宫颈癌筛查文献汇报HPV和TCT课件.ppt

文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。一、转化区一、转化区(移行带移行带)原始鳞柱交界与新生鳞柱交界的宫颈段。原始鳞柱交界与新生鳞柱交界的宫颈段。原始鳞柱交界与新生鳞柱交界的宫颈段。原始鳞柱交界与新生鳞柱交界的宫颈段。原始鳞状上皮原始鳞状上皮原始鳞状上皮原始鳞状上皮原始柱状上皮原始柱状上皮原始柱状上皮原始柱状上皮原始鳞柱交界（原始鳞柱交界（原始鳞柱交界（原始鳞柱交界（OSCJOSCJOSCJOSCJ）新的鳞柱交界（新的鳞柱交界（新的鳞柱交界（新的鳞柱交界（NSCJNSCJNSCJNSCJ）转化区（转化区（转化区（转化区（TZTZTZTZ）正常转化区正常转化区正常转化区正常转化区文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。一、转化区一、转化区(移行带移行带)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。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，通常在子宫颈的以下，绝经后妇女，移行带内移，通常在子宫颈的高处。高处。文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。一、转化区一、转化区(移行带移行带)移行带是移行带是移行带是移行带是CINCINCINCIN和和和和宫颈宫颈宫颈宫颈CaCaCaCa的好发部位，因此细胞学检的好发部位，因此细胞学检的好发部位，因此细胞学检的好发部位，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查必须包括这一部位，阴道镜检查的原则之一就是查必须包括这一部位，阴道镜检查的原则之一就是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。要了解移行带的情况。要了解移行带的情况。要了解移行带的情况。文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。二、鳞状上皮化生二、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。鳞状上皮化生和鳞状上皮化生。鳞状上皮化鳞状上皮化是指成熟的鳞状上皮直接向邻近的柱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。管细胞。鳞状上皮化生鳞状上皮化生是指从子宫颈管基层膜上面具有改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向功能的储备细胞细胞增生而来。文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。二、鳞状上皮化生二、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、成的不同阶层分为：储备细胞增生、未成熟磷化、成熟磷化。熟磷化。文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。三三、宫颈病变的概念、宫颈病变的概念广义：广义：广义：广义：宫颈病变宫颈病变(Cervicallesions)：是一个尚未限定的、比较泛化的概念，指：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，包括在宫颈区域发生的各种病变，包括炎症、损伤、肿瘤炎症、损伤、肿瘤炎症、损伤、肿瘤炎症、损伤、肿瘤(以及癌前病变以及癌前病变)、畸形畸形畸形畸形和子宫内膜异位症和子宫内膜异位症和子宫内膜异位症和子宫内膜异位症等等。文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Company Logo 狭义：狭义：狭义：狭义：临床上将宫颈病变限定在临床上将宫颈病变限定在宫颈细胞学异常宫颈细胞学异常宫颈细胞学异常宫颈细胞学异常和和宫颈上皮内瘤变宫颈上皮内瘤变宫颈上皮内瘤变宫颈上皮内瘤变(CervicalIntraepithelialNeoplasia，CINCIN)。对宫颈病变进行正确处理及采用合适的管理方法是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。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。度处理导致不必要的并发症发生和医疗资源的浪费。文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。不同诊断术语的含义不同诊断术语的含义子宫颈上皮内瘤变子宫颈上皮内瘤变子宫颈上皮内瘤变子宫颈上皮内瘤变（Cervical Intraepithelial NeoplasiaCervical Intraepithelial Neoplasia，CINCIN）：组织学诊断术语，按病变细胞涉及上皮层次分组织学诊断术语，按病变细胞涉及上皮层次分为为、级。级。子宫颈鳞状上皮内病变子宫颈鳞状上皮内病变子宫颈鳞状上皮内病变子宫颈鳞状上皮内病变（Squamous intraepithelial LesionSquamous intraepithelial Lesion，SILSIL）：细胞学细胞学TBS分类诊断术语，按细胞的异型性改分类诊断术语，按细胞的异型性改变分为低度鳞状上皮内病变（变分为低度鳞状上皮内病变（LSIL）和高度鳞状）和高度鳞状上皮内病变（上皮内病变（HSIL）文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。四、宫颈病变三阶梯检查细胞学细胞学阴道镜阴道镜组织病理学组织病理学由于中国国情，对宫颈癌筛查因地区、经济条件、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、医疗资源等差异而采用不同手段，如：细胞学检测、裸眼醋酸染色检查裸眼醋酸染色检查(VIN)(VIN)及复方碘染及复方碘染(VILI)(VILI)检查，高检查，高危型危型HPVDNAHPVDNA检查、肉眼观察高度怀疑宫颈浸润癌等，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，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，即并在阴道镜指导下完成组织病理学检查诊断，即“三阶梯三阶梯”的检查诊断。的检查诊断。文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。五、阴道镜检查指征1 1、宫颈细胞学检查结果异常、宫颈细胞学检查结果异常、宫颈细胞学检查结果异常、宫颈细胞学检查结果异常（1 1）不典型鳞状上皮细胞）不典型鳞状上皮细胞）不典型鳞状上皮细胞）不典型鳞状上皮细胞(ASC-US)(ASC-US)；（2 2）不典型鳞状上皮细胞）不典型鳞状上皮细胞）不典型鳞状上皮细胞）不典型鳞状上皮细胞-不除外高度鳞状上不除外高度鳞状上不除外高度鳞状上不除外高度鳞状上 皮内病变（皮内病变（皮内病变（皮内病变（ASC-HASC-H）；）；）；）；（3 3）低度鳞状上皮内病变（）低度鳞状上皮内病变（）低度鳞状上皮内病变（）低度鳞状上皮内病变（LSILLSIL）；）；）；）；（4 4）高度鳞状上皮内病变（）高度鳞状上皮内病变（）高度鳞状上皮内病变（）高度鳞状上皮内病变（HSILHSIL）；）；）；）；（5 5）鳞状细胞癌（）鳞状细胞癌（）鳞状细胞癌（）鳞状细胞癌（SCCSCC）；）；）；）；文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。