子宫颈病变发病机制与阴道镜成像相关性研究

目的研究子宫颈病变发病过程中异常细胞增殖和新生血管形成与阴道镜成像的相关性,探讨子宫颈红区在阴道镜诊断中的价值。方法收集2019年10月至2020年1月在北京大学第一医院行阴道镜检查并采用R-way阴道镜诊断术语进行描述和阴道镜拟诊的202例病例,对年龄、细胞学和高危型人乳头瘤病毒筛查结果、阴道镜图像及子宫颈组织病理结果进行统计学分析。结果仅红区无其他特征的阴道镜图像以病理组织学低级别鳞状上皮内病变(LSIL,26/70)为最多;红区+厚醋白阴道镜图像以病理组织学子宫颈上皮内瘤变(CIN)2为最多(26/58);红区+厚醋白+异型血管阴道镜图像以病理组织学CIN3为最多(17/29);红区中增生与出血伴随出现的阴道镜图像病理组织学均为子宫颈癌(8/8),以上差异均有统计学意义(P0.05),其他类别阴道镜图像的病理组织类型分布差异无统计学意义(P0.05);以红区为基础的各类阴道镜图像共识别出60.89%(123/202)的高级别鳞状上皮内病变(HSIL)+,其中识别HSIL+特异度最高的图像为红区+增生+出血(100%),其次是红区+厚醋白+异型血管(96.2%),依据R-way阴道镜诊断标准在红区基础上结合增生伴出血、醋白、异型血管、出血等图像识别HSIL+的累积灵敏度为100%;仅红区阴道镜图像联合高级别异常细胞学的曲线下面积(AUC)(0.45)大于仅红区(0.31)。结论阴道镜检查中,多幅图像叠加分析可增加诊断的准确性;子宫颈红区具有重要诊断价值,应作为阴道镜拟诊高级别病变的必备条件;阴道镜检查未见明显异常时应结合高级别异常细胞学结果在红区活检,以降低漏诊率。     

阴道镜在宫颈癌诊断中的应用

阴道镜是介乎于肉眼和低倍显微镜之间的放大窥镜 ,于 192 5年由德国的ＨａｎｓＨｉｎｓｅｌｍａｎｎ发明 ,经过不断改良 ,已发展有光学和电子数码两大类阴道镜。阴道镜通过放大直接观察宫颈表面血管上皮的形态结构以评估病变 ,成为宫颈癌筛查诊断的主要手段。1　阴道镜观察诊断原理阴道镜观察主要以宫颈病灶的表面构型、边界形态、颜色、血管和碘反应几个征象反应病灶的异常。阴道镜诊断名词经历了从混乱到统一的过程 ,1990年第七次国际宫颈病理和阴道镜会议 (ＩＦＣＰＣ)统一了新的分类和标准 ,异常阴道镜图像主要有 :①醋酸白上皮 ,是指涂…     

《中国实用妇科与产科杂志》2016年第5期中心内容预告

正中心内容:妇科肿瘤筛查妇科恶性肿瘤的筛查开启卵巢恶性肿瘤"精准筛查"的新模式新策略子宫癌筛查的进一步思考人乳头瘤病毒(HPV)检测在临床应用中的误区重视阴道镜下异常图像在宫颈病变筛查中的意义客观评价子宫内膜癌筛查方法妊娠期宫颈癌的筛查     

2468例阴道镜检查与病理学诊断结果分析

用阴道镜活检２４６８例妇科门诊患者，在异常阴道镜图像中，白色上皮、腺口白环、白斑、点状血管、异形血管、镶嵌、明显癌及非典型增生的检出率分别为５．６％、１０．４％、１６．０％、１６．０％、１７．４％、２０．３％和７９．２％。腺口白环的癌及非典型增生的检出率为１０．４％。阴道细胞涂片中的Ⅲ、Ⅳ和Ⅴ级涂片中癌的检出率分别为２１．７％、６５．５％和９２％。涂片的级别与异常阴道镜图像有明显的关系。     

