavrebis Semdeg klinikuri monacemebis anketa unda Seivsos bolomde _ pacientis saxelis, gvaris, dabadebis TariRis da sxva saidentifikacio monacemebis srulad CvenebiT. aseve unda mieTiTos minebis raodenoba da masalis aRebis teqnika, bolo menstruaciis TariRi an bolo orsuloba da iseTi klinikuri monacemebi, rogoricaa acikluri sisxldena an saeWvo Sesaxedaobis yeli. masalis amRebi unda darwmundes rom qalma zustad gaigo proceduris arsi da isic, Tu sad da rogor miiRos gamokvlevis Sedegebi.

klinikuri monacemebis anketaSi arsebuli informacia unda iyos konfidencialuri.

fiqsaciis Semdeg mina unda bolomde gaSres. Semdeg unda moTavsdes plastikur konteinerSi da gadaigzavnos laboratoriaSi. konteinerSi ar

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SeiZleba sveli preparatebis moTavseba, radganac SeiZleba Seewebos konteineris Sida zedapirs. konteineri unda iyos moniSnuli pacientis saidentifikacio detalebiT, romelic emTxveva klinikuri monacemebis anketaSi arsebul monacemebs.

monacemebi masalis xarisxze

citologiur daskvna unda moicavdes msjelobas masalis xarisxze, aseve informacias TZ-zonidan masalis aReba/ver aRebis Taobaze. rodesac masala aradamakmayofilebelia, mizezi unda iyos gansazRvruli.

yvela praqtikoss, romelic iRebs citologiur masalas, periodulad unda miewodebodes monacemebi mis mier aRebuli masalis xarisxis Sesaxeb.


1. Arbyn M. & Flemish Working Party Sampling. A technical guideline: collection of adequate Pap smears of the uterine cervix. Scientific Institute of Public Health 2000; IPH/EPI-REPORTS 4, 1-53. Available from: http://www.iph.fgov.be/epidemio/epinl/cervixnl/s_eng1.pdf

2. Boon M.E. & Suurmeijer A.J.H. (1993). The Pap Smear, second edition edn. Coulomb Press Leyden. Bos A.B., van Ballegooijen M., van den Akker van Marle M.E., Hanselaar A.G., van Oortmarssen G.J., & Habbema J.D. (2001). Endocervical status is not predictive of the incidence of cervical cancer in the years after negative smears. Am. J. Clin. Pathol. 115: 851-855.

3. BSCC. How to take a cervical smear, 3rd edition (2003). Uxbridge, British Society of Clinical Cytology. Video and booklet available from www.clinicalcytology.co.uk

4. Buntinx F. & Brouwers M. (1996). Relation between sampling device and detection of abnormality in cervical smears: a meta-analysis of randomised and quasi- randomised studies. BMJ 313: 1285- 1290.

5. Buntinx F., Knottnerus J.A., Crebolder H., Essed G., & Schouten H. (1992). Relation between quality of cervical smears and probability of abnormal results. BMJ 304: 1224.

6. Burghardt E. (1970). Latest aspects of precancerous lesions in squamous and columnar epithelium of the cervix. Int. J. Gynecol. Obstet. 8: 573-580.

7. Burghardt E., Pickel H., & Girardi F. (1998). Colposcopy Cervical Pathology, 3rd revised and enlarged edition. Stuttgart, New York: Georg Thieme Verlag: 1-323.

8. Herbert A., Bergeron C., Wiener H., Schenck U., Klinkhamer P.J., Bulten J., & Arbyn M. (2007). European guidelines for quality assurance in cervical cancer screening: recommendations for cervical cytology terminology. Cytopathology 18: 213-219.

9. Martin-Hirsch P., Lilford R., Jarvis G., & Kitcherner H.C. (1999). Efficay of cervical-smear collection devices: a systematic review and meta-analysis. Lancet 354: 1763-1770.

10. Mitchell H.S. (2001). Longitudinal Analysis of Histologic High-Grade Disease after Negative Cervical Cytology According to Endocervical Status. Cancer 93: 237-240.

11. NCCLS (1994). Papanicolaou technique; approved guideline. Pensylvania: National Comity for Clinical Laboratory Standards, NCCLS Document GP15-A, vol 14 N 8 (video).

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12. NHSCSP (2006). Taking Samples for Cervical Screening a Resource Pack for Trainers. Sheffield: National Health Service Cervical Screening Programme, NHSCSP Publication N°23: 1-47. Available from www.cancerscreening.nhs.uk

13. Siebers A.G., de Leeuw H., Verbeek A.L., & Hanselaar A.G. (2003). Prevalence of squamous abnormalities in women with a recent smear without endocervical cells is lower as compared to women with smears with endocervical cells. Cytopathology 14: 58-65.

14. Solomon D., Davey D., Kurman R., Moriarty A., O'Connor D., Prey M., Raab S., Sherman M.E., Wilbur D., Wright T.C., & Young N. (2002). The 2001 Bethesda System: terminology for reporting

15. Solomon D. & Nayar R. (2004). The Bethesda system for reporting cervical cytology: definitions, criteria and explanatory notes. 2nd edition. New York: Springer, 1-191.

16. Vooijs P.G., Elias A., van der Graaf Y., & Veling S. (1985). Relationship between the diagnosis of epithelial abnormalities and the composition of cervical smears. Acta Cytol. 29: 323-328. results of cervical cytology. JAMA 287: 2114-2119.

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4. saSvilosnos yelis citologiur diagnostikaSi gamoyenebul terminTa Taobaze

citologiuri diagnozi SeiZleba Seicavdes teqstur nawils, Tumca sasurvelia, rom is iyos mokle. yvela diagnozi unda asaxavdes dReisaTvis aRiarebul klasifikacias (ix. naxati #15). The Bethesda system (TBS) pirvelad mowodebul iqna 1988 wels rogorc saSvilosnos yelis ujredebis mdgomareobis interpretaciis modeli. misi mizani iyo moexdina terminologiis unifikacia (naxati #15) da amasTan gaeumjobesebina pacientebis kontroli. ramdenime wliani gamokvlevebis Semdeg, 1991 wels es sistema gadaxedil iqna, 2001 wels ki, isev Seicvala, da Seqmna baza dReisaTvis msoflioSi gamoyenebadi sistemebisTvis (ix. naxati #16). evropuli gaidlainebiT mtkiced rekomendebulia, rom yvela terminologiuri sistema SesabamisobaSi iqnas moyvanili TBS-is kategoriebTan.

WHO,CIN,NHSCSP klasifikaciebi

atipiuri/mosazRvre cvlilebebi

brtyel ujredebSi_epiTeliocitebSi

norma HPV infeqcia

msubuqi A/CIN1

zomieri / CIN 2

mZime / CIN 3/CIS

kibo

jirkvlovani neoplazia / AIS

atipiuri/mosazRvre cvlilebebi

jirkvlovan ujredebSi

betesdas sistema

ASCUS ASC-H

norma LSIL

HSIL

kiboAIS

atipiuri cvlilebebi jirkvlovan ujredebSi

naxati # 15

gardauvalia, rom zogi citologiuri masala iqneba SefasebisTvis aradamakmayofilebeli ujredebis simciris gamo, arasakmarisi fiqsaciis an sisxliT da eqsudatiT ujredebis dafarvis gamo. adeqvaturobis Sefaseba subieqturia, amis gamo citologma werilobiT unda daafiqsiros nacxis aradamakmayofileblad CaTvlis mizezi.

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laboratoriebSi nacxis adeqvaturobis SefasebisaTvis rekomendebulia betesdas klasifikaciis kriteriumebi, kerZod: ujredebis raodenoba unda iyos sul mcire 8 000-12 000 brtyeli ujredi rutinul nacxze da sul mcire 5000 ujredi LBC preparatze. SeniSvnebi SeiZleba mocemuli iyos nacxSi anTebiTi eqsudatis Sesaxeb da transformaciuli zonidan masalis aRebis Sesaxeb rutinuli nacxisaTvis da siTxeze dafuZnebuli preparatebisaTvis, ise rom eqTnebma da eqimebma nimuSis/analizis aRebisas SeZlon klinikuri gadawyvetilebis gakeTeba ganmeordes Tu ara gamokvleva.

papanikolaus klasifikacia

WHO CIN (Richart,1973)

TBC 1991 (Luff,1992)

TBS 2001 (Solomon,Nayer

2003) I norma negatiuri,

epiTeliuri ujrdebis atipia

ar vlindeba

II atipia infeqcia, reaqtiuli cvlilebebi

ASCUS ASCUS ASC-H

atipiuri jirkvlovani ujredebi

AGUS atipiuri jirkvlovani ujredebi

III msubuqi displazia

kondiloma LSIL LSIL CIN I

zomieri displazia

CIN II HSIL HSIL

IV mZime displazia CIN III CIS AIS CGIN AGUS AIS

V invaziuri kibo

naxati #16. sxvadasxva citologiuri klasifikaciebis SeTavseba

4.1. betesdas klasifikacia (2001 weli)

preparatis xarisxis Sefaseba masala damakmayofilebelia SefasebisaTvis; masala aradamakmayofilebelia SefasebisaTvis; masala uvargisia diagnostikisaTvis; masala SeRebili da gamokvleulia, magram aradamkmayofilebelia

epiTeliumis mdgomareobis SefasebisaTvis. zogadi kategorizacia intraepiTeliuri, an avTvisebiani dazianeba ar aRiniSneba; epiTeliuri ujredebis anomalia (dasazustebelia

brtyelujredovani an jirkvlovani); sxva – endometriuli ujredebi qalebSi 40 wlis zemoT.

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aRweriTi interpretacia/diagnozi arasimsivnuri procesebi

intraepiTeliuri dazianeba an avTvisebiani procesi ar aRiniSneba (NLM)

mikroorganizmebi

Trichomonas vaginalis kandidas tipis soko vaginaluri floris siWarbe, damaxasiaTebeli baqteriuli

vaginozisaTvis aqtinomicetebis tipis baqteriebi martivi herpesis virusisTvis damaxasiaTebeli ujreduli

cvlilebebi

sxva arasimsivnuri cvlilebebi

reaqtiuli ujreduli cvlilebebi asocirebuli: o anTebasTan (maT Soris, tipiur reparaciasTan); o dasxivebasTan; o saSvilosnosSida kontracepciasTan; jirkvlovani ujredebis keTilTvisebiani cvlilebebiT

histereqtomiis Semdeg o atrofiuli cvlilebebi;

sxva

endometriuli ujredebi ( > 40 asakis qalebSi)

epiTeliuri ujredebis anomaliebi

brtyelujredovani epiTeliocitebi

atipiuri brtyeli epiTeliocitebi - ganusazRvreli (ucnobi) mniSvnelobis atipiiT (ASC-US) - HSIL-is gamoricxva SeuZlebelia (ASC-H)

dabali xarisxis intraepiTeliuri dazianeba (LSIL) o adamianis papilomavirusiT ( HPV) gamowveuli ujreduli cvlilebebi /msubuqi displazia/CIN 1

maRali xarisxis intraepiTeliuri dazianeba (HSIL) o zomieri (CIN 2) da mZime displazia ( CIN 3), karcinoma in situ o invaziaze saeWvo citologiuri niSnebiT

brtyelujredovani karcinoma jirkvlovani epiTeliocitebi

atipiuri araspecifiuri (NOS) o endocerviqsis ujredebi; o endometriuli ujredebi; o jirkvlovani ujredebi;

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atipiuri jirkvlovani/endocerviqsis ujredebi, saeWvo avTvisebianobaze

endocerviqsuli adenokarcinoma in situ adenokarcinoma

o endocerviqsis o endometriumis o saSvilosnosgare warmoSobis

araklasificirebuli

5. Pap-testis interpretacia

5.1. negatiuri intraepiTeliur dazianebebze an avTvisebianobaze

es kategoria betesdas sistemaSi Seesabameba kategoriebs “normuli da keTilTvisebiani cvlilebebi.”

keTilTvisebiani ujreduli cvlilebebis mravali varianti aris aRwerili: esenia hormonuli statusiT ganpirobebuli (mSobiarobis Semdgomi an atrofiuli) Taviseburebebi, reparaciuli cvlilebebi, mikroglanduluri hiperplazia, tubulo-endometrioiduli metaplazia, tubuluri metaplazia; amave jgufSi erTiandeba is cvlilebebic, romelic ganpirobebulia ujredebis aRebiT saSvilosnos qvemo segmentidan, anTebiT, saSvilosnosSida kontraceptivebis arsebobiT, aseve SemTxveviT nanaxi keTilTvisebiani jirkvlovani ujredebi histereqtomiis Semdeg aRebul nacxebSi. aseTi tipis ujreduli cvlilebebis dafiqsireba saWiro ar aris, Tu is ar gulisxmobs neoplaziis gazrdil risks. amasTanave, trixamona vaginalis, kandidas, aqtinomicetebis msgavsi organizmebis, aseve herpes virusis mravalbirTviani ujredebis naxva unda aRiniSnos, ramdenadac maT aqvT potenciuri klinikuri mniSvneloba.

5.2. ujredebi romelic gansazRvravs brtyelujredul intraepiTeliur dazianebas (neoplazia, displazia)

prekanceruli ujreduli cvlilebebis speqtris aRsawerad gamoyenebul sistemebSi bevri terminologiuri gansxvavebebia. bevr qveyanaSi Tu klinikaSi isini fasdeba rogorc msubuqi, saSualo da mZime displazia/karcinoma in-situ, rac savsebiT esadageba saSvilosnos yelis intraepiTeliuri neoplaziis CIN1-CIN3 xarisxebs. betesdas sistemaSi es speqtri klasificirebulia rogorc dabali-xarisxis da maRali-xarisxis brtyeli intraepiTeliuri dazianeba: LSIL – Low Grade Squamos Intraepithelial Lesion da HSIL – High Grade Squamos Intraepithelial Lesion.

numeraciuli sistemebi (papanikolau I-V) aRar gamoiyeneba: dResdReobiT upiratesad rekomendebulia teqsturi daxasiaTeba rogoricaa displazia da SIL.

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imis gamo, rom bevri qveynisTvis rTulia damkvidrebuli terminologiis Secvla, mkacrad aris rekomendebuli, rom yvela adgilobrivi citologiuri terminologia SesabamisobaSi movides betesdas sistemasTan, radganac es ukanaskneli Zalian farTod gamoiyeneba dRes msoflioSi. magaliTad, janmo-s (WHO) Zveli klasifikacia arCevs displaziis 3 xarisxs (msubuqi, zomieri da mZime/karcinoma in-situ). betesdas kalsifikaciaSi, romelsac exla iyenebs janmo, LSIL-s Seesabameba HPV/msubuqi displazia/CIN1. xolo HSIL-s Seesabameba zomieri/CIN 2 da mZime displazia/karcinoma in-situ/CIN3. (naxati #16)

5.3. LSIL-is da CIN1-is Sesabamisi ujreduli cvlilebebi _ msubuqi displazia

LSIL moicavs cvlilebebs, romelic cnobilia, rom dakavSirebulia adamianis papilomavirusul infeqciasTan (HPV), romelic umetesad gamovlindeba koilocitebiT. LSIL–is gansxvaveba tranzitoruli HPV infeqciisagan mxolod citologiiT SeuZlebelia, rac ganapirobebs dakvirvebis aucileblobas, rom ganisazRvros is kontingenti, romelSic LSIL progresirebs maRali xarisxis dazianebebSi. LSIL betesdas sistemaSi da msubuqi diskariozi NHSCSP-Si (National Health Service Cervical Screening Programme) Seesabameba histologiur diagnozs _ msubuqi displazia da CIN1 (NHSCSP, 2000).

5.4. HSIL-is da CIN2-is Sesabamisi ujreduli cvlilebebi _ zomieri displazia

CIN2 aris Sualeduri mdgomareoba, rodesac ujreduli cvlilebebi bolomde ar Seesabameba CIN3/karcinoma in-situ-s. CIN2 aris zomieri displaziis, zomieri diskariozis eqvivalenti da miekuTvneba HSIL-s. umetes terminologiur sistemebSi zomieri displazia dakavSirebulia mZimesTan, rogorc maRali xarisxis dazianebasTan. metic, es kavSiri ukve mkacrad rekomendebulia. zomieri displaziis klinikuri marTva ar gansxvavdeba mZime displaziis klinikuri marTvisagan (Kocjan et al., 2005).

5.5. HSIL-is da CIN3-is Sesabamisi ujreduli cvlilebebi _ mZime displazia / karcinoma in-situ

citologiaSi HSIL, CIN3 aris mZime displaziis da karcinoma in-situ-s eqvivalenti histologiaSi. marTalia HSIL moicavs rogorc zomier, aseve mZime diskariozs, magram diagnozis gaformebisas ubjobesia CIN3 an mZime displazia Caiweros.

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5.6. invaziuri brtyelujredovani karcinoma

invaziuri kibos diagnozi moiTxovs bioftatis histologiuri kvleviT dadasturebas, magram aris iseTi citologiuri cvlilebebic, romelic miuTiTebs invaziis SesaZlo arsebobas. umetesma sistemebma, betesdas CaTvliT aRniSnes aseTi cvlilebebis diagnozSi Caweris aucilebloba da gansazRvres calke kategoria invaziuri kibos yvelaze xSiri tipisaTvis _ brtyelujredovani kibo.

5.7. ASC atipiuri/mosazRvre brtyeli ujredebi

praqtikaSi xSirad ismeva atipiuri/mosazRvre cvlilebebis diagnozi, Tumca aseTi terminologia SeiZleba gamoyenebuli iyos im SemTxvevebSi, rodesac arsebobs imis realuri eWvi, cvlilebebi ganekuTvneba reaqciuls Tu neoplaziurs. aseTi cvlilebebis umetesi nawili esazRvreba LSIL/msubuqi displazias da betesdas sistemaSi Sesulia rogorc atipiuri brtyeli ujredebi (epiTeliocitebi) ganusazRvreli mniSvnelobis atipiiT (ASC-US _ Atypical Squamous Cells of Undetermined Significance). biofsiiT damtkicda, rom aseTi ujredebi daaxloebiT 10%-Si asocirebulia CIN2,3-Tan biofsiis dros. nacxebis araumetes 3%-s SeiZleba qondes aseTi saxelwodeba magram sixSire damokidebuli iqneba LSIL da HSIL-is adgilobriv sixSireze (Herbert, 2004).

5.8. ASC-H atipiuri brtyeli ujredebi (epiTeliocitebi) – maRali

xarisxis intraepiTeliuri dazianebis (HSIL) gamoricxvis SeuZleblobiT

ASC-H aris atipiuri/mosazRvre cvlilebebis qvejgufi, romelic iwvevs HSIL-is, zogjer kibos eWvs. es diagnozi fiqsirdeba, rodesac paTologiuri ujredebi imdenad cotaa, rom diagnozis ufro dazusteba SeuZlebelia. sistemebis umetesoba gvTavazobs, rom aseTi SemTxvevebi Caiweros diagnozSi da ganisazRvros, rogorc calke kategoria. britanul klasifikaciaSi (BSCC) am kategorias uwodebs “borderline, high-grade not excluded”. es termini ukavSirdeba atipiuri brtyelujredovani cvlilebebis araumetes 5-10% da xSirad asocirdeba kolposkopiiT da biofsiiT damtkicebul CIN2-3-Tan. amasTanave, am terminis gamoyeneba unda moxdes mkacri kontroliT, raTa Tavidan aviciloT misi gamoyeneba amocnobadi HSIL-is SemTxvevaSi (Sherman et al., 1999; Quddus et al., 2001; Sherman, Solomon & Schiffman, 2001).

5.9. jirkvlovanujredovani paTologiebi

jirkvlovani dazianebebi naklebad xSiria, vidre brtyelujredovani, magram qmnis mniSvnelovan jgufs, ramdenadac rTulia misi citologiuri skriningiT gansazRvra da ufro rTulia _ kolposkopiiT dadastureba.

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5.10. AIS endocerviqsis adenokarcinoma in-situ.

bevr sistemaSi, maT Soris betesdas klasifikaciaSi AIS ganisazRvreba rogorc diagnostorebadi qvetipi, romelic Seesabameba maRali xarisxis CGIN–s (cervikaluri jirkvlovani intraepiTeliuri neoplazia - NHSCSP klasifikacia). vinaidan ar arsebobs gansxvavebis mkafio kriteriumebi maRal da dabal CGIN-s Soris, nebismieri jirkvlovani paTologia imarTeba erTnairad.

5.11. adenokarcinoma

rogorc brtyelujredovani karcinomis SemTvevaSi, adenokarcinomuli invaziis diagnostikisTvisac aucilebeli bioftatis histologiuri gamokvleva. Tumca, zog SemTxvevebSi aris iseTi citologiuri cvlilebebi, romelTa safuZvelzec SesaZlebelia invaziur adenokarcinomis diagnostika.

5.12. atipiuri/mosazRvre jirkvlovani ujredebi

rogorc brtyelujredovani cvlilebebis dros, am SemTxvevaSic aris ramdenime magaliTi, rodesac “ganusazRvreli jirkvlovan ujreduli cvlilebebi” fiqsirdeba citologiur diagnozSi, Tumca jirkvlovani neoplazia SedarebiT iSviaTobaa. betesdas sistema arCevs “atipiuri jirkvlovani ujredebis” calke jgufs da aseve BSCC gvTavazobs gamovyoT “mosazRvre cvlilebebi jirkvlovan ujredebSi” brtyel ujredebSi arsebuli mosazRvre cvlilebebis msgavsad. jirkvlovani cvlilebebi, saSvilosnos yelis citologiur gamokvlevisas ufro xSirad endometriulia, vidre endocerviqsuli. xandaxan, saSvilosnosSida kontraceptivebis xmarebisas atipiuri/mosazRvre cvlilebebi jirkvlovan ujredebSi SeiZleba miCneul iqnas ufro keTilTvisebianad. amis gamo rekomendebulia testis drouli ganmeoreba darwmunebisTvis. betesdas sistema gvTavazobs kategorias “neoplaziis Sesabamisi atipiuri jirkvlovani ujredebi” (AGC-neoplaziisken midrekilebiT). es kategoria cudad aris gansazRvruli morfologiur safuZvelze, magram ramdenadac atipiuri ujredebi xSirad Tanarsebobs neoplaziasTan an simsivnesTan erTad, saWiro xdeba rekomendacia Semdgomi kvlevisaTvis (Lee et al., 1991; Biscotti et al., 1997; Soofer & Sidawy, 2000).

5.13. sxva ujreduli cvlilebebi

saSvilosnos yelis citologia ar aris kargi diagnostikuri testi endometriumis kibosaTvis. morfologiurad keTilTvisebiani endometrialuri ujredebi ar aris naxsenebi 1988 wlis betesdas sistemaSi, mxolod menopauzur qalebTan dakavSirebiT gaJRerda. kategoria “sxva” exla SemoTavazebulia morfologiuri gadaxrebis gareSe nacxebis klasificirebisTvis, magram romelTac aqvT mkafiod keTilTvisebiani endometrialuri ujredebi, 40 wlis asaks gadacilebul qalebSi (Montz,

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2001; Fadare et al. , 2005). am ujredebis arseboba gansazRvravs endometriumis kibos ganviTarebis maRal risks, amdenad saWiroebs endometriumis gamokvlevas (Tambouret et al., 1998).


1. Arbyn M., Buntinx F., Van Ranst M., Paraskevaidis E., Martin-Hirsch P., Dillner J. (2004). Virologic .versus cytologic triage of women with equivocal Pap smears: a meta-analysis of the accuracy to detect high-grade intraepithelial neoplasia. J. Natl. Cancer Inst.; 96: 280-293.

2. Biscotti C.V., Gero M.A., Toddy S.M., Fischler D.F., Easley K.A. (1997). Endocervical adenocarcinoma in situ: an analysis of cellular features. Diagn .Cytopathol.;17: 326-332.

3. Davey D.D., Woodhouse S., Styer P.E., Stastny J., Mody D. (2000). Atypical epithelial cells and specimen adequacy: current laboratory practices of participants in the College of American Pathologists Interlaboratory Comparison Program in Cervicovaginal Cytology. Arch. Pathol. Lab. Med.;124: 203-211.

4. European Commission (in press). European Guidelines for Quality Assurance in Cervical Cancer Screening. Eds: Arbyn M., Anttila A., Jordan J., Ronco G., Schenck U., Segnan N., Weiner H. Luxembourg: Office of Official Publ. EU.Fadare O., Ghofrani M., Chacho M.S., Parkash V. (2005). The significance of benign endometrialcells in cervicovaginal smears. Adv. Anat. Pathol.; 12:274-87.

5. Herbert A.(2004). BSCC terminology for cervical cytology: two or three tiers? Why not five, seven or even 14? Cytopathology; 15: 245-251.

6. Herbert A. (2005). Terms without borders: An international approach to terminology. Diagn. Cytopathol; 33: 352-355.

7. Kocjan G., Priollet B.C., Desai M. et al. (2005). BSCC, Bethesda or other? Terminology in cervical cytology European panel discussion. Cytopathology; 16: 113-119.

8. Lee K.R., Manna E.A., Jones M.A. (1991). Comparative cytologic features of adenocarcinoma in situ of the uterine cervix. Acta Cytol.; 35: 117-126.

9. Luff R.D. (Chairman) (1992). The revised Bethesda system for reporting cervical/vaginal cytological diagnoses. Report of the 1991 Bethesda Workshop. Acta Cytol.;36: 273-276.

10. Lundberg G.D., National Cancer Institute (1989). The 1988 Bethesda System for Reporting Cervical/Vaginal Cytologic Diagnoses. JAMA; 262: 931-934.

11. Montz F.J. (2001). Significance of "normal" endometrial cells in cervical cytology from asymptomatic postmenopausal women receiving hormone replacement therapy. Gynecol. Oncol.; 81: 33-39.

12. National Health Service Cervical Screening Programme (2000). Achievable standards, benchmarks for reporting, and criteria for evaluating cervical cytopathology. Second edition including revised performance indicators (2nd edition). NHSCSP publication 1, 1-36. Sheffield, NHS Cancer Screening Programmes.

13. Quality Assurance Reference Centre for the Trent NHSCSP (2002). Do borderline nuclear changes in gynaecological cytology constitute a reliable reporting category? Cytopathology; 13: 220-231.

14. Quddus M.R., Sung C.J., Steinhoff M.M., Lauchlan S.C., Singer D.B., Hutchinson M.L. (2001). Atypical squamous metaplastic cells: Reproducibility, outcome, and diagnostic features on ThinPrep Pap test. Cancer;93: 16-22..

15. Riotton G., Christopherson W.M., Lunt R. (1973). Cytology of the Female Genital Tract. International Histological Classification of Tumours No. 8. World Health Organisation, Geneva.

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16. Sherman M.E., Solomon D., Schiffman M.A. (2001). Qualification of ASCUS. A comparison of equivocal LSIL and equivocal HSIL cervical cytology in the ASCUS LSIL Triage study. Am. J. Clin. Pathol.; 116: 386-394.

17. Sherman M.E., Tabbara S.O., Scott D.R. et al. (1999). "ASCUS, rule out HSIL": cytologic features, histologic correlates, and human papillomavirus detection. Mod. Pathol.; 12: 335-342.

18. Solomon D., Davey D., Kurman R. et al. (2002). The 2001 Bethesda System: terminology for reporting results of cervical cytology. JAMA; 287: 2114-2119.

19. Solomon D., Nayar R. (2004). The Bethesda system for reporting cervical cytology: definitions, criteria and explanatory notes, 2nd edn. Springer, New York.

