高危型HPV感染绝经后女性宫颈高级别鳞状上皮内病变的诊治

doi:10.12280/gjfckx.20220172

摘要/Abstract

摘要：

高级别鳞状上皮内病变（high-grade squamous intraepithelial lesion,HSIL）与高危型人乳头瘤病毒（human papilloma virus,HPV）持续感染有关,被视为宫颈癌前病变,有癌变潜能。绝经后女性由于宫颈的年龄依赖性变化,宫颈HSIL的诊治难度增加。虽然宫颈活组织检查是诊断宫颈病变的金标准,但也存在漏诊现象,然而宫颈管搔刮术可提高绝经期女性HSIL的诊断准确率,尤其阴道镜检查不满意但可疑宫颈病变时宫颈管搔刮术的效果更为显著。尽管切缘阳性被认为是宫颈切除后病变残留/复发的关键因素,切缘阴性也并不意味着病灶已被完全切除。而且因为宫颈萎缩、宫颈缩短和阴道穹窿部消失等原因使宫颈切除性手术操作困难,增加膀胱、直肠等邻近脏器损伤的风险,同时,绝经期女性激素水平降低,宫颈癌好发部位转化区内移至宫颈管内,阴道镜检查无法及时找到可疑部位,导致宫颈癌漏诊。因此,探讨针对绝经后女性宫颈病变的最优诊疗方案有重要的临床意义。通过分析绝经后女性宫颈HSIL的诊治现状及面临的难题,为绝经后妇女宫颈病变的个体化诊治提供理论指导。

关键词: 宫颈鳞状上皮内病变, 绝经后期, 子宫颈, 宫颈上皮内瘤样病变, 高危型人乳头瘤病毒

Abstract:

High-grade squamous intraepithelial lesion (HSIL) is associated with the persistent infection of high-risk human papilloma virus, are considered cervical precancerous lesions with the potential for cancer. Difficulty of diagnosis and treatment of HSIL are increased due to age-dependent changes to the cervix in postmenopausal women. Though cervical biopsy is the gold standard for diagnosing cervical lesions, it is also missed, but endocervical curettage can improve the accuracy of HSIL in menopausal women, especially when colposcopy is not satisfactory but suspicious cervical lesions. Although positive margins are considered a key factor in residual/recurrence of lesions after cervical resection, a negative margin does not mean that the lesion has been completely removed. Moreover, because of cervical atrophy, cervical shortening, disappearance of the vaginal vault and other reasons, the difficulty of cervical resection surgery and the risk of damage to adjacent organs such as bladder and rectum are increased. At the same time, the hormone level of menopausal women is reduced, the predilection site of cervical cancer transformation zone of cervical moved to the cervical canal, and colposcopy cannot find the suspicious part in time, resulting in missed diagnosis of cervical cancer. Therefore, it is of great clinical significance to explore the optimal scheme for diagnosis and treatment of cervical lesions in postmenopausal women. By analyzing the current status and problems faced by cervical HSIL in postmenopausal, it provides individualized theoretical guidance for the diagnosis and treatment of cervical lesions in them.

Key words: Squamous intraepithelial lesions of the cervix, Postmenopause, Cervix uteri, Cervical intraepithelial neoplasia, High-risk human papilloma virus

阿米呢古丽·麦麦提敏, 阿依达娜·居玛别克, 韩莉莉. 高危型HPV感染绝经后女性宫颈高级别鳞状上皮内病变的诊治[J]. 国际妇产科学杂志, 2022, 49(5): 535-539.

Amineguli ·Maimaitimin, Ayidana ·Jumabieke, HAN Li-li. Diagnosis and Treatment of High-Grade Squamous Intraepithelial Lesion in High-Risk HPV-Infected Postmenopausal Women[J]. Journal of International Obstetrics and Gynecology, 2022, 49(5): 535-539.

