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Patología Vaginal: Utilidad De La Citología Y La Colposcopia Como Métodos Diagnósticos *

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Patología Vaginal: Utilidad De La Citología Y La Colposcopia Como Métodos Diagnósticos * Rev Obstet Ginecol Venez 2012;72(3):161-170 Patología vaginal: utilidad de la citología y la colposcopia como métodos diagnósticos * Dras. Yanyn Betzabe Uzcátegui (1), María Carolina Tovar (1), Coromoto Jacqueline Lorenzo (2), Mireya González (3) (1) Médicos Especialistas, egresadas del Curso de Especialización en Obstetricia y Ginecología de la UCV, con sede en MCP. (2) Médico Especialista, Adjunta del Servicio de Ginecología de la MCP. (3) Médico Especialista, Directora del Curso de Especialización en Obstetricia y Ginecología de la UCV con sede en MCP. RESUMEN Objetivo: Evaluar la citología y la colposcopia como métodos diagnósticos de patología vaginal. Métodos: Estudio prospectivo y descriptivo que incluyó 100 pacientes. Se realizó citología, colposcopia y biopsia dirigida o del tercio superior de vagina, cuando no había lesiones. Resultados: La edad media de las pacientes fue 37,7 años. Hubo patología vaginal en 81 pacientes: 19 (23,4.%) neoplasias intraepiteliales vaginales I y 62 (76,5 %) lesiones no neoplásicas, entre ellas 47 (75,8.%) con infección por virus de papiloma humano y 15 (24,2 %) con otras lesiones. Entre las 37 pacientes con cambios colposcópicos, 56,8 % tenían epitelio acetoblanco fino, 45,9 % de los cambios estaban en el tercio superior. Hubo 5 casos de lesiones multifocales. Dos citologías presentaron cambios por virus de papiloma humano. En 66 pacientes hubo cambios histológicos compatibles con infección por este virus, 19 con neoplasia. La sensibilidad y especificidad de la citología para lesiones neoplásicas intraepiteliales fue 0 % y 100 %, de la colposcopia 47 % y 78 % y de ambos 75 % y 16 %, respectivamente. Los factores de riesgo significativos para infección por virus de papiloma humano y neoplasia intraepitelial fueron: edad, patología cervical y vulvar previa, uso de anticonceptivos orales y tabaquismo. Existe asociación significativa entre patología cervical o vulvar y el diagnóstico de infección por virus de papiloma humano en vagina. Conclusiones: La citología no debe ser usada aisladamente como método de pesquisa de lesiones neoplásicas de la vagina; se recomienda asociarla a la colposcopia vaginal. Palabras clave: Patología vaginal, Citología vaginal, Colposcopia vaginal. SUMMARY Objective: To evaluate the colposcopy and cytology as vaginal pathology diagnostic methods. Methods: prospective and descriptive study involving 100 patients. Cytology, colposcopy and directed biopsy, or in the upper vagina third when there was no injuries, was conducted. Results: The average age of the patients was 37.7 years. There was vaginal pathology in 81 patients: 19 (23.4 %) vaginal intraepithelial neoplasia I and 62 (76.5 %) injuries non neoplastic, including 47 (75.8.%) with infection by human papillomavirus and 15 (24.2 %) with other injuries. Among the 37 patients with colposcopy changes, 56.8 % had fine acetoblanco epithelium, 45.9 % of the changes were in the upper third. There were 5 cases of multifocal lesions. Two PAP submitted changes for human papillomavirus. In 66 patients there were histological changes consistent with infection by this virus, 19 with neoplasia. The sensitivity and specificity of cytology for intraepithelial neoplastic lesions was 0 % and 100 %, for the colposcopy 47 per cent and 78 per cent, and for both methods, 75 % and 16 %, respectively. Significant risk factors for infection of human papillomavirus and intraepithelial neoplasia were: age, prior cervical and vulvar disease, use of oral contraceptives and smoking. There is significant association between cervical or vulvar pathology and the diagnosis of infection of human papillomavirus in vagina. Conclusions: Cytology should not be used alone as a method of investigation of neoplastic lesions of the vagina; It is recommended to associate it with the vaginal colposcopy. Key words: Vaginal pathology. Pap smear. Vaginal colposcopy. * Trabajo Especial de Investigación que fue presentado ante la Universidad Central de Venezuela para optar al Título de Especialista en Obstetricia y Ginecología y aprobado en 2006. 