宫颈环形电切术对阴道镜下活检为轻度宫颈上皮内瘤样变的再评估

目的:通过宫颈环形电切术(LEEP)对阴道镜活检诊断为轻度宫颈上皮内瘤样变(C INⅠ)进行重新评估,比较不同病理类型的高危型人乳头瘤病毒感染及TCT(液基细胞学检查)检测结果,评估阴道镜活检诊断C INⅠ的准确性和全面性。方法:选取2007年1月~2009年11月就诊于柳州市人民医院妇科的宫颈疾病患者,行TCT、HPV16及18 DNA及阴道镜检查,同时选取阴道镜下宫颈活检确诊为C INⅠ的患者90例,短期内行LEEP术,并采取自身对照法,对比阴道镜下活检和LEEP术病理结果。结果:阴道镜下活检与宫颈LEEP术后病理结果的符合率为81.11%(73/90),宫颈LEEP术后有49例降级为炎症,占54.44%(49/90),24例仍为C INⅠ,占26.67%(24/90),LEEP术后病理级别未升级的73例患者中,有16例HPV16、18阳性,占21.92%(16/73);宫颈LEEP术后病理升级的有17例,占18.89%(17/90),C INⅡ10例,C INⅢ7例(其中4例患者因年龄大,无生育要求,自愿要求行全子宫切除术,2例术后病检为C INⅡ,1例为C INⅠ,1例LEEP术后累及腺体最后诊断为中分化鳞癌),其中HPV16、18阳性13例(C INⅡ组中有6例,C INⅢ组中有7例),占76.47%(13/17)。高危型HPV(HR-HPV)阳性率及病毒负荷量在低级别宫颈病变及高级别宫颈病变中差异有统计学意义(P<0.01),并随着宫颈病变程度的加重而逐渐升高。TCT检测结果与LEEP术后病理结果存在相关性,TCT检测结果级别偏高,LEEP术后病理结果也趋向于偏高;两种方法的检测结果存在统计学差异(P=0.000),TCT检测结果级别偏低的,LEEP术后病检结果级别可能会偏高。结论:阴道镜直视下活检对确诊C INⅠ尚不够准确,存在着高级别病变漏诊的可能;阴道镜下活检诊断为C INⅠ而细胞学检查结果为HSIL或HR-HPV病毒负荷量较高时要警惕漏诊宫颈高级别病变的可能,LEEP术在明确诊断宫颈上皮内瘤样变中优于活检,是诊断和治疗C IN的一种有效地方法。

Re-evaluation of cervical intraepithelial neoplasia I diagnosed by colposcopic biopsy by loop electrosurgical excision procedure

Objective:To reevaluate mild cervical intraepithelial neoplasia(CIN) diagnosed by colposcopic biopsy by loop electrosurgical excision procedure(LEEP),compare infection of high risk human papillomavirus(HR-HPV) of different pathological types and detection results of Thinprep cytological test(TCT),evaluate the accuracy and comprehensiveness of colposcopic biopsy in diagnosis of CIN Ⅰ.Methods:The cases with cervical diseases visiting the hospital from January 2007 to November 2009 were selected,TCT,HPV16,18 detection and colposcopic examination were conducted,90 cases diagnosed as CIN Ⅰ by colposcopic biopsy were selected and treated by LEEP shortly,a self-control method was used to compare the pathological results of colposcopic biopsy and LEEP.Results:The pathological coincidence of colposcopic biopsy and LEEP was 81.11%(73/90),the pathological results of 49 cases degraded to chronic cervicitis after LEEP,accounting for 54.44%(49/90),and the pathological results of 24 cases remained as CIN I,accounting for 26.67%(24/90);16 cases were found with positive HPV 16,18 among 73 cases whose pathological results did not upgrade after LEEP,accounting for 21.92%(16/73);the pathological results of 17 cases upgraded after LEEP,accounting for 18.89%(17/90),including 10 cases with CIN Ⅱ and 7 cases with CIN Ⅲ(4 cases without birth demand demanded total hysterectomy because of advance age;2 cases were diagnosed as CIN Ⅱ by postoperative pathological examination;one case were diagnosed as CIN I,one case were diagnosed as squamous cell carcinoma of middle differentiation because of gland involved after LEEP),13 cases were found with positive HPV16 and 18(6 cases in CIN Ⅱ group and 7 cases in CIN Ⅲ group),accounting for 76.47%(13/17);there was significant difference in positive rate of HR-HPV and viral load between low-grade cervical lesions and high-grade cervical lesions(P<0.01),and the difference increased with the aggravation of cervical lesions;there was a correlation between results of TCT and pathological results after LEEP,the grades of TCT results were relative high,and the grades of pathological results after LEEP tended to relative high;there was significant difference in detection results between the two methods(P=0.000),the grades of TCT results were relative low,and the grades of pathological results after LEEP were probably low.Conclusion:Colposcopic biopsy is not accurate to definitely diagnose CIN Ⅰ,the possibility of missed diagnosis of high-grade cervical lesions exists,for the cases with CIN Ⅰ diagnosed by colposcopic biopsy and HSIL diagnosed by cytological test or the cases with high viral load of HR-HPV,missed diagnosis of high-grade cervical lesions should be paid more attention to;LEEP is superior to biopsy in definite diagnosis of CIN,which is an effective method in diagnosis and treatment of CIN.