20. Soofer S.B., Sidawy M.K. (2000). Atypical glandular cells of undetermined significance: clinically significant lesions and means of patient follow-up. Cancer; 90: 207-214.

21. Tambouret R., Pitman M., Bell D.A. (1998). Benign glandular cells in posthysterectomy vaginal smears. Acta Cytol.; 42:1403-8.

22. Tavassoli F.A., Devilee P. (Eds) (2003). World Health Organization Classification of Tumours. Pathology and genetics of tumours of the breast and female genital organs. IARCPress. Lyon.

6. laboratoriuli saxelmZRvanelo

saSvilosnos yelis gamokvlevis citologiuri laboratoriis muSaobis xarisxi damokidebulia masalis adeqvatur aRebasa da SeRebvaze, citologiuri nacxis gamokvlevasa da swor interpretaciaze, aseve Sedegebis dafiqsirebaze Sesabamis diagnozis formaSi.

citologiuri masalis mikroskopuli Seswavla da Sedegebis interpretacia subieqturi procedurebia da mniSvnelovnad aris damokidebuli masalis gamomkvlevi piris profesiul momzadebasa da gamocdilebaze, aseve im droze, romelsac masalis gamomkvlevi piri uTmobs citologiuri/histologiuri masalis daTvalierebas (Klinkhamer et al., 1988; Koss, 1989; O'Sullivan et al.,1996). literaturaSi aRwerili sxvaobebi erTi da imave, Tu sxvadasxva laboratoriis mier gacemul diagnozebs Soris warmoadgens swored zemoT aRniSnulis logikur Sedegs (Grenko et al., 2000; Stoler & Schiffman,2001; Stoler, 2002).

xarisxis kontrolis ZiriTadi mizania pacientisaTvis saukeTeso samedicino momsaxurebis SeTavazeba. saSvilosnis yelis kibos skrininguli programisaTvis mniSvnelovania, xarjebi ar “xmardebodes” mcdar diagnostikas.

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6.1. laboratoriis momsaxure personali. laboratoriis mowyoba

citoteqnikosi

saSvilosnos yelis kibos skriningul programaSi citoteqnikosis mTavari movaleobaa asimptomuri qalis nacxis pirveladi daTvaliereba, simsivniswina dazianebebis gamovlena, organizaciuli da laboratoriuli procedurebis teqnikuri Sesruleba, Semdgomi Sedegebis monitoringi, agreTve xarisxis kontrolTan da masalebisa da Sedegebis daarqivebasTan dakavSirebuli procedurebi. citoteqnikosi muSaobs masze pasuxismgebeli piris meTvalyureobis qveS.

organizaciuli samuSao moicavs pacientebTan, nacxis amReb pirebTan, zogadi praqtikis eqimebTan, ginekologebTan, laboratoriebTan da saavadmyofoebTan kavSiris damyarebas;

teqnikuri laboratoriuli procedurebi gulisxmobs masalis miRebas, Sesabamisi laboratoriuli teqnologiiT damuSavebas da usafrTxoebis procedurebis dacvas;

yvela citoteqnikosisaTvis savalebuloa monawileoba uwyveti ganaTlebis da xarisxis kontrolis programebSi.

citoteqnikosma muSaobis principebi da praqtikuli unar-Cvevebi unda aiTvisos laboratoriaSi rutinuli samuSaoebis Sesrulebis dawyebamde.

moTxovnebi citopaTologebisaTvis

citopaTologi pasuxismgebelia saSvilosnos yelidan aRebuli nacxis saboloo diagnostikaze.

citopaTologis movaleobebi saSvilosnos yelis citologiur gamokvlevasTan dakavSirebiT:

yvela im SemTxvevis Sefaseba, romelic egzavneba klinicists Semdgomi meTvalyureobis an mkurnalobis mizniT;

citoteqnikosis diagnozebs Soris SeuTanxmeblobis gadawyveta, im SemTxvevaSi, Tu es diagnozebi klinicistis mier saWiroebs gansxvavebul meTvalyureobas;

meTvalyureoba im SemTxvevebis ganxilvaze, romlebic uCveneben mniSvnelovan gansxvavebas citologiur da/an histologiuri diagnozebs Soris;

kavSiri ginekologebTan da nacxis amReb sxva pirebTan, rac gulismxobs nacxis amRebi pirebisaTvis periodulad moxsenebebis gakeTebas masalis aRebis da xarisxis kontrolis Taobaze;

mudmivi kavSiri citoteqnikosebTan, maTi ganaTleba da daxmareba rTul diagnostikur SemTxvevebSi, agreTve im SemTxvevebSi rodesac citologiuri da histologiuri diagnozebi ar eTanxmeba erTmaneTs;

meTvalyureoba citoteqnologebis da umcrosi samedicino personalis adeqvaturi uwyveti ganaTlebis miRebaze;

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xarisxis kontrolis programebSi monawileoba, maT Soris yovelwliuri angariSis momzadeba, romelic Seexeba citologiuri da histologiuri diagnostikis Sedegebs.

moTxovnebi administraciuli personalisTvis

samdivno da administraciuli personali unda:

erkveodes Sesabamis samedicino terminologiaSi; flobdes Tanamedrove kompiuterul da automatizebul monacemTa

bazasTan muSaobis codnas da Cvevebs; icavdes pacientebis uflebebs da konfidencialobas.

6.2. materialuri da teqnikuri uzrunvelyofa

Senoba, oTaxi, aveji

Senobebi, oTaxebi da aveji unda akmayofilebdes federaluri da/an regionaluri normativebis moTxovnebs da usafrTxoebis standartebs.

laboratoria ise unda iyos ganTavsebuli da aRWurvili, rom maqsimaluri efeqtiT asrulebdes dakisrebul funqciebs. mTeli farTobi unda iyos kargad ganaTebuli da ventilirebuli;

calke unda iyos gamoyofili oTaxebi diagnostikisaTvis, masalis momzadebisaTvis da samdivnosaTvis;

is teritoria, sadac xdeba preparatis momzadeba, aRWurvili unda iyos efeqturi gamwovi sistemebiT da agreTve bionagavis utilizaciis yuTebiT;

laboratorias unda gaaCndes aalebadi da momwamlavi nivTierebebis Sesanaxi specialuri konteinerebi;

citoteqnologis skami unda iyos komfortuli, moxerxebuli sazurgiT da agreTve magidaze unda iyos sakmarisi farTobi mikroskopuli diagnostikisa da Canawerebis gakeTebisaTvis;

mTeli personali garkveuli unda iyos usafrTxoebis da sagangebo SemTxvevebSi moqcevis wesebSi.

masalis SeRebvisaTvis saWiro mowyobiloba, mikroskopebi

saSvilosnos yelis citologiuri gamokvlevisaTvis rekomendebulia papanikolaus originaluri an modificirebuli meTodiT SeRebva (Papanicolaou, 1942; Gill et al., 1974)

saWiro aRWurviloba damokidebulia SeRebvis teqnologiaze (avtomatizebuli an manualuri). SeRebvis Semdeg citologiur masalaSi SesaZlebeli unda iyos qromatinis, aseve, citoplazmis, sxvadasxva gamWvirvalobis da feris ujredebis gamovlena;

aucilebelia maRali xarisxis binokularuli mikroskopi, romelic

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eqvemdebareba mudmiv teqnikur Semowmebas; rutinuli citologiisaTvis gamoiyeneba 4X, 10X da 40X gadidebis

obieqtivi. siTxeze dafuZnebuli citologiisaTvis saWiroa 20X gadidebis obieqtivi.

6.3. saSvilosnos yelidan aRebuli masalis damuSaveba da analizi

laboratriuli damuSaveba

yvela laboratoriuli procedura unda iyos registrirebuli da ganpirovnebuli Sesabamis TanamSromelze. mTeli personali informirebuli unda iyos usafrTxoebis zomebis Taobaze sagangebo SemTxvevebisaTvis.

laboratoriaSi Semosul masalas (mina, SuSis boTli) unda axldes Sesabamisi forma, romelSic, rogorc minimum, miTiTebuli unda iyos pacientis saidentifikacio monacemebi, monacemebi mkurnali eqimis Sesaxeb da klinikuri informacia saSvilosnos yelis mdgomareobis, kontracepciis meTodebis da menstruaciuli ciklis drois Sesaxeb;

citologiur masalasTan da/an TandarTul formasTan dakavSirebuli nebismieri gaurkvevloba unda iqnas werilobiT fiqsirebuli da Tu SesaZlebelia, moixsnas masalis gamomgzavn pirTan dakavSirebis gziT;

masalis da Tanmxlebi furcelis swori verifikaciis Semdeg orive maTganis unda mieniWos unikaluri saidentifikacio nomeri;

masalis gamokvlevamde aucilebelia laboratoriis lokalur da/an skrininguli programis monacemTa bazaSi moviZioT pacientis gamoklvevebis istoria da gavacnoT citoteqnikoss;

siTxeze dafuZnebuli citologiuri masala unda damuSavdes mwarmoeblis instruqciis mixedviT;

minebi unda SeiRebos standartuli papanikolaus meTodiT SeRebvis protokoliT (SeRebvis kontrolis CaTvliT);

aucilebelia safari mina faravdes mTel ujredul masalas (Cveulebriv 50X24mm).

pirveladi Sefaseba

nacxis pirveladi Sefaseba xdeba citoteqnikosis mier

mina unda moTavsdes mikroskopis sasagne magidaze, moniSnuli mxare yovelTvis erT mxares unda mdebareobdes;

rutinuli nacxis SemTxvevaSi, safari minis mTeli are unda daTvalierdes mTlianad, horizontaluri an vertikaluri mimarTulebiT, urTierTgadamfaravi tipiT. siTxeze dafuZnebul preparatebSi unda moxdes mTeli "wris" daTvaliereba. xarisxis kontorlis procesSi SesaZloa dagvexmaros mikroskopuli damuSavebis sistemebi, romelic aRWurvilia eleqtronuli moniSvnis SesaZleblobiT;

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unda moxdes uCveulo da/an paTologiuri ujrdebis moniSvna (xeliT an kompiuterulad);

ganmeorebiTi nacxebi unda Sedardes im nacxebTan, romelTa gamoc mocemuli iyo rekomendacia ganmeorebiTi nacxis aRebaze;

Sedegebis gaformeba sadiagnozo formaSi unda moxdes erovnuli klasifikaciis sistemis mixedviT. unda iyos miTiTebuli masalis adeqvaturoba. aradamakmayofilebeli nacxis SemTxvevaSi aucilebelia ganmeorebiTi nacxis aReba;

daskvnebi da rekomendaciebi, maT Soris ganmeorebiTi nacxis aRebisa da ginekologTan mimarTvis CaTvliT, gacemuli unda iyos Sesabamisi gaidlainis mixedviT;

diagnozSi miTiTebuli unda iyos daskvnasa da rekomendaciaze pasuxismgebeli citoteqnikosis/citopaTologis saidentifikacio monacemebi.

masala, romelic eqvemdebareba meorad Sefasebas

meore piris mier unda gadaixedos:

araadeqvaturi/aradamakmayofilebeli masala; nebismieri ujreduli paTologia, romelic saWiroebs specifikur

rekomendacias; masala rekomendaciiT ganmeorebiT nacxze an mimarTvaze ginekologTan,

kolposkopiur da histologiur gamokvlevaze; sxva, savaraudod maRali riskis nacxi klinikuri informaciis an

pacientis istoriis mixedviT, maT Soris: - pirveli normuli citologia, paTologiuri citologiis an

histologiis Semdeg; - klinikurad saeWvo SemTxvevebi (paTologiuri gamonadeni,

postmenopauzuri sisxldena, paTologiuri an saeWvo cerviqsi); - negatiuri masala, romelic klasificirebuli iyo rogorc

paTologiuri da, ris safuZvelzec gaica rekomendacia Semdgom klinikur mkurnalobaze;

- postmenopauzuri qalis masala (atrofiuli, Zneli saklasifikacio, savaraudod paTologiuri ujredebiT) rodesac gaica rekomendacia ganmeorebiTi nacxis aRebaze estrogenebiT moklevadiani datvirTvis Semgom;

xarisxis kontrolTan dakavSirebuli minebi.

erovnuli programis mixedviT es procedurebi SeiZleba Catardes erTi citoteqnologis da erTi citopaTologis mier.

maqsimalur samuSao datvirTvas, gamosakvlevi minebis raodenobis Sesabamisad, adgens laboratoria. is damokidebulia masalis momzadebis meTodze (rutinuli Tu siTxeze dafuZnebuli citologia). gaTvaliswinebuli unda iyos citoteqnikosis mier Sesrulebuli damatebiTi samuSao - SeRebvis, xarisxis kontrolis procedurebis da sxvaTa CaTvliT. evropis qveynebSi citoteqnikosis dRiuri datvirTva cvalebadobs 25-dan 80

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SemTxvevamde. zogierT qveyanaSi maqsimaluri datvirTva ganisazRvreba saaTobrivad. mag. germaniaSi is Seadgens 10 SemTxvevas erT saaTSi).

rekomendacia:

minebis uwyveti daTvaliereba ar unda grZledebodes 2 saaTze met xans Sesvenebis gareSe;

nacxebis pirveladi Sefasebis xangrZlivoba ar unda aWarbebdes dReSi 6 saaTs. rogorc pirveladi Sefasebis aseve sabolood xelmowerili Sedegebi Senaxuli da xelmisawvdomi unda iyos xarisxis kontrolis procedurebisaTvis;

minebis Tanmxlebi formebi da/an maTi eleqtronuli versiebi Senaxuli unda iyos minimum sami Tvis manZlize;

yvela mina Senaxuli unda iyos minimum 10 wlis manZilze Sesabamis Senaxvis pirobebSi. es mniSvnelovania rogorc pacientebis menejmentis, ise xarisxis kontrolisaTvis;

diagnozebis xelnaweri da kompiuteruli versiebi Senaxvis wesi damokidebulia erovnul normativebze. rekomendebulia diagnozebis Senaxva sul mcire 10 wlis manZilze. mosaxerxebelia citologiuri Sedegebis kodirebuli Canawerebis saxiT Senaxva imis Semdegac rodesac minebi ukve aRaraa xelmisawvdomi.

daarqivebuli Pap nacxebi da cerviqsidan aRebuli masalis histologiuri blokebi warmoadgens qveynis bio-bankis mniSvnelovan resurss.

laboratoriis informaciuli sistema

unda arsebobdes Canawerebis Senaxvis adeqvaturi sistema, umjobesia kompiuterizebuli, romelic advilad misawvdomi da misaRebia laboratoriuli personalisaTvis.

Canawerebis sistema unda Seicavdes, sul mcire:

pacientis saidentifikacio monacemebs; laboratoriis dasaxelebas da misamarTs; laboratoriis ID nomers; nacxis laboratoriaSi Semosvlis TariRs; gamokvlevis Cvenebas: skriningi, Semdgomi meTvalyureoba an sxva

klinikuri gamokvlevebis Cveneba; gamokvlevis tipis Cvenebas (citologia an histologia); rCevas ganmeorebiT nacxze an ginekologTan mimarTvaze; saboloo diagnozs; im pirovneb(eb)is gvars, romelmac Seafasa masala.

laboratoriuli gamokvlevis Sedegebi SesabamisobaSi unda iqnas moyvanili mimdinare standartuli klasifikaciis sistemasTan da monacemebis formatTan, xarisxis/adeqvaturobis Sefasebis CaTvliT.

evropuli gzamkvlevebis mier rekomendebulia citologiuri gamokvlevis

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Sedegebis diagnozSi gadatana SeTanxmebuli erovnuli terminologiiT an sul mcire betesdas sistemasTan SesabamisobiT.

informaciuli sistema:

unda akavSirebdes erTi da imave pacientis mravlobiTi gamokvlevis Sedegebs;

advilad misawvdoms unda xdides wina citologiuri da histologiuri gamokvlevebis Sedegebs, agreTve kolposkopiur da biofsiur gamokvlevis an biofsiis ar aRebis mizezebs;

unda iZleodes mniSvnelovan informacias populaciis skrininguli programis SefasebisaTvis.

yvela zemoT aRniSnuli monacemi unda inaxebodes agreTve kibos erovnul registrSic.

yvela diagnozi avtorizaciamde unda Semowmdes uzustobis gamoricxvis mizniT da mxolod amis Semdeg unda moxdes eleqtronuli an manualuri avtorizacia erovnuli normativebis moTxovnebis mixedviT. citologiuri diagnozebi xelmowerili unda iyos rogorc citoteqnikosis, ise pasuxismgebeli citopaTologis mierac.

yvela zoma unda iqnas miRebuli, rom saboloo diagnozi daiweros da gaices 10 samuSao dRis vadaSi (laboratoriaSi masalis Semosvlis dRis CaTvliT). Tu diagnozis gacema ver eswreba aRniSnul vadaSi, aucilebelia masalis gamomgzavni eqimis informireba, mizezis ganmartebiT.

6.4. xarisxis Sida kontroli

laboratoriuli xarisxis kontroli (xarisxis preanalitikuri kontroli)

laboratoriam unda gamoyos erTi pirovneba, romelic, skriningul programaSi, garda yoveldRiuri samuSaosa, pasuxismgebelia marTvis rekomendaciebis Segrovebaze da maT safuZvelze saxelmZRvanelo dokumentebis (miTiTebebis) momzadebaze. is agreTve momzadebuli unda iyos, rogorc xarisxis kontrolis menejeri, da SeeZlos sxva menejerebTan urTierToba. laboratoris xarisxis kontrolisaTvis mosaxerxebelia praqtikuli gzamkvlevebis gamoyeneba.

maTSi mocemuli procesis detaluri aRweriloba unda Seicavdes:

minebis safexurebrivi gamokvlevis protokolebs; personalis pasuxismgeblobas specifikur procesebze; meTodebs, Secdomebis gamovlenisa da minimizaciisaTvis.

protokolebi unda gadaixedos yovelwliurad da wesrigSi iqnas damuSavdes uwyveti samedicino ganaTlebisaTvis.

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xarisxis analitikuri kontroli (citologia)

skriningis efeqturobis gaumjobeseba unda xdebodes winaswar SeTanxmebuli protokolebis mixedviT.

citologiuri xarisxis Sida kontorolisaTvis arsebobs sami ZiriTadi meTodi:

minebis reskriningi; skriningiT gamovlenili Sedegebis Tanafardoba; korelaciis Sefaseba citologiur da klinikur/histologiur Sedegebs

Soris.

citologiuri samsaxuris xarisxis Sida kontroli didadaa damokidebuli im minebis re-skriningze, romlebic pirvelad Sefasebuli iyo rogorc negatiuri an araadeqvaturi. procedurebi imgvarad unda iyos dagegmili, rom xdebodes skriningis saboloo Sedegebis mgrZnobelobis da specifikurobis gazomva da citologiuri paTologiebis gamovlenis xarisxis monitoringi.

re-skriningis qvemoT CamoTvlili procedurebi mowodebulia citologiuri gamokvlevis mgrZnobelobis Sesamowmeblad, an zogadi xarisxis kontrolisaTvis:

im minebis swrafi gadaxedva, romlebic Tavdapirvelad miCneuli iyo ”negatiurad” an ”araadeqvaturad”;

nacxebis swrafi winaswari gadaxedva/preskriningi;

randomizebuli re-skriningi (sruli reskriningi randomulad aRebuli nacxebis 10%-isa romelbic Sefasebuli iyo rogorc “negatiuri” an “aradamakmayofilebeli”);

pacientTa calke jgufebis miznobrivi re-skriningi;

paTologiuri SemTxvevebis re-skriningi;

cerviqsis negatiuri citologiis retrospeqtuli re-skriningi im pacientebSi, romelTac aqvT maRali xarisxis dazianeba (miznobrivi gadaxedva);

im nacxebis avtomatizebuli reskriningi, romlebic Tavdapirvelad miCneuli iyo negatiurad.

swrafi gadaxedva (RR - Rapid review) gulisxmobs swraf reskrinings, rodesac TiToeuli minis Sefasebaze ixarjeba 30-dan 120 wamamde. mas eqvemdebareba yvela mina, romelic Tavdapirvelad CaTvlili iyo normulad an araadeqvaturad, SeumCneveli paTologiebis identifikaciis mizniT. Semdeg xdeba saeWvo nacxebis sruli daTvaliereba gamocdili citoteqnikosis, an citopaTologis mier, romelic wers saboloo diagnozs.

yvela nacxis swrafi winaswari gadaxedva/preskriningi (RP-pre-screening) swrafi preskriningi gulisxmobs minis nawilobriv mikroskopul daTvalierebas xanmokle periodSi (maqsimum 120 wami) _ srul rutinul daTvalierebamde.

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ZiriTadi gansxvaveba swraf reskriningsa da swraf winaswar gadaxedvas Soris aris is, rom swrafi reskriningis dros xdeba yvela minis swrafi nawilobrvi daTvaliereba citoteqniqosis mier, xolo swrafi gadaxedva xdeba mxolod im minebisa, romelic pirvelad CaTvlili iyo negatiurad (Arbyn et al., 2003).

swrafi preskriningis organizaciuli upiratesobaa is, rom misi meSveobiT xdeba paTologiuri SemTxvevebis umetesobis swrafi gamovlena. aRsaniSnavia, rom procesze zegavlenas ar axdens minaze manamde gakeTebuli aRniSvnebi. swrafi preskriningi warmoadgens mniSvnelovan xarisxis kontrolis proceduras, romelic mgrZnobelobiT daaxloebiT utoldeba swraf gadaxedvas, da aRemateba 10%-ian srul re-skrinings.

randomizebulad aRebuli negatiurad Sefasebuli minebis fraqciis randomizebuli reskriningi

randomuli reskriningi farTod gamoiyeneba aSS-Si, agreTve zogierT evropul qveynebSi. CLIA'88-is rekomendaciiT unda moxdes negatiurad Sefasebuli nacxebis sul mcire 10%-is reskriningi. nacxebi, romelic SeirCeva reskriningisaTvis SeiZleba iyos:

paTologiuri sisxldenis/gamonadenis (mag.: intermenstrauciuli, postkoitusuri, postmenopauzuri) anamnezis SenTxvevebi;

ganmeorebiTi cerviqsuli/vaginuri infeqciebis SemTxvevebi; wina kvlevisas paTologiurad Sefasebuli SemTxvevebi kolposkopiuri kvlevisas cerviqsis paTologiur mdgomareobad

Sefasebuli SemTxvevebi. damiznebiTi re-skriningi ar aris standartizebuli da misi SesaZlebloba, gamoavlinos damatebiTi dazianebebi, ar aris Sedarebuli sxva meTodebTan, rogoricaa randomizebuli an swrafi reskriningi an prereskriningi.

xarisxis Sida kontroli citologiuri da klinikur/histologiuri kvlevebis Sedegebis korelaciaze dayrdnobiT

citologiuri gamokvlevis Sedegebis korelacia klinikur mimdinareobasTan qmnis mniSvnelovan aspeqts xarisxis kontrolisaTvis.

cito-klinikuri korelaciisaTvis. mniSvnelovania kontaqti klinicistebTan, aseve kibos registrSi arsebuli informaciis xelmisawvdomoba.

laboratorias unda qondes im pacientebze zedamxedvelobis meqanizmi, romelTa citologiac saeWvoa maRali xarisxis intraepiTelur dazianebaze an invaziur karcinomaze. cito-histologiuri korelaciis Sefaseba warmoadgens rogorc citologis, ise histologisaTvis uwyveti ganaTlebisa da profesiuli ganviTarebis mniSvnelovan berkets.

laboratoriaSi unda moxdes yvela paTologiuri citologiuri Sedegis Sedareba Semdgomi histopaTologiuri kvlevis SedegTan da garkveuli unda

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iyos Seusabamobis yvela mizezi. korelaciis procesi dokumentirebuli unda iyos laboratoriis xarisxis kontrolis programaSi. maRali korelacia warmoadgens citologiuri diagnostikis pozitiuri prognozis safuZvels.

citologiur-virusologiuri kvlevis Sedegebis korelacia: HPV testireba gamoiyeneba winaswar SerCeuli samizne populaciis gamokvlevis mizniT. im pacientebisaTvis, romelTac daudgindaT ASCUS - is diagnozi, HPV pozitiuroba unda aRiniSnos sul mcire, SemTxvevaTa 30%-Si.

uwyveti Sida ganaTleba

rTuli diagnostikuri SemTxvevebis erToblivi ganxilva citoteqnikosebis da/an citopaTologebis mier, mniSvnelovnad uwyobs xels individuri codnis xarisxis amaRlebas. amasTanave, mniSvnelovania:

bolo gamoSvebis citologiuri literaturiT kargi momarageba;

xelmisawvdomi erTi an meti on-lain citologiuri Jurnalis arseboba;

citoteqnologebisa da citopaTologebis monawileoba regularul SexvedrebSi da SemTxvevebis ganxilvaSi.

6.5. xarsixis gare kontroli

uwyveti gare ganaTleba

miuxedavad imis, rom qveynebis umetesobaSi savaldebulo araa uwyveti ganaTlebis sistemaSi monawileoba, is unda warmoadgendes nebismieri xarisxis kontrolis programis mniSvnelovan nawils. uwyveti ganaTleba warmoadgens mniSvnelovan komponents citologiuri diagnostikis profesionalizmis amaRlebisaTvis masSi monawileoba SeiZleba:

samuSao Sexvedrebsa da simpoziumebze daswrebiT;

SemTxvevebis regionuli interlaboratoriuli ganxilviT;

profesiul testirebaSi monawileobiT;

citoteqnologiis swavlebiT studentebisaTvis, klinikuri paTologiis specialobis rezidentebisaTvis.

regionuli, erovnuli an saerTaSoriso sazogadoebebis wevrobac unda CaiTvalos gare uwyvet ganaTlebis miRebis erT-erT formad. sxva laboratoriebis profesional citoteqnikosebTan da citopaTologebTan kooperacia aZlierebs profesiuli zrdis motivacias.

xarsixis gare kontroli skriningis unarCvevebi

profesiuli testireba savaldebuloa zogierT, (Tumca ara yvela) evropul qveyanaSi. citologiis saerTaSoriso akademiis mier mowodebulia profesiuli testireba da resertifikacia uwyveti ganaTlebisaTvis

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(www.cytology-iac.org ). citologiuri sazogadoebebis evropuli federaciis EFCS mier mowodebulia e.w. QUATE testi. es testi emyareba profesiul testirebis sistemas, romelic gamoiyeneba did birtaneTsa da farTodaa miRebuli daniaSi da italiaSi (www.cytology-efcs.org). testirebisaTvis gamoyenebuli minebis dizaini ar unda gansxvavdebodes Cveulebrivisagan. maT unda axldes diagnozi mosaxerxebeli formiT da Tu SesaZlebelia, Tan Sesabamisi histologiuri preparatebic.

