子宫颈微小浸润癌31例诊治分析

目的 分析子宫颈微小浸润癌(MIC)的临床特点,探讨采用子宫颈锥形切除术(宫颈锥切)治疗的可行性.方法 分析2005年11月至2007年10月在北京协和医院经宫颈锥切确诊为MIC31例患者的临床表现、锥切病理、后续处理及预后.结果 31例MIC患者中,24例有宫颈细胞学结果.所有患者均有阴道镜活检结果,其中1例(3.2%)子宫颈上皮内瘤变2级(CINⅡ),17例(54.8%)为宫颈上皮内瘤变3级(CINⅢ),13例(41.9%)怀疑早期浸润癌.根据锥切病理,23例被确诊为I a,期宫颈浸润癌(I a,期宫颈癌组).8例为I a2期宫颈浸润癌(Ia2期宫颈癌组),I a.期宫颈癌组中,3例(13.0%)有生育要求且切缘阴性的患者宫颈锥切术后接受严密随诊,1例(4.3%)切缘阳性但有生育要求的患者进行了再次锥切,其余19例(82.6%)无生育要求的妇女接受了全子宫(或加双附件)切除.I a2,期宫颈癌组的8例患者全部进行了根治性子宫切除.随诊中除1例保留子宫的患者细胞学提示异常、经阴道镜宫颈活检诊断为CINⅢ外,其余患者未见病变复发,保留子宫的4例随诊期间共发生3例次妊娠.结论 阴道镜活检对于MIC的诊断有重要提示价值,但MIC的确诊必须通过宫颈锥切病理.MIC的锥切后处理主要基于锥切病理,同时需要考虑患者的生育要求和切缘状况.     

宫颈上皮内瘤样病变的诊断与治疗

目的:研究宫颈锥切术对宫颈上皮内瘤样病变的诊断及治疗价值。方法:对2009年11月至2010年10月在我院行阴道镜下多点活检及宫颈锥切术等的44例患者进行回顾性分析,并运用自身对照法,对阴道镜下多点活检和宫颈锥切术的检查效果等进行统计学分析。结果:阴道镜下多点活检与宫颈锥切术病理检查不符合者27例(61.4%),完全符合者17例(38.6%);在因早期浸润而行宫颈锥切术27例中,阴道镜下多点活检其病理检查结果完全符合的仅11例(39.3%),在宫颈锥切术后,对发现的早期浸润癌行广泛子宫切除术2例(4.5%);因CNⅡ级或Ⅲ及有微小浸润而行全子宫切术9例(20.5%);对行宫颈锥切术的33例患者进行术后随访,所有患者均保留了生育功能,且在18个月的随访中,未发现有患者宫颈细胞学检查结果异常。结论:宫颈锥切术在宫颈上皮内瘤样病变的诊断及治疗中具有重要的价值,阴道镜下的多点活检术不能将其取代。是临床值得推荐的诊断及治疗方法,尤其对于具CINⅢ级且想保留生育功能患者。     

宫颈锥切术在诊断宫颈上皮内瘤样病变和早期宫颈癌中的价值

目的探讨宫颈锥切术能否被阴道镜多点活检所代替以及宫颈锥切术在诊断宫颈上皮内瘤样病变（CIN）和早期宫颈癌中的价值。方法回顾分析近5年来，在江苏大学附属宜兴医院妇产科因宫颈病变同时行阴道镜多点活检和宫颈锥切术（包括冷刀和电圈环切术即LEEP术）的患者120例，采用自身对照法，对比研究宫颈锥切术和阴道镜多点活检的病检结果的差异。结果宫颈锥切术与阴道镜下多点活检病理符合者59例（49．17％）；不符合者61例（50．83％），宫颈锥切术后病理诊断加重者35例（占29．17％），浸润癌漏诊率达10．00％。宫颈锥切术的主要并发症为出血。结论宫颈锥切术在诊断CIN和早期宫颈癌具有重要价值，不能被阴道镜多点活检所取代。要重视切缘是否阳性和加强术后的随访。     

