P16及细胞块技术在宫颈上皮内瘤变治疗中的分流作用探讨

发布时间：2018-07-18 21:22

【摘要】：研究背景在中国,宫颈癌是最常见的妇科恶性肿瘤,严重威胁着我国妇女的生命健康。导致宫颈癌的主要原因是人乳头瘤病毒(human papilloma virus, HPV)的持续感染,从正常宫颈感染高危型HPV病毒继而逐渐进展为宫颈癌大概约需8-12年。宫颈上皮内瘤变(cervical intraepithelial neoplasia,CIN)是宫颈癌发展过程中的癌前期病变。及时发现CIN并给予合适的治疗是预防宫颈癌发生、降低宫颈癌死亡率的重要手段。宫颈上皮内瘤变根据细胞异型性的程度和累及宫颈上皮层范围的不同从轻到重分为三级：CIN1、CIN2,CIN3。不同阶段对应的治疗策略也不同。约57-60%的CINl会自然消退；而CIN3则被认为是真正的癌前病变,CIN3消退的可能性是33%。CIN2通常被认为是与CIN3一样需要积极手术治疗的高级别上皮内瘤变,但CIN2的生物学行为却更接近CIN1。目前,对阴道镜活检病理证实为CIN2-3的患者主要治疗方式有两种：冷刀锥切和环形电切除术(loop electrosurgical excisional procedure, LEEP)。两者均能够有效治疗宫颈上皮内瘤变,但却会带来一定的副作用,发生反复流产、严重早产及低出生体重儿的风险较一般人群明显增高。对所有阴道镜活检病理为CIN2-3的患者不加筛选的进行手术,会对很多患者造成过度治疗。因此如何采用合适的手段箭查出高危的CIN2-3进行针对性的手术对于减少过度治疗尤其是减少对年轻、有生育需求的患者的过度治疗具有非常重要的意义。本研究意图探寻有效的方法对宫颈上皮内瘤变的病人进行分流,从而降低对进展为宫颈浸润癌风险较低的病人进行过度治疗的可能。第一部分关于活检证实的CINⅡ-Ⅲ患者锥切病理阴性现象的探讨。目的：通过评估宫颈锥切距活检间隔时间对锥切病理阴性率的影响以及年龄等其它可能的影响因素与锥切病理阴性率的相关性,以寻找发生锥切病理阴性现象的高危因素,从而减少过度治疗的发生。方法：对阴道镜下活检病理证实为CIN2-3并接受LEEP治疗的391例患者进行回顾性分析。收集每一个研究对象活检与LEEP间隔时间及年龄等详细病例资料,用统计学方法分析其与锥切术后病理分级的关系。结果：1、我们将病理结果≤CIN1的患者视为锥切病理阴性,锥切病理阴性的比例是26.9%(105/391)；2、随着宫颈活检与LEEP术间隔时间的增加,锥切病理阴性的比例显著增加,Pearson相关系数为5.44(P=0.020),单因素logistic回归OR：1.374,95%CI：1.089一1.735,P=0.008；3、锥切病理阴性组与锥切病理阳性组患者的避孕方法、活检前细胞学结果、HPV感染情况(分型、定量及高危HPV型数量)、阴道镜结果均无统计学差异。仅活检病理分级和年龄与锥切病理阴性率密切相关(p=0.002, p=0.015)；4、通过多因素logistic回归分析,锥切病理阴性的发生与活检病理分级(p=0.001)、年龄(p=0.039)和活检与锥切间隔时间(p=0.028)密切相关。结论：1、26.9%的阴道镜下活检证实为CIN2-3的患者在进行LEEP治疗时,锥切病理仅提示为CIN1或者无上皮内瘤变；2、活检病理分级为CIN2的年轻女性当锥切距活检间隔时间较长时,锥切病理≤CIN1的几率显著升高。第二部分P16在宫颈活检为CIN2的病理标本中的表达与锥切术后病理分级之间的关系目的：探寻P16在宫颈活检为CIN2的病理标本中的表达与锥切术后病理级别之间的关系,以此来推测是否可用其分流活检为CIN2的病人。方法：以128例CIN2患者作为研究对象进行回顾性分析,取其阴道镜活检组织的石蜡切片利用免疫组化法检测P16的表达。结果：1、对115例CIN2活检标本进行P16染色发现P16阳性检出率为87.8%(101/115)；2、宫颈活检标本P16染色≤++的病人中48.3%LEEP术后病理分级≤CIN1,活检标本中P16染色为+++的病人中34.9%LEEP术后病理分级≤CIN1。与宫颈活检标本P16染色≤++的病人相比,活检标本中P16染色为+++的病人宫颈锥切病理阴性的发生率较低,但差异没有统计学意义(P=0.203)。结论：活检标本中P16免疫组化染色≤++时更容易发生锥切阴性的现象,这提示P16或许有助于预测CIN2患者的预后。但是差异没有统计学意义,或许与研究排除了对活检病理诊断不一致的病例,从而减少了对良性病例的过度诊断有关。第三部分P16在术前液基细胞蜡块的表达与锥切术后病理分级之间的关系目的：通过检测宫颈活检为CIN病人术前液基细胞石蜡包埋组织中P16表达,并探讨其与锥切术后病理及疾病转归的关系,以评估细胞块中P16表达在CIN个性化治疗中的预后价值。方法：选择TCT为ASCUS以上、在1个月内接受阴道镜下活检病理提示为CIN的病人,取其TCT保存液中的剩余组织细胞制成宫颈细胞块,同时在细胞块上用免疫组化法检测P16的表达,所有研究对象在活检后均接受两年的随访。结果：1、与细胞学涂片相比,细胞石蜡切片中细胞的形态结构与组织切片相似,且方便易行、容易保存；2、宫颈脱落细胞块中P16染色评分≥++的患者仅29.9%LEEP术后病理分级CIN1,而P16染色≤+的病人中则有71.4%LEEP术后病理分级≤CIN1,与细胞块标本P16染色≤+的病人相比,细胞块标本中P16染色≥++的病人宫颈锥切病理阴性的发生率较低,差异有统计学意义；3、以P16阳性表达为判定标准,其预测宫颈锥切病理阴性的敏感性、特异性、阳性预测值、阴性预测值分别为91.0%、36.8.5%、70.1%、71.4%；4、4例两年随访治疗中进展为CIN2-3的GIN1患者和6例锥切后两年随访发现疾病复发的患者其细胞块P16染色均≥++。结论：运用细胞块技术有利于对患者做回顾性分析和追踪观察；根据P16在宫颈脱落细胞块的免疫组化染色结果,可以较准确地预测疾病的转归,有助于对CIN级患者进行有效的分流管理,以减少过度治疗的发生。
