한국형 자궁경부 촬영진 ( New Cervicography ) , 세포검사 그리고 HPV-DNA 검사를 이용한 새로운 자궁경부암 검진 모델 ( Model ) 개발

김승조(SJ Kim),박찬규(CK Park),이효표(HP Lee),남궁성은(SE Namkoong),강순범(SB Kang),서호석(HS Saw),이재관(JK Lee),김수녕(SN Kim),김재원(JW Kim),배석년(SN Bae),김찬주(CJ Kim),이근호(KH Lee),이선영(SY Lee),김인호(IH Kim),이찬(C Lee),이정노(JN Lee) 대한산부인과학회 2001 Obstetrics & Gynecology Science Vol.44 No.5

N/A Objective : The false negative rate of conventional cytology is reported to range from 18 to 45%. It is necessary to develop more effective screening strategies that would ideally be more accurate than conventional cytology. This study is designed to investigate the potential of conventional cytology, cervicography, HPV-DNA testing and their combinations as primary screening techniques for cervical neoplasia. The purpose of this project is to develop the models and guidelines for screening tools of cervical cancer of the uterus by evaluating sensitivity, specificity and cost-effectiveness of all the screening methods. Study design : We conducted a screening of random sample of women who visited the department of OB-Gyn. of five different major university hospitals such as Catholic University Hospital, Korea University Hospital, Seoul National University Hospital, Yeonsei University Hospital and Pochon CHA University Bundang CHA Hospital, from May 1, 1996 to April 30, 1999. In a cohort women with an age range of 20 to 70 who underwent routine cytologic screening at Catholic University, Hospital Bundang CHA General Hospital and local clinics from April 1, 1996 to Decomber 31, 2000. cervicography (n=417,125) and testing for HPV-DNA (n=1,347) by the hybrid capture assay were studied for the ability of the cervical cancer screeuing. A new cervicography system with Kim's classification which was developed by Prof. Kim Seung Jo as an adjunctive method for the cervical cancer screening was applied in this cohort study. And then, accuracy, effectivencess, cost-effectiveness of the single or combined screening method were analysed. Result : Sensitivity and specificity of Pap smear were ranged from 55.6% to 83.1% and 72.8% to 88.3% respectively. The combination of Pap smear and cervicography had sensitivity from 89.7% to 98.6%, specificity from 68.2% to 93.2%. With combination of Pap smear, HPV DNA test and cervicography, sensitivity became also highest accuracy among all screening methods from 92.8% to 98.8%. Considering medical charges for diagnosis and social cost occurred by false positive and false negative results, the most cost-effective diagnostic modality was thought to be the combination of Pap smear and cervicography(91,433 won). In patients who were diagnosed as LSIL, colposcopic examination confirmed progression to high grade intraepithelial lesion(HSIL) in 10.7% patients, persistence of LSIL in 55% patients during the 3 year follow-up period. Accuracy of the screening for cervical cancer and CIN can significantly be improved by cytology with new cervicography rather than cytology alone. We concluded that cervicography can be important adjunctive tests for cervical cytology, improving the effectiveness of cervical screening by allowing a more sensitive detection of cervical neoplasia.

임신 28 주에서 42 주의 자궁내 성장제한 태아와 정상 태아의 심박동 양상의 비교

이영,김수평,신종철,이종승,이선영,송희영,황지영,임재춘,김기범 대한산부인과학회 1998 Obstetrics & Gynecology Science Vol.41 No.8