6.6. laboratoriuli erTeulis akreditacia

winaswar gansazRvruli standartebis mixedviT, gareSe organizacia amowmebs (Cooper & Hewison, 2002) da saboloo gamokvlevis Semdeg uzrunvelyofs citologiuri laboratoriis sertificirebas. standartebi warmoadgens SeTanxmebul dokumentebs, romlebic Seicaven teqnikur da sxva kriteriumebs, romlebic daculi unda iqnas yoveldRiuri muSobis dros. gare standartebi unda gansxavdebodes Sida standartebisagan. sxvadasxva saerTaSoriso/erovnuli saakreditacio saagentoebi sTavazoben sertificirebas laboratoriebis gare Semowmebis gziT. akreditaciis SemTxvevaSi ganisazRvreba citologiuri ganyofilebis minimaluri standarti. kerZod, skriningis procesSi unda monawileobdes sul mcire oTxi piri da weliwadSi unda xdebodes, minimum, 1500 nacxis Sefaseba. re-sertifikacia aucilebelia yovel sam weliwadSi erTxel. akreditirebulma laboratoriam xelmisawvdomi unda gaxados Sesabamisi klinikuri informacia da Semowmebis monacemebi skriningul programaSi monawile sxva laboratoriebisaTvis.

6.7 zogadi praqtikis eqimebi, ginekologebi da nacxis amRebi sxva pirebi

masalis amRebi piri informirebuli unda iyos yovelwliurad maT mier aRebuli aradamakmayofilebeli an arsakmarisi xarisxis nacxebis procentuli raodenobis Sesaxeb (qveynis/regionis/laboratoriis saSualo procentul maCvenebelTan SedarebiT). es informacia unda aisaxos Sesabamis formaSi da unda miewodos skriningul programaSi monawile laboratorias.


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2. Arbyn M. & Schenck U. (2000). Detection of false negative Pap smears by rapid reviewing: a metaanalysis.Acta Cytol. 44: 949-957.

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service through the European Model of total quality management. Int J Health Care Qual Assur Inc Leadersh Health Serv 12: 54-58.

5. Baker A. & Melcher D.H. (1991). Rapid cervical cytology screening. Cytopathology 2: 299-301. Baker R.W., Wadsworth J., Brugal G., & Coleman D.V. (1997). An evaluation of 'rapid review' as a method of quality control of cervical smears using the AxioHOME microscope. Cytopathology 8: 85- 95.

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8. Burnett D., Blair C., Haeney M.R., Jeffcoate S.L., Scott K.W., & Williams D.L. (2002). Clinical pathology accreditation: standards for the medical laboratory. J Clin Pathol 55: 729-733.

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14. Gill G.W., Frost J.K., & Miller K.A. (1974). A new formula for a half-oxidized hematoxylin solution that neither overstains nor requires differentiation. Acta Cytol. 18: 300-311

15. . Grenko R.T., Abendroth C.S., Frauenhoffer E.E., Ruggiero F.M., & Zaino R.J. (2000). Variance in the interpretation of cervical biopsy specimens obtained for atypical squamous cells of undetermined significance. Am.J.Clin.Pathol. 114: 735-740.

16. Houliston D.C., Boyd C.M., Nicholas D.S., & Smith J.A. (1998). Personal performance profiles: a useful adjunct to quality assurance in cervical cytology. Cytopathology 9: 162-170.

17. Hutchinson M.L. (1996). Assessing the costs and benefits of alternative re-screening strategies. Acta Cytol. 40: 4-8.

18. Kaminsky F.C., Benneyan J.C., & Mullins D.L. (1997). Automated re-screening in cervical cytology. Mathematical models for evaluating overall process sensitivity, specificity and cost. Acta Cytol. 41: 209-223.

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20. Klazinga N. (2000). Re-engineering trust: the adoption and adaption of four models for external quality assurance of health care services in western European health care systems. Int J Qual Health Care 12: 183-189.

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24. Melamed M.R. (1996). Re-screening for quality control in cytology. Acta Cytol. 40: 12-13. 25. Mitchell H. & Medley G. (1995). Differences between Papanicolaou smears with correct and

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29. O'Sullivan J.P., A'Hern R.P., Chapman P.A., Jenkins L., Smith R., Al-Nafussi A., Brett M.T., Herbert A., McKean M.E., & Waddell C.A. (1998). A case-control study of true positive versus false negative cervical smears in women with cervical intraepithelial neoplasia (CIN) III. Cytopathology 9: 155- 161.

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35. Schenck U., Engelhardt W., Hinrichs F., Jordan B., Müller-Wallraf R., Tenberken K., & Witting C. (1998). Leitlinie zur Zertifizierung von zytologisch tätigen Assistenten/innen in der Gynäkologischen Zytologie durch die Deutsche Gesellschaft Für Zytologie (DGZ).

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37. Smith P.A. & Hewer E.M. (2003). Examination for the Certificate in Advanced Practice in Cervical Cytology--the first year's experience. Cytopathology 14: 101-104.

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7 xarisxis kontrolis gzamkvlevi saSvilosnos yelis histopaTologiuri gamokvlevisaTvis

gamokvlevis histopaTologiuri meTodi uzrunvelyofs dazianebaTa saboloo diagnostikas, ris safuZvelzec xdeba Sesabamisi mkurnalobis SerCeva. igi warmoadgens oqros standarts citologiuri da kolposkopiuri gamokvlevis xarisxis kontrolisaTvis. garda amisa, diagnostikuri informaciis ZiriTadi nawili, romelic inaxeba "kibos registrSi" da gamoiyeneba skrininguli programebis monitoringis mizniT, miRebulia swored histopaTologiuri gamokvlevis Sedegad. histopaTologiuri gamokvlevis Cvenebas warmoadgens persistuli dabali xarisxis dazianebebi, HPV asocirebuli dazianebebis CaTvliT, aseve, maRali xarisxis dazianebebi. citopaTologiuri gamokvleviT SesaZlebelia daisvas rogorc jirkvlovani paTologiebis, ise maRali xarisxis CIN, AIS an invaziuri karcinomis savaraudo diagnozi. histopaTologi kargad unda erkveodes im citologiuri cvlilebebis tipebSi, romelic SeiZleba Seesabamebodes histopaTologiur diagnozs. histopatologiuri diagnozis sizuste pirvel rigSi damokidebulia aRebuli masalis adeqvaturobaze. es SeiZleba iyos kolposkopis kontroliT Catarebuli damiznebiTi biofsiiT (saWiroebis SemTxvevaSi endocerviqsuli kiuretaJiT), transformaciuli zonis mokveTiT (eqscizio), an konizaciiT miRebuli masala. Semdeg, diagnozis sizustes gansazRvravs Sesabamisi makroskopuli aRweriloba, teqnikuri damuSaveba, mikroskopiuli interpretacia da xarisxis kontroli citologiuri da histologiuri diagnozis Sedarebis gziT.

saSvilosnos yelis citologiuri gamokvleva warmoadgens pirvelad skriningul meTods, magram am meTodiT ar xdeba saboloo diagnostika. citologiur nacxSi paTologiis aRmoCenis SemTxvevaSi tardeba kolposkopiuri gamokvleva da xdeba saSvilosnos yelidan aRebuli qsovilis mikroskopiuli Seswavla. adeqvaturi kolposkopiuri daTvalierebis mizania saSvilosnos yelis paTologiuri ubnebis moniSvna biofsiisaTvis. histopaTologiuri diagnozis sarwmunooba damokidebulia biofsiuri masalis adekvaturobaze. biofsiiT aRebuli qsovili, mcire zomis gamo (xSirad milimetrebis farglebSi), saWiroebs zedmiwevniT frTxil damuSavebas. Tu citologiuri diagnozi ar dasturdeba histologiuri gamokvleviT, paTologma unda CaTvalos rom displaziuri dazianebis interpretacia ver moxerxda misi mcire zomis, an endocerviqsuli lokalizaciis gamo. amgvarad, calkeul SemTxvevebSi garkvevis mizniT, aucilebelia citologiuri da histologiuri gamokvlevis mWidro korelacia.

eqsciziuri biofsia warmoadgens qsovilovani masalis aRebis specialur saxes. am dros xdeba citologiurad, kolposkopiurad an biofsiuri masalis gamokvleviT aRmoCenili displaziuri dazianebebis sruli amokveTa. eqsiciziuri biofsiuri masalis Seswavlisas, histopaTologiur diagnozSi naTlad unda iyos aRniSnuli pirveladi dazianebis diagnozi da rezeqciuli kideebis aRweriloba, radgan mikroinvaziis arseboba mniSvnelovan da ZiriTad zegavlenas axdens pacientebis Semdgom menejmentze. rekomendebulia amokveTili qsovilis daWra Tanmimdevrul

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seriul naWrebad _ sruli Seswavlis mizniT. damatebiTi imunohistoqimiuri gamokvleviT xdeba SesaZlo mikroinvaziis an procesSi sisxlZarRvebis monawileobis gansazRvra, agreTve brtyelujredovani da jirkvlovani neoplaziebis diferenciacia (Obermair et al., 1998; Birner et al., 2001).

7.1. damiznebiTi biofsia

damiznebiTi biofsia warmoadgens ramdenime milimetri diametris qsovilis mcire zomis fragmentebs, romelic moSorebulia cerviqsis lorwovanidan biofsiuri maSiT.

damakmayofilebeli kolposkopiis SemTxvevaSi, Tu kolposkopiiT SesaZlebelia CIN-is aSkara ubn(eb)is vizualizacia, damiznebiTi biofsiuri masalis histologiuri Seswavla sakmarisia saboloo diagnostikisaTvis.

aucilebelia masalis masis, diametris, feris, konsistenciis dokumentacia.

saSvilosnos yelis mravlobiTi biofsiis SemTxvevaSi, aucileebelia cerviqsis yvela im ubnis calke interpretacia, saidanac aRebuli iyo masala. masala fiqsirdeba 4%-ian buferul formalinSi oTaxis temperaturaze, Semdeg xdeba parafinSi Cayalibeba rutinuli teqnologiiT. 4-mikroniani parafinuli anaTlebi iRebeba Hhematoqsilin-eoziniT da/an muSavdeba specialuri SeRebvis meTodebisaTvis da saWiroebis SemTxvevaSi imunohistoqimiuri gamokvlevisaTvis.

histopaTologiuri diagnozi:

histopaTologiur diagnozSi unda aRiniSnos:

qsovilis tipi; neoplaziuri dazianebis arseboba/ararseboba da dazianebis tipi; identificirebuli dazianebis xarisxi (avTvisebianobis xarisxi): brtyelujredovani dazianebebi: cerviqsuli intraepiTeliuri neoplazia

1-3 (CIN 1-3), invaziuri kibo; jirkvlovani dazianebebi: maRali da dabali xarisxis cerviqsuli

jirkvlovani intraepiTeliuri neoplazia (CGIN), invaziuri adenokarcinoma an adenosqvamozuri karcinoma;

HPV –sTan asocirebuli cvlilebebi (koilocitebi, diskeratozi); dazianebis zoma (mm); araneoplaziuri dazianebebis aRweriloba; stromuli reaqcia: anTebis an desmoplaziuri reaqciis arseboba da

gavrceleba; invaziuri kibos arsebobis SemTxvevaSi aRniSnuli unda iyos: invaziis

siRrme, limfovaskuluri sistemis monawileoba procesSi da diferenciaciis xarisxi.

am gaidlainis mkacri moTxovnaa CIN-is histologiuri klasifikacia. yuradReba unda iqnas gamaxvilebuli sami xarisxis CIN-is diagnostirebis

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kriteriumebze (CIN 1-3) (WHO, 2003). CIS rogorc wesi gvxvdeba CIN3-Tan kombinaciaSi (didi britaneTis erovnul kibos registrSi orive maTgani iwereba rogorc "saSvilosnos yelis in situ karcinoma"). cnobilia rom farTod gavrcelebuli CIN1/koilocitozisaTvis (Seesabameba LSIL-s) damaxasiaTebelia spontanuri ukuganviTareba da asocirdeba HPV-is produqciul infeqciasTan. CIN2 da CIN3/karcinoma in situ (Seesabameba HSIL-s) ufro metadaa midrekili persistenciisa da progresisaken, Tu ar moxdeba maTi mkurnaloba. am dazianebebSi arsebobs HPV-is genomSi integraciis maRali albaToba. sxvadasxva kvlvebiT naCvenebia CIN2-is regresis ufro maRali albaToba progresis albaTobasTan SedarebiT, gansxvavebiT CIN3-isagan, sadac piriqiT, progresis albaToba sWarbobs regresisas. mcire zomis biofsiur masalaSi, zogjer saWiroa CIN-is miTiTeba rogorc "daudgeneli xarisxis", Tumca msgavs interpretacias unda moveridoT, sadac diagnozis dasma SesaZlebelia. moumwifebeli brtyelujredovani metaplazia da atrofiuli brtyelujredovani epiTeliumi SeiZleba gaxdes mcdari interpretaciis mizezi da SecdomiT miCneul iqnas CIN1-2-ad. msgavs SemTxvevebSi saboloo diagnozis dasmaSi gvexmareba p16-ze pozitiurobis gamovlena da ganmeorebiTi biofsia estrogeniT datvirTvis Semdeg. CGIN-is xarisxis zusti gansazRvra SeuZlebelia. (WHO, 2003). maRali xarisxis avTvisebianobis CGIN, romelic uTanabrdeba adenokarcinoma in situ-s, da dabali xarisxis CGIN eqvemdebareba erTsa da imave menejments. dabali xarisxis avTvisebianobis CGIN-is gamotana diagnozSi iSviaTad xdeba, amasTanave, sifrTxilea saWiro misi diferencirebisas keTilTvisebiani dazianebebisgan, romelic SeiZleba mas gavdes. igive SeniSvnebi Seexeba jirkvlovani displaziis da atipiis diagnostikasac (WHO, 2003).

1. CIN1 (brtyeli kondiloma; koilocitebi; msubuqi displazia): neoplaziuri, bazaluri ujedebi da mitozuri figurebi ikavebs epiTeliumis qveda erT mesameds. am dazianebis dros xSirad aRiniSneba gamoxatuli HPV citopaTiuri efeqtebi perinukleuri sicarieleebis, mravalbirTvianobis, birTvebis membranebis araregularobis da hiperqromaziis (e.w. koilocitozi) CaTvliT.

CIN2 (zomieri displazia): neoplaziuri bazaluri ujredebi da mitozuri figurebi ikavebs epiTeliumus qveda or mesameds. am ujredebis birTvul-citoplazmuri indeqsi maRalia, citoplazma Raribi, birTvi mkvrivi, hiperqromuli, araswori kideebiT; qromatini uxeSi granuluri beltebis saxiT ganawilebuli.

CIN3 (mZime displazia/karcinoma in situ): neoplaziuri bazaluri ujredebi da mitozuri figurebi ikavebs epiTeliumis mTel sisqes. am ujredebis birTv-citoplazmuri indeqsi maRalia, citoplazma Raribi, birTvi mkvrivi, hiperqromuli, araswori kideebiT; qromatini uxeSi granuluri beltebis saxiT ganawlebuli (IARC, 2005).

2. CGIN-is histologiuri interpretacia emyareba arqiteqturuli da citologiuri paTologiebis kombinacias, Tumca mudmivi maxasiaTebelia birTvuli paTologiis arseboba. yovelTvis yvela maxasiaTebeli ar aRiniSneba. arqiteqturuli maxasiaTeblebia: jirkvlebis dajgufeba da,

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gantotebebi. sadinrebSi Sida papiluri gamonazardebi, zrdis kribriformuli (“dacxriluli”) tipi. citologiuri maxasiaTeblebia: mkveTri gadasvla normul da paTologiur epiTeliumebs Soris; intestinuri/fialiseburujredovani metaplazia; mitozuri figurebis arseboba, romelTagan zogi paTologiuria; kargad gamoxatuli birTvakebi; apoptozi. mikroinvaziuri adenokarcinomisagan sadiferenciacio ZiriTadi niSania procesSi mxolod jirkvlovani qsovilis monawileoba, agreTve normuli da paTologiuri jirkvlebis erTmaneTSi Sereva; ar aRiniSneba stromuli reaqcia da mikroinvaziuri adenokarcinomisaTvis damaxasiaTebeli citologiuri cvlilebebi (gazrdili polimorfizmi, ufro metad uxvi da eozinofiluri citoplazma).

7.2. eqsciziuri biofsia

eqsciziuri biofsiuri masala warmoadgens daaxloebiT cilindruli formis qsovils saSvilosnis yelidan, romelic Seicavs endocerviqsuli arxis qveda nawils da eqtocerviqsis nawils. eqsciziuri biofsiis saxeebia: civi daniT (skalpeliT) Catarebuli konizacia, lazeruli konizacia da transformaciuli zonis eqscizio maryuJiT (cold knife conisation (CKC), laser conisation (LC) and Large Loop Excision of the Transformation Zone (LLETZ)/ Loop Electrosurgical Excisional Procedure (LEEP)). civi daniT da lazeriT konizaciiT miRebuli biofsiuri masala warmoadgens cilindruli formis qsovils, maSin rodesac LLETZ/LEEP-masala SemTxvevaTa umetesobaSi warmodgenilia ufro metad diskiseburi formis, eqtocerviqsis nawiliT, zogjer damatebiTi qsoviliT, romelic miiReba endocerviqsis arxis Sua nawilidan.

diagnostikuri miznebi

eqsciziuri biofsiis mizania mTeli paTologiuri qsovilis (romelic gamovlinda kolposkopiiT) amokveTa endocerviqsis arxis da transformaciuli zonis CaTvliT. procedura unda iyos diagnostikuric (unda gvaZlevdes zust histologiuri diagnozis dadgenis saSualebas) da Terapiulic (unda axdendes dazianebis mocilebas mTlianad).

makroskopiuli aRweriloba

makroskopiuli aRweriloba moicavs masalis zomis (sigrZe da diametri), cerviqsul arxSi lokalizaciis (centruli, paracentruli an marginuli), nebismieri xiluli dazianebis, agreTve nebismieri saorientacio aRniSvnis/nakeris mdebareobis Sefasebas (Horn et al., 1999).

teqnologia

eqsciziuri biofsiiT, rogorc wesi, xdeba mTeli transformaciuli zonis mocileba, endocerviqsis arxis qveda nawilis CaTvliT. aucilebelia biofsiuri masalis garkveviT moniSvna (mag: feriT an ZafebiT 12 saaTze), raTa Semdgomi damuSavebisas SesaZlebeli iyos adeqvaturi orientacia

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(Robboy et al., 1994; Robboy et al., 2002). cerviqsis arxis mTlianoba SenarCunebuli unda iyos da ar unda Seicvalos winaswari dilataciiT. arsebobs eqsciziuri biofsiiT miRebuli masalis daWris sxvadasva meTodi. praqtikaSi iyeneben: qinZisTaviT dafiqsirebuli nedli masalis radialur daWras an dafiqsirebuli masalis seriul daWras swori kuTxiT saSvilosnos yelis gareTa piris mimarT. martivi da advilad gansaxorcielebeli meTodia qsovilis gayofa or Tanabar naxevrad, saSvilosnos yelis arxis sigrZivi RerZis paralelurad. am gziT damuSavebuli masala advilia saorientaciod da sainterpretaciod, aseve, rezeqciis kideebis sworad SefasebisaTvis (naxati #17 da #18).

1. radialuri kveTa moicavs masalis sigrZivad gaxnas da radialur

naWrebad dayofas. TiToeuli naWris Tanmimdevruli identifikacia gvaZlevs dazianebis mdebareobis da gavrcelebis zusti gansazRvris saSualebas.

2. paraleluri kveTa unda moxdes masalis minimum erTi kidis

moniSvna melniT. mravalferiani melnis gamoyeneba aadvilebs sxvadasxva kideebis swor orientacias. Tu masala daiyofa wina da ukana nawilebad, ukana nawilis danomvra unda moxdes igive wesiT, rogorc wina nawilis.

3. or nawilad dayofa masalis saSvilosnos yelis arxis sigrZivi

RerZis paralelurad. TiToeuli naxevari unda moiniSnos feradi melniT sul mcire erT kideze. unda ganxorcieldes TiToeuli nawilis 0,1 mm-iani bijiT seriuli kveTa.

naxati #17

histopaTologiuri diagnozi

eqsciziuri biofsiuri masalis histopaTologiuri gamokvlevis diagnozis forma unda gvaZlevdes srulyofil informacias dazianebis Sesaxeb. diagnozi aseve SesabamisobaSi unda iyos saSvilosnos yelis simsivneebis janmo-s histologiur klasifikaciasTan (Tavi 7.8). garda dazianebis histologiuri tipis zusti aRwerilobisa, diagnozSi aRniSnuli unda iyos Semdegi informacia:

neoplaziuri dazianebis avTvisebianobis xarisxi;

dazianebis lokalizacia eqsciziur bifsiur masalaSi;

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dazianebis uni/multifokaluroba;

dazianebis gavrceleba (mikroinvaziuri da invaziuri kibos SemTxvevaSi, stadiurobis adeqvaturi Sefaseba xdeba vertikaluri da horizontaluri diametrebis gazomviT);

stromuli reaqcia;

mikrosisxlZarRvebis CarTuloba dazianebis procesSi;

simsivnuri qsovilis kavSiri rezeqciis yvela kidesTan (daSoreba kideebidan);

damatebiTi araneoplaziuri cvlilebebis aRweriloba da daxasiaTeba (tubuloendometrioiduli metaplazia, mikroglanduluri hiperplazia, endometriozi, regeneraciuli da reparaciuli cvlilebebi);

termini ”mikroinvaziuri karcinoma” SeiZleba exebodes rogorc brtyelujredovan karcinomebs, ise adenokarcinomebs. es termini gamoiyeneba mxolod im SemTxvevaSi, rodesac diagnozSi aRniSnulia saRi qsovilis farglebSi amoWrili dazianebis siRrmis da lateraluri gavrcelebis detaluri gazomvis Sedegebi. diagnozis dazusteba xdeba FIGO-s definiciebis mixedviT _ 1A1 Tu 1A2 stadia (Tavi 7.7). invaziis siRrme unda gaizomos epiTeliumis bazaluri membranidan, xolo dazianebis lateraluri gavrceleba _ unda gaizomos yvelaze farTo naWerSi. 1A1 stadiis dazianebebis dros invaziis siRrmea 3 mm-ze naklebi da sigane naklebia 7 mm-ze. xolo 1A2 stadiis dazianebebis dros invaziis siRrmea 3 – 5 mm, da sigane naklebia 7 mm-ze. adenokarcinomebi unda gaizomos da Caiweros imave saxiT, magram ar arsebobs 1A1 da 1A2 simsivneebis ganmasxvavebeli sarwmuno kriteriumebi. Tu ar xerxdeba invaziuri dazianebis gazomva ise, rogoc naCvenebia zemoT, igi aRwerili unda iqnas rogorc mcire zomis invaziuri karcinoma da klasificirdes rogorc 1B1. limfovaskuluri invazia unda Caiweros, magram igi ar cvlis FIGO-s stadias.

7.3. endocerviqsuli kiuretaJi (ECC)

endocerviqsuli kiuretaJiT xdeba qsovilis aReba endocerviqsidan.

diagnostikuri mizani

endocerviqsuli kiuretaJis mizania:

eqtocerviqsis nebismieri brtyelujredovani dazianebis Sefaseba, romelic vrceldeba endocerviqsis arxSi;

endocerviqsis adenokarcinomis da misi winare dazanebebis gamovlena;'

nebismieri cerviqsgareTa avTvisebiani procesis gamovlena, romelic vrceldeba saSvilosnos yelzec.

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endocerviqsuli kiuretaJi damiznebiTi biofsiasTan kombinaciaSi gvaZlevs saSualebas histologiurad SevafasoT rogorc eqto-, ise endocerviqsi,

saSvilosnos yelidan qsovilis mniSvnelovani nawilis amoWris gareSe. miuxedavad amisa, mxedvelobaSi unda iqnas miRebuli, rom endocerviqsuli kiuretaJi xasiaTdeba SezRuduli mgrZnobelobiT CIN-is da CGIN-is mimarT. metic, endocerviqsuli kiuretaJi cvlis endocerviqsis arxis arqiteqturas, rac gasaTvaliswinebelia Semdgomi konizebuli masalis gamokvlevisas (Hoffman et al., 1993; Mogensen et al., 1997; Boardman et al., 2003).

makroskopuli aRweriloba

unda aRiniSnos masalis fragmentebis raodenoba, diametri, feri da konsistencia.

teqnologia

endocerviqsuli kiuretis gamoyenebiT xdeba qsovilis aReba endocerviqsis arxis yvela kedlidan.

rekomendebulia biofsiuri masalis seriuli daWra.

histopaTologiuri diagnozi

kiuretaJiT miRebuli qsovilis aRwerisas unda Sefasdes:

endocerviqsis jirkvlebis arseboba, endometriuli qsovilis da brtyeli epiTeliumis arseboba;

jirkvlovani an brtyelujredovani intraepiTeliuri neoplaziuri da araneoplaziuri cvlilebebi;

invaziis arsebobis niSnebi; neoplaziuri da araneoplaziuri stromuli cvlilebebi; anTebiTi procesis arseboba da tipi.

7.4. imunohistoqimia

imunohistoqimia warmoadgens damxmare meTods im SemTxvevaSi, rodesac hematoqsiliniTa da eoziniT SeRebili anaTlebiT ver xerxdeba sakmarisi diagnostikuri informaciis miReba (mag. intraepiTeliuri invaziuri neoplaziis dadastureba an gamoricxva). saSvilosnos yelis displaziuri dazianebis Seswavla imunohistoqimiuri meTodiT, ujredTan asocirebuli cilebis sawinaRmdego sxvadasxva antisxeulebiT, gvaZlevs damatebiT informacias rTulad sadiagnostiko SemTxvevebis dros.

sakmaod xSirad gamoiyeneba proliferaciuli markerebi formalinSi dafiqsirebuli da parafinSi Cayalibebuli masalis kvlevisas:

Ki67 antigeni warmoadgens arahistonur cilas, romelic eqspresirdeba birTvSi ujredis ciklis yvela fazis dros garda G0-isa. parafinul

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anaTlebze Ki67 antigenis gamosavlenad Yyvelaze xSirad Ggamoiyeneba monoklonuri antisxeuli MIB1. Ki67 imunopozitiurobis mateba, Cveulebriv, korelaciaSia displaziis xarisxis matebasTan (Bulten et al., 1996). metic, Ki67-is eqspresia gvaZlevs saSvilosnos yelis atrofiuli epiTeliumis (negatiuria Ki67-ze) da neoplaziuri an displaziuri epiTeliumis (pozitiuria Ki67-ze) diferenciaciis saSualebas (Bulten et al., 2000).

proliferaciuli birTvuli antigeni (PCNA), romelic warmoadgens polimeraza-asocirebul cilas da sinTezirdeba ujredis ciklis adreul G1 da S fazebSi, aseve SeiZleba warmoadgendes damxmare markers (Smela et al.,1996).

saSvilosnos yelis neoplaziis dros aRiniSneba p16-s Warbi eqspresia, rac saSualebas gvaZlevs movaxdinoT cerviqsis namdvili CIN/displaziis diferenciacia moumwifebeli metaplaziis an cerviqsis sxva araneoplaziuri cvlilebebisgan (Obermair et al., 1998; Birner et al., 2001).

7.5. monacemebis Segroveba

laboratorias unda qondes standartuli moTxovnis forma ginekologebisaTvis, romelic Seicavs pacientis administraciul monacemebs, informacias wina citologiuri, kolposkopiuri da saSvilosnos yelis/saSvilosnos/saSos/vulvis histologiuri kvlevis Sesaxeb. garkveviT unda iyos miTiTebuli biofsiis tipi da Semdgomi Carevis Cvenebebi. paTohistologiuri diagnozis gaformebis Semdeg parafinis blokebi da minebi inaxeba ganusazRvreli drois ganmavlobaSi, principulad isini unda Seinaxos sul mcire pacientis sicocxlis manZilze.

paTohistologiuri diagnozis forma, rogorc minimumi, unda Seicavdes:

pacientis ZiriTad monacemebs; momarTvis TariRs; masalis specifikurobis aRweras; detalurad Sejamebul paTohistologiur diagnozs, romelic

kodirebulia histologiuri klasifikaciis saerTo standartebis mixedviT.

