Microinvasive cervical carcinoma
Introduction
Introduction of cervical micro-invasive carcinoma Cervical micro-invasive carcinoma refers to preclinical cervical cancer that can only be detected under the microscope and is difficult to find clinically. basic knowledge The proportion of illness: 0.001% - 0.005% Susceptible people: good for adult women Mode of infection: non-infectious Complications: cervical invasive cancer
Cause
Cervical micro-invasive cancer cause
(1) Causes of the disease
Cervical micro-invasive carcinoma is an important stage of the progression of cervical intraepithelial neoplasia CIN (mainly carcinoma in situ) to invasive carcinoma, and the main causes of CIN are as follows:
1. Human papillomavirus infection In recent years, with the deepening of the relationship between human papillomavirus (HPV) infection and the lower genital tract, it has been found that HPV infection has a certain correlation with the occurrence of cervical precancerous lesions. A special type of sexually transmitted disease is the cause of cervical intraepithelial neoplasia. Molecular biology and epidemiological studies have shown that human papillomavirus is carcinogenic. HPV can be divided into different types according to its carcinogenicity: HPV16, 18, 45, 56 are high-risk type, HPV31, 33, 35 and other 11 kinds are medium-risk type, HPV6, 11, 26 and other 8 kinds are low-risk type, CINI and sub-clinical HPV infection are often HPV6, type 11, 80% of CIN III is an HPV16 infection.
Severe dysplasia of the cervix The intracellular chromosomes are often associated with the integration of the HPV gene, thereby triggering the E1, E2 gene, leading to the expression of viral genes in the cervical epithelium, after which the E6, E7 genes encode synthetic multifunctional proteins that interfere with cell growth. High-risk HPV6 protein can play an important role in cell carcinogenesis in 16 and 18 high-risk HPVE6 proteins. The high-risk HPVE6 protein can bind to the tumor suppressor gene p53, which leads to the degradation of p53. The E7 gene product is a nuclear phosphoprotein and tumor suppressor gene retinoblastoma gene. (PRb) product binding results in its functional inactivation, thereby affecting its role in inhibiting cell growth.
2. Other factors
(1) Smoking: smoking has a certain relationship with the occurrence of cervical intraepithelial neoplasia. The degradant nicotine and cervical irritant similar to lung cancer play an important role in the occurrence of cervical intraepithelial neoplasia.
(2) Microbial infection: Neisseria gonorrhoeae, herpes simplex virus (HSV), trichomoniasis infection can increase the susceptibility to HPV, and thus related to the occurrence of cervical intraepithelial neoplasia.
(3) Endogenous and exogenous immunodeficiency: Infection with immunodeficiency virus can increase the incidence of CIN, such as Hodgkin disease, leukemia, collagen vascular disease and HPV infectious diseases.
(two) pathogenesis
1. The stage Ia1 cancer cells have a slight infiltration in the deeper cortex. The cancer cells are bud-like at the beginning of the infiltration, and then round, bifurcated or tongue-shaped, sometimes infiltrating at the edge of the lesion on the basis of extensive gland involvement. There are many lymphocytes infiltrated in the surrounding interstitium.
2. Ia2 stage cancer lesions can be measured, the depth of the infiltrating epithelium is no more than 5mm, the width is less than 7mm, the lesions are small infiltrating foci fusion, the cancer cells can be various degrees of differentiation, sometimes in a mass, sometimes by many nails The reticular formation of the foot, there are many round cells infiltrated in the surrounding interstitial, sometimes visible giant cells, interstitial fibers are relaxed or contracted.
Prevention
Cervical micro invasive cancer prevention
Prevention: In addition to good health after menstruation or post-abortion, in daily life, we must pay attention to the hygiene of the vulva, prevent vaginal inflammation and cervical erosion while maintaining sexual hygiene. In addition, it is necessary to wear cotton underwear and wear it. On the basis of this, regular inspection of women's diseases is also very important.
Early diagnosis, early treatment, and follow-up work.
Complication
Cervical micro-invasive cancer complications Complications Cervical invasive carcinoma
Infection and lesions develop into cervical invasive cancer.
Symptom
Cervical micro-invasive cancer symptoms Common symptoms Increased vaginal discharge increased leucorrhea increased back pain, purulent leucorrhea, cervical mucus
Cervical microfocal invasive carcinoma has no specific symptoms and signs as carcinoma in situ. Betsill (1985) reported that 33% to 81% of cases are asymptomatic, some have increased vaginal discharge, contact bleeding or irregular vaginal bleeding and chronic cervicitis. According to statistics, 56.7% of micro-cancers have contact bleeding and irregular bleeding, 40% of asymptomatic patients, some authors reported that chronic cervicitis accounted for 39.6%, mild and moderate erosion accounted for 28.3% to 75.0%, and severe erosion accounted for 7.5%, leukoplakia accounted for 3.8%, clinical suspicious cancer accounted for 12.5%, and the proportion of cervix smoothness (9.4% to 12.5%) was lower than CIN.