본 연구는 태아 심박동 자궁수축 전자감시장치인 cardiotocogram을 이용하여 자궁내 성장제한이 있는 태아와 정상 태아의 심박동검사를 시행하여, 태아의 기능적인 발육상태를 평가하기 위하여 임신 28주에서 42주 사이의 외인성 원인에 의한 자궁내 성장제한이 있는 67명의 태아를 실험군으로 같은 임신기간중 이화학적 검사상 이상이 없는 정상 태아 85명을 대조군으로하여 기록된 태아 심박동 곡선으로부터 기초 태아 심박동수, 심박동 곡선의 진동주기, 진동폭에 대한 정량적인 분석을 하여 다음과 같은 결과를 얻었다. 1. 평균 기록 소실률은 실험군이 0.67%로서, 대조군의 0.38%보다 매우 유의하게 높았다. 2. 기초 태아 심박동수의 평균은 실험군이 145.3 bpm 으로서, 대조군의 142.9 bpm보다 유의하게 높았으며, 양 군 모두에서 임신 주수의 증가에 따라 유의하게 감소하 였다(r=-0.60, -0.49). 3. 심박동 곡선의 진동주기의 분포율은 2 cpm 이하와 2∼6 cpm 사이의 진동주기에서는 실험군이 대조군보다 유의하게 높았으나, 6 cpm 이상의 진동주기에서는 실험 군이 대조군보다 유의하게 낮았으며, 양 군 모두 임신 주 수의 증가에따라 2∼6 cpm 사이의 진동주기에서는 유의 하게 감소하였고(r=-0.89, -0.61) 6 cpm 이상의 진동주 기의 분포율은 유의하게 증가하였다(r=0.88, 0.58). 4. 심박동 곡선의 진동폭의 분포율은 양 군 모두에서 5 bpm 이하와 5∼10 bpm 사이의 진동폭의 분포율이 실 험군이 대조군보다 매우 유의하게 높았으나, 10∼25 bpm 사이와 25 bpm 이상의 진동폭의 분포율은 실험군이 대조군보다 매우 유의하게 낮았으며, 또한 양 군 모두에 서 임신 주수의 증가에 따라 5∼10 bpm 사이의 진동폭의 분포율이 유의하게 감소하였으나(r=-0.63, -0.71), 10∼ 25 bpm 사이와 25 bpm 이상의 진동폭의 분포율은 유의 하게 증가하였다(r=0.80, 0.62, 0.62, 0.74). 이상의 연구 결과에서 태아 심박동 곡선의 변동성은 대조군보다 실험군에서 현저히 낮은 것을 관찰 할 수 있 었다. 그러나 실험군에서도 대조군과 마찬가지로 임신 주수의 증가에 따라 심박동 곡선의 변동성이 증가하는 것을 알 수 있었다. In order to evaluate the functional state of fetus, cardiotocography was performed on 67 cases of asymmetrical intrauterine growth restriction pregnancy (experimental group) and 85 cases of normal pregnancy (control group) at 28 to 42 weeks` gestation. The signal loss rate, baseline fetal heart rate, oscillation frequency and amplitude were obtained by analyzing the cardiotocographies which were measured by autocorrelated HP 8040-A. The results were as fallows: 1. Mean signal loss rate of experimental group (0.67%) was significantly higher than that in control group(0.38%). 2. Mean of baseline fetal heart rate was significantly higher in experimental group (145.3 bpm) than in control group (142.9 bpm) and was significantly decreased with increasing gestational weeks in both groups(r=-0.60, -0.49). 3. Proportions of oscillation frequency of the cardiotocogram below 2 cpm and between 2-6 cpm were significantly higher in experimental group (4.2%, 83.1%) than in control group (1.7%, 78.7%) however, those above 6 cpm was significantly lower in experimental group (12.7%) than in control group (19.6%). With increasing gestational weeks in both groups, these proportions were significantly increased in frequency above 6 cpm and decreased in frequency between 2∼6 cpm. 4. Proportions of oscillation amplitude below 5 bpm and between 5∼10 bpm were significantly higher in experimental group (6.0%, 63.3%) than in control group (1.5%, 51.2%), however, those between 10∼25 bpm and above 25 bpm were significantly lower in experimental group (27.0%, 3.7%) than in control group (40.3%, 7.0%). With increasing gestational weeks, these proportions were significantly decreased in amplitude between 5∼10 bpm and increased in amplitude between 10∼25 bpm and above 25 bpm in both groups. From the above findings, it suggested that the variability of cardiotocogram be significantly decreased in intrauterine growth restriction fetus than in normal fetus, however, be significantly increased with increasing gestational weeks in both groups.

만삭임신에서 태아 파이브로넥틴 및 질초음파를 이용한 분만의 예측

이영,김창이,김수평,신종철,이종승,정대영,이선영,황지영 대한산부인과학회 1998 Obstetrics & Gynecology Science Vol.41 No.8

