子宫颈管搔刮术对子宫颈上皮内病变的诊断价值研究

Diagnostic value of endocervical curettage in cervical intraepithelial lesions

目的通过单中心大样本分析,探讨适宜行子宫颈管搔刮术(ECC)的人群。方法收集复旦大学附属妇产科医院病理科2013年6月至2018年12月期间同时行ECC和子宫颈点活检病例共116507例。将所有病例分为ECC诊断高于点活检及ECC诊断低于或等于点活检2组,结合活检前3个月内的液基细胞学和高危型人乳头瘤病毒(hrHPV)检查结果,分析影响ECC额外检出率的因素。结果(1)二者联合检测的总阳性率为27.9%(32476/116507),其中鳞状上皮内病变32012例(27.5%)[低级别鳞状上皮内病变(LSIL)为17.9%、高级别鳞状上皮内病变(HSIL)及以上病变(HSIL+)为9.6%]、腺体病变320例(0.3%)、腺鳞病变144例(0.1%)。组织学以LSIL及以上为阳性标准,ECC和子宫颈点活检的阳性率分别为6.9%(7998/116507)及26.8%(31279/116507),P<0.001。(2)病变严重程度上,ECC与点活检诊断一致、高于及低于点活检的比例分别为77.1%(89827/116507)、1.2%(1402/116507)和21.7%(25278/116507),P<0.001。(3)在ECC诊断较点活检严重的病例中,ECC对LSIL、HSIL+、腺体病变及腺鳞病变的额外检出率分别为3.1%(655/20891)、6.1%(673/11121)、16.6%(53/320)及14.6%(21/144)。(4)年龄越大、HPV阳性时ECC诊断高于点活检的概率越大。(5)液基细胞学诊断为无明确诊断意义的不典型鳞状细胞(ASC-US)、LSIL、不能排除高级别鳞状上皮内病变不典型鳞状细胞(ASC-H)+、不典型腺上皮细胞(AGC)+时,ECC诊断高于点活检的概率分别为1.4%(167/13102)、1.8%(119/6722)、4.6%(175/3818)、2.6%(12/455),P<0.001。(6)多因素logistic回归分析结果显示,相对于年龄<30岁组,30~<50岁组的OR=1.264、50~65岁组的OR=3.486、>65岁组的OR=3.925;细胞学结果为ASC-US、LSIL、ASC-H+、AGC+相对于细胞学结果为NILM的OR值分别为1.300、1.461、4.134及4.339;而HPV并非独立的预测因素。结论ECC总体阳性率明显低于子宫颈点活检,其对HSIL+和腺体病变较敏感。年龄在50岁及以上、细胞学结果为ASC-H+或AGC+时对ECC诊断高于点活检的预测作用较大。HPV阳性,ECC诊断高于点活检的概率越高;但多因素分析后,HPV结果并非ECC诊断高于点活检的独立预测因素。故年龄≥50岁及细胞学结果为ASC-H+或AGC+者,阴道镜行点活检的同时适宜行ECC。

Objective To investigate the suitable population for endocervical curettage(ECC)by this retrospective study on a large sample from a unique center.Methods A total of 116507 cases of ECC and cervical biopsy were collected from the database of the Department of Pathology,Obstetrics and Gynecology Hospital of Fudan University from June2013 to December 2018.All cases were divided into 2 groups:ECC diagnosis more severe than cervical biopsy,and ECC diagnosis less severe than or equal to cervical biopsy.The results of liquid-based cytology and high-risk HPV(hrHPV)examination within 3 months before biopsy were also included to analyze the factors affecting the additional yield of ECC.Results(1)The total positive rate of combined detection was 27.9%(32476/116507),including 32012 cases(27.5%)of squamous intraepithelial lesions[LSIL 17.9%,HSIL or worse(HSIL+)9.6%],320(0.3%)cases of glandular lesions and 144(0.1%)cases of adenosquamous lesions.LSIL or worse was considered as the threshold for positive diagnosis.The positive rate of ECC and cervical biopsy was 6.9%(7998/116507)and 26.8%(31279/116507),respectively,P<0.001.(2)Regarding the severity of the lesions,the proportion of ECC diagnosis equal to,more severe than and less severe than cervical biopsy was 77.1%(89827),1.2%(1402)and 21.7%(25278),respectively,P<0.001.(3)In the cases with ECC diagnosis more severe than cervical biopsy,the additional yield of LSIL,HSIL+,glandular and adenosquamous lesions by ECC were 3.1%(655/20891),6.1%(673/11121),16.6%(53/320)and 14.6%(21/144)respectively.(4)The probability of ECC diagnosis more severe than biopsy was found in older and hrHPV positive patients.(5)Patients with cytological interpretations of ASC-US,LSIL,ASC-H+and AGC+has the proportion of ECC diagnosis more severe than biopsy as 1.4%(167/13102),1.8%(119/6722),4.6%(175/3818)and 2.6%(12/455),respectively,P<0.001.(6)The multifactor logistic regression indicated that compared with age group less than 30,the OR value of the additional yield by ECC in 30-<50,50-65 and>65 age group was 1.264,3.486 and 3.925,respectively,P<0.05.Compared with NILM patients,the OR value of the additional yield by ECC with ASC-US,LSIL,ASC-H+and AGC+cytology result was 1.300,1.461,4.134 and 4.339,respectively,P<0.05.HPV status was not an independent predictor.Conclusions The overall positive rate of ECC is significantly lower than that of cervical biopsy.ECC is relatively sensitive to HSIL+and glandular lesion.Age over than 50 years and ASC-H+or AGC+cytological results are more predictive of ECC diagnosis more severe than cervical biopsy.Positive HPV predicts more severe ECC diagnosis,but is not an independent predictor by multifactor analysis.Therefore,for women aged 50 and over,with ASC-H+or AGC+cytological findings,ECC should be performed simultaneously with colposcopic biopsy.