阴道镜筛查CIN及早期宫颈癌78例分析

目的进一步评价阴道镜在宫颈上皮内瘤病变（CIN）及宫颈癌早期诊断中的价值。方法回顾性分析450例，进行阴道镜检查，行镜下定位取活组织病理检查，并与宫颈细胞涂片结果进行对比。结果450例中检出宫颈CINⅠ15例，CINⅡ19例，CINⅢ11例，宫颈鳞癌33例和宫颈湿疣15例，其余357例为慢性宫颈炎。宫颈CCT细胞涂片检出了71．8％宫颈病变，阴道镜检出了80．8％宫颈病变，细胞学与阴道镜下活检联合应用无漏诊。结论阴道镜检查是诊断CIN和宫颈癌的一个可靠方法，细胞学与阴道镜下活检联合应用能提高宫颈病变的检出率。     

液基细胞学与阴道镜联合应用对宫颈癌前期病变的临床意义

目的评价液基薄层细胞学检测(Thin prep Cytology Test,TCT)与阴道镜联合应用诊断宫颈癌前期病变的准确性。方法2004年1月-2006年12月在我院妇科门诊对10 129例已婚受检者行TCT检查,其中对1 452例阳性诊断结果做阴道镜活检。细胞学诊断采用TBS分级系统,阳性诊断包括上皮细胞异常,诊断结果与阴道镜活检诊断对照。结果10 129例宫颈液基细胞学检查中,1 452例(14.33%)细胞学检查异常,其中ASC477例(占4.71%),LSIL462例(占4.56%),HSIL366例(占3.61%),AGC129例(占1.27%),CA18例(占0.18%)。在细胞学检查异常的1 452例病例中,宫颈活检慢性炎占55.99%,CINⅠ占25.41%,CINⅡ占14.05%,CINⅢ/原位癌27例占1.86%,CA39例占2.69%,TCT与阴道镜下宫颈活检阳性符合率为86.02%。结论TCT检查与阴道镜下定位活检、病理检查结合可提高宫颈上皮内瘤样病变诊断的准确率。     

LEEP术后病理检查与阴道镜宫颈活检对宫颈癌前病变的诊断准确性

目的通过比较LEEP术后病理检查和阴道镜宫颈活检对宫颈癌前病变诊断结果的差异,评价阴道镜宫颈活检诊断宫颈癌前病变的准确性。方法对315例行妇科检查的患者行阴道镜宫颈活检和LEEP手术以及术后病理组织检查。结果阴道镜下宫颈活检与LEEP术后组织病理诊断的总符合率为57.15%(180/315),诊断不足20.95%(66/315),诊断过度21.90%(69/315);CINⅠ级诊断符合率为76.67%(23/30),漏诊CINⅡ/CINⅢ级2例,无原位癌和微小浸润癌漏诊。CINⅡ/CINⅢ级(含原位癌)符合率为56.67%(63/111),漏诊浸润癌33例(33/111)。相关因素对比分析发现,阴道镜活检结果为高级别CIN和细胞学检查结果为HSIL及以上,是阴道镜宫颈活检浸润癌漏诊的危险因素(P<0.05)。结论阴道镜宫颈组织活检存在漏诊宫颈微小浸润癌的风险。阴道镜宫颈组织活检对象如果为高级别CIN患者,则应行LEEP术以达到进一步确诊或排除浸润癌的目的。     

