检出高级别子宫颈病变的阴道镜活检程序的优化  

Optimizing biopsy procedures during colposcopy and detection of high-grade cervical lesions

作　　者：唐梦莹 尤志学[2] Tang Mengying;You Zhixue(Department of Obstetrics and Gynecology,the First Clinical Medical College,Nanjing Medical University,Nanjing 210029,China;Department of Gynecology,the First Affiliated Hospital of Nanjing Medical University,Nanjing 210029,China)

机构地区：[1]南京医科大学第一临床医学院妇产科,210029 [2]南京医科大学第一附属医院妇科,210029

出　　处：《中华妇产科杂志》2021年第3期192-199,共8页Chinese Journal of Obstetrics and Gynecology

摘　　要：目的探讨阴道镜下子宫颈活检对高级别子宫颈病变[即子宫颈上皮内瘤变Ⅱ级及以上病变(CINⅡ^(+))]检出的价值,并通过基于不同风险条件组合的阴道镜检查实践,进一步优化阴道镜活检程序。方法前瞻性研究2017年4月至2019年12月在南京医科大学第一附属医院因子宫颈癌筛查结果异常转诊阴道镜检查的346例患者,在阴道镜下对每例患者的子宫颈实施4个点的定位活检(包括异常图像区域的靶向活检和正常区域的随机活检),用于评估靶向活检和随机活检对检出CINⅡ^(+)的价值、多点活检的增量效应。分析基于不同风险条件(包括子宫颈细胞学检查结果、高危型HPV检测结果和阴道镜诊断)的组合后阴道镜下子宫颈活检的效能。结果346例患者的中位年龄为38岁(范围为22~61岁);活检后病理诊断为CINⅡ^(+)190例,占54.9%(190/346)。(1)346例患者均进行了靶向活检,靶向活检检出CINⅡ^(+)184例(96.8%,184/190),其中53例(27.9%,53/190)是在1级阴道镜异常表现(G1)的区域进行活检检出,131例(68.9%,131/190)是在2级阴道镜异常表现(G2)的区域进行活检检出。即以G2作为阴道镜下活检的阈值,阴道镜检出CINⅡ^(+)的敏感度为68.9%(131/190),而以G1为阈值时敏感度升至96.8%(184/190)。对每例行阴道镜检查的患者,在阴道镜诊断为G1或G2时,分别增加2个或1个点的靶向活检可检出所有CINⅡ^(+)。(2)346例患者中,270例进行了随机活检,检出CINⅡ^(+)6例(3.2%,6/190)。随着阴道镜下异常图像(包括G1、G2)累及象限数的增加,随机活检额外的CINⅡ^(+)检出率显著降低(P=0.010)。(3)子宫颈细胞学检查结果≥不除外高级别鳞状上皮内病变的不典型鳞状上皮细胞(ASC-H)、HPV 16型阳性和阴道镜诊断为G2是检出CINⅡ^(+)的高风险因素(P<0.01)。这3项高风险因素中,仅存在1项高风险因素时,第1个点活检的CINⅡ^(+)检出率为34.0%,第2个点活检的CINⅡ^(+)检出率增加Objective To investigate the value of biopsies on diagnosing cervical intraepithelial neoplasia of grade 2 or worse(CINⅡ^(+)),and optimize biopsy procedures of risk-based colposcopy practice.Methods A prospective study was performed on 346 women referred to colposcopy following abnormal cervical cancer screening results at the First Affiliated Hospital of Nanjing Medical University,from April 2017 to December 2019.Up to 4 cervical biopsies were taken during colposcopy and each biopsy specimen was evaluated separately in histology.CINⅡ^(+)identified by any biopsy was the reference standard of disease used to evaluate the diagnostic value of targeted biopsy and random biopsy,and to quantify the improved detection of CINⅡ^(+)by taking multiple biopsies.Cervical cytology,HPV genotyping,and colposcopic impression were used to establish different risk strata to select various multiple biopsies procedures during colposcopy to improve accuracy and efficiency of CINⅡ^(+)detection.Results In total 346 women,190(54.9%,190/346)cases of them were diagnosed as CINⅡ^(+).(1)In total 346 women,96.8%(184/190)CINⅡ^(+)were detected by targeted biopsies,27.9%(53/190)CINⅡ^(+)were detected in biopsies targeted grade 1 abnormal colposcopic findings(G1)on the cervix,and 68.9%(131/190)CINⅡ^(+)were detected in biopsies targetrd grade 2 abnormal colposcopic findings(G2)on the cervix.Colposcopy had a sensitivity of 68.9%when the biopsy threshold was G2,sensitivity increased to 96.8%when the biopsy threshold was defined to be G1.Among women with G1,adding 2 targeted biopsies to the first biopsy were sufficient to detect all CINⅡ^(+),among women with G2,adding 1 targeted biopsy was sufficient.(2)Among 270 women,random biopsies targeted normal colposcopic findings on the cervix were performed in addition to targeted biopsies and in total 3.2%(6/190)additional CINⅡ^(+)were detected.As the number of cervical quadrants involved by abnormal colposcopic images increased,random biopsy detected fewer CINⅡ^(+)that would have other

关 键 词：宫颈上皮内瘤样病变 宫颈肿瘤 阴道镜检查 肿瘤分级 活组织检查 

分 类 号：R737.33[医药卫生—肿瘤]