2468例阴道镜检查与病理诊断结果分析

用阴道镜活检２４６８例妇科门诊患者，在异常阴道镜图像中，白色上皮、腺口白环、白斑、点状血管、异形血管、镶嵌、明显癌及非典型增生的检出率分别为５．６％、１０．４％、１６．０％、１６．０％、１７．４％、２０．３％和７９．２％。腺口白环的癌及典型增生的检出率为１０．４％。阴道细胞涂片中的Ⅲ、Ⅳ和Ⅴ级涂片中癌的检出率２１．７％、６５．５％和９２％。涂片的级别与异常阴道镜图像有明显的关系。     

阴道镜下不同活检方法在高级别子宫颈上皮内病变检出中的作用

目的探讨阴道镜下不同活检方法在HSIL检出中的作用。方法对388例宫颈癌筛查异常的妇女行阴道镜检查,并在阴道镜指引下行四象限点活检+ECC,以病理诊断为金标准。结果阴道镜指引下在子宫颈最异常处的第一块活检检出77.1%(54/70)的HSIL,在病变第二异常处活检额外检出4.3%(3/70)的HSIL,在病变异常处的两块定位活检检出HSIL+的敏感性为81.4%,特异性为96.1%,与筛查异常级别(OR=4.257,95%CI:1.590~11.397,P=0.004)、阴道镜拟诊(OR=27.124,95%CI:12.221~60.199,P=0.000)具有相关性;随机活检额外检出18.6%(13/70)的HSIL,其中6例CIN2,7例CIN3;在筛查低级别异常者中额外检出HSIL 8例,占2.3%(8/344),其中5例CIN2,3例CIN3;在高级别异常者中额外检出HSIL 5例,占11.4%(4/44),其中1例CIN2,4例CIN3,与筛查异常级别(OR=6.833,95%CI:1.702~27.432,P=0.007)具有相关性,ECC无额外HSIL的检出。结论在子宫颈癌筛查异常妇女中,阴道镜下可疑病变部位行阴道镜指引下的2点或以上活检为HSIL检出的主要方法;对于阴道镜下未发现异常的妇女,尤其是对宫颈癌筛查高级别异常的妇女建议行随机活检。     

阴道镜图像与组织学的关系

阴道镜可将宫颈表面形态扩大到20～40倍,并直接观察宫颈上皮及皮下间质内血管的不同表现,以判定具体的阴道镜图像估价宫颈之疾病,或指导宫颈活体组织检查的取材部位以及评定宫颈疾病随访的结果。用法简单易于掌握,但使用者不仅要有认识阴道镜图像的全面知识,也应具备一定的病理组织学的基础,尤其是五种异常阴道镜图像与病理组织学的相关,才能比较准确地作出宫颈疾病的判断。阴道镜重点观察部位是宫颈表面的不典型的或不     

中国子宫颈癌筛查及异常管理相关问题专家共识(二)

正CSCCP中国子宫颈癌筛查及异常管理相关问题专家共识的第二部分内容:阴道镜的规范化检查,组织学确诊的子宫颈上皮内瘤变(CIN)和原位腺癌(AIS)的处理建议。一、阴道镜检查子宫颈的操作规范阴道镜检查作为子宫颈癌筛查异常结果进一步评估的重要检查手段,主要用于对下生殖道可疑病变进行评价。阴道镜检查使用3%~5%醋酸、卢戈碘液,会造成患者一定的不适感,并对患者阴道微环境造成一定的影响,建议     

阴道镜检查对宫颈上皮内瘤样病变的诊断价值探讨

目的 探讨阴道镜对宫颈上皮内瘤样病变（CIN)的诊断价值。方法 分析我院近年宫颈疾患701例阴道镜的检查结果。结果 CIN检出率阴道镜组显著高于肉眼检查组，且以30～49岁段为主，占68．5％。阴道镜图像中以血管异常为主占59％。阴道镜下活检与术后病理诊断的符合率为75％。结论 阴道镜是辅助诊断CIN的重要环节，可以提高CIN检出率。     