阴道镜下宫颈多点活检联合宫颈管搔刮术诊断宫颈病变的临床价值

目的:探讨阴道镜下宫颈多点活检联合宫颈管搔刮术（endocervical curettage，ECC）对诊断宫颈病变的临床价值。方法:选取2019年07月至2019年09月我院门诊经宫颈液基薄层细胞学（thinprep cytology test,TCT）检测异常和/或高危型人乳头瘤病毒（high risk human papillomavirus,HR-HPV）感染的患者383例，所有患者均进行阴道镜下多点活检联合宫颈管搔刮术，术后送病检，比较阴道镜下宫颈单纯四象限多点活检和宫颈四象限多点活检联合ECC对诊断宫颈病变的符合率及漏诊率等。结果:单纯活检诊断出宫颈病变患者142例，未检出宫颈病变患者241例，阴道镜下多点活检联合宫颈管搔刮术诊断出宫颈病变患者163例，未检出宫颈病变患者220例，单纯多点活检阳性率为37.08%（142/383），宫颈多点活检联合ECC阳性率为42.56%（163/383），两种方法相比较，宫颈多点活检联合ECC诊断宫颈病变阳性率显著高于宫颈单纯多点活检，差异有统计学意义（P＜0.001）。以病检结果为金标准，阴道镜下单纯多点活检诊断宫颈病变142例，灵敏度为87.12%，特异度为100%，阳性预测值为100%，阴性预测值为91.29%，漏诊率为12.88%，总符合率为94.51%。结论:阴道镜下宫颈四象限单纯多点活检对诊断宫颈病变患者具有较高的灵敏度、特异度、阳性预测值、阴性预测值及诊断符合率，但仍存在一定的漏诊，需联合ECC进行诊断，以提高宫颈病变的检出率，减少宫颈病变的漏诊，有助于指导治疗。     

阴道镜筛查CIN及早期宫颈癌78例分析

目的进一步评价阴道镜在宫颈上皮内瘤病变(CIN)及宫颈癌早期诊断中的价值。方法回顾性分析450例,进行阴道镜检查,行镜下定位取活组织病理检查,并与宫颈细胞涂片结果进行对比。结果450例中检出宫颈CINⅠ15例,CINⅡ19例,CINⅢ11例,宫颈鳞癌33例和宫颈湿疣15例,其余357例为慢性宫颈炎。宫颈CCT细胞涂片检出了71.8%宫颈病变,阴道镜检出了80.8%宫颈病变,细胞学与阴道镜下活检联合应用无漏诊。结论阴道镜检查是诊断CIN和宫颈癌的一个可靠方法,细胞学与阴道镜下活检联合应用能提高宫颈病变的检出率。     

106例意义不明确的宫颈不典型鳞状上皮细胞的病理诊断

[目的]探讨意义不明确的宫颈不典型鳞状上皮细胞（atypical squamous cells of undetermined significance，ASCUS）的病理诊断。[方法]对106例细胞学诊断为ASCUS的患者行HPV DNA检测，同时在阴道镜下多点活检。[结果]106例ASCUS患者中慢性炎症81例（76．42％），其中高危型HPV感染20例，占24．69％（20／81）；宫颈上皮内瘤变（CIN）25例（CINⅠ12例，CINⅡ9例，CINⅢ4例），其中高危型HPV感染23例，占92．0％（23／25）；慢性炎症和CIN患者的HPV感染阳性率有显著性差异（P〈0．05），且两型及以上HPV感染阳性率两组也有显著性差异（P〈0．05）。[结论]ASCUS患者行阴道镜下活检结合HPV检测，能进一步明确诊断。     

新柏氏液基细胞学检查在诊断宫颈病变中的应用

目的 评价新柏氏液基细胞学检查配合阴道镜检查对子宫颈病变的诊断价值及其临床意义。方法 回顾性分析本院妇科门诊2005年2月至2005年9月间行新柏氏液基细胞学检查配合阴道镜检查对子宫颈病变进行筛查，以组织学诊断为金标准，对结果进行分析。结果 液基细胞学检查1473例，发现异常细胞478例（32．45％）。行阴道镜检查＋活检后病理结果显示：子宫颈鳞癌6例，宫颈上皮内瘤样病变（CIN）61例，其中CINⅠ21例，CINⅡ/CINⅢ49例，急慢性宫颈炎（含HPV感染）402例。新柏氏液基细胞学检查诊断宫颈癌和癌前病变的病理阳性率和准确率分别是CA（100％，100％），HSIL（95．0％，85．0％），LSIL（64．7％，35．3％），ASCUS/AGCUS的病理阳性率为10．53％，HPV感染的病理阳性率为6．56％。结论 用液基细胞学检查配合阴道镜下病理检查能及早发现癌前病变。     

