单纯HPV16／18阳性行阴道镜检查有可疑病变患者的子宫颈组织病理检查结果分析

To analyse the histopathological results of patients with HPV16/18 positive and colposcopic suspicious lesions

目的分析单纯HPV16型和（或）18型（HPV16/18）阳性行阴道镜检查并有可疑病变患者的子宫颈组织病理检查结果，探讨HPV16/18阳性患者直接行阴道镜检查在子宫颈病变早期诊断中的意义。方法收集2014年1月至2016年1月在首都医科大学附属北京朝阳医院妇产科阴道镜门诊就诊的年龄为21-65岁、HPV16/18阳性、细胞学检查结果为阴性或未明确诊断意义的不典型鳞状上皮细胞（ASCUS）、阴道镜检查有可疑病变的患者，收集其子宫颈组织的病理检查结果进行回顾性分析。共有337例患者纳入本研究，其中细胞学检查结果为阴性者214例，为ASCUS者123例。结果（1）337例患者中，子宫颈组织的病理检查结果为子宫颈炎症63例（18.7%）、子宫颈上皮内瘤变（CIN）Ⅰ 89例（26.4%）、CINⅡ-Ⅲ及子宫颈原位腺癌（AIS）182例（54.0%）、早期（指Ⅰa1期）子宫颈癌3例（0.9%）。其中CINⅡ及以上子宫颈病变（包括CINⅡ-Ⅲ、AIS、早期子宫颈癌）所占比例，细胞学检查结果为ASCUS的患者（71.5%，88/123）明显高于细胞学检查结果为阴性的患者（45.3%，97/214；χ2=24.876，P〈0.01）；HPV16型阳性患者（64.4%，150/233）明显高于HPV18型阳性患者（30.3%，27/89；χ2=31.388，P〈0.01）；不同年龄段[20-29岁为69.3%（52/75）、30-39岁为55.1%（75/136）、40-49岁为44.8%（30/67）、≥50岁为47.5%（28/59）]患者间比较，差异也有统计学意义（χ2=16.512，P=0.032）。（2）在细胞学检查结果为阴性的患者中，HPV16型阳性患者的CINⅡ及以上病变所占比例高于HPV18型阳性患者[分别为54.8%（80/146）、26.0%（20/27）；χ2=16.930，P〈0.01]；在细胞学检查结果为ASCUS的患者中，HPV16型阳性患者的CINⅡ及以上病变所占比例也明显高于HPV18型阳性患者[分别为76.5%（78/102）、55.6%（15/27）；χ2=4.642，P=0.031]。（3）与炎症和CINⅠ患者比较，CINⅡ及以上子宫颈病变患者的HPV16型阳性率高、HPV18型阳性率低、ASCUS的发生率高、年龄小、产次少，两组间上述指标分别比较，差异均有统计学意义（P〈0.05）；进一步采用二分类变量logistic回归法进行多因素分析显示，HPV16型阳性、细胞学检查结果为ASCUS是预测CINⅡ及以上病变发生的独立危险因素（P〈0.01）。结论在HPV16/18阳性患者中，CINⅡ及以上子宫颈病变所占比例高，其中HPV16型阳性比HPV18型阳性患者更易发生CINⅡ及以上子宫颈病变。HPV16/18阳性患者直接行阴道镜检查并对有可疑病变者行子宫颈组织病理检查有助于早期发现子宫颈病变。

ObjectiveTo explore the value of histopathologic diagnosis after colposcopy for high-risk HPV16/18 positive patients with negative cytology or atypical squamous cells of undetermined significance （ASCUS） for early screening of cervical lesions. MethodsA retrospective study of cervical histopathologic diagnosis in the HPV16/18 positive patients received colposcopy evaluation before got the histology was carried out between January 2014 and January 2016. The cytology of the patients should be negative or ASCUS. A total of 337 patients with age from 21 to 65 years old were enrolled, including 214 patients with negative cytology, and 123 patients with ASCUS.Results（1） The results of pathology were as follows： 63 （18.7%） cases inflammation, 89 （26.4%） cases cervical intraepithelial neoplasia （CIN）Ⅰ, 182 （54.0%） cases CINⅡ-Ⅲ and adenocarcinoma in situ （AIS）, and 3 （0.9%） cases minimal invasive cancer （stageⅠa1）. The incidence of CINⅡ and above cervical lesions was higher in the patients with ASCUS （71.5%, 88/123） than that in the patients with negative cytology （45.3%, 97/214; χ2=24.876, P〈0.01）, and it was higher in the patients with HPV16 positive （64.4%, 150/233） than that in the patients with HPV18 positive （30.3%, 27/89; χ2=31.388, P〈0.01）. There was statistically significant difference among the different age group in which the patients of 20-29 years old was 69.3% （52/75）, 30-39 years old was 55.1% （75/136）, 40-49 years old was 44.8% （30/67） and 50 years old and above was 47.5% （28/59; χ2=16.512, P=0.032）. （2） Among the patients with negative cytology, the incidence of CINⅡ and above cervical lesions in the patients with HPV16 positive was higher than that in the patients with HPV18 positive [54.8% （80/146） vs 26.0% （20/77） ; χ2=16.930, P〈0.01]. The incidence was also higher in the patients with HPV16 positive than that in the patients with HPV18 positive [76.5% （78/102） vs 55.6% （15/27） ; χ2=4.642, P=0.031] among the patients with ASCUS. （3） Compared to the patients diagnosed inflammation or CINⅠ, the patients diagnosed CINⅡ and above cervical lesions had higher infection rate of HPV16, lower infection rate of HPV18, higher incidence of ASCUS, and smaller parities （all P〈0.05）. A multifactor analysis was carried out, the results showed that HPV16 positive and ASCUS might be independent risk factors to predict the incidence of CINⅡ and above cervical lesions （P〈0.01） .ConclusionsThe incidence of cervical precancerous lesions is high in the women with HPV16/18 infection. Patients with HPV16 infection are more likely to have the CINⅡ and above cervical lesions than patients with HPV18 infection. Patients with HPV16/18 infection are suggested to be directly transferred to clinic of colposcopy, and then getting the histology selectively, which would be help to early detection of the cervical precancerous lesions.