宫颈LEEP活检对阴道镜检诊断为CINⅠ的再评估

Reappraisal on mild cervical intraepithelial neoplasia based on punch biopsy and colposcopical diagnosis through cervical conization by LEEP

目的 评价阴道镜活检诊断轻度宫颈上皮内瘤样变（CINⅠ）的准确性和全面性。方法 对部分经阴道镜活检诊断为CINⅠ的患者进一步行宫颈环型电切术（LEEP），并根据病理组织学诊断分析最终确诊为中度和重度CIN（CINⅡ、CINⅢ）的机率，CIN的病灶多灶性分布以及CIN累及腺体的情况。结果 （1）153例CINⅠ患者接受LEEP宫颈锥切，术后病理组织学确诊为CINⅡ以上者51例（33．33％），其中CINⅡ25例，CINⅡ～CINⅢ18例，CINⅢ4例。另有4例（2．61％）病理组织学诊断为早期浸润癌。（2）同一宫颈锥切标本中存在2种以上病灶者共有41例，占26．80％（41／153）；其中存在2种病灶者27例，存在3种病灶者14例。（3）在病灶累及腺体的22例患者中，确诊为CINⅡ以上者20例（90．91％），包括CINⅡ9例，CINⅡ～CINⅢ8例，CINm3例。另1例为早期浸润癌。高级别（CINⅡ，CINⅢ）与低级别（CINⅠ）病灶共存于同一病例者有18例，占81．82％；其中9例为3种病灶共存，2种病灶共存者9例，仅4例为单一病灶。（4）宫颈锥切组织边缘病灶累及者7例（4．58％），最终全子宫切除2例（1．31％），均为切缘累及病灶为CINⅡ以上者。结论 CIN具有多病灶共存特点，阴道镜活检范围和深度有其局限性；阴道镜活检病理诊断为CINⅠ者应根据阴道镜检查图象满意度、随访可行性、患者年龄、生育要求等因素综合分析来决定进一步诊疗方案，必要时可行宫颈LEEP锥切或局部切除，以避免阴道镜活检对CINⅡ以上病变的漏诊。

Purpose To evaluate the perfectibility and veracity of colposcopically directed biopsy for the diagnosis of cervical intraepithelial neoplasia（CIN）Ⅰ and reappraise the value of cervical conization by loop electrosurgical excision procedure（LEEP） for the diagnosis and treat on CINⅠ.Methods There were one hundred fifty-three CINⅠ cases who received cervical conization by LEEP. Retrospective analysis were carried out to calculate the probability of CINⅡ and CINⅢ diagnosed by histopathologic examination after cervical conization with CINⅠ by LEEP. Besides the multi-focus distribution of CIN was investigated and the high risk of CIN with cervical-gland corroded was discussed. Results Multi-focus existed in about 26.80%（41/153） cases who had more than two kinds of lesions. Among those were 27 cases who had two kinds of lesions, and 14 cases with three kinds of lesions. For those 22 cases with cervical gland encroached by lesions, there were even 18 cases（81.82 %） with CINⅠ and CIN Ⅱ/CINⅢ lesions coexisting. Within which were 9 cases with three kinds of lesions coexisting and 9 cases with two kinds of lesions concomitting. There were 20 cases（90.91%,20/22） with CINⅡ or more in the group suffered from cervical-gland corroded lesions,included 9 cases with CINⅡ ,8 cases with CINⅡ -CINⅢ and 3 with CINⅢ. And another one suffered from microinvasive cervical cancer. The sample borderline of excision was intringed by precancerous lesion in 7 cases（4.58% ,7/153）,and hysterectomy was ultimately carried out in 2 patients（1.31% ,2/153） who had CIN Ⅱ or CINⅢ lesion involved borderline. Conclusions The multi-focus of CIN may coexist in cervical precancerous lesions and colposcopically directed biopsy has limitation not only in the location of biopsy but also in the depth of biopsy. Therapeutic strategy on CINⅠ diagnosed through colposcopical punch biopsy should be kept on the principle of ‘ individual procedure＇ based on the satisfying degree of colposcopical image, age and demand for bearing and feasibility for follow-up. We suggested that high extent of alert should be kept on monitoring patients with cervical gland encroached by CIN lesion. The clinical significance of borderline lesion of cervical conization need to be evaluated further more.