电子阴道镜和光学阴道镜在宫颈早期病变诊断中的比较研究

目的：评价国产电子阴道镜（SLC－2000）检测系统对宫颈早期病变诊断的临床应用价值。方法：在山西省襄垣县宫颈癌高发现场的一组随访病例中,同时应用电子阴道镜和光学阴道镜检查诊断,以组织学为金标准,进行随机对比研究。结果：行宫颈活检的163例患者中,组织学诊断为慢性炎症103例;异常60例,其中乳头状瘤1例,宫颈上皮内瘤变（CIN）I级37例,CINⅡ级18例,CINⅢ级4例。另行颈管刮术33例,病理阳性3例。电子阴道镜和光学阴道镜诊断宫颈阳性病变（≥CIN I级）的灵敏度分别为83．3％和95．0％,差异无显著性（P＝0．075）;电子阴道镜和光学阴道镜的特异度、阳性预测值和准确率分别为61．2％和21．4％、55．6％和41．3％、69．3％和48．5％,差异有显著性（P=0.000,0.035,0.000)。光学阴道镜和电子阴道镜在诊断≥CINⅡ级的宫颈病变中,其灵敏度、特异度、阳性预测值和准确率的差异,均无显著性。电子阴道镜和光学阴道镜的阴性预测值分别为86．3％和88．0％,差异无显著性（P=0.075)。结论：电子阴道镜在诊断≥CIN I级的宫颈病变中,其特异度、阳性预测值和准确率均优于传统的光学阴道镜,但后者的灵敏度较高。在诊断≥CINⅡ级的病变中,两种阴道镜无差别。国产电子阴道镜在宫颈早期病变的诊断、随诊和研究中具有一定的可行性和实用性。     

宫颈不典型鳞状细胞ASCUS 的临床处理探讨

目的:探讨宫颈细胞学检查ASCUS（未明确诊断意义的不典型鳞状细胞）的临床意义和处理方法。方法:2007年8 月至2009年6 月,对上海市闵行区中医医院妇科就诊的119 例细胞学检查报告为ASCUS 患者行阴道镜评估与镜下活检并对比其检查结果,同时进行了高危人类乳头瘤病毒（High-risk human papillomarirus ,HPV ）检测。结果:ASCUS 患者中包含43例（36.13%）宫颈上皮内瘤变（CIN）及原位癌,其中CIN Ⅰ29例（24.37%）、CIN Ⅱ9 例（7.56%）、CIN Ⅲ4 例（3.36%）及原位癌1 例（0.84%）。 高危HPV 阳性51例（42.86%）,其中33例为上皮内瘤变（64.71%）,高危HPV 阴性68例,其中10例为上皮内瘤变,高危HPV 阳性组CIN检出率明显高于阴性组,两者比较有统计学意义（χ2=32.9,P<0.05）。 HPV 检测和阴道镜检查诊断上皮内瘤变的灵敏度,分别为76.74% 和81.40% ,两者比较无统计学意义（P>0.05）。 结论:宫颈细胞学诊断为ASCUS 的病例中上皮内瘤变率高,应加强对AS?CUS 患者的重视,高危HPV 检测和阴道镜检查是对ASCUS 进一步处理的有效方法,尤其对高危型HPV 阳性的病例,应在阴道镜下行活组织检查,正确运用这两种方法,可提高宫颈病变筛查的阳性率。      

液基超薄细胞技术及TBS系统用于宫颈癌及癌前病变筛查

[目的]探讨液基超薄细胞技术（TCT）和Bethesda系统（TBS）在宫颈癌及癌前病变筛查中的临床应用价值。[方法]1100例患者行TCT检查和TBS细胞学分类诊断，阳性诊断包括意义不明的不典型鳞状细胞（ASCUS）。所有ASCUS以上病变的受检者全部在阴道镜下活检。[结果]1100例患者巾ASCUS32例、不除外高度病变的不典型鳞状上皮（ASC—H）18例、低度鳞状上皮内病变（LSTL）26例、高度鳞状上皮内病变（HSIL）16例、鳞状细胞癌2例。阴道镜下活检结果：CINⅠ26例、CINⅡ13例、CINⅢ9例、宫颈鳞癌3例，阴道镜病理检查符合率为71．28％。[结论]TCT技术应用于宫颈涂片细胞学检查，配合阴道镜下活检是筛查和诊断宫颈痛硬痛前病弯的可靠手段。     