高度子宫颈上皮内瘤变患者宫颈锥切前后病理结果分析

目的探讨阴道镜下宫颈活检诊断宫颈上皮内瘤变（CIN）2/3与锥切标本的病理学结果的一致性。方法回顾性分析182例阴道镜下多点活检结果为CIN2/3行宫颈环形电切术（LEEP）或冷刀锥切术患者的临床病理资料。结果在87例CIN2患者中,LEEP锥切术后病理结果：炎症12例,CIN1 19例,CIN2 48例,CIN3 8例,符合率为55.17%（48/87）;在95例CIN3患者中,冷刀锥切术后病理结果：炎症10例,CIN211例,CIN3 68例,宫颈浸润癌6例,符合率为71.58%（68/95）。结论重度宫颈上皮内瘤变患者的宫颈活检诊断与宫颈锥切术后病理结果存在一定的差异,必要时术前应进行诊断性锥切。     

宫颈冷刀锥切术诊治宫颈上皮内瘤变Ⅲ级320例临床分析

目的:探讨宫颈锥切术在宫颈上皮内瘤变Ⅲ级(CINⅢ)的诊断与治疗中的价值。方法:回顾性分析因宫颈CINⅢ行宫颈锥切术的患者320例,采用自身对照法,对比研究宫颈锥切术和阴道镜下活检的病理结果。结果:宫颈锥切术与阴道镜下检查的病理结果完全符合者187例(58.44%),不符合者133例(41.56%)。锥切术后病理诊断级别下降者69例(21.56%),漏诊微小浸润癌60例(Ⅰa1期55例,Ⅰa2期5例)(18.75%),漏诊浸润癌(Ⅰb1期)4例(1.25%)。59例患者再次行子宫切除术,其中32例(54.24%)术后病理转阴,16例病理诊断级别降低。宫颈锥切术的主要并发症是术后出血。结论:宫颈锥切术在CINⅢ的诊断和治疗中具有重要价值。应根据患者年龄、病变程度、切缘状态、生育要求等多方面个体化、综合考虑以决定进一步的治疗方案。     

阴道镜指引下多点活检遗漏子宫颈浸润癌14例临床分析

目的通过分析阴道镜指引下多点活检(CDB)遗漏子宫颈浸润癌患者的资料,探讨阴道镜活检后患者的管理模式。方法 645例CDB病理诊断为宫颈上皮内瘤变(CIN)2及以上病变(CIN2+)患者行子宫颈锥切术,对比锥切术前后的病理结果及14例遗漏的子宫颈浸润癌患者的年龄、筛查结果、阴道镜诊断、病变范围及是否向颈管内延伸等临床资料。结果 CDB病理诊断CIN2+的敏感度为95.0%,特异度为46.2%,子宫颈锥切术前后CIN2/3病理诊断的一致性为71.4%(450/630),宫颈浸润癌遗漏率为2.2%(14/630)。14例遗漏子宫颈浸润癌患者的平均年龄为(43.4±8.7)岁,其中10例筛查结果为高级别病变,11例HPV高危亚型感染(10例为HPV16),12例阴道镜诊断为HSIL+,9例病变范围超过子宫颈面积的50%,13例CDB病理结果为CIN3,10例宫颈锥切术后病理结果提示切缘不净。结论阴道镜指引下多点活检是诊断CIN2/3的一种简单而有效的方法,但可遗漏少部分子宫颈浸润癌。对于病理诊断CIN2/3者建议行子宫颈锥切术进一步诊断及治疗。     

宫颈冷刀锥切治疗宫颈上皮内瘤样病变Ⅲ级的评价

目的 探讨阴道镜下多点活检与宫颈冷刀锥切对于宫颈上皮内瘤样病变Ⅲ级（CINⅢ）病理诊断的符合情况。方法 1995—2005年间对北京大学人民医院92例阴道镜下多点活检病理诊断为CINⅢ的患者进行宫颈冷刀锥切治疗，比较阴道镜下多点活检与宫颈冷刀锥切的病理结果之间的差异。结果 92例中有52例多点活检与冷刀锥切的病理结果一致，符合率为56．5％，40例多点活检与冷刀锥切的结果不同，其中11例多点活检诊断为CINⅡ／Ⅲ，而冷刀锥切诊断为微小浸润癌。结论 宫颈锥切是宫颈上皮内瘤样病变的一种重要诊断与治疗方法。阴道镜下多点活检病理提示宫颈上皮内瘤样病变Ⅲ级并伴随腺体受累可能是存在宫颈浸润癌的一个高危因素。人乳头瘤病毒（HPV）感染与宫颈病变有关，但未发现HPV高危型检测数值高低与患者病理级别之间的联系。     