161 Y. UZCÁTEGUI, ET AL INTRODUCCIÓN tumores metastásicos representan el 80 % a 90 % de los tumores de la vagina, y en la mayoría de los La vagina es un órgano del aparato genital interno casos los tumores primarios son de origen cervical o de la mujer que tiene forma de un tubo fibromuscular endometrial. También los tumores de ovario, recto, aplanado en sentido anteroposterior (1). Se ubica entre riñón y el coriocarcinoma pueden dar metástasis a el cuello uterino y el vestíbulo de la vulva. La forma la vagina (6). En general, las neoplasias malignas es variable y está determinada por la integridad de los vaginales constituyen 1 % a 4 % del total de las ligamentos de la pared pélvica. La pared posterior afecciones malignas ginecológicas (7). mide aproximadamente 11 cm de largo, en tanto Las lesiones vaginales premalignas son clasificadas que la anterior solo tiene 8 cm. El cuello uterino se como NIVA I, II, III, que corresponden a displasia leve, inserta en el fondo de saco vaginal llenando los 3 moderada y severa, respectivamente. Sin embargo, cm de diferencia de la pared anterior con respecto a existe la tendencia (aún no generalizada) a clasificar la pared posterior. La porción inferior de la vagina estas lesiones como neoplasias intraepiteliales de está contraída por los músculos elevadores del ano, bajo grado o de alto grado basado en su histología, mientras que la porción superior tiene un diámetro como resultado del cambio de la terminología de mayor (2). la citología cervical. La propensión de las lesiones Histológicamente, la pared vaginal está constituida de bajo grado de progresar a lesiones de alto grado por tres capas: revestimiento mucoso, muscular y está menos establecida que para las neoplasias fascia vaginal. La mucosa está formada por un epitelio intraepiteliales cervicales (NIC), pero evoca el mismo escamoso estratificado no queratinizado y una lámina concepto (8). Las pacientes con NIVA I y II tienden a propia. El epitelio está sujeto a influencias hormonales ser más jóvenes que las que presentan NIVA III. Se (3); estos cambios hormonales son cíclicos, durante piensa que la NIVA I y la NIVA II representan una la ovulación el contenido de glucógeno es más alto proliferación más benigna, en tanto que la NIVA III y disminuye en grado significativo en el estado es un precursor verdadero de cáncer (4). Aunque la de deficiencia estrogénica (4). La mucosa vaginal NIVA puede ocurrir a cualquier edad, las tasas de forma pliegues transversales, llamados rugosidades. incidencia más altas se observan en mujeres mayores Descripciones más recientes de la pared vaginal de 60 años (9). señalan la presencia de elementos glandulares o Es difícil estimar la incidencia verdadera de sus equivalentes metaplásicos en 3 % a 4 % de las neoplasia intraepitelial vaginal (10). Debido a que mujeres. Estas zonas se han descrito como adenosis, las mujeres con NIVA no suelen tener síntomas y que aunque representan variantes vaginales normales en la mayor parte de los casos se encuentran después o remanentes del desarrollo embrionario; pueden de un frotis de Papanicolaou anormal, la frecuencia describirse también como una zona de transformación suele relacionarse con la prevalencia en estudios de vaginal (3). detección citológica de una población determinada. La patología vaginal puede clasificarse como Las incidencias publicadas varían desde 0,2 hasta 2 lesiones no neoplásicas y neoplásicas. Las lesiones por 100 000 (11,12). neoplásicas pueden ser benignas, premalignas y Existe un alto porcentaje de coexistencia de malignas. Dentro de las lesiones no neoplásicas lesiones intraepiteliales así como invasoras de la vulva, se incluyen la adenosis vaginal, los trastornos vagina y cuello uterino, las cuales están relacionadas inflamatorios de tipo no infeccioso, las infecciones, con infección por el virus de papiloma humano los trastornos pigmentarios tipo melanosis y los quistes (VPH) de alto riesgo oncogénico en un 81,3.% de los (del conducto de Gartner, de las glándulas de Skene casos. Estos datos sugieren un importante papel de y los de inclusión). Las neoplasias premalignas se la infección por VPH en la carcinogénesis del tracto denominan neoplasia intraepitelial vaginal (NIVA) genital inferior femenino que obliga a un examen (5). Por último, dentro de las neoplasias malignas, físico más minucioso de todo el aparato genital el carcinoma de células escamosas es el tumor más especialmente en mujeres jóvenes (13). En 1 % a frecuente de vagina (85 %). Otros tumores malignos 3 % de pacientes con neoplasia cervical coexistirá derivados del epitelio pero de menor ocurrencia son neoplasia vaginal u ocurrirá en una fecha posterior (14). el adenocarcinoma, el carcinoma verrugoso y el Se desconoce la relación precisa entre VPH y carcinoma de células basales. Dentro de los tumores NIVA, pero tal vez incluya un proceso en múltiples malignos no epiteliales se encuentran: sarcomas, etapas asociado con cofactores como actividad melanoma, linfomas, tumores germinales, etc. Los sexual, otros agentes infecciosos (virus del herpes 162 Rev Obstet Ginecol Venez PATOLOGÍA VAGINAL simple y virus de Epstein-Barr), tabaquismo, estado pacientes de cualquier edad, independientemente del inmunitario y predisposición genética. Otros factores motivo de consulta y se excluyeron pacientes vírgenes de riesgo asociados con la presencia de NIVA son y/o con patologías que dificultaran la visualización el antecedente de histerectomías por patologías de la vagina:
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