电子阴道镜在宫颈癌筛查中的应用

目的：使用阴道镜筛出癌前病变及肉眼不能发现的早期宫颈癌,指导活检,提高活检和诊断的准确率,做到早发现,早诊断,早治疗。及时进行癌前阻断,从而降低发病率和死亡率。方法：用电子阴道镜对3722例农村妇女进行宫颈癌筛查,其中对2672例绝经前妇女行常规电子阴道镜检查,发现异常即在阴道镜下定点行组织活检。结果：256例检查结果中,发现异常147例,异常率51．42％,其中98例为CIN1,18例为CIN2,14例为CIN3,5例为原位癌,12例为尖锐湿疣。镜下定位活检100％。结论：阴道镜筛查能有效筛查宫颈癌及宫颈上皮内瘤病变,是提高宫颈癌筛查诊断的重要手段。电子阴道镜在宫颈癌筛查中具有低成本、高效益的特点,即有一定的临床价值和经济价值。     

Abnormal cervical cytology: a risk factor for endometrial cancer recurrence

The objective of this study was to evaluate the relationship between cervical cytology, histologic type, and risk of endometrial cancer recurrence. We performed a retrospective study of patients undergoing surgery for endometrial carcinoma. Risk factors for recurrence including histology, tumor grade, nodal status, myometrial invasion, peritoneal washings, stage, and cervical cytology were assessed. Abnormal cervical cytology was defined as the presence of any endometrial cells on Pap smear. Papillary serous and clear cell carcinomas were considered high-risk histologies. Univariate and multivariate analyses of risk factors for recurrence were performed. Thirty-nine (9%) patients developed recurrent endometrial cancer. More patients with abnormal Pap smears recurred (12% versus 4%, P < 0.05). For endometrioid adenocarcinoma, abnormal cervical cytology occurred in 61% and 7% recurred, while with high-risk histologies, 84% had abnormal cervical cytology and 19% recurred (P < 0.05). Other significant predictors of recurrence on univariate analysis were myometrial invasion, nodal status, washings, stage, and histology. On multivariate analysis, only nodal status remained a significant predictor of recurrence. Abnormal cervical cytology is associated with increased risk of endometrial cancer recurrence. Abnormal cervical cytology occurs more frequently in high-risk histologies, which are known to have a higher risk of recurrence. On multivariate analysis, only nodal spread remains a significant predictor of recurrence.     

Cervical neoplasia in pregnancy. Part 1: screening and management of preinvasive disease

Cervical cancer screening is an essential component of prenatal care. The diagnosis and management of cervical intraepithelial neoplasia (CIN) during pregnancy are challenging, and sufficient information does not exist to allow for a definitive evidence-based approach. The American Society for Colposcopy and Cervical Pathology has recently published guidelines regarding the evaluation of abnormal Papanicolaou tests and the treatment of CIN in this setting. Many techniques traditionally recommended in the evaluation of abnormal cervical cytology and the treatment of CIN in the nonpregnant woman, such as colposcopy, cervical biopsy, and electrosurgical excision, can be applied to the pregnant patient with important exceptions. The vascular cervix associated with the gravid condition and the risk of premature pregnancy loss mandates deviation from existing consensus guidelines in screening for cervical cancer in pregnancy and treating associated CIN. In the present review, current guidelines regarding cervical cancer screening are reviewed, and data from studies of pregnant populations are summarized.     

Why remove all cervical polyps and examine them histologically?

A retrospective analysis of 1366 cervical polyps showed that none had malignant features and 67% were removed from asymptomatic women. A policy removing only cervical polyps from symptomatic women or those with abnormal cervical cytology and limiting histological examination to these polyps would result in significant savings and reduce the small risk of morbidity associated with polypectomy.     

