Liu Angela Hui-Chia, Walker Joan, Gage Julia C, Gold Michael A, Zuna Rosemary, Dunn S Terence, Schiffman Mark, Wentzensen Nicolas
Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland; the University of Oklahoma Health Sciences Center, Oklahoma City, and Oklahoma Cancer Specialists and Research Institute and University of Oklahoma School of Community Medicine, Tulsa, Oklahoma.
Obstet Gynecol. 2017 Dec;130(6):1218-1225. doi: 10.1097/AOG.0000000000002330.
To evaluate the performance of routine endocervical curettage (ECC) for diagnosing high-grade cervical intraepithelial neoplasia (CIN) 2 or worse and additional precancers not otherwise detected by ectocervical biopsies.
In a secondary analysis of the Biopsy Study, a cross-sectional study conducted between 2009 and 2012 at the University of Oklahoma Health and Sciences Center that found an incremental increase in detection of cervical precancers by multiple biopsies at colposcopy, ECC was performed in most women aged 30 years or older. Cervical intraepithelial neoplasia 2 or worse yield by ECC alone was evaluated in analyses stratified by cervical cytology (atypical squamous cells of undetermined significance [ASC-US] or low-grade squamous intraepithelial lesions [LSIL] compared with atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesions [ASC-H] or high-grade squamous intraepithelial lesions [HSIL] or worse), colposcopic impression (less than high-grade compared with high-grade), human papillomavirus (HPV)-16 infection status, whether the examination was satisfactory, and by ECC indications per the current guidelines for cervical cancer screening. The diagnostic value of ECC for detecting additional disease was evaluated by the number of lesion-directed ectocervical biopsies.
Of the 204 women aged 30 years or older, 181 (88.7%) underwent ECC. Overall ECC detected 14.4% CIN 2 or worse (95% CI 10.0-20.2%). Endocervical curettage was more likely to find disease in the endocervix among women with high-grade cytology, positive HPV-16 infection, or high-grade colposcopic impressions (respective P values <.05). Among women with ASC-US or LSIL cytology, those with an unsatisfactory examination had a 13.0% CIN 2 or worse yield on ECC (95% CI 6.1-25.7); when colposcopic examination was normal or satisfactory with visible abnormal lesions, ECC detected less than 5% CIN 2 or worse in the endocervix. An ASC-H or HSIL or worse cytology was associated with a CIN 2 or worse yield of 25.8% by ECC (95% CI 16.6-37.9%). However, ECC found only 3.9% (95% CI 1.9-7.8%) additional CIN 2 or worse beyond the cumulative disease detected by up to four biopsies of visible acetowhite ectocervical lesions. Additional CIN 2 or worse yield by ECC increased when fewer lesion-directed biopsies were taken (P<.05).
The additional yield of CIN 2 or worse by ECC in a colposcopy with up to four ectocervical biopsies was low. Based on our findings, we recommend routine ECC be performed in women aged 45 years old or older with HPV-16 infection and in any woman aged 30 years or older with HSIL or worse or ASC-H cytology, high-grade colposcopic impression, or ASC-US or LSIL cytology and an unsatisfactory examination.
ClinicalTrials.gov, NCT00339989.
评估常规宫颈管刮术（ECC）在诊断高级别宫颈上皮内瘤变（CIN）2级或更严重病变以及宫颈外活检未发现的其他癌前病变中的表现。
在活检研究的二次分析中，这是一项于2009年至2012年在俄克拉荷马大学健康科学中心进行的横断面研究，该研究发现通过阴道镜检查多次活检可增加宫颈前病变的检出率，大多数30岁及以上女性接受了ECC。在按宫颈细胞学（意义不明确的非典型鳞状细胞[ASC-US]或低级别鳞状上皮内病变[LSIL]与非典型鳞状细胞、不能排除高级别鳞状上皮内病变[ASC-H]或高级别鳞状上皮内病变[HSIL]或更严重病变进行分层分析中，评估单独ECC检测出CIN 2级或更严重病变的情况）、阴道镜印象（低级别与高级别）、人乳头瘤病毒（HPV）-16感染状态、检查是否满意以及根据当前宫颈癌筛查指南的ECC适应症进行评估。通过针对病变的宫颈外活检数量评估ECC检测其他疾病的诊断价值。
在204名30岁及以上女性中，181名（88.7%）接受了ECC。总体而言，ECC检测出14.4%的CIN 2级或更严重病变（95%可信区间10.0 - 20.2%）。在细胞学高级别、HPV-16感染阳性或阴道镜印象为高级别的女性中，宫颈管刮术更有可能在宫颈管内发现病变（各自P值<.05）。在ASC-US或LSIL细胞学的女性中，检查不满意的女性ECC检测出CIN 2级或更严重病变的比例为13.0%（95%可信区间6.1 - 25.7%）；当阴道镜检查正常或满意且有可见异常病变时，ECC在宫颈管内检测出CIN 2级或更严重病变的比例不到5%。ASC-H或HSIL或更严重的细胞学与ECC检测出CIN 2级或更严重病变的比例为25.8%相关（95%可信区间16.6 - 37.9%）。然而，ECC发现超出对可见醋酸白宫颈外病变进行多达四次活检所检测出的累积疾病之外，只有3.9%（95%可信区间1.9 - 7.8%）的其他CIN 2级或更严重病变。当针对病变的活检数量较少时，ECC检测出其他CIN 2级或更严重病变的比例增加（P<.05）。
在进行多达四次宫颈外活检的阴道镜检查中，ECC检测出CIN 2级或更严重病变的额外比例较低。基于我们的研究结果，我们建议对45岁及以上感染HPV-16的女性以及任何30岁及以上患有HSIL或更严重病变、ASC-H细胞学、高级别阴道镜印象或ASC-US或LSIL细胞学且检查不满意的女性进行常规ECC。
ClinicalTrials.gov，NCT00339989。
