阴道上皮内瘤变诊治方法进展

阴道上皮内瘤变是包括阴道鳞状上皮不典型增生及原位癌的一组病变,是一种少见的阴道浸润癌癌前病变,与持续性人乳头瘤病毒（HPV）感染、宫颈癌前病变、宫颈癌等的发生密切相关,发病率较低。阴道上皮内瘤变多无明显临床症状,肉眼观察阴道黏膜基本正常,诊断主要依据辅助检查。与宫颈上皮内瘤变诊断的三阶梯诊断程序一致,常在宫颈癌筛查的第二阶段阴道镜检查时偶然发现,常合并宫颈上皮内瘤变。近年来随着阴道镜应用的普及和提高,阴道上皮内瘤变的检出率明显增加。阴道上皮内瘤变的治疗主要依据病变级别,阴道上皮内瘤变Ⅰ级病变可自行消退,不需要治疗,密切随访即可,但对于高危型HPV感染的患者应重视随访。阴道上皮内瘤变Ⅱ～Ⅲ级公认为癌前病变,一旦确诊需积极治疗,临床上的治疗方法有手术治疗、药物治疗、物理治疗及放疗。但至今尚无统一的临床诊疗标准方案,每种方法都有其利弊,根据患者自身情况选择治疗方案非常重要。     

光动力治疗子宫切除术后阴道上皮内瘤变的临床疗效及安全性观察

目的 探讨光动力治疗子宫切除术后阴道上皮内瘤变的临床疗效及安全性。方法 选取72例子宫切除术后阴道上皮内瘤变患者,按照随机分组对照原则将其分为对照组与试验组,每组36例。对照组采取射频消融治疗,试验组采取单纯光动力治疗。比较两组临床效果及安全性。结果 试验组总有效率88.89%高于对照组的69.44%,差异有统计学意义（P<0.05）。试验组治疗3个月后及治疗6个月后人乳头瘤病毒（HPV）转阴率均高于对照组,差异有统计学意义（P<0.05）。两组不良反应发生率比较,差异无统计学意义（P>0.05）。结论 光动力疗法用于子宫切除术后阴道上皮内瘤变治疗的疗效显著,可促进患者HPV转阴,提高临床治愈率,且安全性较高。     

阴道上皮内瘤变的诊治进展

阴道上皮内瘤变（Vaginal intraepithelial neoplasia, VaIN）是局限于阴道上皮内不同程度的非典型增生病灶。2014年国际癌症研究署（International Agency for Research on Cancer, IARC）在WHO第4版《女性生殖器官肿瘤分类》中采用了阴道低级别鳞状上皮内病变（low-grade intraepithelial lesion, LSIL）和高级别鳞状上皮内病变（high-grade intraepithelial lesion, HSIL）二级分类法，代替了既往的阴道上皮内瘤变的三级分类法：VaIN I、VaIN II和VaIN III[1]。目前国内两种分类方法均有使用，即阴道LSIL（VaIN I）,阴道HSIL（VaIN II/III）。     

阴道上皮内瘤变

阴道上皮内瘤变上海医科大学妇产科医院（２０００１１）张惜阴阴道上皮内瘤变（ｖａｇｉｎａｌｉｎｔｒａｅｐｉｔｈｅｌｉａｌｍｅｏｐｌａｓｍ，ＶａＩＮ）是指阴道上皮不典型增生及原位癌的一组病变，它们是阴道上皮癌的癌前病变。ＶａＩＮ的分类与ＣＩＮ的一样，分为...     

二氧化碳激光气化治疗下生殖道高级别鳞状上皮内病变的要点难点

下生殖道高级别鳞状上皮内病变（High Grade squamous intraepithelial lesion, HSIL）包括 子宫颈、阴道和外阴的鳞状上皮内瘤变 2,3 级（Intraepithelial Neoplasia,INs 2,3），是一类多 与高危型 HPV 持续性感染相关的癌前病变。子宫颈上皮内瘤变（Cervical Intraepithelial Neoplasia, CIN2,3）比较常见，而阴道和外阴的鳞状上皮内瘤变（Vaginal Intraepithelial Neoplasia, VaIN;VulvarIntraepithelial Neoplasia,VIN）发生率低，国外报道 VaIN 和 VIN 的年 发病率仅约 0.2~2/10 万[1]和 5/10 万[2]。     