Intermenstrual and post-coital bleeding

Abnormal or unscheduled bleeding from the lower genital tract is common. In some women it can be the first symptom of genital tract malignancy. However in majority of women there is a benign or idiopathic cause. The investigation for the abnormal bleeding is dependent on a number of factors, including age, co-existing medical conditions and cervical smear history. Based on these variables, a gynaecologist will be able to make an assessment of risk of malignancy. The majority of women will have a low risk of malignancy and need not have further investigations. Treatment of abnormal bleeding will depend on the cause, this may be removing the abnormality or hormonal treatment to suppress bleeding. In many women no abnormal cause for the bleeding will be found.     

人乳头瘤病毒检测在宫颈疾病诊断中的意义

目的探讨人乳头瘤病毒（human papillomavirus，HPV）联合宫颈液基细胞学（thin-prep cytology test，TCT）检测在宫颈病变诊断中的临床意义，以及HPV负荷量与宫颈病变程度的相关性。方法对我院妇科2350名患者行宫颈TCT和高危型HPV检测。结果①HPV高危阳性患者共895例，阳性检出率为38．09％，TCT结果正常组内：正常、轻度炎症、中度炎症、重度炎症HPV阳性率分别为17．06％、28．30％、36．43％和30．30％；②TCT结果为正常组、ASCUS、ASC—H、LSIL、HSIL中，HPV阳性率分别为27．60％、52．30％、61．31％、86．11％、91．25％。③将HPV负荷量由低至高行数量分级后，TCT异常率分别为12．92％、25．93％、41．38％、50．52％和65．74％。结论在TCT异常者中，病变程度越高，高危型HPV感染率越高。随着病毒负荷量增加，宫颈病变发生，率增加，其病变程度也越重。     

ⅠA1期子宫颈癌早期诊断与治疗路径分析

目的探讨ⅠA1期子宫颈癌早期诊断和治疗的临床路径。方法对2003年1月至2012年12月诊断及治疗的71例ⅠA1期子宫颈癌患者的临床资料进行回顾性分析。结果在同期581例子宫颈癌患者中,ⅠA1期子宫颈癌患者71例,占12.2%,患者平均年龄（45.0±10.4）岁。在71例ⅠA1期子宫颈癌患者中,70例（98.6%）患者病理类型为鳞状细胞癌;29例（40.8%）患者有异常阴道出血或排液;67例（94.9%）患者有不同程度的宫颈细胞学异常,65例（91.1%）患者高危型人乳头瘤病毒（HR-HPV）阳性;32例（45.1%）患者阴道镜下多点活检病理提示早期浸润癌,62例（87.8%）患者子宫颈锥切术后病理诊断。结论子宫颈癌ⅠA1期患者的早期发现主要通过子宫颈癌筛查,对于筛查异常者及时行阴道镜及病理检查,高度可疑子宫颈癌前病变及浸润癌者建议及时行子宫颈锥切术。     

21～24岁年轻女性子宫颈癌筛查建议及子宫颈病变的处理

21～24岁年轻女性子宫颈癌及癌前病变发生率较低，且该年龄段子宫颈病变逆转可能性大，因此对21～24岁年轻女性初级筛查建议采用单独子宫颈脱落细胞学检测；对于子宫颈细胞学筛查结果异常推荐随访为主；异常组织病理学趋于保守处理，根据病变级别和细胞学筛查结果实施分层管理，并采取子宫颈脱落细胞学、高危型HPV检测以及阴道镜检查随访。     

