阴道镜下四象限活检在宫颈癌前病变筛查中的价值

Value of 4-quadrant biopsies under colposcopy for detecting precancerous lesions in cervical cancer screening

目的评价阴道镜下四象限活检在宫颈癌前病变筛查中的价值。方法利用1999年山西省襄垣县开展的1997例妇女的宫颈癌筛查横断面研究数据，比较阴道镜诊断宫颈高度鳞状上皮及以上病变（HSIL＋）的敏感度、特异度和准确率等，同时比较阴道镜下四象限点活检与阴道镜下可疑病变活检病理结果。结果1997例筛查者中，病理诊断阴性1784例（89．3％），低度鳞状上皮内病变（LSIL）127例（6．4％），HSIL74例（3．7％），鳞状细胞癌（SCC）12例（0．6％）。阴道镜检查为阴性1478例（74．O％）；阴道镜检查为阳性519例（26．0％），其中LSIL463例（23．2％），HSIL41例（2．1％），可疑癌15例（0．8％）。阴道镜检查的阳性率为26．0％（519／1997），与病理诊断结果的一致率为73．8％。以病理诊断为金标准，阴道镜检查发现HSIL＋的敏感度为81．4％，特异度为76．5％。88例人乳头瘤病毒（HPV）阳性、液基细胞学（LBC）诊断未明确意义的非典型鳞状上皮细胞（ASC—US）及以上病变、阴道镜阴性患者中，病理诊断HSIL14例（15．9％），LSIL29例（33．0％）；116例HPV阳性、LBC正常、阴道镜阴性患者中，病理诊断HSIL2例（1．7％），LSIL6例（5．2％）。两组患者的HSIL和LSIL检出率差异均有统计学意义（均P〈0．001）。阴道镜阴性的筛查者中，四象限活检对HSIL和LSIL病变的检出率分别为1．1％和4．7％。阴道镜检查结果异常519例，阴道镜下可疑病变活检与四象限活检诊断结果不一致19例，一致500例，符合率为96．3％。与四象限活检比较，若仅以阴道镜下异常象限进行指示性活检，则漏诊14.8％（19／128）的宫颈病变，其中漏诊8．6％（5／58）的HSIL，漏诊24．1％（14／58）的LSIL。结论阴道镜下四象限活检能发现更多的宫颈病变，准确性高。作为宫颈癌前病变筛查的重要手段，阴道镜下四象限活检可提高宫颈癌前病变的检出率。

Objective To evaluate the value of colposcopical 4-quadrant biopsies for detecting precancerous lesion in cervical cancer screening. Methods We used the data of a cross-sectional screening study in 1999, in which 1 997 women received cervical cancer screening in Xiang Yuan County, Shanxi province. The sensitivity, specificity and accuracy of both 4-quadrant biopsy and eolposeopy directed biopsy to detect high-grade or more severe squamous intraepithelial lesions （HSIL^＋） were calculated. Results 1 784（89. 3%） women who received 4-quadrant biopsies and endocervical curettage were negative. 127 （6.4%） women were diagnosed as LSIL, 74（3.7%） women as HSIL and 12（0.6%） cases of squamous cell carcinoma. 1 478（74. 0%） women who received biopsies in the sites of abnormal lesions were negative, 463 （23.2%） cases of LSIL, 41（2.1%） cases of HSIL, 15（0.8%） cases of squamous cell carcinoma. The positive rate was 26.0% （519/1 997） for colposcopy, and the coincidence rate was 73.7% with pathological diagnosis. Sensitivity and specificity were 81.4% and 76.5% of colposcopy for HSIL^＋. In total of 519 women were found to be with any abnormal colposcopic appearance. The consistency rate between 4-quadrant biopsies and suspicious lesion- directed biopsies was 96.3%. By suspicious lesion-directed biopsy alone, 14.8% cervical lesions were missdiagnosed, of which 8.6%（5/58） cases of total HSIL and 24.1% （14/58） cases of all LSIL. Conclusions 4- quadrant biopsy can detect more HSIL^＋ lesions and is more accurate than suspicious lesion biopsy alone. As an important triage technique to detect cervical precancerous lesions, it can improve the detection rate of HSIL^＋ lesions in cervical cancer screening.