电子阴道镜联合LEEP对宫颈上皮内瘤变的诊治价值

目的:探讨宫颈上皮内瘤变的早期诊断及合理治疗,以减少漏诊、过治及复发。方法:选取LEEP 治疗的宫颈上皮内瘤变（CIN）患者136例,对此组患者术前阴道镜直视下活检结果与LEEP术后病理结果进行对比分析。结果:此组病例中,阴道镜下活检结果与LEEP活检病理学诊断结果的完全符合率为59.6%（81/136）,诊断过度35例（25.7%）,诊断不足20例（14.7%）,两种方法的诊断结果差异有统计学意义（P=0.0403)。各个级别CIN 阴道镜下活检结果与LEEP活检病理学诊断结果的完全符合率分别为 43.5%（CINⅠ）、55.1%（CINⅡ）、80.0%（CINⅢ）。LEEP治疗后切缘阳性患者14例,切缘阳性率为10.3％（14/136）。7例切缘阳性患者再次行全子宫切除术,术后4例患者子宫标本中有病灶残留,其病变残留率为57.1％。结论:阴道镜联合LEEP有助于CIN的早期发现、准确诊断及合理治疗,但存在病变残留可能,需重视术后随访。LEEP治疗后切缘阳性是病灶残留的高危因素,对切缘阳性患者的处理有待于进一步探索。     

宫颈 TCT 异常患者行 HPV 检测在宫颈病变诊断中的临床价值

目的：探讨薄层液基细胞学检查（TCT）异常的患者行人乳头状瘤病毒（HPV）检测在宫颈癌及癌前病变诊断中的临床价值。方法：2010年3月至2012年3月在汉川市人民医院妇科门诊就诊的患者共计2389例行液基细胞学检查,结果异常的有526例患者,同时进行HPVDNA检测和阴道镜下宫颈活检,以组织病理学结果作为诊断的金标准。结果：宫颈活检组织病理学诊断结果：526例患者中宫颈炎及CINI456例,占86．69％,CINIl34例,占6．46％,CINⅢ32例,占6．08％,宫颈浸润癌4例,占0．76％。HPVDNA检测阳性者共有226例,阳性率随病变严重程度的增加而增加。CINII级及其以上病变检出率在HPVDNA检测阳性组中明显高于阴性组中,两组比较有显著性差异（P〈0．05）。结论：细胞学检查结果异常的患者,病理组织学检查结果相差较大,可以从宫颈炎症到宫颈癌。HPVDNA检测可以减少单纯应用薄层液基细胞学而造成的宫颈病变漏诊率,并对细胞学结果有进一步的分流作用。     

阴道镜引导下宫颈活检诊断宫颈病变的临床价值

目的:评价阴道镜引导活检(colposcopically directed biopsy,CDB)诊断宫颈病变的临床价值。方法:399例宫颈病变患者行宫颈CDB,其中101例患者被诊断为宫颈上皮内瘤样病变(cervical intraepithelial nuolasia,CIN)而行宫颈电圈环切术(loop electrosurgical excision procedure,LEEP)、宫颈冷刀锥切术(cold knife conization,CKC)、子宫切除术或广泛子宫切除术。比较宫颈CDB病理诊断结果与最终的病理诊断结果。结果:宫颈病变的宫颈CDB诊断与最终病理诊断符合者56例(55.4%),不符合者45例(44.6%)。最终病理诊断与宫颈CDB病理诊断相比,病变减轻26例(25.7%),加重19例(18.8%)。结论:宫颈CDB能够较为准确地发现宫颈病变,但不能替代CKC。对于高级别宫颈病变行诊断性锥切术可以最大限度地提高宫颈病变诊断的准确性。     

DNA ploidy compared with human papilloma virus testing (Hybrid Capture II) and conventional cervical cytology as a primary screening test for cervical high-grade lesions and cancer in 1555 patients with biopsy confirmation