（6 6）不典型腺上皮细胞（）不典型腺上皮细胞（）不典型腺上皮细胞（）不典型腺上皮细胞（AGCAGC）；）；）；）；（7 7）腺原位癌（）腺原位癌（）腺原位癌（）腺原位癌（AISAIS）；）；）；）；（8 8）腺癌；）腺癌；）腺癌；）腺癌；（9 9）巴氏分级标准中）巴氏分级标准中）巴氏分级标准中）巴氏分级标准中 巴氏巴氏巴氏巴氏bb级以上的结果；级以上的结果；级以上的结果；级以上的结果；（1010）高危型）高危型）高危型）高危型HPVHPV检测结果阳性（需注明检测结果阳性（需注明检测结果阳性（需注明检测结果阳性（需注明hpvhpv检测方法，检测方法，检测方法，检测方法，如：如：如：如：hc-2hc-2法、法、法、法、hpvhpv基因分型法特别是基因分型法特别是基因分型法特别是基因分型法特别是1616、1818型阳性、型阳性、型阳性、型阳性、PCRPCR法）法）法）法）文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。2 2、裸眼醋酸染色或复方碘染色后肉眼观、裸眼醋酸染色或复方碘染色后肉眼观、裸眼醋酸染色或复方碘染色后肉眼观、裸眼醋酸染色或复方碘染色后肉眼观 察（察（察（察（via/vilivia/vili）结果异常。）结果异常。）结果异常。）结果异常。3 3、裸眼直观为宫颈溃疡、肿块或可疑宫、裸眼直观为宫颈溃疡、肿块或可疑宫、裸眼直观为宫颈溃疡、肿块或可疑宫、裸眼直观为宫颈溃疡、肿块或可疑宫 颈浸润癌。颈浸润癌。颈浸润癌。颈浸润癌。4 4、可疑病变处指导性活检、可疑病变处指导性活检、可疑病变处指导性活检、可疑病变处指导性活检文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。5 5、宫颈锥切前确定病变范围、宫颈锥切前确定病变范围、宫颈锥切前确定病变范围、宫颈锥切前确定病变范围6 6、宫颈尖锐湿疣、宫颈尖锐湿疣、宫颈尖锐湿疣、宫颈尖锐湿疣7 7、慢性宫颈炎长期治疗无效、慢性宫颈炎长期治疗无效、慢性宫颈炎长期治疗无效、慢性宫颈炎长期治疗无效8 8、阴道和外阴病变：阴道和外阴上皮内瘤样变、早、阴道和外阴病变：阴道和外阴上皮内瘤样变、早、阴道和外阴病变：阴道和外阴上皮内瘤样变、早、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、尖锐湿疣等期阴道癌、阴道腺病、梅毒、结核、尖锐湿疣等期阴道癌、阴道腺病、梅毒、结核、尖锐湿疣等期阴道癌、阴道腺病、梅毒、结核、尖锐湿疣等文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。July3,2018文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。questionDoescervicalcancerscreeningusingprimary 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?文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Importance 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 Toevaluatehistologicallyconfirmedcumulativeincidentcervicalintraepithelial neoplasia(CIN)grade 3 or worse(CIN3+)detected up to and including 48 months by primary HPV testing alone(intervention)or liquid-based cytology(control).文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Methods The primary objective of this study was to evaluate primary HPV testing for cervical cancer screening in an organized program setting.Participants 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 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.文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Randomization Women were randomly assigned 1:1:1 to 1 of 3(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 results were positive and required follow-up.The primary analysis for this study focuses on the intervention and control groups.文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。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.Participants 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 to return at 48 months for exit with HPV and LBC testing.文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Intervention GroupPrimary 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 either 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 referred for immediate colposcopy and management.文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Control GroupPrimary 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 were referred for colposcopy and management.文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Safety Group Primary HPV testing was followed by reflex LBC in women with positive HPV test results,and they received the same management as the intervention group.However,in the safety group,HPV-negative women were recalled for exit screening with LBC at 24 months.The safety group was closed December 31,2010,when the planned sample size for this group was achieved.Intervention and Control Group Exit Screening Exit screening for both the intervention and control groups occurred 48 months after baseline screening and consisted of HPV testing and LBC(exit co-testing).