二氧化碳激光与光动力治疗阴道上皮内瘤变患者的临床疗效对比分析

目的：回顾性对比分析二氧化碳（CO2）激光与光动力疗法（PDT）治疗阴道上皮内瘤变（VaIN）的临床疗效,为VaIN患者的治疗提供参考。方法：选择2018年1月至2020年6月就诊于郑州大学人民医院,病理组织学确诊为VaIN且采用CO2激光或PDT治疗的患者93例,其中CO2激光组55例,PDT组38例,对比分析CO2激光和PDT治疗VaIN的临床疗效。结果：CO2激光组治疗后人乳头瘤病毒（HPV）转阴例数为46例（83.6%）;PDT组治疗后HPV转阴例数为32例（84.2%）,两组患者治疗6个月后HPV转阴率比较,差异无统计学意义（P>0.05）。CO2激光组患者共43例（78.2%）治愈,其中阴道低级别鳞状上皮内病变（LSIL）患者25例（83.3%）治愈,阴道高级别鳞状上皮内病变（HSIL）患者18例（72.0%）治愈,PDT组患者共30例（78.9%）治愈,其中阴道LSIL患者18例（78.2%）治愈,阴道HSIL患者12例（75.0%）治愈。阴道LSIL及HSIL的病变治愈率在两组间差异无统计学意义（P>0.05）,总治愈率在两组间差异无统计学意义（P>0.05）。CO2激光组的患者1例出现阴道少量流血,1例出现阴道壁粘连;PDT组的患者4例出现阴道分泌物增多。CO2激光组治疗6个月后有4例（7.27%）复发,PDT组治疗6个月后有2例（5.26%）复发。CO2激光组复发率与PDT组差异无统计学意义（P>0.05）。两组患者治疗6个月时均无病变进一步进展。结论：CO2激光治疗与光动力疗法治疗VaIN的疗效相比无差异,无明显不良反应,短期复发率低,两种治疗方法均值得在临床上推广应用。     

外阴上皮内瘤变和阴道上皮内瘤变中低危型和高危型人乳头瘤病毒的分布

人乳头瘤病毒（HPV）在人体肛门、生殖器部位肿瘤的形成中起着关键作用。但是，目前绝大多数的研究集中于宫颈病变上，关于外阴上皮内瘤变（VIN）、阴道上皮内瘤变（VaIN）的研究相对较少。研究VIN及VaIN中HPV的分布，有助于理解低级别的VIN及VaIN（VIN I、VaIN I）的性质以及与高级别病变之间的相关性。     

残端阴道上皮内瘤变的诊断及治疗方法研究进展

阴道上皮内瘤变(vaginal intraepithelial neoplasia,VAIN)是无症状的癌前病变。随着全子宫切除术患者增多,宫颈细胞学检查及阴道镜的广泛应用,残端阴道上皮内瘤变逐渐受到关注。目前尚无关于残端VAIN诊治指南,因此,本文将从残端VAIN诊断、治疗方式作一综合性评述,具体阐述残端VAIN诊断要点及各种治疗方式的优缺点,推荐病灶位于阴道顶端者首选可取得病理标本的手术治疗方式,CO_2激光电切术有望成为VAIN患者理想治疗方法之一。     

下生殖道肿瘤的光动力治疗

对宫颈上皮内瘤样变(CIN)目前主要采用全部或者部分切除,这种治疗方法可能产生许多合并症。年轻妇女的阴道上皮内瘤样变(VIN)发病率在逐年上升。VIN激光全切或部分切除短期疗效较好,但容易复发。而重复治疗易导致阴道损伤。 就皮肤原发鳞癌来看,表面局部光敏剂与便携式非激光光源联合应用和传统治疗方法相比,两者治疗效果相同。作者对VIN和CIN光动力(PDT)治疗的安全性和有效性进行了评价。6例将进行切除术患者,病灶局部涂抹致光敏因子5-氨基乙酰     

LEEP术联合重组人干扰素α2b凝胶对HSIL术后阴道微生态和康复效果的影响

目的 探讨高频电刀宫颈环切术（LEEP）联合重组人干扰素α2b凝胶治疗高级别宫颈上皮内瘤变（HSIL）的疗效。方法 选取110例HSIL患者,采用随机数字表法将患者分为试验组与对照组,各55例。对照组采用LEEP术,试验组术后加用重组人干扰素α2b凝胶治疗。比较两组术后阴道微生态变化、康复效果及安全性。结果 治疗后,两组阴道分泌物pH较前下降,乳酸杆菌菌群数量升高,且试验组的阴道分泌物pH低于对照组,乳酸杆菌菌群数量高于对照组（P<0.05）。试验组的创面愈合时间短于对照组,治疗总有效率和人乳头瘤病毒（HPV）转阴率均高于对照组,宫颈上皮内瘤变（CIN）复发率低于对照组（P<0.05）。试验组不良反应发生率为5.45%(3/55),经处理后缓解,未影响疗程。结论 重组人干扰素α2b凝胶能改善LEEP术后患者阴道微生态,提高治疗效果。     

Treatment of vaginal intraepithelial neoplasia with laser ablation and upper vaginectomy

To assess the effectiveness of laser ablation and upper vaginectomy in the treatment of vaginal intraepithelial neoplasia (VAIN), we have reviewed the charts of 52 patients managed with laser ablation (28 patients) and upper colpectomy (24 patients). On the basis of our results, patient selection and operator skill have a significant influence on the outcome. In posthysterectomy patients with VAIN(3) at the vaginal apex, in the region of vaginal cuff scar, upper vaginectomy is the treatment of choice, while multifocal VAIN(2-3) or colposcopically well defined lesions, involving large areas of vaginal mucosa, could be successfully managed by CO(2) laser ablation.     

