阴道镜下不同活检方法在高级别子宫颈上皮内病变检出中的作用

The role of colposcopy biopsies in the detection of the high-grade cervical squamous intraepithelial leision

目的探讨阴道镜下不同活检方法在HSIL检出中的作用。方法对388例宫颈癌筛查异常的妇女行阴道镜检查,并在阴道镜指引下行四象限点活检+ECC,以病理诊断为金标准。结果阴道镜指引下在子宫颈最异常处的第一块活检检出77.1%(54/70)的HSIL,在病变第二异常处活检额外检出4.3%(3/70)的HSIL,在病变异常处的两块定位活检检出HSIL+的敏感性为81.4%,特异性为96.1%,与筛查异常级别(OR=4.257,95%CI:1.590~11.397,P=0.004)、阴道镜拟诊(OR=27.124,95%CI:12.221~60.199,P=0.000)具有相关性;随机活检额外检出18.6%(13/70)的HSIL,其中6例CIN2,7例CIN3;在筛查低级别异常者中额外检出HSIL 8例,占2.3%(8/344),其中5例CIN2,3例CIN3;在高级别异常者中额外检出HSIL 5例,占11.4%(4/44),其中1例CIN2,4例CIN3,与筛查异常级别(OR=6.833,95%CI:1.702~27.432,P=0.007)具有相关性,ECC无额外HSIL的检出。结论在子宫颈癌筛查异常妇女中,阴道镜下可疑病变部位行阴道镜指引下的2点或以上活检为HSIL检出的主要方法;对于阴道镜下未发现异常的妇女,尤其是对宫颈癌筛查高级别异常的妇女建议行随机活检。

Objective To investigate the role of colposcopy biopsies in the detection of the high-grade squamous intraepithelial lesions （HSIL） in cervix. Methods 388 cases of women with the abnormal screening results were all performed with the colposcopy examination. The transformation zone type, abnormal transformation area and grade were evaluated. All subjects were taken with the colposcopy directed punch biopsies or random biopsy, and endocervical curettage （ECC）. The efficiency of HSIL detection by different biopsy methods were evaluated. Results 54 cases （77.1%） diagnosed of HSIL were obtained from the first colposcopy-directed punch biopsy. The additional diagnostic utility of second colposcopy-directed punch biopsies was 4.3%. The combined sensitivity of two colposcopy-directed biopsies for HSIL detection was 81.4%, the specificity was 96.1%. There were statistical correlation with the abnormal screening level （OR=4.257, 95% CI： 1.590- 11.397,P=0.004） , and the colposcopy diagnosis （OR =27.124, 95% CI： 12.221-60.199, P=0.000） . There were 13 cases diagnosed by random biopsies additionally （18.6%, 13/70） （6 cases of CIN2, and 7 cases of CIN3）, including 8 cases with low abnormal level of screening results （5 cases CIN2 and 3 cases CIN3）, 5 cases with high abnormal level of screening results （ 1 case CIN2 and 4 cases CIN3）. There was statistical correlation with the abnormal screening level （OR = 6.833, 95% CI： 1.702 - 27.432, P = 0.007） , but no statistics correlation with the different types of transformation zone or colposcopy diagnosis. There was no additional HSIL detected by ECC. Conclusions For the women with abnormal cervical screening results, the colposcopy assessment and diagnosis could be very important in the HSIL detection. Colposcopy-directed biopsies of two or more sites in the most suspicious lesion is the main suggested method. Random biopsies is highly recommended even if no abnormal found under colposcopy, especially for womenwith high grade abnormalities in the cervical screening.