文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。proceduresComplete a demographic and behavioral questionnaire After 2010,women completed an abbreviated survey pelvic examinationHPV testing was performed with the Hybrid Capture 2 High Risk HPV DNA test(Qiagen),which detects high-risk HPV types 16,18,31,33,35,39,45,51,52,56,58,59,and 68.To confirm specimen adequacy,461 sequential ThinPrep specimens with valid HC2 results(34 HC2 positive and 427 negative)were tested with an in-house beta-globin polymerase chain reaction test and all were positive.As part of the trial protocol,samples with no visible cell pellet after conversion were rejected as inadequate.LBC slides were prepared using the ThinPrep 2000(Hologic)processor and smears were screened manually by program cytotechnologists.Abnormal cytology test results were referred to a cytopathologist for final interpretation and reporting.文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。The main trial objective was to compare the rates of cervical intraepithelial neoplasia(CIN)grade 3 or greater(CIN3+)48 months after baseline screening with primary HPV vs LBC.Detailed trial methods and results have been previously described.As outlined in Figure 1,round 1 refers to the baseline screen and any 12-month follow-up results in both the intervention and control groups.The 24-month screen round refers only to women in the control group because the intervention group did not receive 24-month screening,and this 24-month screen round included 24-month screen results and 36-month follow-up results.The 48-month exit round refers to 48-month exit screening results(plus 24-month results for the control group)and associated outcomes for both the intervention and control groups 文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Trial Outcomes Primary end points：Rates of CIN3+at 48 months in the intervention and control groups.Secondary trial end included in this analysis：rates of CIN2+at 48 months,the threshold for colposcopy referral and further evaluation,and evaluation of the impact of primary HPV testing on colposcopy services through evaluation of colposcopy referral rates in each group.Other secondary end pointsnot included in this analysis：histologically confirmed CIN2+detected at 2 years in both the control and safety groups;clearance of HPV infection in women who were baseline HPV positive measured at 24 and 48 months;detection of histologically confirmed CIN3+in HPV-positive women who received 12-month retesting measured at 24 months in the safety group;and total estimated cost per woman screened and total estimated cost per quality-adjusted life-year gained for each technology measured at 48 months.All intervention and control group women who did not have a CIN2+lesion detected during the trial or otherwise became ineligible(eg,hysterectomy,moved out of province)were invited for the 48-month exit screening.Women who were negative on both LBC and HPV co-testing at 48 months were deemed negative for CIN2+.Women who were either LBC of greater than or equal to ASCUS or HPV positive at 48 months were referred for colposcopy and biopsied to determine their status as CIN3+,CIN2+,less than or equal to CIN1,or normal.