BACKGROUND: Because 80% of cervical cancers arise in low-resource settings, many inexpensive strategies are being tested. In that spirit, the authors are testing large-scale genomic or DNA ploidy measurements as an inexpensive and semiautomated strategy. METHODS: Patients entered either a screening or diagnostic study of several optical technologies: quantitative cytology, quantitative histopathology, and fluorescence and reflectance spectroscopy using a point probe, a multispectral digital colposcope, or a combination of the two. We calculated sensitivities, specificities, positive and negative predictive values, and their confidence interval testing conventional cytology, Hybrid Capture (HC) II testing, and DNA ploidy measured on the Feulgen-stained quantitative Pap smear. RESULTS: The current investigation reports on 1555 patients for whom colposcopically directed biopsies were read 3 times by study pathologists. The final histopathologic diagnosis was high grade (cervical intraepithelial neoplasia [CIN] 2, CIN 3, carcinoma in situ [CIS], and cancer) in 16% of patients. Using high-grade squamous intraepithelial lesions (SILs) histopathology as the threshold and gold standard, the sensitivity and specificity, respectively, were: 0.47 and 0.96 for conventional cytology, 0.91 and 0.80 for HC II, and 0.59 and 0.93 for DNA ploidy. The positive and negative predictive values (PPV, NPV) for conventional cytology were 0.70 and 0.90, 0.46 and 0.98 for HC II, and 0.63 and 0.92 for DNA ploidy. CONCLUSIONS: DNA ploidy shows comparable sensitivity, specificity, PPV, and NPV values to conventional cytology and HC II. Unlike conventional cytology, DNA ploidy is semiautomated and can be performed in less than 8 hours. Cost effectiveness studies are under way, but in the authors' laboratory DNA ploidy is inexpensive.     

Chapter 14: Role of triage testing in cervical cancer screening

The classic model of cervical cancer prevention-primary screening with cytology, followed by diagnostic colposcopically directed biopsy, and finally treatment of cancer precursors-is undergoing dynamic change. The introduction of human papillomavirus (HPV) DNA testing and other new modalities provides more options but increases complexity in the sequence of screening, triage, diagnosis, and patient management. This chapter will focus on the role of triage and risk stratification in management. The utility of HPV testing has been established for triage of cytologic findings of atypical squamous cells of undetermined significance but not for low-grade squamous intraepithelial lesions or worse. Countries without established cytology services may consider alternative screening, triage, and treatment programs that may be more readily implemented than a resource-rich "cytology followed by colposcopy" paradigm requiring an infrastructure of highly trained personnel. The diagnostic step of colposcopy and directed biopsy is not completely sensitive in the detection of cervical intraepithelial neoplasia (CIN) 2 or 3 as is sometimes assumed. The partial insensitivity of this diagnostic step results in a population of women with negative colposcopically directed-biopsy findings but at increased risk for missed prevalent disease: these women may require additional triage rather than resumption of routine screening. As more efficient screening, triage, and diagnosis increase the sensitivity of detection of even very small CIN2 or CIN3, overtreatment of lesions that might otherwise regress becomes a concern and highlights the need to identify accurate markers of risk of progression to cancer. Markers of molecular events further along the pathway from HPV infection to development of cancer may ultimately provide more specificity in triage and diagnosis.     

妊娠期宫颈上皮内瘤样病变的筛查及治疗

综述了妊娠期宫颈上皮内瘤样病变的筛查方法 ,强调保守性治疗 ,反复阴道镜检查及镜下活检是安全可靠的 ,追加醋酸白试验可增加过度诊断 ,但敏感性可大大提高。如果阴道镜检查排除宫颈浸润癌 ,妇产科医生可将治疗时间推迟至产后 ,母婴危险性将降低。LEEP(loopelectrosurgicalexcision)治疗及宫颈锥切只应有于病理或阴道镜检查高度可疑癌或已证实为癌症的孕妇。妊娠期CIN转归率较高 ,但必须严密随访。     

Clinical Significance of Atypical Squamous Cells of Undetermined Significance among Patients Undergoing Cervical Conization

Background: Atypical squamous cells of undetermined significance (ASCUS) feature a wide variety of cervical cells, including benign and malignant examples. The management of ASCUS is complicated. Guidelines for office gynecology in Japan recommend performing a high-risk human papillomavirus (HPV) test as a rule. The guidelines also recommend repeat cervical cytology after 6 and 12 months, or immediate colposcopy. The purpose of this study was to determine the clinical significance of ASCUS. Materials and Methods: Between January 2012 and December 2014, a total of 162 patients underwent cervical conization for cervical intraepithelial neoplasia grade 3 (CIN3), carcinoma in situ, squamous cell carcinoma, microinvasive squamous cell carcinoma, and adenocarcinoma in situ at our hospital. The results of cervical cytology prior to conization, the pathology after conization, and high-risk HPV testing were obtained from clinical records and analyzed retrospectively. Results: Based on cervical cytology, 31 (19.1%) of 162 patients were primarily diagnosed with ASCUS. Among these, 25 (80.6%) were positive for high-risk HPV, and the test results of the remaining 6 patients (19.4%) were uncertain. In the final pathological diagnosis after conization, 27 (87.1%) and 4 patients (12.9%) were diagnosed with CIN3 and carcinoma in situ, respectively. Conclusions: Although ASCUS is known as a low-risk abnormal cervical cytology, approximately 20% of patients who underwent cervical conization had ASCUS. The relationship between the cervical cytology of ASCUS and the final pathological results for CIN3 or invasive carcinoma should be investigated statistically. In cases of ASCUS, we recommend HPV tests or colposcopic examination rather than cytological follow-up, because of the risk of missing CIN3 or more advanced disease.     