저자들은 1996년 12월부터 1997년 6월까지 가톨릭대학부속 성바오로병원 산부인과 외래에 내원한 임신 37주 이상인 산과적 합병증이 없는 단태 임산모 67명을 대상으로 실제적 진통개시 예측 지표로 Bishop 점수, 경질 초음파 및 파이브로넥틴 값을 비교하여 다음과 같은 결과를 얻었다. 1) 제1군과 제2군의 평균 연령, 임신 횟수, 마지막 채 검시 임신 기간 및 신생아 체중등엔 통계적으로 유의한 차이가 없었다. 2) 제1군과 제2군의 초음파 계측값 중 자궁경부 길이 는 각각 2.24±0.86 cm, 2.78±0.66 cm로 제1군이 유의하 게 짧았으며(p=0.012), 자궁경관 지수도 각각 1.08±0.86, 0.55±0.25로 제1군이 유의하게 높았다(p=0.008). 3) 제1군과 제2군의 파이브로넥틴 값은 각각 103.23± 14 ng/ml 및 9.28±36 ng/ml로 제1군이 높았다. ( p=0.003 ). 한편, 두 군 사이의 Bishop 점수는 통계적 의의가 없었다. 4) 분만 예측에 유의한 자궁경관 길이, 자궁경관 지수 및 파이브로넥틴 값의 cutoff value는 각각 60 ng/ml 이상, 0.82 이상 및 2.51 cm 미만이었고, 분만 예측의 효율성 비교에서는 파이브로넥틴 값이 가장 유용하였다(p= 0.0003, odds ratio=104.67). 이상의 결과로 파이브로넥틴 값과 초음파를 이용한 자궁경부의 계측이 모두 분만 예측에 사용 가능하며, 특히 파이브로넥틴이 가장 유용한 지표였다. Objective: To predict the onset of labor in term pregnancy, we performed digital examination of cervix, transvaginal ultrasonographic evaluation of the uterine cervix, and fetal fibronectin in cervicovaginal secretions in women after 37 complete weeks of gestation. Study design: Total 67 prmiparous or multiparous women were divided into two groups based on the duration between evaluation and onset of labor; Group 1 (n=46), within seven days; Group 2 (n=21), beyond seven days, retrospectively. Bishop score was assessed by digital vaginal examination. Then biometric analysis of uterine cervix (endocervical length, presence of funneling, funnel length, funnel width and cervical index) was done by trasvaginal ultrasonography. The cervicovaginal fetal fibronectin was measured quantitatively by fetal fibronectin immunoassay (Adeza Biomedical, U.S.A.). The efficacy of these method were analyzed with Pearson chi-square test, receiver-operator characteristic curve, and multiple logistic regression test. Results: 1. There were no significant differences in maternal age, parity, gestational age and birth weight between two groups. 2. Group 1 showed significantly shorter endocervical length (Group 1: Group 2=2.24±0.86 cm: 2.78±0.66 cm, p=0.012), higher value of cervical index (1.08±0.86: 0.55±0.25, p=0.008) and higher level of fetal fibronectin( 103.23±14 ng/ml: 9.28 ±36 ng/ml, p=0.003) than those of group 2. 3. Receiver-operator characteristic curve analysis showed that a level of fetal fibronectin in cervicovaginal secretion ≥60 ng/ml, cervical index ≥0.82 and endocervical length <2.51 cm had the diagnostic performance in predicting group 1. Fetal fibronectin level in cervicovaginal secretion ≥60 ng/ml showed the highst diagnostic index in predicting the onset of labor within 7 days (p=0.0003, odds ratio=104.67). Conclusion: From these results, the assay of fetal fibronectin in cervicovaginal secretions is more accurate than ultrasonographic examination of the uterine cervix in the prediction of the onset of term labor and the fetal fibronectin assay may improve the diagnostic efficiency to identify a subgroup of patients who may require aggressive treatment.

선천성 부신증식증에 의한 음핵비대증 환아에 대하여 음핵신경과 혈관총을 보존한 음핵성형술을 실시한 증례보고

송승규,김수평,김은중,김사진,이귀세라,이선영,유진희 대한산부인과학회 1997 Obstetrics & Gynecology Science Vol.40 No.5

Congenital adrenal hyperplasia, which is caused by the disorder of the enzyme for synthesizing adrenal hormones, results in hypertropy of the clitoris due to overporduction of adrenal androgen. Diagnosis of the congenital adrenal hyperplasia can be obtained by the study of steroid levels in blood and urine. The blood levels of ACTH, testosterone and 17-hydroxyprogesterone were increased and the concentration of 17-ketosteroid were decreased after the dexamethasone suppression test. The internal genital organ was normal appearance on the pelvic CT scan. Clitoromegaly due to congenital adrenal byperplasia was corrected previously by the various operational procedures in which the clitoris was removed entirely for only physial appearance. However the sensitive function of the clitoris after the operative correction through puberty is to be preserved by the method $quot;clitoroplasty$quot; for preserving neurovascular supply to the clitoris. The writer experienced a case of a 5-year-old girl with congenital adrenal hyperplasia and tried this clitoroplasty for surgical treatment of clitoromegly for preservation of postoperative sensitivity of the clitoris.