文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Results Primary End Points Among baseline HPV or LBC-negative women,rates of CIN3+at 48 months were significantly higher across all age groups in the control compared with the intervention group(Table 2).Cumulative incidence curves show that women who were HPV negative at baseline had a significantly lower risk of CIN3+at 48 months compared with cytology-negative women.Secondary End Points In the first round of screening,significantly more CIN2+cases were detected in the intervention group(HPV tested)compared with the control group.Cumulative CIN2+incidence curves show no significantly different disease detection across trial groups.In the intervention group,cumulative incidence was higher earlier in the trial at 18 and 42 months compared with the control group.In this trial,all women in the intervention and control groups had the same intervention at the 48-month exit(HPV and cytology co-testing).By the end of trial follow-up(72 months),incidence was similar across both groups.文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Among 19 009 women who were randomized(meanage,45 years10th-90th percentile,30-59),16 374(8296 86.9%in the intervention group and 8078 85.4%in the control group)completed the study.At 48 months,significantly fewer CIN3+and CIN2+were detected in the intervention vs control group.文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Discussion In this trial,by 48 months,among women screened for cervical cancer with HPV testing without cytology,there were significantly fewer CIN3+and CIN2+cases compared with women who were screened with cytology alone at baseline.Women who were HPV negative at baseline were significantly less likely to have CIN3+and CIN2+at 48 months compared with women who were cytology negative at baseline.These results have demonstrated that primary HPV testing detects cervical neoplasia earlier and more accurately than cytology.Although cervical screening guidelines from a number of organizationshave recommended primary HPV testing based on the natural history of cervical cancer,cross-sectional studies,18 studies where HPV-based screening was part of a screening group,or where studies ultimately evolved into primary HPV evaluations,none of these studies were designed specifically to examine HPV testing as the primary screening modality.This trial,which compares primary HPV testing vs LBC with standardized triage and colposcopy follow-up,found primary HPV testing detected significantly more CIN3+and CIN2+cases in the first round and significantly reduced CIN3+and CIN2+rates 48 months later.This trial also confirmed that women who were HPV negative at baseline have lower rates of CIN2+at 48 months than cytology-negative women at baseline.Previous studies found the benefit of HPV and cytology co-testing was based primarily on the contribution of HPV,21 which this trial now prospectively validates.Further analyses modeling the cost-effectiveness of HPV primary screening using parameters from this study will be carried out to assess the potential economic effect of moving to HPV-based screening 文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Conclusions Among women undergoing cervical cancer scree