TERC基因联合阴道镜及HPV检测在早期宫颈病变诊断中的应用

目的：探讨阴道镜、人端粒酶RNA组分（hTERC）基因扩增和人乳头瘤病毒（HPV）分型检测在早期宫颈病变诊断中的临床意义。方法：对经阴道镜初步诊断为宫颈病变的219例患者,应用荧光染色体原位杂交（FISH）技术检测hTERC基因扩增、表面等离子谐振技术（SPR）检测HPV感染情况,并进行统计学分析。结果：①阴道镜诊断宫颈CINⅠ级59例,CINⅡ级76例,CINⅢ级56例,宫颈癌28例,与组织学最终诊断相比较,两种方法有相关性（P＜0.05）。②hTERC基因在宫颈炎性病变、CINⅠ、CINⅡ、CINⅢ及宫颈鳞癌中的阳性扩增率分别为7.9%,10.9%,44.6%,63.2%和82.6%,各组间比较差异有统计学意义（P＜0.000 1）。③132例进行HPV分型检测的患者中,高危亚型感染54例,低危亚型感染29例,阴性49例, HPV阳性患者的感染类型同宫颈上皮内瘤变等级有关（P=0.041 9）。④同时进行hTERC基因及HPV检测患者中,54例HPV高危亚型患者hTERC基因发生异常扩增者33例,29例低危亚型中发生异常扩增7例,组间比较差异有统计学意义（P＜0.01）。结论：阴道镜作为宫颈病变的初诊手段有一定的漏诊和过度诊断;HPV高危亚型感染可能是导致hTERC基因异常扩增的因素之一;hTERC基因扩增和HPV感染与宫颈高级别病变的进展密切相关,可能是导致宫颈癌发生的直接诱因;阴道镜、HPV和hTERC基因联合检查是判断早期宫颈病变进展并做出诊断的有效手段。     

The prognostic value of pretreatment 2-[18F]-fluoro-2-deoxy-d-glucose positron emission tomography scan in women with cervical cancer

There is substantial risk that prognosis determined with routine clinical staging for cervical cancer may be inaccurate. This is primarily due to understaging due to the lack of detection of nodal disease. This is particularly true for para-aortic nodal metastases. Treatment based on such staging may also be inadequate for the same reason. Positron emission tomography (PET) has been demonstrated to be useful in the staging of cervical cancer and superior to either computed tomography or magnetic resonance imaging in the detection of nodal disease. Our objective was to determine the prognostic value of pretreatment 2-[(18)F]-fluoro-2-deoxy-d-glucose (FDG) PET scan in women with cervical cancer. We reviewed the records of 56 women with cervical cancer who underwent FDG PET scan prior to treatment. The primary outcome was the effect of abnormal FDG uptake consistent with metastatic nodal disease on 20-month disease-free survival. The pretreatment PET scan demonstrated abnormal FDG uptake in the pelvic nodes alone in 14 (25%) women, in pelvic and para-aortic nodes in 10 (17.9%), and in neither pelvic nor para-aortic nodes in 32 (57.1%). Women with positive pelvic nodes by PET as well as women with positive para-aortic nodes had significantly poorer 20-month disease-free survival compared to women with negative nodes (P= 0.0003 and P= 0.0017, respectively). We conclude that pretreatment FDG PET scan revealing abnormal FDG uptake consistent with nodal disease is a robust predictor of disease recurrence and may alter the therapeutic management of some patients.     

Telomerase activity in Papanicolaou smear-negative exfoliated cervical cells and its association with lesions and oncogenic human papillomaviruses

OBJECTIVE: The goal of this study was to evaluate telomerase activity in exfoliated cervical cells and its association with cytology, pathology, and human papillomavirus (HPV). METHODS: Telomerase activity and HPV DNA sequences were examined in the exfoliated cervical cells from a general population of 245 women aged more than 30 years undergoing routine cervical screening by Papanicolaou smear. The women who were found to have telomerase activity or abnormal cytology in their exfoliated cervical cells were examined for cervical lesions by colposcopy and biopsy. RESULTS: Cytology for our population (mean, 56 years) revealed only one abnormal smear (1/245, 0.4%), in which a cervical intraepithelial neoplasia grade I (CIN I) lesion was found. The exfoliated cervical cells used to prepare the smear were negative for telomerase and contained low-risk HPV DNA. Telomerase activity was found in 16 exfoliated cell samples (16/245, 6.5%); high-risk HPV DNA was found in 9 of these samples (9/16, 56%) and 9 of the biopsy specimens that could be evaluated from patients testing positive for telomerase revealed CIN I lesions (9/11, 82%). CONCLUSIONS: Telomerase activity is often associated with high-risk HPV infection and it is suggested that telomerase assay can help to detect occult cervical lesions.