参考文献 30

[1]	Allouch S, Malki A, Allouch A, et al. High-Risk HPV Oncoproteins and PD-1/PD-L1 Interplay in Human Cervical Cancer: Recent Evidence and Future Directions[J]. Front Oncol, 2020, 10:914. doi: 10.3389/fonc.2020.00914. doi: 10.3389/fonc.2020.00914 pmid: 32695664
[2]	魏丽惠. 面向加速消除宫颈癌的挑战[J]. 中国妇产科临床杂志, 2021, 22(1):1-2. doi: 10.13390/j.issn.1672-1861.2021.01.001. doi: 10.13390/j.issn.1672-1861.2021.01.001
[3]	Duan R, Xu K, Huang L, et al. Temporal Trends and Projection of Cancer Attributable to Human Papillomavirus Infection in China, 2007-2030[J]. Cancer Epidemiol Biomarkers Prev, 2022, 31(5):1130-1136. doi: 10.1158/1055-9965.EPI-21-1124. doi: 10.1158/1055-9965.EPI-21-1124
[4]	Arbyn M, Weiderpass E, Bruni L, et al. Estimates of incidence and mortality of cervical cancer in 2018: a worldwide analysis[J]. Lancet Glob Health, 2020, 8(2):e191-e203. doi: 10.1016/S2214-109X(19)30482-6. doi: 10.1016/S2214-109X(19)30482-6
[5]	Perkins RB, Guido RS, Castle PE, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines for Abnormal Cervical Cancer Screening Tests and Cancer Precursors[J]. J Low Genit Tract Dis, 2020, 24(2):102-131. doi: 10.1097/LGT.0000000000000525. doi: 10.1097/LGT.0000000000000525
[6]	Safaeian M, Wright TC Jr, Stoler MH, et al. The IMproving Primary Screening And Colposcopy Triage trial: human papillomavirus, cervical cytology, and histopathologic results from the baseline and 1-year follow-up phase[J]. Am J Obstet Gynecol, 2021, 225(3):278.e1-278.e16. doi: 10.1016/j.ajog.2021.03.047. doi: 10.1016/j.ajog.2021.03.047
[7]	WHO guideline for screening and treatment of cervical pre-cancer lesions for cervical cancer prevention[EB/OL]. 2nd ed. Geneva: World Health Organization, 2021.
[8]	薛鹏, 王福媛, 李晴, 等. 阴道镜对宫颈病变诊断价值的荟萃分析[J]. 国际妇产科学杂志, 2021, 48(2):159-164. doi: 10.12280/gjfckx.20200748. doi: 10.12280/gjfckx.20200748
[9]	Kim SI, Kim SJ, Suh DH, et al. Pathologic discrepancies between colposcopy-directed biopsy and loop electrosurgical excision procedure of the uterine cervix in women with cytologic high-grade squamous intraepithelial lesions[J]. J Gynecol Oncol, 2020, 31(2):e13. doi: 10.3802/jgo.2020.31.e13. doi: 10.3802/jgo.2020.31.e13
[10]	Ren H, Jia M, Zhao S, et al. Factors Correlated with the Accuracy of Colposcopy-Directed Biopsy: A Systematic Review and Meta-Analysis[J]. J Invest Surg, 2022, 35(2):284-292. doi: 10.1080/08941939.2020.1850944. doi: 10.1080/08941939.2020.1850944
[11]	Stuebs FA, Schulmeyer CE, Mehlhorn G, et al. Accuracy of colposcopy-directed biopsy in detecting early cervical neoplasia: a retrospective study[J]. Arch Gynecol Obstet, 2019, 299(2):525-532. doi: 10.1007/s00404-018-4953-8. doi: 10.1007/s00404-018-4953-8 pmid: 30367250
[12]	Lang L, Jia Y, Duan Z, et al. The role of endocervical curettage in detection and treatment of cervical canal lesions[J]. Histol Histopathol, 2022, 37(1):63-68. doi: 10.14670/HH-18-394. doi: 10.14670/HH-18-394
[13]	谢幸, 孔北华, 段涛. 妇产科学[M]. 9版. 北京: 人民卫生出版社, 2018:297.
[14]	Fontham E, Wolf A, Church TR, et al. Cervical cancer screening for individuals at average risk: 2020 guideline update from the American Cancer Society[J]. CA Cancer J Clin, 2020, 70(5):321-346. doi: 10.3322/caac.21628. doi: 10.3322/caac.21628
[15]	周晖, 刘昀昀, 罗铭, 等. 2022 NCCN子宫颈癌临床实践指南(第1版)》解读[J]. 中国实用妇科与产科杂志, 2021, 37(12):1220-1226.
[16]	Jenkins TM, Shojaei H, Song SJ, et al. Role of Ancillary Techniques in Cervical Biopsy and Endocervical Curettage Specimens as Follow-Up to Papanicolaou Test Results Indicating a Diagnosis of Atypical Squamous Cells, Cannot Exclude High-Grade Squamous Intraepithelial Lesion, or High-Grade Squamous Intraepithelial Lesion[J]. Acta Cytol, 2020, 64(1/2):155-165. doi: 10.1159/000498888. doi: 10.1159/000498888
[17]	Andersson S, Megyessi D, Belkić K, et al. Age, margin status, high-risk human papillomavirus and cytology independently predict recurrent high-grade cervical intraepithelial neoplasia up to 6 years after treatment[J]. Oncol Lett, 2021, 22(3):684. doi: 10.3892/ol.2021.12945. doi: 10.3892/ol.2021.12945 pmid: 34434283