子宫颈四象限随机活检与阴道镜下定位活检HSIL+检出率比较

目的:通过分析宫颈定位活检及宫颈锥切标本病理HSIL+病变位点,理论上探讨随机点活检与定位活检在HSIL+检出率的差异。方法:回顾研究2016年1月至2018年6月在北京大学第一医院妇科因阴道镜下宫颈多点定位活检病理提示HSIL+,于阴道镜检查活检后1月内行宫颈锥切术的299例患者资料。综合宫颈点活检及宫颈锥切病理结果,对HSIL+病变累及部位、点数进行统计分析。结果:宫颈HSIL+病变最常见位点为6点和12点。根据病变所累及位点数将病例分为4组(1～3,4～6,7～9,10～12点)。细胞学低级别异常者173例(57.90%),细胞学高级别异常者126例(42.10%),不同的细胞学等级中不同组别所占比率存在统计学差异(P=0.00); HPV16/18阴性者130例(43.50%),阳性者169例(56.50%),两者中不同组别所占比率无统计学差异(P=0.06)。58例(19.40%)患者病变点位置未累及3/6/9/12点中任意一点,四组患者累及3/6/9/12点的比率存在统计学差异(P=0.00)。结论:阴道镜下四象限随机活检对于HSIL+的检出作用有限,尤其是在病变累及位点数≤3点者,建议阴道镜医生加强培训和实践,掌握阴道镜下定位活检技术,避免HSIL+的漏诊。     

四种不同检查方法在诊断宫颈病变中准确性比较

通过宫颈细胞学筛查 ,阴道镜下宫颈活检诊断宫颈病变是常用的方法。而临床上常常发现经阴道镜下多点活检病理报告为CINⅡ～Ⅲ级 (含原位癌 )者切宫术后病理检查结果程度加深 ,以致部分患者手术范围不足。因此我们于 2 0 0 1年 10月～ 2 0 0 2年 9月对 2 2例门诊诊断为CIN (含原位癌 )收住院患者在手术前行宫颈环形电切术 (loopelextro surgicalexcisionprocedure ,LEEP)。根据LEEP锥切术后的病理结果决定手术方式 ,并对比宫颈细胞学检查、阴道镜检查、阴道镜下多点活检及LEEP四种检查手段在宫颈病变诊断中的准确程度。资料与方法1 …     

48例阴式扩大性子宫颈切除术临床分析

目的探讨阴式扩大性宫颈切除术保守性治疗Ⅰa1期宫颈鳞癌及不适于行宫颈锥切术的宫颈上皮内瘤变（CIN）Ⅲ级患者的可行性及安全性。方法2002年7月-2007年5月,选择经环形电切术（LEEP）并活检后病理诊断的宫颈鳞癌Ⅰa1期（除外脉管癌栓）、大面积CINⅢ（阴道镜下病变面积≥3／4）、CINⅢ合并阴道上段上皮内瘤变（VAIN）、CINⅡ-Ⅲ锥切术后或LEEP术后复发、病变残存、切缘阳性,且要求保留子宫和（或）生育功能的患者,行阴式扩大性宫颈切除术治疗,对其临床资料进行分析。结果48例患者顺利实行阴式扩大性宫颈切除术,其中Ⅰa1期宫颈鳞癌患者5例,大面积CINⅢ患者38例（9例累及腺体）,CINⅢLEEP术后病变残存2例、切缘阳性2例,CINⅡ锥切术后复发1例。患者年龄27-40岁,中位年龄34岁,平均手术时间60min（30-100min）,平均出血量加ml（5-300ml）,平均住院天数10d（7-17d）。随访1～39个月,随访时间的中位数为14个月,无术后并发症及复发病例。结论阴式扩大性宫颈切除术是一种保守性治疗Ⅰa1期宫颈鳞癌、大面积CINⅢ、CINⅢ合并VAIN以及CINⅡ-Ⅲ锥切术后复发、病变残存、切缘阳性等不适于行宫颈锥切术患者的、安全有效的术式。     

Cervical conization findings in women with dysplastic cervical cytology and normal colposcopy

A review of 134 cervical conizations performed in a 36-month period showed that 18 were performed on patients with two or more cervical smears showing dysplasia but with essentially negative, satisfactory colposcopic evaluations, including normal colposcopically directed biopsies and endocervical curettings. A histologic diagnosis of cervical intraepithelial neoplasia (CIN) of various grades was established in 15 (83%) of the 18 conization specimens. Six (33%) of the 18 specimens harbored CIN 3. The histologic diagnosis of a more severe lesion than that indicated on cytology was rendered in five of the cases. Cervical conization should be performed when colposcopic evaluation of the cervix, vagina and vulva fails to identify the source of persistent CIN on Papanicolaou smears.     