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7.6. xarisxis kontroli

yvela momsaxure personali, romelic muSaobs saSvilosnos yelis skriningis histologiur nawilSi, kargad unda iyos garkveuli mTeli muSaobis procesSi. xarisxis Sida kontroli moicavs laboratoriis samuSao wignis Canawerebis kontrols, usafrTxoebis instruqciebs da protokolebs (Vutuc et al.). mniSvnelovania regularuli Sida Sexvedrebi teqnikuri sakiTxebis garkvevis, treningebis organizebisa da diagnostikuri problemebis garCevis mizniT. rekomendebulia paTologiebis, citoteqnikosebis da ginekologebis interdisciplinuri Sexvedrebis mowyoba.

naxati #18

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7.7. saSvilosnos yelis kibos stadiebi FIGO-s mixedviT

0 stadia _ carcinoma in situ, cervikaluri intraepiTeliuri neoplazia CIN III (daavadeba ar scildeba bazalur membranas, invazias adgili ar aqvs);

I stadia _ kibo ar scildeba saSvilosnos yelis sazRvrebs (saSvilosnos tanis invazia ar miiReba mxedvelobaSi);

IA stadia _ mikroinvaziuri kibo, romelic klinikurad ar vlindeba, diagnozi ismeva mikroskopiuri kvleviT;

IA1 _ stromuli invazia ar aRemateba 3 mm-s, xolo dazianebis horizontaluri zoma ar aRemateba 7 mm-s. (optimaluri mkurnalobis pirobebSi sicocxlis 5 wliani xangrZlivoba aRiniSneba SemTxvevaTa 98%-Si);

IA 2 _ stromuli invaziis siRrmea 3 mm-dan 5 mm-mde, xolo dazianebis horizontaluri zoma ar aRemateba 7 mm-s. (optimaluri mkurnalobis pirobebSi sicocxlis 5 wliani xangrZlivoba aRiniSneba SemTxvevaTa 95%-Si);

IB _ kibo ar scildeba saSvilosnos yels da is an klinikurad vizualizdeba, an aRiniSneba IA2 –ze meti xarisxis mikrodazianeba;

IB1 _ xiluli dazianeba ar aRemateba 4 sm-s (optimaluri mkurnalobis pirobebSi sicocxlis 5 wliani xangrZlivoba aRiniSneba SemTxvevaTa 85 %-Si);

IB 2 _ xiluli dazianeba, aRemateba 4 sm-s (optimaluri mkurnalobis pirobebSi sicocxlis 5 wliani xangrZlivoba aRiniSneba SemTxvevaTa 75 %-Si);

II stadia _ kibo scildeba saSvilosnos yelis sazRvrebs (saSvilosnos tanis invazia ar miiReba mxedvelobaSi);

II A _ kibo scildeba saSvilosnos yelis sazRvrebs, aRiniSneba saSos zeda ori mesamedis invazia, magram parametriumi Tavisufalia (optimaluri mkurnalobis pirobebSi sicocxlis 5 wliani xangrZlivoba aRiniSneba SemTxvevaTa 75 %-Si);

II B _ kibo scildeba saSvilosnos yelis sazRvrebs, aRiniSneba parametriumis invazia, magram ar vrceldeba menjis kedlamde da saSos qveda erT mesamedze (optimaluri mkurnalobis pirobebSisicocxlis 5 wliani xangrZlivoba aRiniSneba SemTxvevaTa 65 %-Si);

III stadia _ kibo vrceldeba menjis kedlamde an saSos qveda mesamedze, iwvevs hidronefrozis da Tirkmlis ukmarisobis Camoyalibebas;

III A _ kibo vrceldeba saSos qveda mesamedze, magram ar vrceldeba menjis kedlamde (optimaluri mkurnalobis pirobebSi sicocxlis 5 wliani xangrZlivoba aRiniSneba SemTxvevaTa 30 %-Si);

III B _ kibo vrceldeba menjis kedlebamde da iwvevs hidronefrozis da Tirkmlis ukmarisobis Camoyalibebas (optimaluri mkurnalobis pirobebSi sicocxlis 5 wliani xangrZlivoba aRiniSneba SemTxvevaTa 30 %-Si);

IV stadia _ kibo vrceldeba sxva organoebSi;

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IV A _ Sardis buStis da swori nawlavis invazia (optimaluri mkurnalobis pirobebSi sicocxlis 5 wliani xangrZlivoba aRiniSneba SemTxvevaTa 10 %-Si);

IV B _ Soreuli metastazebi (menjis gare mdebare limfur kvanZebSi, TirkmlebSi, ZvlebSi, filtvebSi, RviZlSi, Tavis tvinSi) (optimaluri mkurnalobis pirobebSi sicocxlis 5 wliani xangrZlivoba aRiniSneba SemTxvevaTa 5 %-ze naklebSi).

7.8. saSvilosnos yelis avTvisebiani simsivneebis janmos mier mowodebuli klasifikacia

epiTeliuri simsivneebi brtyelujredovani simsivneebi da maTi winamorbedebi brtyelujredovani karcinoma araspecifiuri tipis keratinizebuli arakeratinizebuli bazaloiduri verukozuli kondilomatozuri papiluri limfoepiTeliomis msgavsi brtyelujredovani - gardamavali mikroinvaziuri brtyelujredovani karcinoma brtyelujredovani inrtaepiTeluri neoplazia saSvilosnos yelis intraepiTeliuri neoplazia CIN 3/brtyelujredovani karcinoma in situ keTilTvisebiani brtyelujredovani dazianebebi wvetiani kondiloma brtyelujredovani papiloma fibroepiTeliuri polipi jirkvlovani simsivneebi da maTi winamorbedi dazianebebi adenokarcinoma mucinuri karcinoma endocerviqsuli intestinuri beWdiseburujredovani minimaluri cvlilebiT viloglanduluri endometrioiduli adenokarcinoma naTelujredovani karcinoma serozuli adenokarcinoma mezonefruli adenokarcinoma

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mikroinvaziuri adenokarcinoma adenokarcinoma in situ jirkvlovani displazia keTilTvisebiani jirkvlovani dazianebebi miuleruli papiloma endocerviqsuli polipi sxva epiTeliuri simsivneebi adenosqvamozuri karcinoma naTelujredovani varianti adenoiduri cisturi karcinoma adenoiduri bazaluri karcinoma neiroendokrinuli simsivneebi karcinoidi atipiuri karcinoidi mcire ujreduli karcinoma didujredovani neiroendokrinuli karcinoma aradiferencirebuli karcinoma

mezenqimuri simsivneebi da simsivnis msgavsi procesebi

leiomiosarkoma endometriuli stromuli sarkoma, dabali xarisxis avTvisebianobis aradiferencirebuli endocerviqsuli sarkoma botroiduli sarkoma rbili qsovilebis alveoluri sarkoma angiosarkoma periferiuli nervebis avTvisebiani simsivne leiomioma genitaluri rabdomioma postoperaciuli TiTistara ujredebis kvanZi Sereuli epiTeliuri da mezenqimuri simsivneebi

karcinosarkoma (avTisebiani miuleruli Sereuli simsivne, metaplaziuri karcinoma) adenosarkoma vilmsis simsivne adenofibroma adenomioma melanocituri simsivneebi

avTvisebiani melanoma nevusujredovani nevusi

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Sereuli simsivneebi

germinaciuli xazis simsivneebi yviTris parkis simsivneebi dermoiduli cista mwife cisturi teratoma limfoiduri da hematopoezuri simsivneebi

avTvisebiani limfoma leikemia meoradi simsivneebi


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6. Crum C.P., Egawa K., Fu Y.S., Lancaster W.D., Barron B., Levine R.U., Fenoglio C.M., & Richart R.M. (1983). Atypical immature metaplasia (AIM). A subset of human papilloma virus infection of the cervix. Cancer 51: 2214-2219.

7. Goldstein N.S., Ahmad E., Hussain M., Hankin R.C., Perez-Reyes N. (1998). Endocervical glandular atypia: does a preneoplastic lesion of adenocarcinoma in situ exist? Am. J. Clin. Pathol. 110:200-209.

8. Heatley M.K. (2001). How many histological levels should be examined from tissue blocks originating in cone biopsy and large loop excision of the transformation zone specimens of cervix? J Clin Pathol 54: 650-651.

9. Hoffman M.S., Sterghos S.Jr., Gordy L.W., & Gunasekar D. (1993). Evaluation of the cervical canal with the endocervical brush. Obstet. Gynecol. 82: 573-577.

10. Horn L.C., Riethdorf L., & Loning T. (1999). Leitfaden für die Präparation uteriner Operationspräprate. Pathologe 20: 9-14.

11. IARC (2005). Cervix Cancer Screening. IARC Handbooks of Cancer Prevention. Vol. 10. IARCPress, Lyon.

12. Ismail S.M., Colclough A.B., Dinnen J.S., Eakins D., Evans D.M., Gradwell E., O'Sullivan J.P., Summerell J.M., & Newcombe R.G. (1989). Observer variation in histopathological diagnosis and grading of cervical intraepithelial neoplasia [see comments]. BMJ 298: 707-710.

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13. Klaes R., Benner A., Friedrich T., Ridder R., Herrington S., Jenkins D., Kurman R.J., Schmidt D., Stoler M., & von Knebel D.M. (2002). p16INK4A immunohistochemistry improves interobserver agreement in the diagnosis of cervical intraepithelial neoplasia. Am. J. Surg. Pathol. 26: 1389-1399.

14. Klaes R., Friedrich T., Spitkovsky D., Ridder R., Rudy W., Petry U., Dallenbach-Hellweg G., Schmidt D., & von Knebel D.M. (2001). Overexpression of p16(INK4A) as a specific marker for dysplastic and neoplastic epithelial cells of the cervix uteri. Int. J. Cancer 92: 276-284.

15. Kobak W.H., Roman L.D., Felix J.C., Muderspach L.I., Schlaerth J.B., & Morrow C.P. (1995). The role of endocervical curettage at cervical conization for high-grade dysplasia. Obstet. Gynecol. 85: 197-201.

16. Melnikow J., Nuovo J., Willan A.R., Chan B.K.S., Howell L.P. (1998). Natural history of cervical squamous intraepithelial lesions: a meta-analysis. Obstet. Gynecol. 92:727-35.

17. Mitchell M.F., Tortolero-Luna G., Wright T., Sarkar A., Richards-Kortum R., Hong W.K., Schottenfeld D. (1996). Cervical human papillomavirus infection and intraepeithelial neoplasia: a review. J Natl Cancer Inst Monog 21:17-25.

18. Mogensen S.T., Bak M., Dueholm M., Frost L., Knoblauch N.O., Praest J., & Svanholm H. (1997). Cytobrush and endocervical curettage in the diagnosis of dysplasia and malignancy of the uterine cervix. Acta Obstet Gynecol Scand 76: 69-73.

19. National Health Service Cervical Screening Programme (1999). Histopathology Reporting in Cervical Screening. Working Party of the Royal College of Pathologists and the NHS Cervical Screening Programme. NHSCSP publication 10, 16 pp. Sheffield, NHS Cancer Screening Programmes. Available at: www.cancerscreening.nhs.uk

20. Obermair A., Wanner C., Bilgi S., Speiser P., Reisenberger K., Kaider A., Kainz C., Leodolter S., Breitenecker G., & Gitsch G. (1998). The influence of vascular space involvement on the prognosis of patients with stage IB cervical carcinoma: correlation of results from hematoxylin and eosin staining with results from immunostaining for factor VIII-related antigen. Cancer 82: 689-696.

21. Ostor A.G. (1993). Natural history of cervical intraepithelial neoplasia: a critical review. Int J Gynecol Pathol 12:186-92

22. Pathology and Genetics of Tumours of the Breast and Female Genital Organs (2003). World Health Organization Classification of Tumours, IARCPress, Lyon

23. Pretorius R.G., Zhang W.H., Belinson J.L., Huang M.N., Wu L.Y., Zhang X., & Qiao Y.L. (2004). Colposcopically directed biopsy, random cervical biopsy, and endocervical curettage in the diagnosis of cervical intraepithelial neoplasia II or worse. Am. J. Obstet. Gynecol. 191: 430-434.

24. .Robboy S.J., Kraus F.T. & Kurman R.J. (1994). Gross discription: processing and reporting of gynecologic and obstretric specimens. In: Blaustein's pathology of the female genital tract. (ed Kurman R.J.), 4 edn, pp. 1225-1240. Springer-Verlag.

25. .Robboy S.J., Russell P., Anderson M.C., & Bentley R.C. (2002). Cutup - the gross description, processsing and reporting of specimens. Pathology of the Female Reproductive Tract 861-877.

26. .Singer A. & Monaghan J.M. (2000). Lower Genital Tract Precancer: Colposcopy, Pathology and Treatment., 2nd edn, Blackwell Science Ltd, Oxford.

27. Smela M., Chosia M., & Domagala W. (1996). Proliferation cell nuclear antigen (PCNA) expression in cervical intraepithelial neoplasia (CIN). An immunohistochemical study. Pol J Pathol 47: 171-174.

28. .Sobin L.H., Wittekind Ch. (eds.) (2002). TNM Classification of Malignant Tumours. 6th edition, Wiley-Liss, Inc. and WHO 2003.

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29. .Stoler M.H. & Schiffman M.A. (2001). Interobserver reproducibility of cervical cytologic and histologic interpretations. JAMA 285: 1500-1505.

30. Vutuc C., Haidinger G., Waldhoer T., Ahmad F., & Breitenecker G. (1999). Prevalence of selfreported cervical cancer screening and impact on cervical cancer mortality in Austria. Wien. Klin. Wochenschr. 111: 354-359.

8. atipiuri Pap-testis marTva

8.1. atipiuri brtyeli ujredebis (epiTeliocitebis) citologiuri diagnozis mqone qalebis marTva

ASC – atipiuri brtyeli ujredebi - epiTeliocitebi iyofa or kategoriad: atipiuri brtyeli epiTeliocitebi ganusazRvreli (ucnobi, dauzustebeli) mniSvnelobis atipiiT (ASC-US) da atipiuri brtyeli epiTeliocitebi HSIL-is gamoricxvis SeuZleblobiT (ASC-H). arsebobs sxvadasxva faqtorebi, romlebic unda iyos gaTvaliswinebuli ASC-is mqone qalTa marTvisas. pirvel rigSi is, rom ASC-is citologiuri diagnozi moicavs Zalze mcire informacias yvela sxva citologiur kategoriasTan SedarebiT (Stoler MH, 2001, Confortini M et al. 2003, Gatscha RM et al 2001). meore mxriv, invaziuri kibos gavrceleba dabalia ASC-is mqone qalebSi (< 0,1-0,2%) (Jones BA et al. 2001). da bolos, mniSvnelovania is faqtic, rom CIN2,3-is gavrceleba ufro maRalia ASC-H-is mqone qalebSi ASC-US-is mqone jgufTan SedarebiT. amis gamo, ASC-H-is marTva unda xdebodes HSIL-is analogiurad (NCCN Cervical Cancer Screening V.I.2009).

ALTS-s da sxva kvlevebis klinikuri monacemebi aCvenebs, rom 6-Tviani intervaliT Catarebuli 2-jeradi citologiuri gamokvleva, an HPV dnm testireba, an erTjeradi kolposkopiuri gamokvleva warmoadgens, tolfass, usafrTxo da efeqtur midgomas ASC-US-is mqone qalTa marTvisas (ASCUS-LSIL Triage Study (ALTS) Group 2003). pirdapiri kolposkopiuri kvleva mizanSewonilia im SemTxvevaSi, rodesac dakvirvebis reJimidan qalis amovardnis albaToba didia. vinaidan erTjeradi kolposkopiuri gamokvleviT SeiZleba gamorCenil iqnas mniSvnelovani dazianeba, kolposkopiaze gamogzavnili qalebi, visac ar aRmoaCndaT CIN2,3, saWiroeben damatebiT dakvirvebas.

8.2. dabali xarisxis brtyelujredovani intraepiTeliuri dazianebis

LSIL-is citologiuri diagnozis mqone qalebis marTva

metaanalizis monacemebiT, maRali (onkogenuri) riskis HPV dnm dadebiTi testi aRmoaCnda LSIL-is mqone qalTa 76,6%-s (Arbyn M et al 2006). LSIL-is mqone qalTa Soris kolposkopiuri gamokvleviT, CIN 2 an ufro mZime paTologia aRiniSneba SemTxvevaTa 12-16%-Si (Alvarez RD,et al 2007, Chute DJ et al 2006, ASCUS-LSIL Triage Study (ALTS) Group 2003 ). sami Sromis mixedviT LSIL-is da normuli kolposkopiis dros daavadebis ganviTarebis riski aris minimaluri (Hellberg

80

D et al 1994, Milne DS et al 1999, Teale GR et al 2000). LSIL-is mqone qalebis ganmeorebiTi PAP testi ubrundeba normas SemTxvevaTa 50%-Si (Teale GR et al 2000).

ALTS-is monacemebiT, CIN2,3-is riski LSIL-is mqone qalebSi msgavsia ASC-US-is mqone qalebisa. es saSualebas iZleva, aRniSnuli orive jgufis marTva moxdes erTnairad.

8.3. ASC-US-is da LSIL-is mqone qalTa marTvis rekomendaciebi

ASC-US da LSIL mqone qalebisaTvis rekomendebulia kolposkopiuri gamokvleva (rekomendaciis xarisxi A, mtkicebulebis done I) (naxati #19).

Tu kolposkopiuri kvleviT gamovlenili iqna CIN, maSin misi xarisxidan gamomdinare, is unda iyos marTuli Sesabamisi gaidlainis mixedviT. CIN-is xarisxis dasadgenad saWiroebisamebr unda Catardes damiznebiTi biofsia.

Tu cerviqsuli intraepiTeliuri dazianeba (CIN) ar iqna gamovlenili, maSin Pap testi unda Catardes 12 Tvis Semdeg (rekomendaciis xarisxi B, mtkicebulebis done II). Tu klinikurad vlindeba atrofiis niSnebi, maSin ganmeorebiTi citologiuri kvlevis win unda Catardes adgilobrivi estrogenTerapia. aseve, Tu saxezea infeqciuri faqtoriT gamowveuli mwvave anTeba, maSin windawin unda Catardes etiologiuri antimikrobuli mkurnaloba (European Guidlines for Quality Assuarence in Cervical Cancer Screening 2008).

aradamakmayofilebeli kolposkopiis pirobebSi, rodesac SCJ-is sazRvari ar vizualizdeba misi cerviqsul arxSi ganlagebis gamo, Tu 12-Tviani intervalis Semdeg isev gamovlinda atipiuri Pap diagnozi, normuli kolposkopiis miuxedavad unda Catardes cerviqsuli arxis kiuretaJi (ASCUS-is an LSIL-is SemTxvevaSi), xolo ASC-H-is an HSIL-is SemTxvevaSi marTva unda gagrZeldes Sesabamisi gaidlainis mixedviT (rekomendaciis xarisxi B, mtkicebulebis done II) (Thomas C. et al 2006. ASCCP guidline for the management of women with abnormal cervical cancer screening tests). Tu 12 Tvis Semdeg Pap testi iqneba negatiuri, maSin rekomendebulia dabruneba rutinuli citologiuri testirebis reJimSi (European Guidlines for Quality Assuarence in Cervical Cancer Screening 2008).

8.4. ASC-H-is mqone qalTa marTvis rekomendaciebi

ASC-H-is mqone qalebisaTvis rekomendebulia kolposkopiuri gamokvleva (rekomendaciis xarisxi A, mtkicebulebis done II) (NCCN Cervical Cancer Screening V.I.2009; Thomas C. et al 2006). (naxati #20).

Tu dazianeba vlindeba, cerviqsuli intraepiTeliuri dazianebis xarisxidan gamomdinare is unda iyos marTuli Sesabamisi gaidlainis mixedviT.

Tu kolposkopiuri kvleviT dazianeba ar vlindeba, ganmeorebiTi Pap testi unda Catardes 6 Tvis Semdeg (NCCN Cervical Cancer Screening V.I.2009). iseve

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rogorc ASCUS/LSIL-is SemTxvevaSi, atrofiis da infeqciis arsebobis dros windawin unda Catardes Sesabamisi mkurnaloba (European Guidlines for Quality Assuarence in Cervical Cancer Screening 2008). Tu 6 Tvis Semdeg isev vlindeba citologiuri atipia, xolo kolposkopia aris isev negatiuri, unda Catardes cerviqsuli arxis kiuretaJi (ASCUS-is an LSIL-is SemTxvevaSi) (rekomendaciis xarisxi B, mtkicebulebis done II) (Thomas C. et al 2006. ASCCP guidline for the management of women with abnormal cervical cancer screening tests), an diagnostikuri eqscizio (LEEP/LLETZ) (ASC-H-is an HSIL–is SemTxvevaSi)(NCCN Cervical Cancer Screening V.I.2009).

Tu 6-Tviani intervaliT Catarebul or Tanamimdevrul citologiur testSi ar iqna aRmoCenili intraepiTeliuri dazianeba an malignizaciis niSnebi, rekomendebulia dabruneba rutinuli citologiuri testirebis reJimSi (rekomendaciis xarisxi A, mtkicebulebis done I) (Thomas C. et al 2006. ASCCP guidline for the management of women with abnormal cervical cancer screening tests).

ASCUS, LSIL

kolposkopia, saWiroebisamebr

damiznebiTibiofsia

dazianeba (CIN) vlindeba,

dazianeba

(CIN) arvlindeba

saWiroebisamebrestrogenoTerapiada/an infeqciebis

mkurnaloba

CIN –is marTvagaidlainismixedviT

PAP testi 12 Tvis Semdeg

normuli

ASCUS, LSIL

rutinuliskriningi


damiznebiTi biofsia, Tu SCJ ar

vizualizdeba + cerviqsuli kiuretaJi

dazianeba (CIN)ar vlindeba




HSIL,

ASC-H

HSIL, ASC-H * -is marTva

gaidlainismixedviT

naxati # 19

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ASC_Hkolposkopia,

saWiroebisamebrdamiznebiTi

biofsia


dazianeba

(CIN) arvlindeba

saWiroebisamebrestrogenoTerapiada/an infeqciebis

mkurnaloba


PAP testi 6 da 12 Tvis

Semdeg

2-jer normuli

ASCUS, LSIL

rutinuliskriningi


damiznebiTi biofsia, Tu SCJ ar

vizualizdeba + cerviqsuli kiuretaJi

dazianeba (CIN)ar vlindeba




HSIL *,

ASC-H

kolposkopia, eqsciziuribiofsia

LEEP/LLETZ

naxati # 20

8.5. maRali xarisxis brtyelujredovani intraepiTeluri dazianebis HSIL-is citologiuri diagnozis mqone qalebis marTva

HSIL-is citologiuri diagnozi mianiSnebs cerviqsuli dazianebis maRali riskis arsebobaze.

erTjeradi kolposkopiuri gamokvleva CIN2-s an ufro mZime paTologias avlens HSIL-is mqone qalTa 53-66%-Si. amasTanave, CIN2 an ufro mZime dazianeba aRmoCenilia im qalTa 84-97%-Si, visac Cautarda maryuJiT eleqtroqirurgiuli eqscizios procedura (Alvarez RD, Wright TC., 2007. Massad LS et al., 2001, Dunn TS at al., 2003). HSIL-is mqone qalTa daaxloebiT 2%-s aqvs invaziuri kibo (.Jones BA, Davey DD 2000).

HSIL-is mqone qalebSi arsebobs CIN2-is an ufro mZime dazianebebis A da HPV dnm testis pozitiuri Sedegebis maRali sixSire. amgvarad, HPV an citologiuri testirebis ganmeorebiTi gamoyeneba ar aris mizanSewonili (Evans MF et al 2006).

vinaidan kolposkopiiT SeiZleba gamorCenil iqnas CIN2,3 dazianebis mniSvnelovani raodenoba, HSIL-is mqone qalebSi kolposkopiurad CIN2,3-is gamouvlinebloba ar warmoadgens CIN2,3 dazianebis ararsebobis utyuar dasturs. sistemurma da retrospeqtulma analizma uCvena, rom mikroinvaziis 56% da invaziuri dazianebis 30% gamorCenili iqna

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kolposkopiuri kvlevis dros (Hopman EH et al., 1998). gamorCenili kibos ori mesamedi aris kolposkopistis Secdomis, xolo erTi mesamedi TviTon kvlevis teqnikuri SezRuduli SesaZleblobebis Sedegi (Benedet JL et al.,1985, Liu WM et al 1989). dadgenilia, rom aradamakmayofilebeli kolposkopia ufro xSirad vlindeba invaziis dros (mikroinvaziis 61%-Si da invaziis 71%-Si), vidre CIN –is SemTxvevaSi (14%-Si) (Hopman EH et al., 1998).

Sedegad, HSIL-is mqone qalTa umetesobas sabolood utardeba diagnostikuri eqscizios procedura (Prendiville W. 2003). aqedan gamomdinare, HSIL-is mqone qalTa marTvisas bevri eqsperti sadiagnostiko da samkurnalo saxiT gamarTlebulad miiCnevs midgomas “aRmoaCine da umkurnale” _ sawyis gamokvlevad maryuJiT eleqtroqirurgiuli eqscizios Catarebas (Holschneider CH. et al, 1999, Numnum TM, et al. 2005). Tumca, gacnobierebuli unda iqnes isic, rom miuxedavad zemoaRniSnulisa, CIN2,3 dazianebaTa umetesoba uSualod mozardebsa da axalgazrdebSi regresirebs spontanurad (Melnikow J et al 1998, Peto J et al 2004).

8.6. HSIL-is mqone qalTa marTvis rekomendaciebi

HSIL-is mqone qalebisaTvis rekomendebulia kolposkopiuri gamokvleva (rekomendaciis xarisxi A, mtkicebulebis done I) (NCCN Cervical Cancer Screening V.I.2009; Thomas C. et al 2006; European Guidlines for Quality Assuarence in Cervical Cancer Screening 2008) (naxati #21).

Tu dazianeba vlindeba, cerviqsuli intraepiTeliuri dazianebis xarisxis miuxedavad unda Catardes eqsciziuri procedura (LEEP/LLETZ) (rekomendaciis xarisxi B, mtkicebulebis done II) (NCCN Cervical Cancer Screening V.I.2009; Thomas C. et al 2006; European Guidlines for Quality Assuarence in Cervical Cancer Screening 2008).

Tu kolposkopiuri kvleviT dazianeba ar vlindeba, unda gadaixedos Pap diagnozi, rac imas niSnavs, rom igive preparati unda iqnas Sefasebuli ori sxva citopaTologis mier** (rekomendaciis xarisxi C, mtkicebulebis done III). amave dros, unda iqnas aRebuli axali nacxi ganmeorebiTi citologiuri kvlevisaTvis (European Guidlines for Quality Assuarence in Cervical Cancer Screening 2008). Tu ganmeorebiTi Sefasebisas Secvlili iqneba saboloo diagnozi, marTva unda gagrZeldes am ukanasknelisaTvis SemuSavebuli gaidlainebis Sesabamisad (rekomendaciis xarisxi B, mtkicebulebis done II) xolo Tu Pap diagnozi ar Seicvala, miuxedavad imisa, rom kolposkopiurad dazianeba ar iqna gamovlenili, unda Catardes diagnostikuri eqsciziuri procedura (LEEP/LLETZ) (rekomendaciis xarisxi B, mtkicebulebis done II).

