对宫颈锥切术阳性切缘患者临床处理的探讨

Clinical management of patients with positive excision margin after cervical conization： analysis of 148 cases

目的探讨宫颈锥切术后切缘阳性病例残留病灶情况和复发的危险因素，为进一步治疗和随访提供参考。方法回顾性分析因宫颈上皮内瘤变Ⅲ级（CINⅢ）和Ial期宫颈鳞癌行环形电圈切除术（LEEP）或宫颈冷刀锥切术（CKC）切缘阳性患者148例，其中CINⅢ118例，Ia期宫颈鳞癌30例。平均年龄（35±5）岁。统计切缘阳性病例锥切术后病理学结果、切缘阳性部位、补充2次手术标本残留病灶情况、随访复发情况等数据。结果CINⅢ患者以宫颈外切缘阳性为主，占74．6％（88／118），其2次手术标本同级别病变残留率19％（4／21）；Ia期宫颈鳞癌病例中，切缘阳性以颈管切缘阳性及颈管缘、宫颈外缘双阳性为主，占86．6％（26／30），其同级别病变残留率53．6％（15／28）。二者切缘阳性部位和同级别病变残留率比较，差异有统计学意义（P值分别〈0．01，〈0．05）。宫颈外切缘阳性患者，2次手术标本同级别病变残留病灶残留率11．8％（2／17），颈管切缘阳性和颈管、宫颈外切缘双阳性患者，同级别病变残留病灶残留率53．1％（17／32），两者差异有统计学意义（P〈0．01）。施行补充2次手术者无一例复发。在未施行2次手术随访的92例中，CINⅢ90例，复发15例，复发率16．7％；Ial期宫颈鳞癌2例，有1例进展。结论宫颈锥切术有一定的切缘阳性率，阳性切缘病例中，仅部分病例有同级别的病灶残留。阳性切缘同级别病灶残留的可能性与病变严重程度以及阳性切缘部位有关。CINⅢ患者同级别病灶残留的可能性较低，可以严密随访；而存在镜下浸润及颈管缘阳性的病例高度提示存在残留病灶可能，应考虑补充2次手术。

Objective To explore the situation of residual lesions in excision margin after loop electrosurgical excision procedure （LEEP） and cold knife conization （CKC） and the risk factors of recurrence in the cases featuring with positive margin. Methods The medical records of 1213 women undergoing LEEP or CKC, aged （ 35 ± 5 ） （ 22 - 40 ） , were retrospectively reviewed. 148 of the 1213 patients （12.2%） who were identified as with positive margin were re-underwent pathological reexamination. 118 of the 148 patients were diagnosed as with cervical intraepithelial neoplasia Ⅲ （CIN Ⅲ） and 30 as with stage Ia invasive cervical carcinoma. These patients were followed up for 12 - 99 months. The pathologic diagnoses, position of positive margin, and residual lesion in subsequent specimens were analyzed. Results Endocervical positive margins were identified in 30 of the 118 （25.4%） CIN Ⅲ patients and 26 of the 30 （86. 6% ） stage Ia patients. Residual lesions were found in 15 of the 28 （53.6%） stage I a cases and 4 pf the 19 （ 19% ） CIN Ⅲ cases. The rates of endocervical positive margin and residual lesion were higher in stage I, patients. The risk of residual lesion was 53.1% （17/32） in the patients with endocervical positive margins, significantly higher than that of the patients with extracervical positive margin （ 16. 7% ）. Recurrence was found in 90 patients during follow-up. Conclusion Residual lesions often occur in some patients with positive margin. Choice between additional surgery and closely follow-up in the young patients with positive margins who want to preserve their fertility depends on the lesion seriousness and positive position. Residual lesions more frequently exist in the patients with microinvasion and endocervical positivity. Additional surgery should be considered in these cases.