High-Dose-Rate Brachytherapy in the Management of High-Grade Intraepithelial Neoplasia of the Vagina

The majority of women with high-grade intraepithelial neoplasia (VAIN 3) are over 60 years of age and have a history of premalignant or malignant disease of the cervix. Although the natural history of VAIN is not well defined, high-grade lesions are premalignant. Ablative treatment with laser or 5-fluorouracil cream is commonly unsatisfactory. Several series have reported a low rate of recurrence and complications if VAIN 3 is treated with low-dose-rate brachytherapy. This retrospective review reports the outcome of 14 patients treated with high-dose-rate brachytherapy, with a dose of 34 to 45 Gy in 4.5- to 8.5-Gy fractions. Treatment was well tolerated with no severe early or late toxicity observed. At a median follow-up of 46 months 1 patient progressed to invasive carcinoma of the vagina; in another patient VAIN 3 persisted.     

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。　　     

Vaginal intraepithelial neoplasia. Report of 14 cases

From 1978 to 1985 we have found 14 cases of vaginal intraepithelial neoplasia (VAIN) in patients previously hysterectomized. VAIN was detected by an abnormal cytology; diagnostic process included a second cytology, colposcopy, Schiller test, and directed biopsies. VAIN was classified as grade I in 5 patients (35.7%); grade II in 5 patients (35.7%); and grade III in 4 patients (28.6%). Pathogenic classification of VAIN was: VAIN de novo 9 cases (64.3%); VAIN after vaginal irradiation, 3 cases (21.4%); VAIN following incomplete removal of a cervical intraepithelial neoplasia, one case (7.1%); and VAIN as manifestation of a multicentric neoplasia of the lower genital tract, one case (7.1%). The mean time between hysterectomy and VAIN diagnosis was 6.9 years; this time was larger for those women hysterectomized by benign uterine diseases (9.0 years vs. 2.4 years). Our conclusion is that patients who have lost their uterus by malignant or benign diseases should be followed-up with periodic vaginal cytology in order to detect vaginal neoplasia in its pre-invasive stages.     

全子宫切除术后阴道上皮内瘤样病变治疗探讨

阴道上皮内瘤样病变（VAIN）是指局限于女性阴道上皮的癌前病变。目前研究认为感染人乳头瘤病毒（HPV）是VAIN发生的最主要因素,持续HPV感染是VAIN疾病进展的独立危险因素,VAIN患者常同时合并宫颈上皮内瘤变（CIN）,因液基薄层细胞检测（TCT）普及,筛查率提高,能对宫颈病变起到早期诊断并提高诊断率的作用。对于CIN2+抗病毒治疗及环形电极切除术（LEEP）治疗后病变持续存在或复发者,全子宫切除术成为一种治疗选择。因宫颈因素或者非宫颈因素行全子宫切除术后患者的VAIN受多种因素影响,如缺乏特异性临床症状,病灶特殊性、阴道结构的限制,术后解剖结构改变等可能导致延误诊治,且临床上尚无治疗全子宫切除术后VAIN的指南。综述全子宫切除术后VAIN的治疗进展。     

Vaginal cancer in a patient treated for cervical intraepithelial neoplasia (CIN 3): case report

In 1% to 3% of patients with cervical intraepithelial neoplasia (CIN), vaginal intraepithelial neoplasia (VAIN) will either coexist or occur at a later date. The time interval from an earlier diagnosis of CIN 3 to a current diagnosis of VAIN 3 varies from two to 17 years. Invasive vaginal cancer occurred in a woman five years after total abdominal hysterectomy for cervical intraepithelial neoplasia. In women who have undergone total hysterectomy for cervical intraepithelial neoplasia or cervical cancer, postoperative cytologic and colposcopic follow-up of the vagina is necessary.     