**- qarTvel eqspertTa konsensusi

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calke jgufs warmoadgenen axalgazrda asakis qalebi, visTvisac aqtualuria fertilobis sakiTxi. am SemTxvevaSi, damakmayofilebeli kolposkopiis pirobebSi da damiznebiTi biofsiiT da cerviqsuli arxis kiuretaJiT miRebuli masalis histologiuri kvleviT dadasturebuli maqsimum CIN1-is (≤CIN1) diagnozis dros, SesaZlebelia gamoviyenoT dakvirvebis taqtika. Pap testi da kolposkopia unda Catardes 6-Tviani intervaliT 1 wlis ganmavlobaSi (rekomendaciis xarisxi B, mtkicebulebis done III). Tu an Pap, an kolposkopiuri diagnozi SenarCunda, an ganicdis progress, maSin unda Catardes eqsciziuri procedura (LEEP/LLETZ). dakvirvebis 1 wlis Tavze, Tu qals zedized 2-jer aReniSna normuli, rogorc kolposkopiuri diagnozi, ise PAP testi, maSin is ubrundeba rutinuli skriningis reJims (rekomendaciis xarisxi B, mtkicebulebis done II) (Thomas C et al 2006).

naxati # 21

8.7. atipiuri jirkvlovani epiTeliocitebis AGC-is citologiuri diagnozis mqone qalebis marTva

AGC-is gamovlenis sixSire SedarebiT dabalia. magaliTad, aSS-is 2003 wlis monacemebiT AGC-is sixSire Seadgens mxolod 0,4%-s (Davey DD et al. 2004). Tumca AGC xSirad ganpirobebulia keTilTvisebiani paTologiebiT, rogoricaa anTebiTi cvlilebebi da polipebi, klinicistebs gaazrebuli unda hqondeT, rom AGC araiSviaTad asocirdeba mniSvnelovan neoplaziur mdgomareobebTan, maT Soris saSvilosnos yelis, endometriumis, sakvercxis da falopis milebis adenokarcinomasTan. bolo kvlevebma uCvena, rom AGC-is mqone qalTa 9-38%-s aReniSneba mZime neoplazia (CIN2,3, AIS), xolo 3-17%-s _ invaziuri kibo (Sharpless KE et al 2005, De Simone CP et al 2006, Tam KF et al 2003, Derchain SF et al 2004).

HSIL kolposkopia saWiroebisamebr

damiznebiTi biofsia

dazianeba

vlindeba *

dazianeba ar

vlindeba

PAP diagnozis gadaxedva

diagnozi Seicvala

diagnozi ar Seicvala

eqsciziuri procerdura (LEEP/LLETZ)

* calke jgufad SesaZlebelia gamoiyos axalgazrda asakis qalebi, damakmayofilebeli kolposkopiiT da ≤CIN1 diagnoziT. (ix. teqsti)

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AGC-is mqone qalTa Soris sayuradRebo paTologiaTa xarisxi da tipebi variaciobs asakTan erTad. miuxedavad imisa, rom sxvadasxva jirkvlovani dazianeba, malignizaciis CaTvliT, asocirdeba AGC-sTan, Zalze xSiria AGC-is mqone qalebSi btyelujreduli dazianebis (CIN) arseboba. ginekologiuri avTvisebiani procesi, 35 wlamde asakis qalebSi, ufros asakobriv jgufTan SedarebiT naklebad gvxvdeba. orsuloba ar cvlis Sefardebas AGC-sa da ginekologiur neoplazias Soris. AGC-is prognozuli Rirebuleba gacilebiT maRalia, vidre ASC-is da LSIL-is diagnozebis SemTxvevaSi. amitom, is qalebi romlebsac aReniSnebaT AGS diagnozi, saWiroeben yuradRebiT gamokvlevas. am ukanasknelTa Soris unda iyos kolposkopia, endocerviqsis da endometriumis gamokvleva. saSvilosnos yelis ganmeorebiTi citologiuri gamokvleva ar xasiaTdeba sakmarisi mgrZnobelobiT imisaTvis, rom gamoyenebuli iqnas AGC-is mqone qalebis sawyisi kvlevis testad (Krane JF et al 2004, Fetterman B et al 2006).

8.8. AGC-is mqone qalTa marTvis rekomendaciebi

Tu qalis asaki ar aRemateba 35 wels da endometriumis kibos risk faqtorebis arseboba ar aRiniSneba, unda Catardes kolposkopiuri kvleva da mxolod cerviqsuli arxis kiuretaJi (rekomendaciis xarisxi A, mtkicebulebis done II). endometriumis kibos risk faqtorebs miekuTvneba: gacximovneba, estrogenis miReba gestagenuri komponentis gareSe, policisturi sakvercxis sindromi, qronikuli anovulacia, tamoqsifeniT Terapia. Tu qalis asaki aRemateba 35 wels, an mas aReniSneba gaurkveveli etiologiis sisxldena saSodan, an Pap testSi vlindeba atipiuri endometriuli ujredebi, an saxezea endometriumis kibos ganviTarebis sxva risk-faqtorebi, maSin damatebiT unda Catardes endometriumis biofsiac (rekomendaciis xarisxi B, mtkicebulebis done II) (NCCN Clinical Practice Guidelines in Oncology. Cervical Cancer Screening. V.I.2009).

jirkvlovan paTologias specifiuri kolposkopiuri maxasiaTebeli ar aqvs. SesaZlebelia arsebobdes marcvlebis Serwyma da ZmarmJava-TeTrebadi cvlilebebi transformaciis zonis proqsimalurad. kolposkopiur kvlevas da damiznebiT biofsias jirkvlovani paTologiis gamovlenis mimarT aReniSnebaT dabali mgrZnobeloba. jirkvlovani atipiis gamo kolposkopiuri kvleva saWiroa TandarTuli CIN-is gamosavlenad, romelic SemTxvevaTa 50%-Si gvxvdeba, agreTve biofsiis adeqvaturi meTodis da masStabis gansazRvrisaTvis. (Luesley DM et al 1987, Cullimore JE et al 1992, Bertrand M et al 1987.)

Tu kolposkopia damakmayofilebelia, xolo dazianebis xarisxi ≤CIN1 da cerviqsuli kiuretaJis Sedegi normulia, SesaZlebelia SemTxvevis konservatiuli marTva (Pap testi da kolposkopia 6-Tviani intervalebiT 2 wlis ganmavlobaSi) (rekomendaciis xarisxi B, mtkicebulebis done II). yvela danarCen SemTxvevaSi unda Catardes diagnostikuri eqsciziuri procedura (rekomendaciis xarisxi B, mtkicebulebis done II) (Guidelines for the NHS Cervical

86

Screening Programme. 2004, European Guidlines for Quality Assuarence in Cervical Cancer Screening 2008).

SesaZlebelia eleqtromaryuJiT eqsciziuri kveTa (LEEP/LLETZ), Tumca upiratesoba eniWeba saSvilosnos yelis skalpeliT konizaciis proceduras, mokveTili qsovilis kideebis Termuli dazianebis Tavidan acilebis mizniT. aseve, diagnostikuri eqscizios procedura, miuxedavad uaryofiTi testisa (kolposkopia, endocerviqsis da endometriumis gamokvleva), SesaZloa savaldebulo iyos im qalebSi, visac aReniSnebaT AGC-neoplaziisken midrekilebiT (neoplaziis Sesabamisi atipiuri jirkvlovani ujredebi), AIS-is (adenocarcinoma in situ) an AGC-is diagnozi ganmeorebiTi citologiuri testirebiT.

axalgazrda asakis qalebSi, rodesac fertilobis sakiTxi aqtualuria da kolposkopia damakmyofilebelia, mTliani transformaciis zonis eqscizios SemTxvevaSi unda iqnas mokveTili cerviqsuli arxi 1-sm-is siRrmeze (Nicklin JL, et al 1991). ufrosi asakis qalebSi, an rodesac kolposkopia ar aris damakmayofilebeli, biofsiis siRrmem unda miaRwios 2-2,5 sm-s (Guidelines for the NHS Cervical Screening Programme 2004).

amokveTil qsovilis kideebis pozitiurobis SemTxvevaSi, saWiroa ganmeorebiTi kveTis Catareba negatiuri kideebis miRebamde raTa gamoricxul iqnes invaziis arseboba (Guidelines for the NHS Cervical Screening Programme, 2004).

mkurnalobis Semdeg saWiroa yuradRebiT dakvirveba. momdevni oTxi wlis ganmavlobaSi rekurentuli daavadeba gamovlenilia 15%-Si. dakvirveba unda ganxorcieldes Pap testiT, nacxSi aucileblad unda iyos endocerviqsuli ujredebi.

histereqtomiis Catareba dasaSvebia:

Tu orsuloba ar aris sasurveli;

eqsciziuri biofsiis Semdeg pozitiuri kideebis SemTxvevaSi;

Tu konizaciis Semdeg gamovlinda maRali xarisxis citologiuri atipia;

Tu qals ar aqvs konservatiuli mkurnalobis Catarebis survili;

Tu ganviTarda cerviqsuli stenozi, romelic xals uSlis adeqvatur dakvirvebas;

Tu arsebobs am operaciis sxva klinikuri Cveneba, rodesac invaziuri daavadebis arseboba gamoricxulia;

Tu miuxedavad adeqvaturad Catarebuli eqsciziuri biofsiisa, saxezea mopersistencie jirkvlovani citologiuri paTologiis arseboba (Guidelines for the NHS Cervical Screening Programme, 2004).

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8.9. Pap testSi endometriuli ujredebis mqone qalebis marTva

cerviqsuli skriningis amocanas ar warmoadgens endometriumis kibos gamovlena, Tumca iSviaTad, rogorc normuli, ise atipiuri endometriuli ujredebi gvxvdeba citologiur nacxSi da es xels uwyobs endometriumis kibos adreul diagnostikas. citopaTologma aseTi nacxis interpretaciis dros, garda morfologiisa, unda gaiTvaliswinos qalis asaki, menstruaciuli ciklis dRe, hormonuli Terapiis da saSvilosnos Sida kontracepciis moxmareba. yvela zemoxsenebuli faqtoris gaTvaliswinebiT rekomendirebulia:

Tu endometriuli ujredebi Seesabameba menstruaciuli ciklis fazas, maSin Semdgomi gamokvlevebi saWiro ar aris.

Tu endometriuli ujredebi ar Seesabameba menstruaciuli ciklis fazas, maSin Semdgomi gamokvlevebi saWiro ar aris axalgazrda asakis qalebSi, xolo ufros asakovan jgufSi saWiroa damatebiTi gamokvleva.

AGC

kolposkopia (saWiroebisamebrdamiznebiTi biofsia) dacerviqsuli kiuretaJi

(saWiroebisamebrendometriumis biofsia)

CIN1 vlindeba, jirkvlovanineoplazia arvlindeba da

kolposkopia arisdamakmayofilebeli

dazianeba (jirkvlovanida CIN) ar vlindeba,

kolposkopiadamakmayofilebeliaA


PAP testi 6 TveSi erTxel

2 wlisganmavlobaSi

4-jer normuli

ASCUS≤

rutinuliskriningi

kolposkopia

AGC

eqsciziuriprocedura

LEEP/LLETZ

dazianeba (jirkvlovani an CIN) vlindeba, an/da

kolposkopiaaradamakmayofilebelia

eqsciziuriprocedura

LEEP/LLETZ

naxati #22

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1. Tu endometriuli ujredebi vlindeba im qalebSi, romlebsac aqvT saSvilosnos Sida kontraceptivi (“spirali”), maSin Semdgomi gamokvlevebi saWiro ar aris;

2. Tu normuli endometriuli ujredebi vlindeba postmenopauzuri asakis qalebSi (miuxedavad imisa, isini Rebuloben Tu ara estrogenul Terapias), saWiroa Semdgomi gamokvleva. unda iqnas Catarebuli saSosmxrivi ultrabgeriTi kvleva endometriumis sisqis gansazRvrisaTvis. Tu es maCvenebeli ar aRemateba 4 mm-s, maSin damatebiTi gamokvleva aRar aris saWiro, xolo Tu endometriumis sisqe aRemateba 4 mm-s unda Catardes an endometriumis biofsia, an kiuretaJi, an histeroskopia kiuretaJiT;

3. atipiuri endometriuli ujredebis gamovlenis SemTxvevaSi, aseve unda Catardes ultrabgeriTi kvleva, histeroskopia da/an kiuretaJi.


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8. Confortini M, Carozzi F, Dalla Palma P, et al. Interlaboratory reproducibility of atypical squamous cells of undetermined significance report: a national survey. Cytopathology 2003;14 263-8.

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10. Davey DD, Neal MH, Wilbur DC, Colgan TJ, Styer PE, Mody DR. Bethesda 2001 implementation and reporting rates: 2003 practices of participants in the College of American Pathologists Interlaboratory Comparison Program in Cervicovaginal Cytology. Arch Pathol Lab Med 2004;128:1224-9.

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13. Dunn TS, Burke M, Shwayder J. A ”see and treat” management for high-grade squamous intraepithelial lesion pap smears. J Low Genit Tract Dis 2003;7:104-6.

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15. European Guidlines for Quality Assuarence in Cervical Cancer Screening 2008 16. Fetterman B, Shaber R, Pawlick G, Kinney W. Human papillomavirus DNA testing in

routine clinical practice for prediction of underlying cervical intraepithelial neoplasia 2,3_ at initial evaluation and in follow-up of women with atypical glandular cell Papanicolaou tests. J Low Genit Tract Dis 2006;3:179

17. Gatscha RM, Abadi M, Babore S, Chhieng D, Miller MJ, Saigo PE. Smears diagnosed as ASCUS: interobserver variation and follow-up.Diagn Cytopathol 2001;25:138-40.

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20. Hopman EH, Kenemans P, Helmerhorst TJ. Positive predictive rate of colposcopic examination of the cervix uteri: an overview of literature. Obstetrics and Gynecology Survey, 1998, 53: 97–106.

21. Krane JF, Lee KR, Sun D, Yuan L, Crum CP.Atypical glandular cells of undetermined significance.Outcome predictions based on human papillomavirus testing. Am J Clin Pathol 2004;121:87-92.

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situ and glandular atypia of the uterine cervix. British Journal of Obstetrics and Gynaecology, 1987, 94: 699–703.

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28. NCCN Clinical Practice Guidelines in Oncology. Cervical Cancer Screening. V.I.2009 29. Nicklin JL, Wright RG, Bell JR et al. A clinicopathological study of adenocarcinoma in situ

of the cervix. The influence of cervical HPV infection and other factors, and the role of conservative surgery. Australia and NewZealand Journal of Obstetrics and Gynaecology, 1991, 31: 179–183.

30. Numnum TM, Kirby TO, Leath CA 3rd, Huh WK, Alvarez RD, Straughn JM Jr. A prospective evaluation of ”see and treat” in women with HSIL Pap smear results: is this an appropriate strategy? J Low Genit Tract Dis 2005;9:2-6

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31. Peto J, Gilham C, Deacon J, et al. Cervical HPV infection and neoplasia in a large population-based prospective study: the Manchester cohort. Br J Cancer 2004;91:942-53.

32. Prendiville W. (2003a). LLETZ: theoretical rationale, practical aspects, clinical experience, optimizing the technique. In: Colposcopy: Management Options (eds Prendiville W., Ritter J., Tatti S. & Twiggs L.), pp. 75-89.

33. Saunders, Edinburgh Results of a randomized trial on the management of cytology interpretations of atypical squamous cells of undetermined significance ASCUS-LSIL Triage Study (ALTS) Group. Am J Obstet Gynecol 2003;188:1383-92.

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35. Tam KF, Cheung AN, Liu KL, et al. A retrospective review on atypical glandular cells of undetermined significance (AGUS) using the Bethesda 2001 classification. Gynecol Oncol 2003;91:603-7

36. Thomas C. Wright Jr, MD; L. Stewart Massad, MD; Charles J. Dunton, MD; Mark Spitzer, MD; Edward J. Wilkinson, MD; Diane Solomon, MD, for the 2006 American Society for Colposcopy and Cervical Pathology–sponsored Consensus Conference . 2006 consensus guidelines for the management of women with abnormal cervical cancer screening tests.American Journal of Obstetrics & Gynecology. October 2007 346-355

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9 saSvilosnos yelis gaRrmavebuli gamokvlevis meTodebi

9.1. kolposkopiuri kvleva

kolposkopi pirvelad Seqmnili iyo hainzelmanis mier (Hinselmann, 1925). is warmoadgens optikur xelsawyos, romelic iZleva optimaluri ganaTebis pirobebSi saSvilosnos yelisa da saSos gamokvlevis saSualebas 6-40-jeradi gadidebis pirobebSi. kolposkopi gamoiyeneba:

1. saSvilosnos yelis paTologiuri citologiuri pasuxis mqone qalTa SefasebisaTvis;

2. saSvilosnos yelis klinikurad saeWvo mdgomareobis mqone qalTa SefasebisaTvis.

SeniSvna: hainzelmanis Tanaxmad kolposkopis daniSnuleba aris misi gamoyeneba ZiriTadi skrining-meTodis saxiT ginekologiuri gamokvlevis

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dros. is amJamadac gamoiyeneba msgavsi daniSnulebiT evropisa da laTinuri amerikis zogierT qveynebSi, saSvilosnos yelis citologiur gamokvlevasTan kombinaciaSi. aRniSnuli mizniT kolposkopis gamoyeneba xasiaTdeba kiboswinare dazianebebis gamovlenis SedarebiT maRali mgrZnobelobiT, magram misi specifikuroba sakmaod dabalia populaciis skriningis TvalsazrisiT (ix. qveviT).

paTologiuri Pap-testis mqone qalebSi kolposkopiis mizans warmoadgens:

1. transformaciis zonis zusti topografiis gansazRvra;

2. citologiuri kvlevis Sedegad CIN-is arsebobaze eWvis dadastureba an gamoricxva;

3. invaziuri kibos dadastureba an gamoricxva;

4. jirkvlovani dazianebis dadastureba an gamoricxva;

5. mkurnalobis xelSewyoba da CIN-is progresis an ukuganviTarebis monitoringi.

transformaciis zona

transformaciis zona warmoadgens saSvilosnos yelis nawils, romelic embrionul periodSi dafarulia cilindruli epiTeliumiT da romelic Semdgomi metaplaziis procesis Sedegad xdeba brtyeli. es normuli movlenaa da aRiniSneba yvela qalSi. cilindruli epiTeliumis ubani, romelic metaplaziis procesis Sedegad gardaiqmneba brtyel epiTeliumad iwodeba transformaciis zonad. metaplaziis procesis stimulators warmoadgens saSos pH. dedis estrogenebis zemoqmdebiT, dabadebamde da dabadebis Semdeg mokle periodSi iwyeba metaplaziis procesi. Semdeg es procesi ferxdeba vidre qali miaRwevs pubertul asaks, rodesac sakuTari estrogenebis zemoqmedebiT saSos pH kvlav xdeba mJave da cilindruli epiTeliumi saSos mJavianobis pirobebSi metaplaziis Sedegad transformirdeba brtyel epiTeliumad. transformaciis zona mniSvnelovania imis gamo, rom swored aq aris SesaZlebeli displaziis (CIN) ganviTareba. Tu es ukanaskneli ar iqneba aRmoCenili da mocilebuli, man SesaZlebelia progresireba ganicados da gadaizardos brtyeli epiTeliumis invaziur karcinomaSi.

kolposkopiis meTodis aRwera (teqnika)

saTanado konsultaciis Semdeg qali Tavsdeba savarZelze. vulvis makroskopiuli (SeuiaraRebeli TvaliT) daTvalierebis Semdeg saSoSi idgmeba sarke saSvilosnos yelis vizualizaciis mizniT. gamoyenebuli sarkis zoma damokidebulia saSos anatomiaze. xdeba saSvilosnos yelis Camorecxva fiziologiuri xsnariT, amgvarad saSvilosnos yels cildeba lorwo, sisxli da saSos gamonadeni. am stadiaze mwvane filtris

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gamoyeneba aZlierebs kapilarTa arqiteqtonikis vizualizacias (Jordan, 1985; Sellors & Sankaranarayanan, 2003).

saSvilosnos yelis damuSaveba ZmarmJavis 3- an 5%-iani xsnariT `ZmarmJava-TeTrebadi~ ubnebis saxiT avlens kiboswinare dazianebebs. ZmarmJava-TeTrebadobis xarisxobrivi Sefaseba SesaZlebelia damuSavebidan minimum 20 wamis Semdeg. ZmarmJava iwvevs qsovilTa SeSupebas da ujredSida proteinebis koagulacias, ris Sedegadac mcirdeba epiTeliumis gamWvirvaloba (transparentoba). am ukanasknelis fonze ver xerxdeba epiTeliumqveSa kapilarebis vizualizacia da Tavad epiTeliumic fermkrTaldeba. kolposkopia xasiaTdeba dabali specifikurobiT, vinaidan ZmarmJava-TeTrebadi ubnebi yvela SemTxvevaSi rodi niSnavs kiboswinare dazianebas.

ZmarmJava-TeTrebadi epiTeliumiT aseve SeiZleba xasiaTdebodes:

1. umwifari brtyelujredovani metaplazia; 2. regenerirebadi epiTeliumi; 3. Tandayolili transformaciis zona; 4. adamianis papilomavirusuli infeqcia; 5. saSvilosnos yelis intraepiTeliuri neoplazia (CIN); 6. jirkvlovani intraepiTeliuri neoplazia; 7. invaziuri brtyelujredovani karcinoma; 8. adenokarcinoma.

kolposkopists unda SeeZlos originaluri brtyeli epiTeliumis, cilindruli epiTeliumis, brtyeli da cilindruli epiTeliumis sazRvris (SCJ) da transformaciis zonis amocnoba. transformaciis zona warmoadgens ubans, sadac viTardeba kiboswinare dazianebebi. mniSvnelovania, kolposkopistma sworad gansazRvros da Seafasos transformaciis zona da gadawyvitos, es ukanaskneli Seesabameba normas Tu ara. Tandayolili transformaciis zona (CTZ) warmoadgens saSvilosnos yelis (zogjer ki _ saSos) im nawils, romelic mucladyofnis periodSi warmodgenili iyo cilindruli epiTeliumiT, magram mucladyofnis periodSive da uSualod dabadebis Semdeg metaplaziis procesis Sedegad transformacia ganicada brtyel epiTeliumad. zogjer rTulia Tandayolili transformaciis zonis aRmoCena, magram mis maxasiaTebel Taviseburebas warmoadgens is, rom igi sustad ZmarmJava-TeTrebadia, ar iRebeba lugolis xsnariT. es zona araprofesionalis mier, SeiZleba SecdomiT miCneul iyos CIN 1, an VAIN-ad.

Tu SeuZlebelia brtyeli da cilindruli epiTeliumis sazRvris vizualizacia endocerviqsul arxSi transformaciis zonis gadanacvlebis Sedegad, sasurvelia arxis qveda nawilis daTvaliereba endocerviqsuli sarkis meSveobiT. im SemTxvevaSi, rodesac SesaZlebelia transformaciis zonis srulyofilad daTvaliereba, kolposkopia fasdeba damakmayofileblad. rodesac transformaciis zonis srulyofilad danaxva SeuZlebelia brtyeli da cilindruli epiTeliumis SeerTebis adgilis endocerviqsul arxSi Rrmad gadanacvlebis gamo, kolposkopia iTvleba aradamakmayofileblad.

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saSvilosnos yelis damuSaveba lugolis xsnariT (Sileris testi) iZleva brtyeli epiTeliumis homogenur muq yavisfer Seferilobas. aRniSnuls safuZvlad udevs is faqti, rom normuli brtyeli epiTeliumi mdidaria glikogeniT, romelic iodTan urTireTqmedebisas iRebeba yavisfrad. kiboswinare ujredebi gaRaribebuli arian glikogeniT da, cxadia, naklebad iRebebian iodiT. Sileris testi SesaZlebelia gamoyenebul iqnas paTologiuri ubnebis sademarkaciod mkurnalobis win. amasTanave, ar unda dagvaviwydes, rom glikogeniT Raribi yvela epiTeliuri ujredi rodia paTologiuri: umwifari brtyelujredovani metaplazia, regenerirebadi epiTeliumi, Tandayolili transformaciis zona da adamianis papilomavirusiT inficirebuli normuli epiTeliumi SesaZlebelia, aseve iyos glikogeniT Raribi da, Sesabamisad, ar SeiRebos lugolis xsnariT.

SeniSvna: Sileris testi dadebiTia im SemTxvevaSi, rodesac ubnebi ar iRebeba lugolis xsnariT.

cerviqsuli intraepiTeliuri neoplaziisaTvis (CIN) damaxasiaTebeli kolposkopiuri Taviseburebebi

arsebobs epiTeliumqveSa angioarqiteqtonikis cvlilebebi, romlebic miuTiTebs kiboswinare dazianebaze. isini Sejamebulia Semdeg paTologiebad:

1. punqtacia (laqovaneba): nazi an uxeSi _ gamomdinare dazianebis simZimidan;

2. mozaika: nazi an uxeSi _ gamomdinare dazianebis simZimidan;

3. atipiuri sisxlZarRvebi: saeWvo karcinomaze;

4. ZmarmJava-TeTrebadobis xarisxi: maRali xarisxis dazianeba dabali xarisxis dazianebasTan SedarebiT ufro intensiurad TeTrebadia;

5. dazianebis sazRvrebi: dabali xarisxis dazianebas axasiaTebs aramkveTri an dakbiluli boloebi, maSin rodesac maRali xarisxis dazianeba xasiaTdeba mkveTri swori konturebiT.

dabali xarisxis dazianebisaTvis damaxasiaTebel kolposkopiur Taviseburebebs warmoadgens dazianebis aris susti, mkrTali ZmarmJava-TeTrebadoba. aRniSnul SemTxvevaSi, SesaZloa, ver moxerxdes epiTeliumqveSa sisxlZarRvTa vizualizacia, magram Tu sisxlZarRvebi xilvadia, isini Rebuloben nazi punqtaciis an mozaikis formas. dazianeba ar iRebeba lugolis xsnariT.

maRali xarisxis dazianebisaTvis damaxasiaTebel kolposkopiur Taviseburebebs warmoadgens intensiuri ZmarmJava-TeTrebadi cvlilebebi, dazianebul areSi iodis CarTvis ararseboba, uxeSi punqtacia an mozaika, atipiuri sisxlZarRvebis arseboba. Tu atipiuri sisxlZarRvebi mkveTradaa gamoxatuli an araTanabarzomieria, saeWvoa malignizaciis arseboba.

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kolposkopiuri terminologia

saSvilosnos yelis paTologiisa da kolposkopiis saerTaSoriso federaciam (IFCPC) 2002 wels miiRo Sesworebuli kolposkopiuri klasifikacia da sabaziso kolposkopiuri terminologia (ix. cxrili 5) IFCPC-is mier rekomendebulia, rom aRniSmuli axali formati iqnas gamoyenebuli saSvilosnos yelis kibos kvlevis, klinikuri diagnostikis da mkurnalobis procesSi (Walker et al., 2003).

cxrili #5 kolposkopiuri maxasiaTeblebis klasifikacia, mowodebuli saSvilosnos yelis paTologiisa da kolposkopiis saerTaSoriso federaciis (IFCPC) mier 2002w.

