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1、内容回顾,一、转化区 二、鳞状上皮化生 三、宫颈病变的概念 四、三阶梯检查 五、阴道镜检查指征,一、转化区(移行带),原始鳞柱交界与新生鳞柱交界的宫颈段。 原始鳞状上皮 原始柱状上皮 原始鳞柱交界（OSCJ） 新的鳞柱交界（NSCJ） 转化区（TZ） 正常转化区,一、转化区(移行带),移行带位置的变动主要取决于柱状上皮生长能力的优势，而上皮的生长受激素的影响。 在年轻妇女可见鳞柱交界的部位多位于解剖学外口以下，绝经后妇女，移行带内移，通常在子宫颈的高处。,一、转化区(移行带),移行带是CIN和宫颈Ca的好发部位，因此细胞学检查必须包括这一部位，阴道镜检查的原则之一就是要了解移行带的情况。,二、
2、鳞状上皮化生,柱状上皮转化为鳞状上皮存在两种不同转化机制即鳞状上皮化生和鳞状上皮化生。 鳞状上皮化是指成熟的鳞状上皮直接向邻近的柱状上皮内生长，是成熟的鳞状上皮保护层取代子宫颈管细胞。 鳞状上皮化生是指从子宫颈管基层膜上面具有改向功能的储备细胞细胞增生而来。,二、鳞状上皮化生,这些细胞一旦受到刺激开始分层和分化，最后分化为成熟的鳞状上皮，根据鳞状上皮化生过程的不同阶层分为：储备细胞增生、未成熟磷化、成熟磷化。,三、宫颈病变的概念,广义：宫颈病变(Cervicallesions)：是一个尚未限定的、比较泛化的概念，指在宫颈区域发生的各种病变，包括炎症、损伤、肿瘤(以及癌前病变)、畸形和子宫内膜异
3、位症等 。,Company Logo,狭义：临床上将宫颈病变限定在宫颈细胞学异常和宫颈上皮内瘤变(CervicalIntraepithelialNeoplasia，CIN)。 对宫颈病变进行正确处理及采用合适的管理方法是宫颈癌防治体系中关键的组成部分。 不适当的处理可能增加宫颈癌的发病风险，抑或过度处理导致不必要的并发症发生和医疗资源的浪费。,不同诊断术语的含义,子宫颈上皮内瘤变（Cervical Intraepithelial Neoplasia，CIN）： 组织学诊断术语，按病变细胞涉及上皮层次分为、级。 子宫颈鳞状上皮内病变（Squamous intraepithelial Lesion
4、，SIL）： 细胞学TBS分类诊断术语，按细胞的异型性改变分为低度鳞状上皮内病变（LSIL）和高度鳞状上皮内病变（HSIL）,四、宫颈病变三阶梯检查,细胞学阴道镜组织病理学 由于中国国情，对宫颈癌筛查因地区、经济条件、医疗资源等差异而采用不同手段，如：细胞学检测、裸眼醋酸染色检查(VIN)及复方碘染(VILI)检查，高危型HPVDNA检查、肉眼观察高度怀疑宫颈浸润癌等，这些筛查结果异常者，需转诊阴道镜检查和诊断，并在阴道镜指导下完成组织病理学检查诊断，即“三阶梯”的检查诊断。,五、阴道镜检查指征,1、宫颈细胞学检查结果异常 （1）不典型鳞状上皮细胞(ASC-US)； （2）不典型鳞状上皮细胞-
5、不除外高度鳞状上 皮内病变（ASC-H）； （3）低度鳞状上皮内病变（LSIL）； （4）高度鳞状上皮内病变（HSIL）； （5）鳞状细胞癌（SCC）；,（6）不典型腺上皮细胞（AGC）； （7）腺原位癌（AIS）； （8）腺癌； （9）巴氏分级标准中巴氏b级以上的结果； （10）高危型HPV检测结果阳性（需注明hpv检测方法，如：hc-2法、hpv基因分型法特别是16、18型阳性、PCR法）,2、裸眼醋酸染色或复方碘染色后肉眼观 察（via/vili）结果异常。 3、裸眼直观为宫颈溃疡、肿块或可疑宫 颈浸润癌。 4、可疑病变处指导性活检,5、宫颈锥切前确定病变范围 6、宫颈尖锐湿疣 7、慢性
6、宫颈炎长期治疗无效 8、阴道和外阴病变：阴道和外阴上皮内瘤样变、早期阴道癌、阴道腺病、梅毒、结核、尖锐湿疣等,July3,2018,question,Does cervical cancer screening using primary cervical human papillomavirus (HPV) testing compared with cytology result in a lower likelihood of cervical intraepithelial neoplasia grade 3 or worse (CIN3+) at 48 months?,Importa
7、nce,There is limited information about the relative effectiveness of cervical cancer screening with primary human papillomavirus (HPV) testing alone compared with cytology in North American populations.,Objective,To evaluate histologically confirmed cumulative incident cervical intraepithelial neopl
8、asia (CIN) grade 3 or worse (CIN3+) detected up to and including 48 months by primary HPV testing alone (intervention) or liquid-based cytology (control).,Methods,The primary objective of this study was to evaluate primary HPV testing for cervical cancer screening in an organized program setting.,Pa
9、rticipants,Inclusion criteria were women in British Columbia, Canada, with a personal health number, aged 25 to 65 years who had not had a Papanicolaou test in the previous 12 months, were not pregnant, were not HIV positive or receiving immunosuppressive therapy, and had no history of CIN2+ in the
10、past 5 years; did not have invasive cervical cancer; or did not have total hysterectomy. Women who met inclusion criteria and were patients of 224 collaborating clinicians in Metro Vancouver and Greater Victoria were invited to participate.,Randomization,Women were randomly assigned 1:1:1 to 1 of 3
11、(intervention, control, or safety) groups between January 2008 and December 31, 2010. Starting January 1, 2011, women were assigned 1:1 to the intervention or control when the safety group was closed. Women and clinicians were blinded to group assignment until 24 months or if the baseline screen res
12、ults were positive and required follow-up. The primary analysis for this study focuses on the intervention and control groups.,Interventions,Participants randomized to HPV testing alone (intervention group) with negative test results were recalled at 48 months for exit with HPV and LBC testing. Part
13、icipants randomized to LBC testing (control group) with negative test results were asked to return at 24 months for repeat testing with LBC in accordance with the cervical cancer screening guidelines in British Columbia. If LBC results were negative at this 24-month screen, participants were asked t
14、o return at 48 months for exit with HPV and LBC testing.,Intervention Group,Primary HPV testing was followed by reflex LBC in women with positive HPV test results. At baseline, if HPV positive and LBC negative, women were recalled in 12 months for HPV and LBC testing. At 12 months, if women were eit
15、her HPV or LBC positive (atypical squamous cells of undetermined significance ASCUS), they were referred for colposcopy. If both HPV and LBC negative at 12 months, they were recommended for exit screen at 48 months. If the baseline reflex LBC result was greater than or equal to ASCUS, they were refe
16、rred for immediate colposcopy and management.,Control Group,Primary LBC testing was followed by reflex HPV testing for women with ASCUS. If ASCUS and HPV positive at baseline, women were referred for immediate colposcopy. Women with ASCUS and HPV-negative baseline results were recalled for LBC again at 12 months and were referred for colposcopy if their LBC result was greater than or equal to ASCUS. Women with baseline LBC low-grade squamous intraepithelial lesions or greater results