[Abstract]:Background in China, cervical cancer is the most common gynecologic malignant tumor, which is a serious threat to the life and health of women in China. The main cause of cervical cancer is the continuous infection of human papilloma virus (HPV). It will take about 8-12 years for cervical cancer to gradually develop to cervical cancer from the high risk HPV virus of normal cervix. Intraepithelial neoplasia (cervical intraepithelial neoplasia, CIN) is a precancerous lesion in the development of cervical cancer. Timely discovery of CIN and appropriate treatment are important means to prevent the occurrence of cervical cancer and reduce the mortality of cervical cancer. Cervical intraepithelial neoplasia is based on the degree of cell heteromorphic and the difference in the range of cervical epithelium involving the cervical epithelium. The light to weight is divided into three levels: CIN1, CIN2, and CIN3. different stages of treatment. The CINl of about 57-60% will disappear naturally; and CIN3 is considered a real precancerous lesion, and the possibility of CIN3 regression is that 33%.CIN2 is usually considered to be a high grade intraepithelial neoplasia that requires active surgical treatment as CIN3, but the biological line of CIN2 To be closer to CIN1., there are two main treatments for CIN2-3 in patients with biopsy pathology confirmed by colposcopy: cold knife coning and circular electrosurgical excision (loop electrosurgical excisional procedure, LEEP). Both can effectively treat cervical intraepithelial neoplasia, but it will bring certain side effects, recurrent abortion, serious early The risk of producing and low birth weight infants is significantly higher than that of the general population. Surgery on all patients with CIN2-3 for all colposcope biopsy pathology will cause excessive treatment in many patients. Therefore, how to use appropriate means to detect high risk CIN2-3 for targeted hand operation is especially reduced to reducing overtreatment. The purpose of this study is to explore effective ways of diverting patients with cervical intraepithelial neoplasia to reduce the possibility of overtreatment of patients with lower risk of invasive cervical cancer.