I. normuli mdgomareobis kolposkopiuri maxasiaTeblebi originaluri (pirveladi) brtyeli epiTeliumi

cilindruli epiTeliumi transformaciis zona

II. paTologiuri mdgomareobis kolposkopiuri maxasiaTeblebi

sustad gamoxatuli ZmarmJava-TeTrebadi (aceto-TeTri) epiTeliumi

intensiurad gamoxatuli ZmarmJava-TeTrebadi (aceto-TeTri) epiTeliumi

nazi mozaika uxeSi mozaika nazi punqtacia (laqovaneba) uxeSi punqtacia (laqovaneba) nawilobrivi ioddadebiToba iodnegatiuroba atipiuri sisxlZarRvebi

III. invaziur karcinomaze saeWvo kolposkopiuri maxasiaTeblebi IV. aradamakmayofilebeli kolposkopia

brtyeli da cilindruli epiTeliumis sazRvari (SCJ) ar vizualizdeba

Zlieri anTeba, Zlieri atrofia, travma saSvilosnos yeli ar viazualizdeba

V. sxva paTologia kondilomebi

keratozi (leikoplakia) erozia anTeba atrofia deciduozi polipebi

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transformaciis zonis axali klasifikacia

IFCPC-is mier mowodebul axal klasifikaciaSi erT-erT yvelaze mniSvnelovan rekomendacias warmoadgens transformaciis zonis sami tipis gansazRvra (Walker et al., 2003; Prendiville et al., 2003). transformaciis zonis klasifikacia dafuZnebulia 3 maCvenebelze:

1. transformaciis zonis eqtocerviqsuli komponentis sidide;

2. transformaciis zonis zeda (proqsimaluri) sazRvris mdebareoba;

3. transformaciis zonis zeda (proqsimaluri) sazRvris xilvadoba.

gamoyofen transformaciis zonis sam tips: mTlianad eqtocerviqsze ganTavsebuls, an rodesac aRiniSneba eqtocerviqsuli da srulad vizualizebuli endocerviqsuli konponentis Tanaarseboba, an rodesac upiratesad endocerviqsuli ganlagebis gamo arasrulyofili vizualizaciaa (ix. naxati #23). transformaciis zonis eqtocerviqsuli komponenti gansazRvravs didia Tu patara transformaciis zona. `didi~ ninSavs imas, rom transformaciis zona moicavs eqtocerviqsis naxevarze mets.

transformaciis zonis aRniSnuli sami gansxvavebuli tipi gansazRvravs individur Terapiul midgomas. miuxedavad imisa, rom xSirad samkurnalod mxolod eqsciziuri procedura gamoiyeneba, maryuJis zomis da formis SerCevis dros unda iyos gaTvaliswinebuli transformaciis zonis tipi.

cxrili #6 transformaciis zonis TZ topografiuli klasifikacia (Prendiville, 2003b)

TZ-is tipi

sidide mdebareoba xilvadoba kolposkopiis

adekvaturoba

I tipi I tipi II tipi II tipi III tipi III tipi III tipi

patara didi patara didi _ patara didi

mTlianad eqtocerviqsze mTlianad eqtocerviqsze nawilobriv endocerviqsSi nawilobriv endocerviqsSi mTlianad endocerviqsSi nawilobriv endocerviqsSi nawilobriv endocerviqsSi

vizualizdeba srulad vizualizdeba srulad vizualizdeba srulad vizualizdeba srulad ar vizualizdeba srulad ar vizualizdeba srulad ar vizualizdeba srulad

damakmayofilebeli damakmayofilebeli damakmayofilebeli damakmayofilebeli aradamakmayofilebeliaradamakmayofilebeliaradamakmayofilebeli

transformaciis zona _ I tipi savsebiT misaRebia mkurnalobis rogorc eqsciziuri, ise destruqciuli meTodis gamoyeneba transformaciis zonis I tipis warmatebuli mkurnalobis mizniT. patara zomis transformaciis zonis SemTxvevaSi SesaZlebelia 2 × 1,5 sm zomis maryuJis gamoyeneba, maSin, rodesac didi zomis transformaciis zonis SemTxvevaSi SerCeuli unda iyos SedarebiT farTo maryuJi an maryuJTa kombinacia.

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transformaciis zona _ II tipi

transformaciis zonis II tipis SemTxvevaSi SesaZlebelia destruqciuli meTodis gamoyenebac, magram meti momxre yavs eqsciziur proceduras: 2 × 2 sm zomis maryuJis gamoyeneba patara zomis transformaciis zonis SemTxvevaSi, maryuJTa kombinacia ki _ didi zomis transformaciis zonis SemTxvevaSi.

transformaciis zona _ III tipi

eqsciziuri procedura savaldebuloa transformaciis zonis III tipis nebismier SemTxvevaSi. transformaciis zonis III tipi xasiaTdeba arasrulyofili eqscizios maRali riskiT. am SemTxvevaSi SeiZleba mizanSewonili iyos LEEP/LLETZ-is alternatiul meTodze fiqri. aseT alternativas warmoadgens rogorc mavTuliT eleqtroeqscizio, ise skalpeliT an qirurgiuli lazeriT Catarebuli eqscizio (Mor-Yosef et al.,1990).

kolposkopiuri kvlevis sarwmunooba

kolposkopia moiTxovs mravalwlian gamocdilebas, raTa gamomuSavdes kolposkopiuri suraTis aRqmisa da Sefasebis unari. gamocdil kolposkopists SesaZloa Seswevdes zusti histologiuri diagnozis ganWvretis unari, magram sazogadod, kolposkopiur-histologiuri korelaciis maCvenebeli ar aris maRali. (Hopman et al., 1995; Etherington et al., 1997).

testis sarwmunoobis obieqturi Sefaseba moiTxovs damoukidebel Semowmebas oqros standartis mixedviT, romelic, Cveulebriv, dafuZnebulia histologiuri kvlevis Sedegebze. ramdenadac sabiofsio ubnis SerCeva xdeba kolposkopis meSveobiT, kolposkopiis mgrZnobelobis Sefaseba gazviadebulia. uaryofiTi, anu normuli kolposkopiuri SemTxvevebi sakmaod xSirad miiCneva WeSmaritad “negatiurad” histologiuri dasabuTebis gareSe. metic, saSvilosnos yelis jirkvlovani paTologiis arsebobis an SCJ-is endocerviqsuli lokalizaciis SemTxvevaSi kolposkopia SeiZleba iyos cru uaryofiTi.

cxra kvlevis Sedegebis metaanalizma aCvena, rom kolposkopiis mgrZnobeloba da specifiuroba CIN2+-s aRmoCenis TvalsazrisiT Seadgenda Sesabamisad 85-96 % da 48-69 %-s (Mitchell et al., 1998). Tumca am kvlevaTa umravlesoba moicavs ama-Tu-im gadxras. CineTSi Catarebul erT-erT detalur kvlevaSi saSvilosnos yelis biofsia nawarmoebi iyo ara mxolod kolposkopiurad saeWvo ubnebidan, aramed

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naxati #23

kolposkopiurad negatiur SemTxvevebSic, transformaciis zonis oTxive kvadrantidan (Pretorius et al., 2001; Pretorius et al., 2004; Pretorius et al., 2006). damakmayofilebeli kolposkopiis pirobebSi CIN2 da meti dazianebis mqone qalebSi kolposkopiurad gansazRvruli biofsiis mgrZnobelobam Seadgina 57% (Pretorius et al., 2004). ALTS kvlevaSic aseve ASCUS-isa da LSIL-is mqone qalebSi kolposkopiurad 2 wlis ganmavlobaSi kumulirebuli CIN3-is gamovlenam, Sesabamisad, Seadgina mxolod 54% da 56% (ASCUS-LSIL. Triage Study Group, 2003a; ASCUS-LSIL. Triage Study Group, 2003b). sxva literaturuli wyaroebis mixedviT damakmayofilebeli kolposkopiis mqone pirebSi kolposkopiuri diagnostikis sizustis prognozuli maCvenebeli maRali xarisxis dazianebebTan mimarTebaSi Seadgens minimum 65%-s (Guidelines for the NHS Cervical Screening Programme 2004).

amgvarad, dabali specifikurobidan gamomdinare, kolposkopia ar aris rekomendebuli skrinig-meTodad. bolo monacemebi uCvenebs, rom kolposkopiis mgrZnobeloba saSvilosnos yelis arsebuli an dawyebiTi maRali xarisxis intraepiTeliuri neoplaziis SemTxvevaSi sagrZnoblad Camouvardeba mosalodnels.

kolposkopia warmoadgens mniSvnelovan gadasarCev (gadasaxarisxebel) meTods paTologiuri citologiuri Sedegebis mqone qalebis marTvisas.

TZ ganlagebuliaeqtocerviqsze, sruladvizualizdeba, SeiZlebaiyos patara an didizomis

TZ Sedgebaendocervikalurikomponentisagan, romelic sruladvizualizdeba daeqtocervkalurikomponentisagan, romelic SeiZleba iyospatara an didi zomis

TZ Sedgebaendocervikalurikomponentisagan, romelic srulad arvizualizdeba daeqtocervkalurikomponentisagan, romelic SeiZleba iyospatara an didi zomis

I tipi II tipi III tipi

transformaciis zona Sedgeba endocerviqsuli komponentisagan, romelic srulad vizualizdeba da eqtocerviqsuli komponentisagan, romelic SeiZleba iyos patara an didi zomis

transformaciis zona Sedgeba endocerviqsuli komponentisagan, romelic srulad ar vizualizdeba da eqtocerviqsuli komponentisagan, romelic SeiZleba iyos patara an didi zomis

transformaciis zona ganlagebulia eqtocerviqsze, srulad vizualizdeba, SeiZleba iyos patara an didi zomis

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saSosa da vulvis kolposkopiuri gamokvleva

Tavdapirvelad, sasurvelia vulvis makroskopiuli daTvalireba. saSos kedlebis gamokvleva warmoadgens kolposkopiuri gamokvlevis nawils. saSvilosnos yelis kolposkopiuri Sefasebis Semdeg saSos sarkis gamotanis kvaldakval SesaZlebelia saSos kedlebis daTvaliereba. SesaZlebelia paTologiuri procesebis (warmonaqmnebis) identifikacia da saTanado marTva. Tu saSvilosnos an saSos zedapiri ar Seesabameba normas, sasurvelia vulvis kolposkopiuri gamokvleva.

saSvilosnos yelis kolposkopiuri gamokvleva postmenopauzur asakSi

postmenopauzuri asakis qalebSi, romlebic ar Rebuloben CanacvlebiT estrogenul Terapias, saSvilosnos yeli SeiZleba iyos atrofiuli. saSvilosnos yelisa da saSos epiTeliumi Txeldeba, ase rom SesaZlebeli xdeba epiTeliumqveSa kapilaruli qselis vizualizacia, romelic Tavis mxriv, SeiZleba gamoiyurebodes wiTlad da atipiurad. aRniSnul SemTxvevebSi ZmarmJavas sinjis gamoyeneba kiboswinare dazianebis aRmoCenis mizniT nakleb efeqturia. Tu postmenopauri asakis qalebSi saSvilosnos yelis Sefasebisas wavawydebiT sirTuleebs, sasargeblo iqneba estrogenSemcveli intravaginaluri malamos mokle (3-4 kviriani) kursis daniSvna.

kolposkopia orsulobisa da mSobiarobis Semdgom periodSi

orsulobis dros kolposkopiuri gamokvlevis Cvenebas warmoadgens saSvilosnos yelis paTologiuri Pap-testi. orsuli qalis saSvilosnos yelis kolposkopiuri Sefaseba gacilebiT rTulia, vinaidan saSvilosnos yeli hipertrofirebulia, SeSupebulia da xasiaTdeba gaZlierebuli vaskularizaciiT. amitom, aRniSnul SeTxvevebSi, gamokvlevisTvis sasurvelia SedarebiT didi zomis sarkis gamoyeneba. saSvilosnos yeli Cveulebriv dafarulia lorwoTi, romelic Znelad cildeba. gansakuTrebiT pirvelad mSobiareebSi, SesaZlebelia, iyos umwifari metaplazia, romelic SeiZleba gaxdes mcdari diagnozis mizezi. saSvilosnos yelis epiTeliumi decidualuri cvlilebebis Sedegad SeiZleba daemsgavsos simsivnur epiTeliums. yvela aRniSnul faqtorTan erTad paTologiasTan asocirebulma sisxlZarRvovanma cvlilebebma gamoucdeli kolposkopisti SeiZleba Seiyvanos SecdomaSi, ris Sedegadac miviRebT realurTan SedarebiT gacilebiT ufro mZime diagnozs.

paTologiuri Pap-testis mqone orsuli qalebi Sefasebuli unda iyvnen gamocdili kolposkopistis mier. Tu kolposkopisti grZnobs, rom adgili aqvs malignizaciis citologiur an kolposkopiur niSnebs, sasurvelia biofsiis warmoeba an bioftatebis aReba. magram malignizaciis niSnebis ararsebobis SemTxvevaSi biofsiis warmoeba gadavadebuli unda iqnas

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mSobiarobis Semdgomi periodisTvis. orsulobis dros Catarebul biofsias xSirad axlavs sisxldena da nimuSi xSirad gamousadegari xdeba srulfasovani histologiuri SefasebisaTvis.

uSualod mSobiarobis Semdgom periodSic Znelia saSvilosnos yelis mdgomareobis Sefaseba. mSobiarobis Semdgom pirvel ovulaciamde, gansakuTrebiT im qalebSi, visac jer kidev laqtaciis periodi aqvT, saSvilosnos yeli SeiZleba gamoiyurebodes atrofiulad, rac kidev ufro arTulebs citologiur da kolposkopiur gamokvlvas. Tu zemoaRniSnuli qmnis diagnostikur problemebs, sasargeblo iqneba intravaginaluri estrogenoTerapiis mokle kursis Catareba. im SemTxvevebSi, rodesac ar arsebobs eWvi malignizaciaze, mizanSewonilia mocda da kolposkopiisa da/an mkurnalobis gadadeba im periodamde, rodesac estrogenebis Semcveloba daubrundeba normas.

daskvnebi

1. kolposkopia iZleva saSvilosnos yelis, saSosa da vulvis kiboswinare

dazianebebis identifikaciis, lokalizaciisa, aseve biofsiis adgilis gansazRvris saSualebas;

2. zogierT qveyanaSi, kolposkopia gamoiyeneba skrining-meTodad, magram gamomdinare misi dabali specifikurobidan, sasurveli ar aris misi gamoyeneba pirveladi skrinigisaTvis. igi unda iqnas gamoyenebuli im qalebis gamokvlevisaTvis, romelTac gamouvlindaT saSvilosnos yelis paTologiuri citologiuri Sedegi;

3. kolposkopiuri gamokvlevis Catareba savaldebuloa saSvilosnos yelis intraepiTeliuri neoplaziis mkurnalobis win;

4. kolposkopiuri gamokvleva sasurvelia Caataros mxolod kargad momzadebulma da gamocdilma kolposkopistma (NHSCSP, 1996a; NHSCSP, 1996b; NHSCSP, 1997; NHSCSP, 2004a);

5. kolposkopistebi unda axorcielebdnen TavianTi muSaobis audits (kritikuli Sefaseba), raTa daadasturon, rom maTi kolposkopiuri diagnozebi da mkurnalobis Sedegebi SesabamisobaSia saerTaSoriso doneze SeTanxmebul standartebTan;

6. kolposkopiuri kvlevis Sedegebi dafiqsirebuli unda iyos pacientis istoriaSi.

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9.2. saSvilosnos yelis biofsia

saSvilosnos yelidan biofsiuri masalis aReba unda warmoebdes kolposkopiuri kontrolis qveS, paTologiaze saeWvo yvelaze mkveTrad gamoxatuli cvlilebebis mqone ubnebidan.

mcire zomis qsovilis aReba SesaZlebelia sxvadasxva specialuri maSis (kolxotomis) saSualebiT. kolposkopistma unda uzrunvelyos saukeTeso nimuSis gagzavna paTologiur gamokvlevaze. savaldebuloa, rom bioftati moicavdes rogorc zedapirul epiTeliums, aseve epiTeliumqveSa stromas, raTa ganisazRvros dazianebis lokalizacia. savaldebuloa, rom bioftati moicavdes analizisaTvis sakmaris masalas. ar Seicavdes Termokoagulaciis ubnebs da swrafad iyos dafiqsirebuli formalinis xsnarSi. damiznebiTi biofsia xSirad ar xasiaTdeba sakmarisi siRrmiT, ris gamoc SesaZloa ver moxdes mikroinvaziuri dazianebebis diagnostika. Cveulebriv, adgilobrivi anesTezia ar aris savaldebulo, Tumca aSkaraa, rom adgilobriv anesTezias SeuZlia damiznebiT biofsiasTan dakavSirebuli diskomfortis Semcireba (Martin & Prendiville, 2004). aucileblobis SemTxvevaSi SesaZlebelia erTze meti biofsiuri masalis aReba. mcire biofsiis warmoeba SesaZlebelia agreTve mcire diametris maryuJis gamoyenebiT. am dros, sasurvelia, masalis aRebamde adgilobrivi anesTeziis Catareba. am meTods upiratesoba gaaCnia srulyofili nimuSis aRebis TvalsazrisiT, romelSic iqneba stromis Sesaferisi moculoba qsovilebis deformaciis gareSe (Cartier & Cartier, 1993; Abdel-Hady et al, 2001). mikroinvaziuri kibos aRmoCenis an gamoricxvis TvalsazrisiT, upiratesoba eniWeba mcire zomis maryuJiT aRebul biofsias, damiznebiT kolxotomiT aRebul biofsiasTan SedarebiT (Prendiville et al., 1986). Tu damiznebiTi biofsiis Sedegad vRebulobT araadekvatur histologiur diagnozs, sasurvelia ganmeorebiTi gamokvleva narCeni kolposkopiuri dazianebis gamovlenis mizniT.

biofsiuri masalis aRebis dros sisxldenis ganviTarebis SemTxvevaSi, misi SeCereba SesaZlebelia rogorc diaTermiis, ise monselis xsnariT sisxlmdeni zedapiris damuSavebis gziT (Anderson et al., 1996).

biofsiuri masalis histologiuri gamokvleva diagnostikuri TvalsazrisiT SesaZloa xasiaTdebodes garkveuli naklovanebebiT. erTi mxriv, arasworad aRebuli nimuSi warmoadgens dazianebis araswori Sefasebis ZiriTad mizezs, meore mxriv, histologiuri Sefasebis subieqturoba amcirebs mis sarwmunoebas (Ismail et al., 1989; Stoler & SChiffman, 2001).

damiznebiTma biofsiam yvelaze metad dazianebuli ubnidan, SeiZleba mogvces mxolod miniSnebiTi histologiuri diagnozi. damiznebiTi biofsiis Semdeg Catarebuli konizaciisa da histereqtomiis Sedegad miRebuli masalis histologiuri kvlevis SedarebiTma analizma uCvena, rom damiznebiTma biofsiam xSirad SeiZleba srulyofilad ver Seafasos arsebuli dazianebis simZime. maRali xarisxis CIN-is arasrulyofili Sefaseba xdeba SemTxvevaTa 4,3-57,1%-Si. CIN 3-is msgavsad SeiZleba ver moxerxdes adreuli invaziuri dazianebis diagnostikac.

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9.3. endocerviqsuli gamofxeka (kiuretaJi)

endocerviqsuli kiuretaJis (ECC) mizania endocerviqsis brtyelujredovani an jirkvlovani dazianebis gamovlena, romelic ver iqna moxvedrili kolposkopiuri kontroliT aRebul biofsiur masalaSi.

am manipulaciis Sedegad, rTulia invaziuri dazianebis arseboba-araarsebobis dadastureba, vinaidan nimuSi xSirad zedapirulia. garda amisa, endocerviqsuli kiuretaJi azianebs adgilobriv arqiteqtonikas, ris gamoc ispoba sxvaoba adenokarcinoma in situ-sa da invaziur adenokarcinomas Soris. endocerviqsuli masalis aReba endocerviqsuli jagrisis meSveobiT, diagnotikuri TvalsazrisiT xasiaTdeba SedarebiT dabali cru-uaryofiTi SedegebiT, vidre endocerviqsuli kiuretaJi (Andersen et al., 1988; Weitzman et al., 1988; Hoffman et al., 1993; Mogensen et al., 1997).

aSS-Si endocerviqsuli kiuretaJi xSirad gamoiyeneba saSvilosnos yelis biofsiasTan erTad. evropis qvenebSi ki aRniSnul kombinacias naklebad mimarTaven. aq endocerviqsuli dazianebis gamosaricxad upiratesobas aniWeben diagnostikur konizacias (Gath et al., 1995). dauSvebelia endocerviqsuli kiuretaJis gamoyeneba orsulobis periodSi (Wright et al., 2002).

10. cerviqsuli intraepiTeliuri neoplaziis marTva

10.1 kolposkopiurad/histologiurad gamovlenili CIN1-is marTva

CIN1, droTa ganmavlobaSi, SemTxvevaTa 60-70%-Si ubrundeba normas, 15%-Si ganicdis persistencias, xolo 0-30%-Si aris SesaZlebeli misi CIN2,3-Si, 1%-Si ki invaziur kiboSi gadasvla (Soutter et al., 1986; Bolger & Lewis, 1988; Anderson et al., 1992). kolposkopistma unda icodes, rom CIN1-is diagnozi yovelTvis ar aris sarwmuno. es naCvenebia ASCUS/LSIL kvlevaSi (2001), rodesac damiznebiTi biofsiiT miRebuli masalis histologiuri kvleviT dadgenili CIN1-is SemTxvevaSi preparatebis ganmeorebiTi Sefasebis dros diagnozi dadasturda mxolod 43%-Si, 41%-Si Sefasda rogorc norma, xolo SemTxvevaTa 13%-Si diagnozi damZimda CIN2,3-mde. sxva kvlevis dros, rodesac CIN1-is diagnozis gamo Catarda eqsciziuri mkurnaloba (LEEP/LLETZ), mokveTili qsovilis histologiuri analiziT dadginda, rom SemTxvevebis 23-55%-Si adgili hqonda CIN2,3-s (Massad et al., 1996).

mniSvnelovania is faqti, rom gamouvleneli (faruli) CIN2,3-is an karcinoma in situ-s arsebobis riski ufro maRalia CIN1-is mqone im qalebSi, romlebsac manamde citologiurad gamouvlindaT HSIL an atipiuri jirkvlovani ujredebi (AGC), CIN1-is mqone im qalebTan SedarebiT, romelTac win uZRoda citologiurad ASC (atipiuri brtyeli

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epiTeliocitebis) an LSIL Sedegebi. CIN2,3 gamovlenilia HSIL-is mqone qalTa 84-97%-Si, visTanac gamoyenebuli iyo maryuJiT eleqtroqirurgiuli eqscizios procedura (Massad LS et al. 2001, Alvarez RD et al. 2007, Dunn TS et al. 2003). amitom, calkea gamoyofili rekomendaciebi CIN1-is mqone qalebisaTvis, romelsac citologiurad manamde aReniSnaT HSIL an AGC.

dabali xarisxis dazianebis marTvis dros, erTi mxriv, unda iyos daculi balansi dazianebis TavisTavad ukuganviTarebasa da, meore mxriv, mkurnalobis gareSe dazianebis ufro maRali xarisxis “gaparvas” Soris.

10.2. CIN1-is mqone qalebis marTvis rekomendaciebi

SesaZlebelia orgvari midgoma: dakvirveba da mkurnaloba. orives aqvs dadebiTi da uaryofiTi mxareebi. unda iqnas ganxiluli ori varinti:

1. kolposkopia aris damakmayofilebeli:

am dros SesaZlebelia rogorc dakvirveba, ise mkurnloba. dakvirvebis dros unda Catardes ganmeorebiTi Pap testi da kolposkopia 12 da 24 Tvis Semdeg (rekomendaciis xarisxi B, mtkicebulebis done II). es midgoma gansakuTrebiT mizanSewonilia axalgazrda asakis qalebisaTvis (Moscicki et al., 2004). Tu dazianeba SenarCunebuli iqneba 2 wlis ganmavlobaSi, maSin unda iyos ganxiluli mkurnalobis esa Tu is meTodi (rekomendaciis xarisxi C, mtkicebulebis done II). mkurnalobis meTodi gansazRvruli unda iyos klinicistis mier, pacientis anamnezis, klinikuri mdgomareobis da materialur-teqnikuri SesaZleblobebis gaTvaliswinebiT (rekomendaciis xarisxi A, mtkicebulebis done I).

mkurnalobis SemTxvevaSi SesaZlebelia gamoyenebuli iyos rogorc ablaciuri, ise eqsciziuri meTodebi (rekomendaciis xarisxi A, mtkicebulebis done I). rekurentuli (ganmeorebiTi) CIN1-is SemTxvevaSi upiratesoba eniWeba mkurnalobis eqsciziur meTods (LEEP/LLETZ).

calke jgufad unda gamoiyos CIN1-diagnozis mqone is qalebi visTanac winmswrebi citologiuri diagnozi iyo HSIL an AGC. aseT viTarebaSi misaRebia rogorc diagnostikuri eqscizio, ise dakvirveba kolposkopiuri da citologiuri gamokvlevis gziT 6-Tviani intervaliT, 1 wlis ganmavlobaSi (ix. HSIL-is marTvis gaidlaini).

2. kolposkopia aris aradamakmayofilebeli:

faruli maRali xarisxis dazianebis (HGCIN) gamoricxvis mizniT upiratesoba eniWeba eqsciziur mkurnalobas (LEEP /LLETZ) (rekomendaciis xarisxi A, mtkicebulebis done III) (Spitzer et al., 1998).

CIN1-is mkurnalobis miuRebeli midgoma:

1. “aRmoaCine da umkurnale”, rodesac kolposkopiis, rogorc pirveladi testis, Catarebis dros aRmoCenili ZmarmJava-TeTrebadi epiTeliumis gamo tardeba eleqtromaryuJiT eqsciziuri procedura. aseT viTarebaSi xSiria gadametebuli mkurnaloba;

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2. adgilobrivi destruqciuli (ablaciuri) mkurnaloba aradamakmayofi-lebeli kolposkopiis dros (rekomendaciis xarisxi E, mtkicebulebis done I) (Spitzer et al., 1998);

3. podofilinis da misi msgavsi nivTierebebis aplikacia saSos da saSvilosnos yelis lorwovanze (rekomendaciis xarisxi E, mtkicebulebis done II);

4. histereqtomia, rogorc samkurnalo meTodi histologiurad dadasturebuli CIN1-is dros miuRebelia (rekomendaciis xarisxi E, mtkicebulebis done II), Tu ar arsebobs sxva ginekologiuri paTologiac (mag. saSvilosnos mioma) (European Guidlines for Quality Assuarence in Cervical Cancer Screening 2008).

calke unda iyos gamoyofili HPV dnm testirebis gamoyeneba CIN1-is mqone qalebSi. Tu HPV dnm testirebiT dadginda maRali riskis HPV virusis arseboba, maSin unda Catardes samkurnalo RonisZiebebi, xolo Tu HPV dnm testirebiT gamovlinda mxolod dabali riskis HPV virusis arseboba, SesaZlebelia dakvirvebiTi taqtikis gamoyeneba.