Colposcopy in the diagnosis of cervical neoplasia

Two hundred and ninety one women were evaluated for cervical cancer by cytology and colposcopy. Of these, 152 patients underwent colposcopically directed biopsy for histological evaluation. Colposcopy and cytology were in agreement in 88 per cent of cases whereas colposcopy and histopathology were in agreement in 79 per cent of cases. Cytology underestimated the severity of the lesion in nine per cent while colposcopy underestimated the lesion in 7.2 per cent (False negative rate). In 13.8 per cent of cases colposcopy overestimated the lesion (False positive rate). The cone biopsy rate in this series was 30 per cent. We conclude that since colposcopy shows excellent correlation with histopathology, it will be a useful tool to reduce cone biopsy rates, particularly in younger women in the child-bearing age group.     

Risk assessment to guide cervical screening strategies in a large Chinese population

Three different cervical screening methods [cytology, human papillomavirus(HPV) testing and visual inspection with acetic acid(VIA)] are being considered in China for the national cervical screening program. Comparing risks of CIN3 and cervical cancer (CIN3+) for different results can inform test choice and management guidelines. We evaluated the immediate risk of CIN3+ for different screening results generated from individual and combined tests. We compared tests using a novel statistic designed for this purpose called Mean Risk Stratification (MRS), in a pooled analysis of 17 cross sectional population‐based studies of 30,371Chinese women screened with all 3 methods and diagnosed by colposcopically‐directed biopsies. The 3 tests combined powerfully distinguished CIN3+ risk; triple‐negative screening conferred a risk of 0.01%, while HPV‐positive HSIL+ that was VIA‐positive yielded a risk of 57.8%. Among the three screening tests, HPV status most strongly stratified CIN3+ risk. Among HPV‐positive women, cytology was the more useful second test. In HPV‐negative women, the immediate risks of CIN3+ ranged from 0.01% (negative cytology), 0.00% (ASC‐US), 1.1% (LSIL), to 6.6 (HSIL+). In HPV‐positive women, the CIN3+ risks were 0.9% (negative cytology), 3.6% (ASC‐US), 6.3% (LSIL) and 38.5% (HSIL+). VIA results did not meaningful stratify CIN3+ risk among HPV‐negative women with negative or ASC‐US cytology; however, positive VIA substantially elevated CIN3+ risk for all other, more positive combinations of HPV and cytology compared with a negative VIA. Because all 3 screening tests had independent value in defining risk of CIN3+, different combinations can be optimized as pragmatic strategies in different resource settings.     

Ointment-based mechlorethamine treatment for mycosis fungoides

Atypical immature squamous metaplasia (AIM) is a poorly understood lesion with uncertain biological and clinical significance. This report reviews 170 cases of cervical condylomata and 60 cases of high-grade cervical intraepithelial neoplasia (CIN II/III); AIM was found in association with 34% of condylomata and 16% of high-grade CIN. Thirty-seven cases of AIM alone were reviewed and nearly all presented with a cytologic diagnosis of CIN I or condyloma and a colposcopic appearance of white epithelium with or without punctation and mosaic structure. The mean ages of patients with condylomata, AIM, CIN II, and CIN III were 27, 27, 32, and 37 years, respectively. By immunoperoxidase techniques 75% of condylomata, 16% of AIM, and 0% of CIN lesions were positive. The histologic criteria for the diagnosis of AIM and it's morphologic distinction from CIN and relationship to condylomata, are outlined. AIM is a distinct histologic entity that shares similar epidemiologic, morphologic and biologic characteristics with condyloma. When AIM is found alone in biopsy material, careful correlation of cytology, and biopsy results should be performed and therapy should be based on the size and distribution of the lesion.