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Title: [Analysis of the missed diagnosis of invasive carcinoma under the microscope in HSIL diagnosed by colposcopy-guided biopsy and related influencing factors].
Author: Qian XY, You ZX, Cao QW, Zou BB, Xing Y.
Journal: Zhonghua Fu Chan Ke Za Zhi; 2018 Sep 25; 53(9):613-619. PubMed ID: 30293297.
Abstract:
Objective: To observe the missed diagnosis of invasive carcinoma under the microscope (ICUM) in high grade squamous intraepithelial neoplasia (HSIL) , and analyze associated factors influencing missed ICUM. Methods: A retrospective study was performed on patients diagnosed with HSIL by colposcopy-guided biopsy and treated with loop electrosurgical excision procedure (LEEP) at the First Affiliated Hospital of Nanjing Medical University, from December 2014 to December 2016. They were non-pregnant, ≤50 years old and the cervical volume without obvious enlargement and exogenous surface without and ulcerative lesions. A total of 283 cases with early cervical cytology results, never received cervical traumatic treatment or cervical biopsy in another hospital before, and their colposcopic images were clear enough to reevaluate. The ultimate pathological diagnosis was based on the higher-level pathological diagnosis between the results of cervical biopsy and LEEP to evaluate ICUM missed in HSIL and the risk factors. Results: (1) Among the 283 cases with HSIL diagnosed by colposcopy-directed biopsy, 44 cases (15.5%, 44/283) were missed diagnosis of ICUM, which consisted of 29 cases Ⅰ a1, 4 cases Ⅰ a2 and 11 cases Ⅰ b1 in the ultimate pathology. (2) Analysis of associated factors for missed ICUM: univariate analysis showed that, as the age increased, the risk of missed ICUM also increased (the rates of missed diagnosis for <30, 30-39, 40-50 years were 7.7%, 11.5%, 22.0%, respectively; χ(2)=6.254, P=0.012 by trend test) . The more the number of high-grade features, the higher risks (the rates of missed diagnosis for 1, 2, 3, 4 high-grade features were 10.2%, 17.6%, 23.8%, 30.8%, respectively; χ(2)=7.686, P=0.006 by trend test) . The locations of HSIL were only endocervical, only ectocervical and mixed, the risk increased by this sequence (2.8%, 5.1%, 28.7%; χ(2)=26.193, P<0.01 by trend test) . The rate of missed diagnosis for not completely visible squamocolumnar junction (SCJ) was higher than that of the completely visible one (22.3% vs 2.1%; χ(2)=19.680, P<0.01) . The rate of missed diagnosis was higher for existing atypical vessels than those without (60.7% vs 10.6%; χ(2)=48.279, P<0.01) . The rate of missed diagnosis for visible lesion size ≥40 mm(2) was higher than that of <40 mm(2) (27.3% vs 4.2%; χ(2)=28.921, P<0.01) . The rate of missed diagnosis for the proportion of visible lesion size in ectocervical size ≥0.75 was higher than that of <0.75 (83.3% vs 14.1%; P<0.01) . The rate of missed diagnosis for the maximum linear length of visible lesion ≥10 mm was higher than that of <10 mm (46.9% vs 9.0%; χ(2)=44.473, P<0.01) . But the different severity of cervical cytology before colposcopy was not associated with missed ICUM (P>0.05) . Multivariable analysis found that visibility of SCJ, atypical vessels, visible lesion size and maximum linear length of visible lesion were associated with missed diagnosis of ICUM (all P<0.05) . Conclusions: The diagnostic value of HSIL by colposcopy is limited. Meanwhile, for the patients who are ≤50 years old with HSIL diagnosed by cervical biopsy, invisibility of SCJ, atypical vessels, visible lesion size and maximum linear length of visible lesion evaluated by colposcopy are the independent risk factors of missed ICUM. Thereby, it is necessary to take active intervention for HSIL with these risk factors. 目的： 观察阴道镜直视下子宫颈活检诊断的高级别鳞状上皮内病变（HSIL）中镜下浸润癌（ICUM）的检出情况，并分析影响检出ICUM的相关因素。 方法： 收集2014年12月—2016年12月在南京医科大学第一附属医院就诊的非妊娠期、年龄≤50岁并经阴道镜直视下子宫颈活检诊断为HSIL后接受了子宫颈环形、电极切除（LEEP）术的患者共1 425例。选择其中子宫颈体积无明显增大、有初筛子宫颈细胞学检查结果、既往未行子宫颈有创性治疗、保存的阴道镜图像足够清晰可满足再次评估的HSIL患者283例纳入本研究，以子宫颈活检或LEEP术后组织学诊断中级别最高者作为最终病理检查结果，观察阴道镜直视下子宫颈活检诊断的HSIL中ICUM的检出情况，并分析影响检出ICUM的相关因素。 结果： （1）283例阴道镜直视下子宫颈活检诊断的HSIL患者中，LEEP术后病理诊断为子宫颈ICUM者44例，其中Ⅰa1、Ⅰa2和Ⅰb1期分别为29、4和11例，子宫颈活检术诊断的HSIL中ICUM的检出率为15.5%（44/283）。（2）检出ICUM的相关因素分析：单因素分析显示，随着年龄增加检出ICUM的风险增加（<30岁、30~39岁、40~50岁患者的检出率分别为7.7%、11.5%、22.0%；χ(2)=6.254，P=0.012）；阴道镜下高级别病变的图像数目越多，检出ICUM的风险增加（图像数目为1、2、3、4个时检出率分别为10.2%、17.6%、23.8%、30.8%；χ(2)=7.686，P=0.006）；HSIL病变位置为仅位于子宫颈管内、仅位于子宫颈阴道部及同时位于子宫颈阴道部和子宫颈管内，其检出率分别为2.8%、5.1%及28.7%，病变同时位于子宫颈阴道部和子宫颈管内时检出ICUM的风险明显增加（χ(2)=26.193，P<0.01）；鳞柱交界（SCJ）不完全可见者检出ICUM的风险明显高于完全可见者（检出率分别为22.3%、2.1%；χ(2)=19.680，P<0.01）；可见非典型血管者检出ICUM的风险明显高于非典型血管不可见者（检出率分别为60.7%、10.6%；χ(2)=48.279，P<0.01）；可见病变面积≥40 mm(2)者检出ICUM的风险明显高于<40 mm(2)者（检出率分别为27.3%、4.2%；χ(2)=28.921，P<0.01）；可见病变面积占子宫颈阴道部面积的比例≥0.75者检出ICUM的风险较<0.75者明显增加（检出率分别为83.3%、14.1%；P<0.01）；可见病变的最长线性长度≥10 mm者检出ICUM的风险明显高于<10 mm者（检出率分别为46.9%、9.0%；χ(2)=44.473，P<0.01）；而初筛时子宫颈细胞学严重程度的不同与检出ICUM的风险不相关（P>0.05）。多因素logistic回归分析显示，阴道镜下SCJ不可见、可见非典型血管、可见病变面积≥40 mm(2)、可见病变的最长线性长度≥10 mm是检出ICUM的独立危险因素（P均<0.05）。 结论： 阴道镜直视下子宫颈活检诊断的HSIL中存在ICUM；对于年龄≤50岁的子宫颈活检诊断为HSIL的患者，阴道镜下评估的SCJ可见性、有无非典型血管、可见病变的面积、可见病变的最长线性长度是影响检出ICUM的独立危险因素，对存在这些危险因素的患者应积极干预。.

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