10.3. kolposkopiurad/histologiurad gamovlenili CIN2,3-is marTva

CIN2,3 moicavs dazianebebs, romlebic Tavidanve gansazRvrulia, rogorc zomieri (saSualo xarisxis) displazia (CIN2) da mZime displazia/karcinoma in situ (CIN3). Tumca CIN2 dazianeba CIN3-Tan SedarebiT aris ufro heterogenuli da xangrZlivi dakvirvebis pirobebSi xasiaTdeba regresis SedarebiT meti albaTobiT, histologiuri sxvaoba CIN2-sa da CIN3-s Soris mcirea (Melnikow J et al,1998, Robertson AJ et al. 1989, Mitchell MF et al 1996). Sesabamisad, damatebiTi usafrTxoebis uzrunvelsayofad, CIN2-sa da CIN3-is histologiuri diagnozis mqone qalTa marTvis rekomendaciebi gaerTianebulia erT gaidlainSi.

CIN2,3-is progresis sixSire carcinoma in situ-Si an kiboSi Seadgens 20%-s (sxvadasxva kvlevebis Tanaxmad aRwevs 53%-s). persistenciis sixSire 50%-s (15-96%), xolo regresi SeiniSneba SemTxvevaTa 29%-Si (4-67%) (Galvin et al., 1955; Fu et al.,1981).

10.4 CIN 2,3-is mqone qalebis marTvis rekomendaciebi

CIN2,3-is histologiuri diagnozisa da damakmayofilebeli kolposkopuri gamokvlevis mqone qalebisaTvis rogorc eqscizio, aseve ablacia iTvleba mkurnalobis adeqvatur meTodebad (rekomendaciis xarisxi A, mtkicebulebis done I). upiratesoba eniWeba eqsciziur proceduras (LEEP /LLETZ) kveTis siRrmis regulaciisa da mokveTili qsovilis histologiuri Sefasebis

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SesaZleblobis gamo. diagnostikuri eqscizios procedura rekomendebulia recidiuli CIN2,3-is mqone qalebisaTvis. (rekomendaciis xarisxi A, mtkicebulebis done II) (Wright et al., 2003;Prendiville, 2003a) CIN2,3-is histologiuri diagnozisa da aradamakmayofilebeli kolposkopiuri gamokvlevis pirobebSi ablacia ar aris misaRebi, rekomendebulia diagnostikuri eqscizios procedura (rekomendaciis xarisxi A, mtkicebulebis done II). CIN2,3-is SemTxvevaSi sawyisi Terapiis saxiT ar aris misaRebi histereqtomia (rekomendaciis xarisxi E, mtkicebulebis done II) (NCCN Cervical Cancer Screening V.I.2009; Thomas C. et al 2006; European Guidlines for Quality Assuarence in Cervical Cancer Screening 2008).

10.5. mikroinvaziuri kibo

im SemTxvevaSi, rodesac invaziis xarisxi ar aRemateba adreul stromul invazias, adgilobrivi eqsciziuri mkurnaloba iTvleba mkurnalobis adekvatur maTodad.

adgilobrivi eqsciziuri proceduriT (LEEP /LLETZ) SesaZlebelia mikroinvaziuri brtyelujreduli karcinomis (FIGO 1A1) mkurnaloba im SemTxvevaSi, Tu:

1. mokveTili qsovilis kideebi Tavisufalia CIN-is an invaziuri procesisagan;

2. multidisciplinaruli sabWos gadawyvetilebiT invaziis stadia ar aRemateba 1A1.

Tu mikroinvaziuri kibo iqna amokveTili, magram aRmoCnda, rom CIN scdeba mokveTis sazRvrebs (eqto- an endocerviqsul sazRvrebs), saWiroa Catardes damatebiTi eqsciziuri procedura CIN-is bolomde mosaSoreblad, raTa gamoricxuli iyos sxva satelituri invaziuri dazianebis keris arseboba. es manipulacia unda Catardes miuxedavad imisa, dagegmilia Tu ara histereqtomia, makroinvaziis gamosaricxad (European Guidlines for Quality Assuarence in Cervical Cancer Screening 2008).

10.6. CIN-is mkurnalobis SesaZlo garTulebebi

konservatiuli mkurnalobis garTulebebi Zalzed iSviaTia. adreul garTulebebs miekuTvneba sisxlisdena, infeqcia da gaZlierebuli TeTradSla. Soreul garTulebebs miekuTvneba cerviqsuli stenozi da orsulobis dros yelis ukmarisoba, romelic SesaZloa II trimestris TviTneburi abortiT damTavrdes. es ukanaskneli ZiriTadad gvxvdeba skalpeliT Catarebuli konizaciis dros (Luesley D.M., et al 1985). Tumca sistemuri analizi uCvenebs, rom yvela eqsciziuri proceduris Semdeg momatebulia rogorc mcire masis nayofiT, ise naadrevi mSobiarobis sixSire (Kyrgiou M et a. 2006). stenozi da aradamakmayofilebeli kolposkopia

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da citologia, rogorc wesi, gamowveulia hemostazis mizniT yelze nakeris dadebiT (Martin-Hirsch P et.al 2000). iSviaTad, saSvilosnos yelis stenozis gamo premenopauzur qalebSi SesaZlebelia hematometras ganviTareba. postmenopauzur asakSi stenozis gamo SesaZloa ar gamovlindes saSvilosnos tanis kibos iseTi pirveli indikatori, rogoric aris postmenopauzuri sisxlisdena. stenozi agreTve problemaa CanacvlebiTi hormonuli Terapiis mimRebi qalebisaTvis, romlebsac aucileblad dasWirdebaT yoveldRiuri gestageni _ estrogenuli komponentiT gamowveuli endometriumis proliferacis dasaTrgunad.

10.7. dakvirveba mkurnalobis Semdeg

yvela qali, romelsac Catarebuli aqvs mkurnloba nebismieri xarisxis CIN-is gamo (CIN1, 2 Tu 3) saWiroebs dakvirvebas mkurnalobis Semdeg (Martin-Hirsch et al., 2000). mkurnalobis eqsciziur meTodebs aqvT is upiratesoba, rom iZleva mokveTili qsovilis histologiuri gamokvlevis saSualebas, ris drosac fasdeba mokveTili qsovilis kideebis mdgomareoba: ramdenad Tavisufalia isini CIN an meti dazianebisagan. fasdeba agreTve, mikroinvaziis da jirkvlovani paTologiis arseboba. narCeni an rekurentuli daavadebis riskis mqone qalebi saWiroeben ufro intensiur dakvirvebas mkurnalobis Semdeg. dakvirvebis intensivobis, sixSiris da xangrZlivobis gansazRvraze moqmedeben Semdegi faqtorebi:

1. 40 welze ufros qalebSi metia rekurentuli da persistuli daavadebis riski;

2. dazianebis tipi: jirkvlovani paTologia saWiroebs yuradRebiT postoperaciul dakvirvebas cerviqsis arxis SefasebiT (cerviqsuli braSis gamoyeneba citologiuri kvlevisaTvis);

3. dazianebis xarisxi: maRali xarisxis dazianeba ufro midrekilia persistenciisaken da ganmeorebisaken;

4. eqsciziuri masalis kideebis histologiuri kvleva (arasruli kveTis gamosavlenad).

maRali xarisxis dazianebis (CIN2,3,CGN) gamo namkurnalebi qalebi saWiroeben 6-, 12- da 24-Tvian dakvirvebas da Semdegi 5 wlis ganmavlobaSi yovelwliur citologiur kvlevas (Pap tests). mkurnalobidan 6 Tvis Semdeg agreTve keTdeba kolposkopia (Guidelines for the NHS Cervical Screening Programme 2004; Nieminen et al., 2006). persistuli da rekurentuli daavadebebis umetesoba vlindeba mkurnalobidan pirveli 24 Tvis ganmavlobSi (Chew et al., 1999; Flannelly et al., 2001). Tumca, arsebobs monacmebi, rom riskis SenarCuneba xdeba 10 wlis ganmavlobaSi (Soutter et al.,1997).

dabali xarisxis dazianebis (CIN1) gamo namkurnalebi qalebi saWiroeben dakvirvebas 6, 12 da 24 Tvis Semdeg Pap testirebiT. mkurnalobidan 6 Tvis Semdeg agreTve keTdeba kolposkopia (Guidelines for the NHS Cervical Screening

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Programme 2004; Nieminen et al., 2006). normuli maCveneblebis SemTxvevaSi qali ubrundeba rutinuli skriningis reJims (Guidelines for the NHS Cervical Screening Programme 2004).

AIS-is gamo namkurnaleb qalebSi rekurentuli daavadebis ganviTarebis riski gacilebiT maRalia, vidre CIN2,3-is SemTxvevaSi (Soutter et al., 2001)

10.6. eqsciziur masalaSi kideebis mdgomareobis mniSvneloba

Tu eqsciziuri masalis kideebi Tavisufalia CIN-isa da meti dazianebisagan, narCeni daavadebis sixSire eqsciziuri proceduris Catarebis Semdeg sakmaod mcirea (Andersen et al., 1990; Murdoch et al., 1992; Lopes et al., 1993;Majeed et al., 1994; Moore et al., 1995; Chang et al., 1996; Gold et al., 1996; Gardeil et al., 1997; Dobbs et al., 2000; Flannelly et al., 2001). kvlevebis safuZvelze dadginda, rom eqsciziuri qsovilis eqtocerviqsul kidesTan SedarebiT, endocerviqsul kideSi gamovlenili dazianeba warmoadgens ufro maRal risks narCeni daavadebis ganviTarebis (Ostergard, 1980; Walton et al., 1980; Schantz & Thormann, 1984; Boonstra et al., 1990; Murdoch et al., 1992; Lapaquette et al., 1993; Lopes et al., 1993; Gardeil et al., 1997; Flannelly et al., 2001). 40 wlis da ufrosi asakis qalebSi rekurentuli da persistuli daavadebis riski ufro maRalia (Paraskevaidis et al., 2000; Flannelly et al., 2001).

50 wlis da ufrosi asakis qalebi, romlebsac aRmoaCndaT CIN3 eqsciziuri masalis endocerviqsul kideSi, da visTanac damakmayofilebeli citologiuri da kolposkopiuri kvleva ar aris garantirebuli, saWiroeben ganmeorebiT eqsciziur proceduras sufTa kideebis misaRebad.


1. Alvarez RD, Wright TC. Effective cervical neoplasia detection with a novel optical detection system: A randomized trial. Gynecol Oncol 2007;104:281-9.

2. Anderson D.J., Strachan F., & Parkin D.E. (1992). Cone biopsy: Has endocervical sampling a role? Br J Obstet Gynaecol 99: 668-670

3. Bolger B.S. & Lewis B.V. (1988). A prospective study of colposcopy in women with mild dyskariosis or koilocytosis. Br J Obstet Gynaecol 95: 1117-1119

4. Chew G.K., Jandial L., Paraskevaidis E., & Kitchener H.C. (1999). Pattern of CIN recurrence following laser ablation treatment: long-term follow-up. Int. J. Gynecol. Cancer 9: 487-490

5. Dobbs S.P., Asmussen T., Nunns D., Hollingworth D., Brown L.J., & Ireland D. (2000). Does histological incomplete excision of cervical intraepithelial neoplasia following large loop excision of transformation zone increase recurrence rates? A six year cytological follow-up. BJOG 107: 1298-1301

6. Dunn TS, Burke M, Shwayder J. A “see and treat” management for high-grade squamous intraepithelial lesion pap smears. J Low Genit Tract Dis 2003;7:104-6.

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7. Flannelly G., Bolger B., Fawzi H., De Lopes A.B., & Monaghan J.M. (2001). Follow-up after LLETZ: could schedules be modified according to risk of recurrence? BJOG 108: 1025-1030.

8. Fu Y.S., Reagan J.W., & Richart R.M. (1981). Definition of precursors. Gynecol. Oncol. 12: 220-231.

9. Galvin G.A., Jones H.W., & Te Linde R.W. (1955). The significance of basal-cell hyperactivity in cervical biopsies. Am. J. Obstet. Gynecol. 70: 808-817

10. Gardeil F., Barry-Walsh C., Prendiville W., Clinch J., & Turner M.J. (1997). Persistent intraepithelial neoplasia after excision for cervical intraepithelial neoplasia grade III. Obstet. Gynecol. 89: 419-422

11. Gold M., Dunton C.J., Murray J., Macones G., Hanau C., & Carlson J.A., Jr. (1996). Loop electrocautery excisional procedure: therapeutic effectiveness as an ablation and a conization equivalent. Gynecol. Oncol. 61: 241-4

12. Kyrgiou M., Koliopoulos G., Martin-Hirsch P., Arbyn M., Prendiville W., & Paraskevaidis E. (2006). Obstetric outcomes after conservative treatment for intra-epithelial or early invasive cervical lesions: a systematic review and meta-analysis of the literature. Lancet 367: 489-498

13. Lopes A., Morgan P., Murdoch J., Piura B., & Monaghan J.M. (1993). The case for conservative management of "incomplete excision" of CIN after laser conization. Gynecol. Oncol. 49: 247-9

14. Luesley D.M., McCrum A., Terry P.B., Wade Evans T., Nicholson H.O., Mylotte M.J., Emens J.M., & Jordan J.A. (1985). Complications of cone biopsy related to the dimensions of the cone and the influence of prior colposcopic assessment. Br J Obstet Gynaecol 92: 158-164.

15. Martin-Hirsch P., Paraskevaidis E., & Kitchener H. (2000). Surgery for cervical intraepithelial neoplasia. Cochrane Database Syst Rev

16. Massad L.S., Halperin C.J., & Bitterman P. (1996). Correlation between colposcopically directed biopsy and cervical loop excision. Gynecol. Oncol. 60: 400-403

17. Melnikow J, Nuovo J, Willan AR, Chan BK,Howell LP. Natural history of cervical squamous intraepithelial lesions: a meta-analysis. Obstet Gynecol 1998;92:727-35.

18. Mitchell MF, Tortolero-Luna G, Wright T, et al. Cervical human papillomavirus infection and intraepithelial neoplasia: a review. J Natl Cancer Inst Monogr 1996;21:17-25

19. Moscicki A.B., Shiboski S., Hills N.K., Powell K.J., Jay N., Hanson E.N., Miller S., Canjura-Clayton K.L., Farhat S., Broering J.M., & Darragh T.M. (2004). Regression of low-grade squamous intraepithelial lesions in young women. Lancet 364: 1678-1683.

20. Murdoch J.B., Morgan P.R., Lopes A., & Monaghan J.M. (1992). Histological incomplete excision of CIN after large loop excision of the transformation zone (LLETZ) merits careful follow-up, not retreatment. Br. J. Obstet. Gynaecol. 99: 990-993

21. NHSCSP (2004a). Colposcopy and programme management: guidelines for the NHS Cervical Screening Programme. Luesley, D. and Leeson, S. NHSCSP publication 20, 1-80. Sheffield, Manor House. NHS Cancer Screening Programmes

22. Nieminen P, Anttila A, Bützow R, Heikkilä E, Hiltunen-Back E, Puistola U, Rantanen V, Räisänen I, Santalahti A, Talvensaari-Mattila A, Vartiainen J, Vuento M, Yliskoski M. (2006). Guideline for the diagnosis and treatment of pre-cancerous lesions of the cervix uteri, vulva, and vagina. Duodecim & the Finnish Association of Colposcopists

23. Ostergard D.R. (1980). Cryosurgical treatment of cervical intraepithelial neoplasia. Obstet. Gynecol.56: 231-233.

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24. Paraskevaidis E., Lolis E.D., Koliopoulos G., Alamanos Y., Fotiou S., & Kitchener H.C. (2000). Cervical intraepithelial neoplasia outcomes after large loop excision with clear margins. Obstet. Gynecol. 95: 828-831.

25. Prendiville W. (2003a). LLETZ: theoretical rationale, practical aspects, clinical experience, optimizing the technique. In: Colposcopy: Management Options (eds Prendiville W., Ritter J., Tatti S. & Twiggs L.), pp. 75-89. Saunders, Edinburgh

26. Robertson AJ, Anderson JM, Beck JS, et al. Observer variability in histopathological reporting of cervical biopsy specimens. J Clin Pathol 1989;42:231-8

27. Soutter W.P., de Barros Lopes A., Fletcher A., Monaghan J.M., Duncan I.D., Paraskevaidis E., & Kitchener H.C. (1997). Invasive cervical cancer after conservative therapy for cervical intraepithelial neoplasia [see comments]. Lancet 349: 978-980

28. Soutter W.P., Haidopoulos D., Gornall R.J., McIndoe G.A., Fox J., Mason W.P., Flanagan A., Nicholas N., Barker F., Abrahams J., Lampert I., & Sarhanis P. (2001). Is conservative treatment for adenocarcinoma in situ of the cervix safe? BJOG 108: 1184-1189

29. Soutter W.P., Wisdom S., Brough A.K., & Monaghan J.M. (1986). Should patients with mild atypia in a cervical smear be referred for colposcopy? Br J Obstet Gynaecol 93: 70-74.

30. Spitzer M., Chernys A.E., Shifrin A., & Ryskin M. (1998). Indications for cone biopsy: pathologic correlation. Am. J. Obstet. Gynecol. 178: 74-9.

31. Stoler M.H. & Schiffman M.A. (2001). Interobserver Reproducibility of Cervical Cytologic and Histologic Interpretations. JAMA 285: 1500-1505

32. Walton L.A., Edelman D.A., Fowler W.C., Jr., & Photopulos G.J. (1980). Cryosurgery for the treatment of cervical intraepithelial neoplasia during the reproductive years. Obstet. Gynecol. 55: 353-7

33. Wright T.C., Cox J.T., Massad L.S., Carlson J., Twiggs L.B., & Wilkinson E.J. (2003). 2001 consensus guidelines for the management of women with cervical intraepithelial neoplasia. Am. J. Obstet. Gynecol. 189: 295-304.

11. cerviqsuli skriningi gansakuTrebul SemTxvevebSi

11.1 cerviqsuli skriningi da orsuloba

Tu qals orsulobamde cerviqsuli paTologia ar hqonda gamovlenili, misTvis Pap testis Catareba ar aris aucilebeli orsulobis dros. Tu rutinul skriningze mosuli qali aRmoCnda orsulad, maSin SesaZlebelia testis Catareba gadaidos mSobiarobis Semdgomi periodisaTvis. Tu orsulobamde qals hqonda cerviqsuli paTologia, maSin momdevno Pap testis Catareba SesaZlebelia orsulobis meore trimestrSi, Tu ar arsebobs raime klinikuri ukuCveneba.

atipiuri Pap testis pirobebSi kolposkopiis Catareba SesaZlebelia orsulobis periodSi. orsulobis dros Catarebuli kolposkopiis mTavari daniSnuleba aris invaziuri dazianebis arsebobis gamoricxva. Tu orsuls aReniSna citologiuri diagnozi ≤LSIL da kolposkopiuri kvleviT maRali xarisxis dazianebis arseboba gamoiricxa, maSin ganmeorebiTi citologiuri

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da kolposkopiuri kvleva unda Catardes mSobiarobidan 3-4 Tvis Semdg. Tu qals aReniSna maRali xarisxis dazianeba CIN2,3, maSin ganmeorebiTi kolposkopiuri kvleva unda Catardes 3-Tviani intervaliT orsulobis ganmavlobaSi, xolo daskvniTi gamokvleva unda Catardes mSobiarobidan 3-4 Tvis Semdeg. am dros ukve unda zustad ganisazRvros mkurnalobis aucilebloba.

orsul qalSi mkurnalobis gadavadebis usafrTxoeba dasturdeba kohortuli da retrospeqtuli arakontrolirebadi kvlevebiT (Coppola et al., 1997). saSvilosnos yelis kibos sixSire orsulebs Soris aris dabali da TviTon orsulobis process ar aqvs prognozulad uaryofiTi efeqti (Woodrow N et.al 1998). CIN3-is progresis riski orsulobis periodSi aris dabali, xolo mSobiarobis Semdeg ganviTarebuli spontanuri ukuregresis sixSire aris maRali. erT kvlevaSi ukuganviTareba dafiqsirda SemTxvevaTa 69%-Si (Yost et al., 1999).

Tu klinikurad an kolposkopiurad saeWvoa invaziuri daavadebis arseboba, maSin mniSvnelovania adekvaturi biofsiis Catareba. vinaidan orsulobis periodSi Catarebuli eqsciziuri procedura (LEEP/LLETZ) SemTxvevaTa 25%-Si Seicavs sisxlisdenis ganviTarebis risks (Robinson WR et al 1997), es manipulacia unda Catareds specializirebul dawesebulebaSi. orsulobis dros ar tardeba cerviqsuli arxis kiuretaJi (Thomas C. et. al 2006).


1. Coppola A., Sorosky J., Casper R., Anderson B., & Buller R.E. (1997). The clinical course of cervical carcinoma in situ diagnosed during pregnancy. Gynecol.Oncol. 67: 162-165.

2. Robinson WR, Webb S, Tirpack J et al. Management of cervical intraepithelial neoplasia during pregnancy with loop excision. Gynecologic Oncology, 1997, 64(1): 153–155

3. Thomas C. Wright Jr, MD; L. Stewart Massad, MD; Charles J. Dunton, MD; Mark Spitzer, MD; Edward J. Wilkinson, MD; Diane Solomon, MD, for the 2006 American Society for Colposcopy and Cervical Pathology–sponsored Consensus Conference 2006 consensus guidelines for the management of women with abnormal cervical cancer screening tests.

4. Woodrow N, Permezel M, Butterfield L et al. Abnormal cytology in pregnancy. Australia and New Zealand Journal of Obstetrics and Gynaecology, 1998, 38: 161–165.

5. Yost N.P., Santoso J.T., McIntire D.D., & Iliya F.A. (1999). Postpartum regression rates of antepartum cervical intraepithelial neoplasia II and III lesions. Obstet. Gynecol. 93: 359-362.

11.2. cerviqsuli skriningi histereqtomiis SemTxvevaSi

histereqtomiebul qalebSi, visac aReniSnebodaT CIN dazianeba, SenarCunebulia saSos intraepiTeliuri dazianebis (VAIN) da kibos ganviTarebis riski. sxvadasxva kvlevebSi VAIN-is sixSire histereqtomiis Semdeg meryeobs 1-4%-mde farglebSi (Gemmell et al., 1990, Burghardt & Holzer, 1980). Soreuli Sedegebis metaanaliziT dadginda, rom Tu rekurentuli CIN-is ganviTareba histereqtomiis Semdeg ufro iSviaTia, vidre eqsciziuri

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mkurnalobis Semdeg, kibos ganviTarebis sixSire orive SemTxvevaSi erTnairia (50-60 SemTxveva 100 000 qalze wliurad) (Soutter W.P et al).

gasaTvaliswinebelia Semdegi:

1. Tu qali, romelsac Cautarda histereqtomia, 10 wlis ganmavlobaSi imyofeboda rutinuli skriningis reJimSi da mas ar aReniSneboda CIN dazianeba, is ar saWiroebs Semdgom dakvirvebas;

2. Tu qali, romelsac Cautarda histereqtomia, 10 welze naklebi drois ganmavlobaSi imyofeboda rutinuli skriningis reJimSi da mas ar aReniSneboda CIN dazianeba is saWiroebs saSos takvis Pap tests operaciidan 6 da 18 Tvis Semdeg. normuli Pap diagnozis SemTxvevaSi Semdgomi dakvirveba ar aris saWiro;

3. Tu qals, romelsac Cautarda histereqtomia, aReniSneboda CIN da es dazianeba mTlianad iqna mocilebuli, maSin is saWiroebs saSos takvis Pap tests operaciidan 6 da 18 Tvis Semdeg. normuli Pap diagnozis SemTxvevaSi Semdgomi dakvirveba ar aris saWiro;

4. Tu CIN dazianeba mTlianad ar iqna moSorebuli, maSin qals sWirdeba iseTive dakvirveba, rogorc im qalebs visac SenarCunebuli aqvT saSvilosnos yeli (European guidelines for quality assurance in cervical cancer screening.Second Edition 2008).

Tu qals aReniSneba histologiurad dadasturebuli CIN da iseTi ginekologiuri paTologia, romlis mkurnaloba SesaZlebelia histereqtomiiT, maSin histereqtomia aRiarebulia mkurnalobis misaReb meTodad (Guidelines for the NHS Cervical Screening Programme, 2004).


1. Burghardt E. & Holzer E. (1980). Treatment of carcinoma in situ: evaluation of 1609 cases. Obstet. Gynecol. 55: 539-45

2. Gemmell J., Holmes D.M., & Duncan I.D. (1990). How frequently need vaginal smears be taken after hysterectomy for cervical intraepithelial neoplasia? Br J Obstet Gynaecol 97: 58-61

3. Guidelines for the NHS Cervical Screening Programme. 2004 4. European guidelines for quality assurance in cervical cancer screening (Second Edition

2008) 5. Soutter W.P., Sasieni P., & Panoskaltsis T. (2005). Long-term risk of invasive cervical

cancer after treatment of squamous cervical intraepithelial neoplasia. Int. J. Cancer118: 2048-2055.

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11.3. imunosupresuli qalebis cerviqsuli skriningi

imunodeficitis mqone qalebSi CIN daavadebis riski maRalia. aseve maRalia riski am daavadebis kiboSi progresis, xolo warmatebuli mkurnalobis sixSire _ naklebia. magaliTad, im qalebs, visac Catarebuli aqvT Tirkmlis transplantacia, 5 jer ufro xSirad aReniSnebaT atipiuri Pap diagnozi, zogad populaciasTan SedarebiT (ter Haar-van Eck S.A et al 1995). aseve momatebuli CIN-is sixSire sistemuri wiTeli mgluraTi daavadebul qalebSi (Dhar J.P., et al 2001). HIV dadebiT qalebSi sxvadasxva kvlevebis monacemebiT CIN-is sixSire meryeobs 20-40%-mde farglebSi (Mandelblatt J.S., et.al 1992)

aseTi qalebi saWiroeben yovelwliur rogorc citologiur, ise kolposkopiur dakvirvebas.


1. Dhar J.P., Kmak D., Bhan R., Pishorodi L., Ager J., & Sokol R.J. (2001). Abnormal cervicovaginal cytology in women with lupus: a retrospective cohort study. Gynecol. Oncol. 82: 4-6.

2. Mandelblatt J.S., Fahs M., Garibaldi K., Senie R.T., & Peterson H.B. (1992). Association between HIV infection and cervical neoplasia: implications for clinical care of women at risk for both conditions. AIDS 6: 173-178.

3. ter Haar-van Eck S.A., Rischen-Vos J., Chadha-Ajwani S., & Huikeshoven F.J. (1995). The incidence of cervical intraepithelial neoplasia among women with renal transplant in relation to cyclosporine. Br J Obstet Gynaecol 102: 58-61.

11.4. citologiuri da kolposkopiuri kvlevebis Sedegebis uTanxmoebis (SeuTavseblobis) SemTxvevebis marTva

gvxvdeba iseTi SemTxvevebi, rodesac maRali xarisxis ujreduli atipiis dros kolposkopia aris normuli. aseT qalebSi CIN2 da meti dazianebis ganviTarebis riski maRalia. aseT SemTxvevaSi sanam iqneba gamotanili Pap testis cru dadebiTobis daskvna, an sanam Catardeba sadiagnostiko eqsciziuri procedura diagnozis dasazusteblad, unda iqnas Tavidan gaanalizebuli pirveladi citologiuri preparati**, amasTanave aRebuli unda iqnas Tavidan axali nacxi ganmeorebiTi citologiuri kvlevisaTvis.

