臺灣博碩士論文加值系統

子宮頸鱗狀上皮癌為女性癌症的第五位，因子宮頸抹片篩檢的推行，子宮頸侵襲性鱗狀上皮癌發生率已逐年下降，相對子宮頸腺癌發生率則在上昇，同時子宮內膜腺癌發生率也有上昇的趨勢。大多數子宮頸腺癌及子宮內膜腺癌的個案，可以做出明確的診斷，但在檢體較少的切片或腫瘤位於子宫下段與子宮內頸交界時，區別是子宮頸或子宮內膜腺癌則有其困難性，但兩者開刀治療方式卻絕然不同，所以正確的診斷及區分此兩種腺癌有其臨床重要性。
傳統的子宮頸抹片主要用來偵測子宮頸上皮病變，包括鱗狀上皮及腺體細胞病變。但在子宮頸抹片中單用細胞形態學不足以區分腺體細胞病變是來自子宮頸或子宮內膜。我們進一步用五種免疫染色來幫忙鑑別診斷子宮頸或子宮內膜腺癌。
本研究收集了37例病理切片証實為子宮頸腺癌或子宮內膜癌的子宮頸抹片，發現當細胞呈聚合型排列且核大小差異有三倍大時，較偏向子宮頸腺體細胞病變。
使用的五個免疫染色標記包括CK-2，p16，CK34ßE12，bcl-2 及Ki-67。子宫頸腺癌p16核染色陽性率及Ki-67核染色陽性率較子宮內膜癌高 (p=0.02 及 p<0.0001)。p16及Ki-67核染色陽性，其陽性概似比分別為7.4及2.8。CK-2 ，CK34ßE12，bcl-2的表現在這兩種腺癌皆無明顯差異。
此研究顯示子宮頸抹片的細胞形態學及在小檢體中利用p16及Ki-67免疫染色對鑑別診斷子宮頸腺癌及子宮內膜癌有幫忙。

Cervical squamous cell carcinoma is the fifth cause of death in female cancers in Taiwan. The incidence and mortality of cervical cancer are decreased in the last decades in most developed countries, including Taiwan, because of the effectiveness of the cytology screening programs. By contrast, the incidence and mortality of cancers of uterine corpus are slowly increasing. In most situation, the diagnosis for endometrial or endocervical adenocarcinoma is straightforward. However, the diagnosis of adenocarcinoma from endometrial or endocercival origin sometimes is difficult, when few tissue fragments are obtained from endocervical curreting or biopsy specimens, and from the tumor located at the interface between endocervical canal and lower uterine segment.The surgical protocol for endometrial adenocarcinoma or endocervical adenocarcinoma is different. Therefore, the correct diagnosis is important in clinical practice.
Conventional Pap smear is developed for detecting the cervical abnormalities including squamous and glandular lesions. However, only use of the cytomorphology of the glandular lesions in Pap smears is not sufficient to differentiate the cell origin of endocervix form endometrium. We further use five immunostain markers to help the differential diagnosis between endocervical adenocarcinoma and endometrial adenocarcinoma.
In this study, we collected and reviewed 37 Pap smears which are diagnosed as endometrial or endocervical adenocarcinomas in surgical specimens. The results showed the syncytial arragement and the nuclear size variation with three fold difference are more common in endocervical glandular lesions.
The pannel of five immunostain markers includes CK-2, p16, 34ßE12, bcl-2 and Ki-67.The positive rates of nuclear staining of p16 and Ki-67 are higher in endocervical adenocarcinomas than endometrial adenocarcinomas (p=0.02 and p&lt;0.0001, respectively). The positive likelihood ratio of nuclear p16 and Ki-67staining are 7.4 and 2.8 respectively. The CK-2, 34ßE12 and bcl-2 expression showed no significant difference in both cancers. Taken together, data suggests that use of cytomorphology in Pap smear combined with p16 and Ki-67 imunohistochemistry in small surgical specimens are helpful for the differential diagnosis of endocervical and endometrial adenocarcinoma.

中文摘要..................................................1
英文摘要..................................................3
第一章 文獻回顧...........................................5
第一節 子宮頸癌與子宮內膜癌的盛行率............................5
第二節 子宮頸癌的組織形態及分化............................... 5
第三節 子宮內膜癌的組織形態及分化..............................6
第四節 子宮頸抹片篩檢..........................................6
第五節 子宮頸抹片的判讀........................................8
第六節 傳統子宮頸抹片(conventional cytology)及薄層子宮頸抹片(liquid base cervical cytology)的比較..........................8
第七節 子宮頸癌的危險因子......................................9
第八節 台灣人類乳突病毒在子宮頸癌及子宮頸癌前病變的盛行率.....10
第九節 子宮內膜癌的危險因子...................................11
第十節 人類乳突病毒與子宮內膜癌...............................11
第十一節 子宮頸抹片的限制及人類乳突病毒DNA檢測在篩檢上的應用.12
第十二節 子宮頸抹片的腺體細胞病變.............................13
第十三節 子宮頸腺癌及子宮內膜癌在子宮頸抹片的鑑別診斷.........14
13.1.子宮頸抹片中的子宮內膜細胞......................14
13.1.1 盛行率........................................14
13.1.2 形態學........................................14
13.1.2.1正常子宮內膜細胞.............................14
13.1.2.2 非典型子宮內膜細胞..........................15
13.1.2.3 背景細胞…..................................16
13.1.3子宫內膜腺癌在子宮頸抹片的診斷條件.........................16
13.2 子宮頸抹片中的子宮頸腺體細胞 ...................17
13.2.1非典型子宮頸腺體細胞...........................17
13.2.2子宮頸腺癌.....................................17
13.3 子宮頸腺癌與子宮內癌在細胞學的鑑別診斷……………18
第十四節 子宮頸腺癌與子宮內膜癌在病理切片下的鑑別診斷.........18
第十五節 蛋白激酶CK-2(protein kinase CK-2)與子宮內膜癌及人類乳突病毒………………………………………………………………………………19
第二章 研究動機及目的....................................20
第三章 研究材料與方法 ................................. 21
第一節 子宮頸抹片的收集及細胞形態學的紀錄.....................21
第二節 子宮頸抹片的判讀.......................................21
第三節 組織晶片的製作及檢體的收集.............................21
3.1 免疫染色..........................................22
3.2 免疫染色的判讀....................................23
第四節 統計分析...............................................23
第四章 結果..............................................24
第一節子宮頸抹片中，子宮頸癌與子宮內膜癌細胞形態學的比較......24
1.1子宮頸癌與子宮內膜癌細胞形態學的比較................24
1.2複閱後的子宮頸抹片診斷..............................25
第二節 正常子宮頸、正常子宮內膜癌、子宮頸腺癌與子宮內膜癌病理切片免疫染色結果................................................26
2.1 CK-2及p16在正常子宮頸、正常子宮內膜癌、子宮頸腺癌與子宮內膜癌免疫染色結果..........................................26
2.2 34βE12,bcl-2及Ki-67在正常子宮頸、正常子宮內膜癌、子宮頸腺癌與子宮內膜癌免疫染色結果................................27
第三節 p16及Ki-67診斷子宮頸腺癌的敏感度，特異度及概似比.....28
第五章 討論.............................................30
第六章 結論..............................................40
第七章 參考文獻..........................................41
第八章 圖表..............................................46
第九章 附錄..............................................69

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