Clinical features and risk of recurrence among patients with vaginal intraepithelial neoplasia

OBJECTIVE: The best treatment modality and factors affecting recurrence among women with vaginal intraepithelial neoplasia (VAIN) are yet to be determined. The aims of the current study were to describe the clinical features, results of treatment, and factors affecting recurrence among patients with VAIN. METHODS: We conducted a retrospective review of 121 women with VAIN after confirming the histologic diagnosis. Patient demographics, clinical features, and results of therapy were recorded. Factors affecting recurrence were assessed using the odds ratio and the 95% confidence intervals among patients who were followed up for 7 months or more and had at least one posttreatment Papanicolaou smear. Significant univariate odds ratios were assessed jointly in a multivariate model with a stratified analysis. RESULTS: The mean age of the patients was 35.0 (+/-17), 41% of the patients smoked, 39% had a history of human papillomavirus infection, 27% had history of sexually transmitted diseases, 22% had history of surgery for cervical intraepithelial neoplasia (CIN), and 23% had total hysterectomy. The upper third of the vagina was the most common site of VAIN and 61% of the lesions were multifocal. Associated cervical and vulvar intraepithelial neoplasia (VIN) were present in 65 and 10%, respectively. Recurrences of VAIN and progression to invasive vaginal cancer occurred in 33 and 2%, respectively. Recurrences following partial vaginectomy, laser, and 5-fluorouracil were 0, 38, and 59%, respectively (P = 0.0001). Multifocality and method of treatment were significant independent predictors of VAIN recurrences (odds ratio 3.3, 95% CI 1.2, 9.2, P = 0.02, and 22.4, 95% CI 1.3, 393.6, P = 0.001, respectively), with no interaction, based on a stratified analysis. CONCLUSIONS: VAIN occurs most often among women with CIN or VIN, commonly involves the upper third of the vagina, and is often multifocal. Partial vaginectomy provides the highest cure rate and multifocality is a risk factor for recurrence.     

Vaginal intraepithelial neoplasia: treatment by carbon dioxide laser and risk factors for failure

OBJECTIVE: To evaluate the effectiveness of CO(2) laser ablation of vaginal intraepithelial neoplasia (VAIN) and to define prognostic factors. STUDY DESIGN: Medical records of 24 patients with VAIN II or III, treated by CO(2) laser ablation from 1990 to 1998 were reviewed. The grade, location, and focality of the lesions, the age, follow-up period and menopausal status of the patients, the power and duration of laser ablation, the presence of concurrent cervical or vulvar neoplasia or previous hysterectomy were evaluated as possible prognostic factors. RESULTS: Ablations of the VAIN were successfully accomplished in all of the patients with a mean period of 25.2+10.2 min, including additional simultaneous ablations of the cervix or vulva in eight (33.3%) patients. There was no early or late major complication. VAIN was completely eliminated in 17 (70.8%) patients after the first and in 19 (79.2%) patients after multiple episodes of ablation with a mean follow-up of 26.7+19.6 months. VAIN progressed to invasive vaginal carcinoma in one woman. None of the evaluated prognostic factors was found to be related to the persistence or recurrence. CONCLUSION: CO(2) laser ablation was a safe and effective method for the treatment of VAIN. However, since no prognostic factor was defined, all patients should be closely evaluated for persistence, recurrence or progression to invasion.     

阴道上皮内瘤变13例临床分析

目的 探讨阴道上皮内瘤变(VAIN)的病因、临床特点、诊断、治疗及预后.方法 回刎顾性分析浙江省肿瘤医院2002年3月至2008年12月收治的13例VAIN患者的临床资料,其中2例为VAINⅡ、11例为VAINⅡ～Ⅲ或VAINⅢ.结果 13例VAIN患者中,行人乳头状瘤病毒(HPV)检测12例,其阳性率为92%(11/12).VAIN临床表现无特异性,1例阴道分泌物增多;4例阴道局部糜烂充血或呈乳头状增生,2例小结节状改变.13例VAIN患者中,合并宫颈癌6例、宫颈上皮内瘤变(CIN)4例外阴上皮内瘤变(VIN)3例;与宫颈病变(包括宫颈癌和CIN)同时确诊5例、与外阴病变(即VIN)同时确诊3例,其余5例均在复查这些疾病时确诊.与宫颈病变或外阴病变同时确诊的8例VAIN患者采用手术治疗,其中l例VAIN合并CIN因病变广泛术后补充氩气刀治疗,1例VAIN合并VIN因术后切缘阳性补充氩气刀治疗;1例中晚期宫颈癌行同步放化疗后随访时发现的VAIN患者行根治性放疗;3例术后随访时发现的VAIN(VAINⅡ、VAINⅡ～Ⅲ、VAINⅢ各1例)行氩气刀治疗;1例官颈癌Ⅲb期合并VAINⅢ患者治疗.本组患者的平均随访时间为25.6个月(6～87个月),2例患者因官颈癌发生远处转移而死亡,11例活检或阴道液基薄层细胞学检查(TCT)无异常,随访期内无一例进展为浸润癌.结论 HPV感染是VAIN发病的主要原因;VAIN的临床表现隐匿,多在治疗或复查宫颈病变、外阴病变时确诊;治疗以手术为主;VAIN很少进展为浸润癌,预后较好.