Human papilloma virus testing in patient follow-up post cone biopsy due to high-grade cervical intraepithelial neoplasia

OBJECTIVE: We evaluated the contribution of the human papilloma virus (HPV) load in planning follow-up and management of women post cone biopsy for high-grade cervical intraepithelial neoplasia (CIN2-3). METHODS: Ninety-six suitable women were followed-up by Pap smears: two consecutive abnormal smears dictated referral for colposcopy-directed biopsy. Before colposcopy, HPV tests determined high-risk HPV DNA type and load (Hybrid Capture System type I). Patients histologically diagnosed with CIN1 or CIN2-3 underwent repeat conization or hysterectomy for residual disease. HPV load was compared to cytology for the detection of residual disease. RESULTS: At follow-up, 20/89 (22.4%) studied women had positive cytology reports of either low- (n = 11) or high-grade (n = 9) squamous intraepithelial lesion (SIL). Colposcopic biopsies diagnosed 9 CIN1 and 8 CIN2-3 cases. Residual disease was corroborated in 16/17 (94.1%) women and the status was readjusted based on cone biopsy/hysterectomy: CIN2-3 in 9 and CIN1 in 7. The positive prediction values for CIN2-3 residual disease with high-grade SIL, CIN2-3 on colposcopic punch biopsy, and high HPV load were 89, 100, and 100%, respectively. For CIN1 residual disease with low-grade SIL, CIN1 on colposcopic punch biopsy, and low and borderline HPV load, they were 54.5, 77.7, and 100%. The HPV load was a more accurate predictor for CIN1 or CIN2-3 on the cervical specimen in cases with low-grade SIL or CIN1 on colposcopic biopsy. CONCLUSIONS: Evaluating HPV loads after a positive cytology report may assist in triaging women post conization biopsy for CIN2-3 to appropriate treatment. Its high positive predictive value, specificity, and sensitivity for CIN1 and CIN2-3 and supplementary information could be especially pertinent for clinical management of low-grade SIL cases.     

阴道上皮内瘤变28例临床分析

目的: 探讨阴道上皮内瘤变(VAIN)的临床特点、危险因素、诊治及预后。方法: 回顾性分析北京协和医院2005-2011年住院收治VAIN病例28例临床资料。其中VAINⅡ7例,VAINⅢ21例。结果: 患者年龄29～76岁(中位年龄48岁)。绝经21例(75%)。26例(93%)无临床症状。25例(89%)病变位于阴道顶端。27例进行超薄液基细胞学涂片(TCT)检查异常。23例人乳头瘤病毒(HPV)检测阳性。15例有子宫切除术史,其中因宫颈上皮内瘤变(CIN)和宫颈癌切除子宫10例。子宫切除术后至诊断VAIN时间：宫颈疾病平均3.1年,非宫颈疾病8.8年。不同级别VAIN在年龄、子宫切除原因、目前及既往合并宫颈疾病、TCT结果差异无统计学意义。28例全部进行手术治疗,3例术后复发。结论: HPV病毒感染、宫颈病变、宫颈病变或宫颈癌行子宫切除术史是VAIN的危险因素;细胞学-阴道镜-组织病理学适用于VAIN的诊断及随诊;宫颈病变切除子宫治疗后应密切随访,尤其是术后3年内应警惕VAIN。　　     

The diagnosis and management of cervical intraepithelial neoplasia in the patient under the age of twenty-one

The diagnosis and management of 260 patients between the ages of 15 and 21 with cervical intraepithelial neoplasia is discussed. These patients represented 22% of all new patients seen in the Colposcopy Clinic of The Johns Hopkins Hospital between January 1975 and December 1979.Sixty-six percent of the patients were referred for evaluation of two Papanicolaou smears which were compatible with the diagnosis of CIN I while only 1.5% of the patients were referred with the cytologic diagnosis of CIN III. The colposcopic impression in the majority of patients was CIN I. There was excellent correlation between the colposcopic impression and histopathology. Thirteen percent of the patients evaluated had surgical procedures, 11% (29 patients) underwent conization and 2% (five patients) hysterectomy.The majority of patients under the age of 21 had minimal degree of cervical intraepithelial neoplasia. The importance of conservative management is discussed.     