Tu citologiuri atipia iqneba dadasturebuli, ganmeorebiTi kolposkopiuri kvleva unda Catardes. es kvleva sasurvelia Catardes optimalur pirobebSi: Tu saxezea qvemo genitaluri traqtis infeqciebis arseboba, an hipoestrogenia postmenopauzuri asakis qalebSi, windawin unda Catardes Sesabamisi mkurnaloba.

**- qarTvel eqspertTa konsensusi

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gansakuTrebuli yuradReba unda mieqces SCJ-is sazRvris Sefasebas. Tu SCJ vizualizdeba da kolposkopiurad atipia ar vlindeba, maSin yuradRebiT unda iqnas Sefasebuli saSos kedlebi. Tu dazianeba ver iqna aRmoCenili, unda Catardes transformaciis zonis eqscizio cerviqsuli arxis qveda mesamedis kveTiT.

Tu SCJ ar vizualizdeba da dazianeba ar vlindeba arc saSvilosnos yelze, arc saSos kedlebze, aseT SemTxvevaSic unda Catardes transformaciis zonis eqscizio cerviqsuli arxis qveda mesamedis kveTiT.

sasurvelia yvela SemTxveva, romlelSic adgili aqvs citologiuri, kolposkopiuri da histologiuri kvlevebis Sedegebis SeuTavseblobas, ganxilul iqnas multidisciplinarul sabWoze (European guidelines for quality assurance in cervical cancer screening (Second Edition 2008)

12. samkurnalo procedurebi

kolposkopiurad dadgenili dazianebis marTva SesaZlebelia aRniSnuli ubnis ablaciuri (adgilobrivi destruqciuli) da eqsciziuri meTodebiT, xolo zogierT SemTxvevebSi dakvirvebis gziT. transformaciis zonis histologiuri Sefasebis TvalsazrisiT upiratesoba eniWeba mkurnalobis eqsciziur meTodebs (ablaciasTan SedarebiT), amokveTili qsovilebis histologiuri gamokvleva paTologs aZlevs mikroinvaziuri kibos, jirkvlovani dazianebis dadasturebisa an gamorcxvis, amokveTili qsovilis kideebis mdgomareobis dadgenisa da eqscizios siRrmis gansazRvris saSualebas. aseve zemoaRniSnulis safuZvelze kolposkopists SeuZlia Caataros diagnostikuri TvalsazrisiT sakuTari unar-Cvevebis auditi.

12.1 dazianebuli ubnis amokveTa

amokveTis (eqscizios) mizans warmoadgens dazianebuli ubnis srulyofili mocileba. amokveTili qsovilis nimuSi saWiroebs histologiur gamokvlevas. kolposkopiuri Sefaseba da eqscizios dagegmva dasaSvebia mxolod gamocdili kolposkopistis mier.

transformaciis zonis eqscizio ar unda iyos nawarmoebi CIN 1-is dros, garda im SemTxvevisa, rodesac aRniSnuli diagnozi persistirebs erT weliwadze xangrZlivi drois monakveTSi. maRali xarisxis intraepiTeliur neoplaziaze, adreul stromul invaziaze da mikroinvaziaze eWvis arsebobis SemTxvevaSi aRniSnuli meTodis gamoyeneba aucilebelia dauyovnebliv transformaciis zonis mosakveTad gamoiyeneba Semdegi meTodebi: LEEP (maryuJiT eleqtroqirurgiuli eqscizios procedura) LLETZ (maryuJiT transformaciis zonis farTe eqscizio) meTodi, skalpeliT konizacia, lazeruli eqscizio da NETZ (nemsiT transformaciis zonis eqscizio). LLETZ mdgomareobs saSvilosnos yelis qsovilebis mocilebaSi

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diaTermuli maryuJis gamoyenebiT. LEEP warmoadgens Crdilo-amerikul termins LLETZ-is analogiuri meTodis aRwerisaTvis. terminebi LLETZ da LEEP warmoadgens sinonimebs. saSvilosnos yelis qsovilebis skalpeliT konizacia warmoadgens qsovilTa mokveTas qirurgiuli danis gamoyenebiT. am dros miRebuli qsovilis nimuSi konusiseburi formisaa. lazeruli eqsciziuri konizacia niSnavs, rom saSvilosnos yelis qsovilebi mocilebulia CO2 lazeris gamoyenebiT _ kveTis reJimSi. NETZ gulisxmobs, rom transformaciis zona amoRebulia aradrekadi diaTermuli mavTulis gamoyenebiT. SWETZ (transformaciis zonis eqscizio aradrekadi mavTuliT) da NETZ warmoadgens erTsa da imave meTods.

eqscizios warmoebis dros rekomendebulia Semdegi momentebis gaTvaliswineba:

1. procedura unda tardebodes kolposkopiuri kontrolis qveS;

2. dazianebis are amoRebul unda iqnas mTlian transformaciis zonasTan erTad;

3. sasargebloa, amosakveTi ubnis markireba ciferblatis 12 sT-is poziciis miTiTebiT, raTa histopaTologs gauadvildes orientacia;

4. sasurvelia, qirurgma ar daazianos eqtocerviqsuli epiTeliumi da/an endocerviqsuli arxi;

5. usargebloa orientaciis mizniT saSvilosnos yelis gamafarToeblis gamoyeneba;

6. amosakveTi nimuSis zoma da forma gansazRvruli unda iyos dazianebis kolposkopiuri suraTis mixedviT;

7. eqscizio savaldebuloa, Tu dazianeba vrceldeba endocerviqsul arxSi;

8. Tu dazianeba vrceldeba endocerviqsul arxSi, eqscizios Semdeg unda Catardes saSvilosnos yelis arxis gamokvleva;

9. histopaTologiuri kvleva unda Catardes gamocdili paTologis mier;

10. histopaTologi informirebuli unda iyos citologiuri da kolposkopiuri cvlilebebis Taobaze;

11. skalpeliT Catarebuli konizaciis pirobebSi miRebuli qsovilis kideebi Tavisufalia Termuli artefaqtebisagan maSin, rodesac lazeruli eqscizios an diaTermuli maryuJiT eqscizios SemTxvevaSi SesaZlebelia kideebis dazianeba. gamocdili operatoris mier Catarebuli kveTis SemTxvevaSi Termuli artefaqtebis saerTo jami minimumamdea dayvanili. Martin-Hirsch-isa da Tanaavtorebis (2000) mier Catarebulma meta-analizma uCvena, rom kideebis dauzianeblobis TvalsazrisiT, skalpeliT konusur biofsias upiratesoba eniWeba lazerul an LLETZ meTodebTan SedarebiT;

12. transformaciis zonis eqsciziom ramodenime fragmentad SesaZloa gaarTulos histopaTologiuri Sefaseba. mikroinvaziis arsebobis SemTxvevaSi, misi fragmentulad amokveTis pirobebSi gaZnelebulia paTohistologiuri Sefaseba. LLETZ meTodis gamoyenebisas, yelis arxis gareTa piri da arxis qveda nawili amoRebuli unda iqnas erT blokad.

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centridan daSorebuli, lateralurad arsebuli dazianebuli ubani, SesaZlebelia, mocilebul iqnas calke nimuSis saxiT;

13. Tu nawarmoebia skalpeliT konizacia, maqsimaluri sifrTxilea saWiro iseTi gverdiTi efeqtebis minimumamde dasayvanad, rogoricaa sisxlisdena da saSvilosnos yelis stenozi. sisxldenisagan Tavis dasaRwevad, sasurvelia, operaciuli Carevis win saSilosnos yelSi adrenalinis (1 : 200 000 ganzavebiT) Seyvana. sisxldenis kontrolis mizniT diaTermiis da monselis xsnaris gamoyenebis (Anderson et al., 1996) Semdeg cerviqsuli stenozis ganviTarebis SesaZlebloba gacilebiT dabalia, vidre im SemTxvevebSi, rodesac konizaciis dros ganviTarebuli sisxldenis SesaCereblad mimarTaven saSvilosnos yelze nakerebis dadebas.

12.2. adgilobrivi destruqciuli Terapia (ablacia)

adgilobrivi destruqciuli mkurnalobis mizans warmoadgens CIN-is likvidacia radikaluri diaTermiis, lazeruli vaporizaciis, krioTerapiis an civi koagulaciis gamoyenebiT.

radikaluri diaTermiis (an eleqtrokoagulaciis) SemTxvevaSi gamoiyeneba aradrekadi nemsi da Carevis mizans warmoadgens qsovilTa destruqcia daaxloebiT 1 sm siRrmeze.

diaTermokoagulacia warmoadgens meTods, sadac saSvilosnos yelis epiTeliumis destruqciisaTvis gamoiyeneba siTburi zemoqmedeba 2-3 mm siRrmeze. destruqcia sakmaod zedapirulia, imisaTvis rom igi rekomendebuli iyos CIN-is samkurnalod.

lazeruli vaporizaciis dros gamoiyeneba CO2-lazeri maRali simZlavris reJimSi: kolposkopiuri kontrolis qveS lazeris sxivi axdens qsovilebis mocilebas.

krioTerapia (an kriokauterizacia) warmoebs kriozondis meSveobiT, romelic exeba dasaSlel qsovilebs da axorcielebs maT gayinvas: destruqciis siRrmea 3-4 mm.

civi koagulaciis SemTxvevaSi gamoiyeneba krioTerapiis magvari zondi, mxolod qsovilebis destruqcia warmoebs 1000C-mde maTi gacxelebis gziT.

yvela zemoCamoTvlili meTodis gamoyeneba SesaZlebelia ambulatoriul pirobebSi. dilemas qmnis mxolod is, rom xdeba qsovilebis destruqcia in vivo, da ar xdeba qsovilis histopaTologiuri gamokvleva. amis gamo arsebobs riski imisa, rom zogjer jirkvlovani paTologia, AIS an adreuli invaziuri karcinoma darCes aRmouCeneli. cxadia, aseT SemTxvevebSi Semdgomi mkurnaloba warimarTeba araadeqvaturad. es warmoadgens erT-erT im mizezTagans, ris gamoc upiratesoba eniWeba eqsciziur meTods. Tumca, Sesabamis pirobebSi sxva meTodebic SeiZleba iyos usafrTxod da efeqturad gamoyenebuli.

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destruqciuli mkurnalobis SesarCevi kriteriumebi:

1. savaldebuloa sruli transformaciis zonis vizualizacia;

2. savaldebuloa erTi an meti biofsiuri masalis aReba kolposkopiurad gamoxatuli cvlilebebis mqone ubnidan an ubnebidan;

3. biofsiis daskvna cnobili unda iqnas destruqciuli mkurnalobis dawyebamde;

4. krioTerapia ar unda iqnas SeTavazebuli qalebisaTvis, visac aqvs iseTi dazianeba, romelic moicavs eqtocerviqsis 75%-ze mets, vrceldeba saSos kedlebze an scildeba kriozondis kideebs 2 mm-ze metad (Gafflkin et al., 2003; Denny et al., 2005). aRniSnuli exeba aseve civ koagulacias, magram ara radikalur diaTermias;

5. citologiuri, kolposkopiuri an biofsiuri masalis histopaTologiuri kvlevis dros ar unda iyos gamovlenili invaziuri dazianeba;

6. Pap-testSi ar unda iyos jirkvlovani atipiuri ujredebi;

7. destruqciuli mkurnaloba unda tardebodes kolposkopiuri kontrolis qveS, gamocdili kolposkopistis mier;

8. savaldebuloa adeqvaturi dakvirveba dinamikaSi.

rodesac gamoiyeneba mkurnalobis ablaciuri meTodi, transformaciis zonis destruqcia unda warmoebdes minimum 4 mm siRrmemde (ufro usafrTxoa qsovilTa daSla 7 mm siRrmemde). destruqcia unda scildebodes dazianebis eqto- da endocerviqsul sazRvrebs (Anderson & Hartley, 1980; Boonstra et al., 1990).

literaturis sistematuri mimoxilvis safuZvelze aSkaraa, rom gawafuli operatoris mier warmoebuli civi koagulacia da lazeruli ablacia efeqturia CIN-is yvela xarisxis SemTxvevaSi (Martin-Hirsch et al., 2000). radikaluri diaTermia SeiZleba sakmaod efeqturi iyos; ase, magaliTad, Chanen & Rome-s monacemebiT, gankurnebis maCvenebeli Seadgenda 98%-s _ erTjeradi Carevis pirobebSi (Chanen & Rome, 1983). krioTerapia gamoyenebuli unda iqnas mxolod transformaciis zonis I tipis SemTxvevaSi da umjobesia, ganxorcieldes orjeradi moyinvis meTodiT (Schantz & Thormann, 1984).

ablaciuri mkurnaloba miznad unda isaxavdes transformaciis zonis srulyofil destruqcias, vinaidan Tavidan iqnas acilebuli recidivebis maRali sixSire (Burke et al., 1980).

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13. saSvilosnos yelis intraepiTeliuri neoplaziis (CIN) mkurnalobis evropuli standarti

1. gamomdinare iqidan, rom saSvilosnos yelis intraepiTeliuri

neoplaziis (CIN) mkurnalobisa da eradikaciisas konservatiul qirurgiul Carevas (ablaciur teqnikas) ar aqvs dadasturebuli upiratesoba; srulyofili histopaTologiuri SefasebisaTvis upiratesoba eniWeba eqsciziur (mokveTis) proceduras;

2. ablacia rekomendebulia situaciebSi, rodesac:

xdeba transformaciis zonis sruli vizualizacia;

ar aris jirkvlovani paTologia;

ar aris invazia;

ar aris sxvaoba citologiur da histologiur diagnozebs Soris.

3. krioTerapia unda gamoiyenebodes mxolod dabali xarisxis saSvilosnos yelis intraepiTeliuri neoplaziis (CIN 1) SemTxvevaSi da aucileblad orjeradi moyinvis teqnikiT;

4. rodesac eqsciziuri procedura gamoiyeneba samkurnalo mizniT, yvela Careva mimarTuli unda iyos iqiTken, rom dazianebis ubnis mocileba moxdes erT nimuSad. histologiur daskvnaSi miTiTebuli unda iyos nimuSis zomebi da amokveTili qsovilis kideebis mdgomareoba intraepiTeliuri an invaziuri dazianebis arsebobis TvalsazrisiT;

5. eqtocerviqsis dazianebis SemTxvevaSi samkurnalo Carevis mizania 6 mm-is siRrmeze arsebuli qsovilebis mocileba;

6. «aRmoaCine da umkurnale» midgoma pirveli vizitisas SeiZleba ganaxorcielos im specialistma, romlis mier amokveTil nimuSebis umetes nawilSi (90%-sa da metSi) gamovlinda CIN. ASCUS-is da LSIL-is gamo mkurnaloba pirvel vizitze gamoyenebuli unda iqnas mxolod gamonaklis SemTxvevebSi, raTa minimumamde iqnas dayvanili arasaWiro samkurnalo Carevebis ricxvi;

7. CIN-isA arasrulyofili amokveTis pirobebSi (LEEP/LLETZ eqscizios proceduriT miRebuli qsovilis kideebSi CIN-is gavrcelebis SemTxvevaSi) arsebobs misi recidivis maRali albaToba, magram gaumarTlebelia ganmeorebiTi eqscizios proceduris rutinulad gamoyeneba im SemTxvevaSi, rodesac:

transformaciis zona vizualizdeba srulyofilad;

ar aris jirkvlovani paTologia;

ar aris invazia;

qalis asaki ar aRemateba 50 wels. 8. 50 welze ufrosi asakis qalebi, visac nawarmoebi aqvT arasrulyofili

eqscizio da CIN gavrcelebulia endocerviqsSi, warmoadgenen recidivis ganviTarebis maRali riskis jgufs. aseT SemTxvevebSi aucilebelia minimum yuradRebiani da adekvaturi dakvirveba dinamikaSi endocerviqsis citologiuri testirebis gziT. alternatiul midgomas warmoadgens ganmeorebiTi eqsciziuri proceduris warmoeba;

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9. adenokarcinoma in situ/CGIN-is mqone qalebis marTvisas, im SemTxvevaSi, rodesac qals surs fertilobis SenarCuneba, SesaZlebelia lokaluri eqscizios gamoyeneba. amasTanave, arasrulyofili eqscizio moiTxovs momavalSi srulyofil amokveTas sufTa kideebis aremde da faruli invaziuri dazianebis gamoricxvas;

10. mikroinvaziuri brtyelujredovani kibos _ FIGO-is klasifikaciiT IA1 stadia _ mqone qalTa marTva gulisxmobs eqscizios gamoyenebas, Tu:

amokveTili qsovilis kideebi Tavisufalia CIN-isa da invaziisagan;

Tu invaziis kera amokveTilia, margam CIN vrceldeba amokveTili qsovilis farglebs gareT. ganmeorebiTma eqscizios proceduram unda uzrunvelyos CIN-is mocileba da gamoricxos momavalSi invaziuri dazianeba;

paTohistologiuri gamokvleva unda Caataros ginekologiur paTologiaSi specializaciebulma paTologma.


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14. skrining programis Sefasebis ZiriTadi indikatorebi qvemoT CamoTvlilia is indikatorebi, romelic programis muSaobis Sefasebis da SesaZlo problemebis adreul periodSi gamovlenis saSualebas iZleva, raTa moxdes maTi efeqturad gadaWra. indikatorebi iyofa 3 ZiriTad jgufad:

a. skrining programis intensivobis Sefasebis indikatorebi;

b. skrininguli testebis efeqturobis Sefasebis indikatorebi da

g. diagnostirebis unaris da mkurnalobis efeqturobis Sefasebis indikatorebi.

a) skriningis intensivoba 1. programis gavrceleba programis gavrcelebas angariSoben regionisTvis an qveynisTvis

Tu skrining programis momsaxurebis areali warmoadgens mTels

regions an qveyanas, maSin programis gavrceleba Seadgens 100%-s.

formula: programis momsaxurebis arealSi mcxovrebi samizne qalebis

raodenoba

Sesabamis regionSi an qveyanaSi mcxovrebi samizne qalebis

raodenoba

2. samizne populaciis dafarva nacxis citologiuri kvleviT

formula: gansazRvrul intervalSi erTxel mainc gamokvleuli qalebis

raodenoba

samizne populaciis Semadgeneli qalebis raodenoba

3. mowveuli qalebis damyoloba (iTvleba im SemTxvevaSi rodesac skriningi

efuZneba mowveva/gamoZaxebis sistemas)

moicavs im mowveul qalebs romelTac gaiares skriningi

damyoloba iangariSeT mopatiJebis periodidan 6 Tvis ganmavlobaSi

formula: gansazRvrul intervalSi mowveuli qalebis raodenoba romelTac

gaiares gamokvleva

gansazRvrul intervalSi mowveuli qalebis raodenoba

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b) skrininguli testebis muSaoba 1. gamokvleuli qalebis ganawileba citologiuri diagnozis mixedviT

formula: citologiuri diagnozis mqone gamokvleuli qalebis raodenoba

gamokvleuli qalebis raodenoba

2. ganmeorebiTi citologiuri kvlevisTvis dabareba

formula: ganmeorebiT testirebaze regularul intervalze nakleb

droSi dabarebuli qalebis raodenoba


3. qalebis damyoloba ganmeorebiT citologiur kvlevaze

formula: ganmeoebiT testirebaze regularul intervalze nakleb droSi gamokvleuli qalebis

raodenoba

regularul intervalze nakleb droSi dabarebuli qalebis

raodenoba

4. kolposkopiur kvlevaze mimarTvis sixSire

formula: kolposkopiaze mimarTuli qalebis raodenoba


5. kolposkopiur kvlevaze mimarTvianobis dadebiTi prognozuli Rirebuleba

SesaZlebelia gamoTvlili iqnas rogorc mTlianad, ise calke CIN1-

is, CIN2,3-is da kibosaTvis.

SesaZlebelia gamoTvlili iqnas citologiuri diagnozebis

Sesabamisad (ASCUS, LSIL, HSIL)

formula: kolposkopiurad/histologiurad dadasturebuli CIN-is mqone

qalebis raodenoba

kolposkopiurad gamokvleuli qalebis raodenoba

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6. sxvadasxva histologiuri diagnozebis gamovlenis sixSire (iTvleba calke

CIN1-is, CIN2,3-is da kibosaTvis)

formula: histologiurad dadasturebuli CIN-is mqone qalebis raodenoba


7. kiboTi avadobis maCvenebeli normuli citologiis mqone qalebSi

formula: ukanaskneli 3 wlis ganmavlobaSi normuli citologiis mqone

qalebis raodenoba romelTac ganuviTardaT kibo

ukanaskneli 3 wlis ganmavlobaSi normuli citologiis mqone

qalebis raodenoba

g) diagnostikuri Sefaseba da mkurnaloba 8. kolposkopiur kvlevaze mimarTvisadmi qalebis damyoloba

formula: kolposkopiurad gamokvleuli qalebis raodenoba

kolposkopiur kvlevaze mimarTuli qalebis raodenoba

9. maRali xarisxis intraepiTeliuri dazianebis mkurnaloba

formula: skriningiT gamovlenili namkurnalevi CIN2,3-is mqone

qalebis raodenoba

skriningiT gamovlenili CIN2,3-is mqone qalebis raodenoba

10. dabali xarisxis intraepiTeliuri dazianebis mkurnaloba

formula: skriningiT gamovlenili namkurnalevi CIN1-is mqone

qalebis raodenoba

skriningiT gamovlenili CIN1-is mqone qalebis raodenoba

11. skriningiT gamovlenili intraepiTeliaruli dazianebebis mqone qalebSi

histereqtomiis procenti

formula: CIN-is mqone histereqtomia Catarebuli qalebis raodenoba

histologiuri CIN-is mqone qalebis raodenoba

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12. mkurnalobidan 6 Tvis Semdeg uaryofiTi citologiuri Sedegis mqone

qalebis procenti

formula: mkurnalobidan 6 Tvis Semdeg uaryofiTi citologiuri Sedegis

mqone qalebis raodenoba

mkurnalobidan 6 Tvis Semdeg citologiurad gamokvleuli

qalebis raodenoba

15. gaidlainis gadasinjvisa da ganaxlebis vada – 3 weli

16. gaidlainis miRebis xerxi/wyaro

gaidlainis SemuSavebis meTodologia

meToduri saxelmZRvanelo Seqmnilia ”saqrTvelos saSvilosnos yelis paTologiis da kolposkopiis sazogadoebis”, romelic ZiriTadad Sedgenilia “European Guidelines for Quality Assurance in Cervical Cancer Screening”-is (2008 second edition); “Cervical Cancer Screening”-is (2009, National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology (USA); “2006 Consensus Guidelines for the management of women with abnormal cervical cancer screening tests”-is (American Society for Colposcopy and Cervical Pathology); “2006 Consensus Guidelines for the management of women with cervical intraepithelial neoplasia and adenocarcinoma in situ”’-s (American Society for Colposcopy and Cervical Pathology); “Colposcopy and Programme Management; Guidelines for the NHS Cervical Screening Programme 2004”-s (Great Britain) safuZvelze.

mtkicebulebaTa doneebisa da rekomendaciebis xarisxis sqema

monacemebi, romlebic am saxelmZRvaneloSi iqna gamoyenebuli, klasificirebulia qvemoT moyvanili sqemis mixedviT, xolo rekomendaciebi formulirebulia igive wesiT, standartuli klasifikaciis mixedviT. rekomendaciebis xarisxi

mtkicebulebis done

A. kargad gamoxatuli efeqtu-robis da klinikuri sargeblobis mqone rekomendacia B. saSualod gamoxatuli efeq-turobis da SezRuduli sargeblo-bis mqone rekomendacia C. rekomendaciis efeqturobis

I minimum 1 randomizebuli, kontro-lirebadi kvlevis monacemebi II. minimum 1 klinikuri ararando-mizebuli kvlevis monacemebi -kohortuli an SemTxveva-kontrolirebadi meTodiT Catarebu-li kvlevidan (upiratesad erTze meti centris monacemebi), an

124

mtkicebuleba ar aris sakmarisi imisaTvis rom gadawydes misi gamoyenebis an ar gamoyenebis sakiTxi; magram rekomendacia SesaZlebelia gamoyenebuli iyos sxva mosazrebebze dayrdnobiT D. rekomendaciis efeqturobis ar arsebobis saSulod gamoxatuli mtkicebuleba E. rekomendaciis efeqturobis ar arsebobis kargad gamoxatuli mtkicebuleba

mravalricxovani seriuli kvleve-bidan, an mniSvnelovani Sedegebi arakontrolirebadi eqsperimente-bidan. III. monacemebi aRiarebuli avtorebis Sexedulebebidan gamomdinare, romlebic efuZneba klinikur gamocdilebas, aRweri-lobiT Seswavlas, an eqspertTa komitetebis angariSs

17. alternatiuli gaidlaini ar arsebobs

18. avtorTa jgufi

saqarTvelos saSvilosnos yelis paTologiis da kolposkopiis sazogadoeba, erovnuli skrining centri

Tamar alibegaSvili _ mean-ginekologi, medicinis mecnierebaTa kandidati, saqarTvelos saSvilosnos yelis paTologiis da kolposkopiis sazogadoebis gamgeobis Tavmjdomare, erovnuli skrining centris ginekologiuri samsaxuris koordinatori;

giorgi burkaZe _ klinikuri paTologi, medicinis mecnierebaTa doqtori, profesori, saqarTvelos saSvilosnos yelis paTologiis da kolposkopiis sazogadoebis gamgeobis wevri, n. yifSiZis sax. sauniversiteto klinikis paTologiuri anatomiis departamentis xelmZRvaneli, erovnuli skrining centris citologiuri diagnostikis samsaxuris xelmZRvaneli;

eka daTunaSvili _ mean-ginekologi, saqarTvelos saSvilosnos yelis paTologiis da kolposkopiis sazogadoebis gamgeobis wevri.

eqspertebi:

Tengiz Carkviani _ onkologi, medicinis mecnierebaTa doqtori, profesori, “saqarTvelos onkoginekologTa sazogadoebis” viceprezidenti;

Tengiz asaTiani _ mean-ginekologi, Tssu postdiplomuri samedicino ganaTlebis da uwyveti profesionaluri ganviTarebis institutis reproduqciuli janmrTelobis

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departamentis xelmZRvaneli, asocirebuli profesori, saqarTvelos mean-ginekologTa asociaciis prezidenti;

nikoloz kintraia _ mean-ginekologi, medicinis mecnierebaTa doqtori, sruli profesori, Tssu meanoba ginekologiis departamentis xelmZRvaneli, s/s akad. k. CaCavas sax. meanoba ginekologiisa da perinataluri medicinis s/k institutis ginekologiuri seqtoris xelmZRvaneli;

liana gogiaSvili _ klinikuri paTologi, medicinis mecnierebaTa doqtori, profesori. aleqsandre naTiSvilis morfologiis institutis klinikuri da eqsperimentuli paTologiis departamentis xelmZRvaneli;

zurab cagareli _ klinikuri paTologi, medicinis mecnierebaTa doqtori, profesori. aleqsandre naTiSvilis morfologiis institutis citologiis laboratoriis xelmZRvaneli, mecnierebis damsaxurebuli moRvawe;

mixeil janjalia _ onkologi, “aliansi kibos winaaRmdeg” prezidenti;

lela woworia _ saqarTvelos Sromis, janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti;

Tea TavidaSvili _ saqarTvelos Sromis, janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti.

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