In 1985 and 1994, the diagnostic criteria of FIGO for stage Ia not only required clear depth of infiltration, but also required calculation of the horizontal spread of lesions, suggesting that the diagnosis of cervical microfocal invasive carcinoma is a histological diagnosis, which must be based on all cervical cancers. Cervical resection or cervical conization, continuous or sub-continuous slice microscopy of the whole hysterectomy specimen can be diagnosed. Therefore, two points are emphasized in the diagnosis of MICA: 1 the necessity of combined use of auxiliary diagnostic methods; 2 carefully selected materials and tissues importance.
Examine
Cervical micro-invasive cancer examination
1. The accuracy of cytological diagnosis of cytology is related to the degree of lesions. The census data of the Cancer Hospital of Chinese Academy of Medical Sciences in the high incidence area of cervical cancer show that in early stage cervical cancer (including carcinoma in situ and early invasive carcinoma) and cervical atypical hyperplasia Among them, the incidence of cytological abnormalities was significantly different, namely, Pascal IIa 3.1% and 31.6%, IIb 21.5% and 32.9%, III 18.5% and 15.2%, IV 35.4% and 7.6%, and V18.5%. 10.1%, the cytological positive rate (IV+V grade) in the two was significantly different, which were 53.8% and 17.7%, respectively, indicating the importance of cytology in screening early cervical cancer (Zhang Wenhua et al., 1994). See Table 1, Frable et al. (1998) report that the positive predictive value of traditional cytology is 80%, with 10% to 15% false negatives. Recently, the application of new cytology techniques for thin-layer liquid-based cytology (TCT) The detection rate was improved, the positive rates of HSIL and cancer were 92.9% and 100%, respectively, and the conventional smears were 77.8% and 90.9% (Martha et al., 1999). The Chinese Academy of Medical Sciences Cancer Hospital was the first in the Sino-US collaborative project. The positive detection rates of HSIL and squamous cell carcinoma in 1997 were 93.2% and 100%, respectively.
2. Colposcopy In the diagnosis of CIN and early cervical cancer, colposcopy and cytology are indispensable auxiliary diagnostic methods. The colposcopy image of early invasive carcinoma is similar to CIN III, but more abnormal, "triple image" More common, vinegar white epithelium is thicker, the boundary is clear, the surface is slightly raised or irregular, the point blood vessels and (or) inlaid coarse and irregular, the blood vessels are dilated, the spacing increases, visible shaped blood vessels such as spiral, hairpin or comma In the census, colposcopy was used in the census. According to Coppleson (1986), the proportion of severe abnormalities (ie, grade III) in early cancer and atypical hyperplasia was 87.1% and 20.98%, respectively. Of the 62 cases of early cancer, except for 2 cases of normal or benign colposcopy, the abnormal image reached 96.7% as shown in Table 2. There was no case of invasive carcinoma missed by colposcopy combined with cytology and neck tube scraping (Zhang Wenhua et al., 1994). However, colposcopy is difficult to identify the presence or absence of cervical interstitial infiltration.
3. Cervical biopsy and neck tube scraping should be performed under the naked eye (VIA) or colposcopy indication for cervical multi-point biopsy. Deep biopsy or large wedge biopsy at the suspected site, especially biopsy and neck when clinically suspected adenocarcinoma Tube scraping is more necessary (Teshima et al., 1985; Zhang Wenhua et al., 1993). For many reasons, even a multi-point biopsy under colposcopy may miss early infiltrates, leading to insufficient preoperative diagnosis.
4. Cervical conization is still the most important and most reliable diagnostic method for micro-focal invasive carcinoma. Most authors believe that only cone biopsy can make an accurate diagnosis of MI-CA, but for taking, slicing, and making Pathological diagnosis and other technical requirements are strict, otherwise it may lead to missed diagnosis or high diagnosis. With the application of early combined diagnosis method, the diagnostic cone cutting rate is significantly reduced. In recent years, due to the younger trend of CIN and early cervical cancer, cervical conization The number of applications has increased.
(1) The indications are revised to:
1 cytology multiple positive, colposcopy negative or unsatisfactory or colposcopy biopsy and neck tube scraping were negative.
2 cytology examination and colposcopy positioning biopsy or neck tube scraping results do not match.
3 iodine staining, VIA or colposcopy biopsy suspected early invasive cancer.
Grade 4 high CIN lesions extend beyond the scope of the colposcopy and extend into the neck.
5 clinically suspected early adenocarcinoma, normal or abnormal cytology, no obvious abnormal images of CIN or squamous cell carcinoma.
For young patients with cytology and/or colposcopy who only suggest SPI or CINI grades, conization should be avoided as much as possible. Clinical or colposcopy for suspected invasive cancer is a contraindication for surgery.