The value of endocervical curettage in the management of the patient with abnormal cervical cytologic findings

Patients with adequate colposcopic examinations and dysplasia on the endocervical curettage specimen usually undergo further diagnostic evaluation. This study evaluated 712 patients and found the frequency of positive endocervical curettage specimens to be 17.6%. Cervical conization or hysterectomy specimens were examined in 66 cases with a positive endocervical curettage. Of these, 69.7% had histologic evidence of discontinuous dysplasia in the endocervical canal. The endocervical curettage specimens were grouped by the percentage of endocervical epithelium that was dysplastic: group 1, less than 10%; group 2, 10% to 50%; group 3, greater than 50%. Confirmed histologic endocervical involvement was 80%, 56%, and 60%, respectively. The involvement of the endocervical canal also increased with increasing grade of cervical intraepithelial neoplasia. Of the 66 cases examined with positive endocervical curettage specimens, 62.1% had grade 3 cervical intraepithelial neoplasia on the ectocervix. Seven patients had positive endocervical margins, with six of these occurring in grade 3 cervical intraepithelial neoplasia lesions. Two unsuspected cases of cervical malignancy were identified by endocervical curettage.     

Diagnostic and therapeutic efficacy of cervical conization.

Cervical conization was perfromed on 756 patients at the University of Kentucky Medical Center from July 1, 1964, to January 1, 1973. Sixty-six patients were pregnant at the time of conization. Eighty-six per cent of patients with cytologic findings of carcinoma in situ had histologic verification of carcinoma in situ or severe dysplasia, and there was absolute correlation between cytology and histology in 75 per cent of patients will occult invasive cancer. Cervical biopsies without colposcopic direction predicted either severe dysplasia or carcinoma in situ in 77 per cent of cases but were accurate in only seven of 24 patients with occult invasive cancer. Carcinoma in situ was present in 30 per cent of hysterectomy specimens following conization but recurred in only seven per cent of patients followed without hysterectomy. Recurrent carcinoma in situ following hysterectomy was more common in patients with residual intraepithelial cancer in the uterus but was independent of the size of the vaginal cuff removed. Major postconization complications requiring hospitalization occurred in 3.4 per cent of nonpregnant patients and in 7.5 per cent of pregnant patients.     

Diagnostic and therapeutic laser conization for cervical intraepithelial neoplasia

OBJECTIVE: The clinical efficacy of conservative treatment using Nd-YAG laser technique for cervical intraepithelial neoplasia (CIN) was evaluated in a large series of CIN patients based on the long-term follow-up results. METHODS: We have treated 2107 women preoperatively diagnosed as having CIN by Nd-YAG contact laser conization with vaporization of the base. Their postoperative histologic findings and clinical outcomes were evaluated. RESULTS: The cone specimen was reported as showing that 1956 (92.8%) of 2107 cases had no CIN or CIN 1-3 and 151 (7.2%) cases had invasive diseases. 1956 cases without invasive diseases were followed up for 16 to 252 months. Incomplete excision occurred in 230 (12.3%) of 1874 patients with CIN lesion in the cone specimen, but failure rate (persistence or recurrence) was only 1.2%. 192 (83.5%) of 230 postoperative CIN patients with positive surgical margins showed no abnormal cytology or colposcopy during follow-up period. Preoperative underdiagnosis of biopsy results compared with cytologic or colposcopic findings elevated the risk for incomplete excision and failure rate. CONCLUSION: The combination of laser excision and vaporization of the base was useful to detect unexpected invasive disease and revealed excellent therapeutic effects for CIN. Preoperative cytologic or colposcopic findings should be taken into account for the conservative treatment of CIN.     

Zervikale intraepitheliale Neoplasie 3

Cervical intraepithelial neoplasia (CIN) grade 3 represents the direct precancerous lesion of invasive cervical cancer and is associated with persistent infection with human papillomavirus (HPV), mainly types 16 and 18. Conization represents the current therapy for CIN?3. In Germany approximately 90,000 –100,000 conizations are carried out per year. Currently most interventions are performed not as cold knife but as electrosurgical loop or laser conizations. Because of significant adverse events in subsequent pregnancies, such as cervical insufficiency, premature rupture of the membranes and prematurity, conization procedures should only be performed in cases with histologically proven indications, as tissue sparing as possible and under colposcopic guidance. In pregnancy CIN?3 should be monitored continuously to exclude a microinvasive disease and t therapy is then postponed until postpartum.