高级别宫颈上皮内瘤变行子宫切除术患者术前病理确诊方式的回顾性分析

目的:通过对比阴道镜下活检病理、宫颈锥切术中冰冻病理与术后石蜡病理（paraffin section examination，PSE）的一致性，对高级别宫颈上皮内瘤变行子宫切除术的术前病理确诊方式进行研究。方法:选取2010年1月至2015年12月阴道镜活检病理为宫颈上皮内瘤变Ⅱ级(CINⅡ)和Ⅲ级(CINⅢ、原位癌)在我院行宫颈锥切术患者共454例，其中依宫颈锥切术中冰冻病理即刻行子宫切除手术治疗患者238例，另外216例为待宫颈锥切术后石蜡病理回报后再次子宫切除手术治疗的患者，对比阴道镜下活检病理、宫颈锥切术中冰冻病理与术后石蜡病理的一致性，以及对比锥切术后石蜡病理与再次子宫切除术后病理的一致性。结果:阴道镜活检与术中冰冻病理诊断的符合率为89.11%（270/303），CINⅡ为63.33％（38/60），22例升级为CINⅢ；CINⅢ为95.47%（232/243），11例升级（9例升级为宫颈癌Ⅰa1期，2例升级为Ⅰb1期）。阴道镜活检与术后石蜡病理诊断的符合率为77.53%(352/454)。CINⅡ为22.99%(20/87)，67例升级（57例升级为CINⅢ，8例升级为宫颈癌Ⅰa1期，2例升级为Ⅰa2期）；CINⅢ为 90.46%（332/367），35例升级（26例升级为宫颈癌Ⅰa1期，7例升级为Ⅰb1期，2例升级为Ⅱa期）。阴道镜活检对宫颈癌的漏诊率总体为9.91％(45／454)。宫颈锥切术中同时送冰冻病理患者303例，宫颈锥切术中冰冻病理与术后石蜡病理诊断的符合率为88.12%(267/303)。CINⅡ为60.00%(36/60)，24例升级（18例升级为CINⅢ，5例升级为宫颈癌Ⅰa1期，1例升级为Ⅰa2期）；CINⅢ为95.06%(231/243),12例升级（9例升级为宫颈癌Ⅰa1期，2例升级为Ⅰb1期，1例升级为Ⅱa期）。宫颈锥切术中冰冻病理对宫颈癌的漏诊率总体为5.94%（18/303）。宫颈锥切术中同时送冰冻病理患者303例，宫颈锥切术术中冰冻病理比阴道镜活检病理诊断的符合率高，差异有统计学意义（χ2= 27.68,P﹤0.05）。待宫颈锥切术后石蜡病理回报后再次手术治疗的216例患者中，宫颈锥切术后石蜡病理对高级别宫颈上皮内瘤变及浸润癌诊断的准确率可达99.07％（214/216）。结论:阴道镜活检是初步诊断高级别宫颈上皮内瘤变的一种方法；宫颈锥切术具有诊断与治疗的作用，术中冰冻病理（frozen section examination，FSE）能够提早发现部分微小浸润癌及浸润癌，但是存在一定的误诊和漏诊率。因此，建议对所有无生育要求的高级别宫颈上皮内瘤变患者，应先行宫颈锥切术，待术后石蜡病理回报后再行子宫切除术，以达到规范治疗。

Retrospective analysis of preoperative pathological diagnosis of high grade cervical intraepithelial neoplasia with hysterectomy

Objective:A comparative analysis was carried out by the pathological results of colposcopy biopsy，intraoperative frozen section pathology and consistency paraffin section examination(PSE) of cervical conization specimens to study the preoperative pathological diagnosis of high grade cervical intraepithelial neoplasia before hysterectomy.Methods:A retrospective study was carried out in 454 cases with CIN Ⅱ-Ⅲ underwent colposcopy biopsy then conization of cervix，between January 2010 and December 2015 in our hospital，238 cases of patients were treated with frozen pathology immediately after cervix conization.In addition，216 cases of the patients were reoperated after the cervical conization，by contrast colposcopy biopsy，intraoperative frozen section pathology and consistency paraffin section examination of cervical conization specimens and by contrast the consistency of pathology after cervical conization and hysterectomy.Results:The diagnosis coincidence rate of colposcopy biopsy and intraoperative frozen section pathology was 89.11%（270/303），CINⅡ was 63.33％（38/60），22 cases were upgraded to CINⅢ.CINⅢ was 95.47%（232/243），11 cases were upgraded (9 cases were upgraded to Ⅰa1，2 cases were upgraded to Ⅰb1).The coincidence rate between the biopsy of the colposcopy and the pathological diagnosis of paraffin was 77.53%(352/454).CINⅡ was 22.99%(20/87)，67 cases were upgraded (57 cases were upgraded to CINⅢ，8 cases were upgraded to cervical cancer stage Ⅰa1，2 cases were upgraded to Ⅰa2 stage)，CINⅢ was 90.46% (332/367)，35 cases were upgraded (26 cases were upgraded to cervical cancer Ⅰa1 stage，7 cases were upgraded to Ⅰb1 stage，2 cases were upgraded to Ⅱa stage).The total missed diagnosis rate of colposcopy biopsy to cervical cancer was 9.91%(45/454).303 cases of frozen histopathological patients in cervical conization，the coincidence rate between frozen pathology and paraffin pathological diagnosis in cervical conization was 88.12%(267/303).CINⅡ was 60%(36/60)，24 cases were upgraded (18 cases were upgraded to CINⅢ，5 cases were upgraded to cervical cancer stage Ⅰa1，1 case were upgraded to Ⅰa2 stage)，CINⅢ was 95.06% (231/243)，12 cases were upgraded (9 cases were upgraded to cervical cancer Ⅰa1 stage，2 cases were upgraded to Ⅰb1 stage，1 cases were upgraded to Ⅱa stage).The total missed diagnosis rate of frozen pathology to cervical cancer in cervical conization was 5.94%(18/303).303 cases of frozen histopathological patients in cervical conization，the diagnostic accuracy of intraoperative frozen section pathology is higher than colposcopy biopsy in statistically significant (χ2=27.68,P﹤0.05).216 cases of the patients are reoperated after the cervical conization，the accuracy of conization of cervix for the diagnosing of high grade squamous intraepithelial lesion and invasive cervical cancer could reach 99.07％(214／216).Conclusion:Colposcopy biopsy is a preliminary diagnosis of high grade squamous intraepithelial lesion；Cervical conization has the role of diagnosis and treatment，which can significantly reduce the rate of missed diagnosis of invasive cervical cancer.Frozen section examination(FSE) can be found in the early part of microinvasive carcinoma and invasive carcinoma,but there is still a certain rate of misdiagnosis and missed diagnosis in the diagnosis of CIN.Therefore，it is suggested that cervical conization should be performed first for all patients with high-grade cervical intraepithelial neoplasia，and then the hysterectomy can be performed after the paraffin pathology is returned， so as to achieve the standard treatment.