(2) Pay attention to the following points when cutting:
1 Cytology smear, colposcopy or iodine test must be performed before conization.
2 Avoid excessive vaginal and cervical preparations to avoid damage to the cervical epithelium.
3 using cold knife cone cutting.
4 preoperative expansion of the cervical canal and neck tube scraping.
5 Conical range includes the abnormal range of colposcopy, the conversion area and the lower neck.
3. Cervical ring electrotomy (LEEP) and large ring transformation area resection (LLETZ) as a new diagnosis and treatment of CIN and early cancer, many authors have reported since the 1990s, Meesing et al. (1994) considered that the indication for LLETZ conization biopsy is:
(1) Not satisfied with colposcopy.
(2) Positive neck tube scraping.
(2) Cytology and cervical biopsy results are inconsistent (more than 2 levels).
(4) The lesion is severe, such as severe atypical hyperplasia or cytology suggesting invasive changes.
This diagnostic method has thermal damage and is suitable for the diagnosis of early invasive cancer. It needs further study. Although LEEP treatment has been used as a diagnosis and treatment method since the 1990s, it is suspected early in cytology or colposcopy. Invasive cancer, it is still recommended to use cold knife cone cutting (CKC) is more appropriate.
Diagnosis
Diagnosis and differentiation of cervical micro-invasive carcinoma
Diagnostic criteria
Although the diagnostic criteria for cervical micro-focal invasive cancer have been revised many times, there are still differences, and the problems are mainly concentrated in the following aspects:
1. The depth of infiltrating interstitial is the most important quantitative standard for diagnosing MICA. The standards of different authors at home and abroad are different. The depth of measurement can vary from 1 to 9 mm. The measurement methods are also different. Most of them are measured from the basement membrane. There is also an infiltration tip that measures from the surface of the cancer to the cancer in the vertical direction (Ke Yingxi, 1992). Regarding the depth of interstitial infiltration, the initial Meswavdt is diagnosed with 5 mm. Later, many authors used this standard, but found the lymph of MICA. Metastasis rate (1.2%) and mortality rate are very low (Hasumi et al., 1986). Some domestic and foreign scholars advocate that the depth of infiltration should be 3mm as the boundary. It is found that most of the lymph node metastasis of stage Ia occurs between 3.1 and 5.0 mm in infiltration depth. It is considered that 1mm is good to reflect the interstitial infiltration without metastasis.
2. Tumor area and volume Burghardt and Holzer have proposed that volume is an important factor in determining prognosis. It is generally bounded by 500mm3 and has been accepted by European pathologists. FIGO used two parameters of tumor infiltration depth and width in 1985. Differentiating Ia1 and Ia2 and identifying the Ib period criteria, due to the microscopic measurement techniques, the complexity of volume measurement and subjective factors, some scholars have objections. At present, FIGO's diagnostic criteria for horizontal infiltration have been accepted by most authors.
3. Infiltration of vascular (lymphatic vessels and blood vessels) as a diagnostic criterion differs. Most believe that vasculature is associated with lymph node metastasis and recurrence (Boyce et al., 1981; Van Nagell et al., 1983). Therefore, it is advocated that there is a tumor thrombus in the vessel. MICA should not be diagnosed again, but some scholars have a negative attitude (Simon et al., 1986), Hasumi et al. (1980) reported 135 MICA, and none of the 6 cases of vascular invasion occurred lymph node metastasis. Coppleson (1992) collected Several groups of reports have demonstrated the relationship between vessel and depth of invasion: infiltration <1 mm, vessel invasion 0% to 8%, and 3 to 5 mm, 12% to 43%, indicating that vessel invasion is related to infiltration depth. A factor.
Differential diagnosis
4. Invasive interstitial lesion morphology (focal fusion) Fidler et al (1959) first proposed that lesion fusion is a parameter related to metastasis. Conversely, it is considered that fusion lesions are common when infiltration is deep, but there is no obvious relationship with lymphatic metastasis. Simon et al. (1986) suggested that the concept of focal fusion was ambiguous and subjective. Because microinvasive adenocarcino-ma cannot be seen as a basal cell membrane in the squamous epithelium, the definition cannot be clearly defined. In addition, most of the adenocarcinomas have several lesions, and the number of conservative surgical outcomes is not Many, not completely squamous epithelial microinvasive cancer as a blueprint for treatment, should be considered individually after conical resection, especially in rare adenocarcinomas, such as clear cell carcinoma and adenoma malignum Although their glands resemble normal endometrial glands, their depth is different from normal. Adenosquamous carcinoma has poor cell differentiation and poor prognosis. Only newly reported villi are present. Adenocarcinoma (villoglandular cervical adenocarcinoma), although also in the younger age group, has a good prognosis.
