子宫颈高危型HPV阳性而细胞学阴性患者临床管理方法的初步探讨 ——附137例因CINⅡ行LEEP术患者的分析  

Study on clinical management of HPV＋/Pap- during cervical cancer screening

作　　者：黄爱娟 赵昀[1] 邹晓莲 闫瑾 赵超[1] 崔淑慧[1] 李燕燕 任丽华[1] 李静然[1] 李明珠[1] 王悦[1] 王建六[1] 魏丽惠[1] 

机构地区：[1]北京大学人民医院妇产科[黄爱娟现在北京市东城区第二妇幼保健院妇科,100044 [2]云南省妇幼保健院妇科 [3]云南省第二人民医院妇科

出　　处：《中华妇产科杂志》2017年第11期745-750,共6页Chinese Journal of Obstetrics and Gynecology

基　　金：科学技术部国家重点研发计划（2016YFC1302901）;国家卫生和计划生育委员会公益性行业科研专项（201502004）;北京市自然科学基金（7174359）

摘　　要：目的初步探讨子宫颈高危型HPV（HR-HPV）阳性而细胞学阴性（HPV＋/Pap-）患者的临床管理方法。方法收集2010年1月—2014年12月在北京大学人民医院妇科门诊因子宫颈上皮内瘤变（CIN）Ⅱ行子宫颈环形电极切除（LEEP）术，且临床资料完整的患者，共137例。通过追溯137例患者阴道镜活检前的子宫颈细胞学检查和HR-HPV检测联合筛查结果以及LEEP术后的病理检查、术后4~6个月随访时的子宫颈细胞学检查和HR-HPV检测结果，复核HPV＋/Pap-患者的子宫颈细胞学涂片的判读结果，初步分析其合理的临床管理方法。结果（1）活检前HR-HPV阳性率为98.5%（135/137），细胞学阳性率69.3%（95/137），HR-HPV阳性率显著高于细胞学阳性率（χ2=43.32，P〈0.01）。（2）HPV＋/Pap-患者共42例，占30.7%（42/137）。重新复核其细胞学涂片，16例（38.1%，16/42）维持原细胞学阴性结果，26例（61.9%，26/42）修订为细胞学阳性，首次细胞学判读的漏诊率为19.0%（26/137）。这26例患者的细胞学涂片判读结果出现误判的原因，13例（50.0%）由于异常细胞数量较少造成漏诊，8例（30.8%）由于异常细胞形态与正常细胞相似、异常细胞形态不典型而造成，另有5例（19.2%）由于染色问题影响判读结果。（3）LEEP术后病理检查显示，37例术后诊断升级，其中34例升级为CINⅢ，2例子宫颈微小浸润癌，1例为子宫颈浸润癌Ⅰb期；37例为CINⅠ或未见子宫颈上皮内病变；63例术后病理诊断依然为CINⅡ。LEEP术后4~6个月随访显示，细胞学阳性率为11.7%（16/137），HR-HPV阳性率为34.3%（47/137）。结论与单独细胞学检查比较，细胞学联合HPV检测明显提高子宫颈病变筛查的敏感度。对于初筛结果为HPV＋/Pap-的患者，应复核其细胞学涂片，并进一步加强细胞学取材和细胞学判读的质量控制，以减少CINⅡ的漏诊。LEEP术在达到治疗作用的�ObjectiveTo study the clinical management way for HPV＋/papanicolaou （Pap）- during cervical cancer screening. MethodsTo analyze retrospectively the data from the patients who had loop electrical excision procedure （LEEP） for biopsy confirmed cervical intraepithelial neoplasia （CIN） Ⅱ in Peking University People′s Hospital from Jan. 2010 to Dec. 2014. Results（1） For biopsy confirmed CIN Ⅱ, HPV positive rate was 98.5% （135/137）, Pap test positive [≥atypical squamous cell of undetermined significance （ASCUS）] rate was 69.3% （95/137）, there was significant difference between them （χ2=43.32, P〈0.01）. （2） For the 42 patients with HPV＋/Pap-, whose cytology slides were reviewed again. Among them, the interpretations of there were 16 cases confirmed as the same before, while 26 cases were changed to abnormal （≥ASCUS）. Cytology be misdiagnosed was 19.0% （26/137） at the first review. Among the 26 cases, 13 （50.0%） cases were missed for the little amount of abnormal cells, 8 （30.8%） cases for mild atypical morphology changed; the other 5 （19.2%） cases missed for stain problems. （3） For the cervical LEEP samples, 37 cases of the pathology diagnosis were upgrade to CIN Ⅲ＋, among them, 2 cases of microinvasive cervical carcinoma, 1 case of invasive cancer, 34 cases of CIN Ⅲ; 37 cases were CINⅠ or no lesion found; 63 cases were still CIN Ⅱ. Four to six months later after LEEP, the cytology abnormal rate was 11.7% （16/137）, and the HR-HPV positive rate was 34.3% （47/137）. ConclusionsCompared with cytology alone, cytology combined with HPV testing increase the sensitivity of cervical high grade lesion. For the cases of HPV＋/Pap- cases, the cytology slides should be reviewed. The quality control of cervical exfoliate sample collection and interpretation should be strengthened. LEEP procedure is not only a treatment method, but also it could provide samples to confirm the diagnosis.

关 键 词：乳头状瘤病毒科 宫颈上皮内瘤样病变 细胞诊断学 

分 类 号：R737.33[医药卫生—肿瘤]