[18]	Arbyn M, Xu L, Simoens C, et al. Prophylactic vaccination against human papillomaviruses to prevent cervical cancer and its precursors[J]. Cochrane Database Syst Rev, 2018, 5(5):CD009069. doi: 10.1002/14651858.CD009069.pub3. doi: 10.1002/14651858.CD009069.pub3
[19]	Alder S, Megyessi D, Sundström K, et al. Incomplete excision of cervical intraepithelial neoplasia as a predictor of the risk of recurrent disease-a 16-year follow-up study[J]. Am J Obstet Gynecol, 2020, 222(2):172.e1-e12. doi: 10.1016/j.ajog.2019.08.042. doi: 10.1016/j.ajog.2019.08.042
[20]	Fernández-Montolí ME, Tous S, Medina G, et al. Long-term predictors of residual or recurrent cervical intraepithelial neoplasia 2-3 after treatment with a large loop excision of the transformation zone: a retrospective study[J]. BJOG, 2020, 127(3):377-387. doi: 10.1111/1471-0528.15996. doi: 10.1111/1471-0528.15996
[21]	Tidy JA, Lyon R, Ellis K, et al. The impact of age and high-risk human papillomavirus (hrHPV) status on the prevalence of high-grade cervical intraepithelial neoplasia (CIN2+) in women with persistent hrHPV-positive, cytology-negative screening samples: a prospective cohort study[J]. BJOG, 2020, 127(10):1260-1267. doi: 10.1111/1471-0528.16250. doi: 10.1111/1471-0528.16250
[22]	Zhao Y, Zhao F, Hu S, et al. Value of multi-quadrants biopsy: Pooled analysis of 11 population-based cervical cancer screening studies[J]. Chin J Cancer Res, 2020, 32(3):383-394. doi: 10.21147/j.issn.1000-9604.2020.03.09. doi: 10.21147/j.issn.1000-9604.2020.03.09
[23]	Jones R, Dale F, Fite JJ, et al. Endocervical glandular involvement is associated with an increased detection rate of high-grade squamous intraepithelial lesions on the Papanicolaou test[J]. J Am Soc Cytopathol, 2020, 9(3):137-145. doi: 10.1016/j.jasc.2019.12.004. doi: S2213-2945(20)30021-1 pmid: 32147423
[24]	Spinillo A, Dominoni M, Boschi AC, et al. The relationship of human papillomavirus infection with endocervical glandular involvement on cone specimens in women with cervical intraepithelial neoplasia[J]. Gynecol Oncol, 2020, 159(3):630-635. doi: 10.1016/j.ygyno.2020.09.034. doi: 10.1016/j.ygyno.2020.09.034 pmid: 33041069
[25]	Ikeda M, Mikami M, Yasaka M, et al. Association of menopause, aging and treatment procedures with positive margins after therapeutic cervical conization for CIN 3: a retrospective study of 8,856 patients by the Japan Society of Obstetrics and Gynecology[J]. J Gynecol Oncol, 2021, 32(5):e68. doi: 10.3802/jgo.2021.32.e68. doi: 10.3802/jgo.2021.32.e68 pmid: 34132067
[26]	刘媛媛, 郭瑞霞, 李碧军, 等. 绝经后妇女子宫颈癌前病变的特点分析[J]. 中华妇产科杂志, 2021, 56(2):114-120. doi: 10.3760/cma.j.cn112141-20201010-00768. doi: 10.3760/cma.j.cn112141-20201010-00768
[27]	Abdulaziz A, You X, Liu L, et al. Management of high-grade squamous intraepithelial lesion patients with positive margin after LEEP conization: A retrospective study[J]. Medicine(Baltimore), 2021, 100(20):e26030. doi: 10.1097/MD.0000000000026030. doi: 10.1097/MD.0000000000026030
[28]	Fu K, Lei M, Yang WQ, et al. The treatment strategy of patients with positive margins after cervical cold knife conization-A 7-year retrospective study in China[J]. Int J Gynaecol Obstet, 2022, 156(1):159-165. doi: 10.1002/ijgo.13683. doi: 10.1002/ijgo.13683
[29]	Wang X, Xu J, Gao Y, et al. Necessity for subsequent surgery in women of child-bearing age with positive margins after conization[J]. BMC Womens Health, 2021, 21(1):191. doi: 10.1186/s12905-021-01329-x. doi: 10.1186/s12905-021-01329-x pmid: 33962590
[30]	Li X, Liu M, Ji Y, et al. The effectiveness of cold-knife conization (CKC) for post-menopausal women with cervical high-grade squamous intraepithelial lesion: a retrospective study[J]. BMC Surg, 2021, 21(1):241. doi: 10.1186/s12893-021-01238-8. doi: 10.1186/s12893-021-01238-8 pmid: 33975589