The first part is about the pathological negative phenomenon of CIN II - III patients confirmed by biopsy. Objective: To evaluate the correlation between the pathological negative rate of the cone-cutting pathological negative rate and the correlation between the other possible factors of age and other possible factors, in order to find the high risk of the pathological negative phenomenon of conical cutting. Factors to reduce the occurrence of overtreatment. Methods: a retrospective analysis of 391 patients with CIN2-3 and LEEP treatment under colposcopy was reviewed. The detailed data of the biopsy and LEEP interval and age of each study were collected, and the relationship between the pathological classification after coning and the correlation of the pathological classification was analyzed by statistical method. Fruit: 1, we regarded the patients with pathological results less than CIN1 as coning pathological negative, and the proportion of conical pathological negative was 26.9% (105/391); 2, with the increase of time interval between cervical biopsy and LEEP, the proportion of conical pathological negative was significantly increased, Pearson correlation coefficient was 5.44 (P= 0.020), and single factor Logistic regression OR:1.374,95%CI:1.089 1.73. 5, P=0.008, 3, the method of contraception, the results of pre biopsy cytology, HPV infection (typing, quantitative and high risk HPV type), the results of the colposcopy were not statistically significant in the conical pathological negative group and the conical pathological positive group. Only the biopsy and age were closely related to the age of coning disease (p=0.002, p=0.015); 4, through multiple factors. Logistic regression analysis, coning pathological negative occurrence and biopsy pathological grading (p=0.001), age (p=0.039) and biopsy and conical interval time (p=0.028) are closely related. Conclusion: 1,26.9% biopsy confirmed that CIN2-3 in patients with CIN2-3, conical pathology only suggests CIN1 or no intraepithelial neoplasia; 2, biopsy pathology When the CIN2 interval was longer, the probability of conization was less than CIN1.
The relationship between the expression of the second part of P16 in the pathological specimens of cervical biopsy and CIN2 and the pathological grade after conization: To explore the relationship between the expression of P16 in the pathological specimens of the cervix biopsy as CIN2 and the pathological grade after coning, in order to speculate on the possibility of using its shunt biopsy as the patient of CIN2. Method: 128 cases of CIN2 A retrospective analysis was carried out as a study object. The paraffin section of the biopsy tissue of the colposcopy was used to detect the expression of P16. Results: 1, the positive rate of P16 positive was 87.8% (101/115) in 115 cases of CIN2 biopsy specimens, and 2, and the pathological grading of 48.3%LEEP after 48.3%LEEP in the cervical biopsy specimens was less than that of + + in the cervical biopsy specimens. CIN1, in the biopsy specimens, the pathological grading of the patients with + + + + + + + + + + + in patients with 34.9%LEEP was less than CIN1. and the cervical biopsy specimens were less than + + with P16 staining and + +. The incidence of pathological negative cervical conization in patients with P16 staining with + + + in the biopsy specimens was lower, but the difference was not statistically significant (P =0.203). Conclusion: P16 immunohistochemical staining in biopsy specimens. Color less than + + is more likely to occur coning negative phenomenon, which suggests that P16 may be helpful in predicting the prognosis of CIN2 patients, but the difference is not statistically significant, perhaps with the study excluded from the pathological diagnosis of biopsy cases, thus reducing the over diagnosis of benign cases.
The relationship between the expression of paraffin block in the third part of P16 and the pathological grading after coning: Objective: To investigate the relationship between the expression of P16 in the paraffin embedded tissues of the liquid base cells in CIN patients by detecting cervical biopsy and the relationship between the pathology and the prognosis of the disease after coning, in order to evaluate the expression of P16 in the cell block in the individualized treatment of CIN. Methods: to select TCT more than ASCUS, the patients receiving the biopsy pathologic hint under colposcopy within 1 months were CIN, and the remaining tissue cells in the TCT preservation solution were made into cervical cells and the expression of P16 was detected by immunohistochemistry on the cell block. All the subjects were followed up for two years after the biopsy. The results were two years after the biopsy. 1, compared with the cytological smears, the cell morphology and structure of cell paraffin sections are similar to those of tissue section, and it is convenient and easy to preserve. 2, the patients with P16 staining score of the cervical exfoliative cell block more than + + are only CIN1 after 29.9%LEEP operation, and the pathological grading of the P16 staining is less than CIN1 after 71.4%LEEP, and the cell block mark. Compared with the patients with P16 staining less than +, the incidence of cervical cone cut pathological negative in patients with P16 staining more than + + was lower and the difference was statistically significant. 3, the sensitivity, specificity, positive predictive value and negative predictive value of P16 positive expression for cervical conization were 91%, 36.8.5%, 70.1%, 71.4 respectively. 4,4 patients who were followed up for two years were followed up with CIN2-3 GIN1 and 6 cases after conical resection. The cell block P16 staining was greater than + +. Conclusion: the cell block technique is beneficial to the retrospective analysis and tracing observation of the patients. According to the immunohistochemical staining results of P16 in the cervix exfoliated fine cell, it can be compared. Accurate prediction of the outcome of disease is helpful to effective shunt management for patients with grade CIN, so as to reduce the incidence of overtreatment.
【学位授予单位】：山东大学
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R737.33

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