1 502例子宫颈HSIL患者行LEEP锥切术后随访半年的临床结局及术后病灶残留的危险因素分析

Clinical outcome and high risk factor for residual lesion analysis of HSIL half a year after loop electrosurgical excision procedure： a clinical study of 1 502 cases

目的探讨子宫颈高级别鳞状上皮内病变（HSIL）行子宫颈环形电极切除（LEEP）术后随访半年的临床结局，并对术后病灶残留的危险因素进行分析。 方法收集2011年1月至2013年12月在复旦大学附属妇产科医院行LEEP锥切术，术后组织标本经病理检查诊断为子宫颈HSIL且有术后半年随访记录的患者共1 502例。随访内容包括子宫颈液基薄层细胞学检查（TCT）、高危型HPV（HR-HPV）检测、阴道镜下子宫颈活检。回顾性分析HSIL患者的临床结局，探讨术后病灶残留、复发或进展的监测方法，并分析术后病灶残留的危险因素。结果（1）临床结局：1 502例HSIL患者中，术后无病灶残留1 454例，有病灶残留48例，术后病灶残留率为3.20%（48/1 502）。（2）术后病灶残留、复发或进展的监测方法：1 502例HSIL患者中，LEEP锥切术后病灶残留48例，其中阴道镜子宫颈活检诊断40例（83.3%），子宫颈管搔刮术（ECC）诊断4例（8.3%），阴道镜子宫颈活检与ECC均诊断者4例（8.3%）。（3）术后病灶残留的危险因素分析：单因素分析显示，年龄≥50岁者术后病灶残留率明显高于〈50岁者[分别为9.70%（16/165）、2.39%（32/1 337）；χ2=25.33，P〈0.01]；有病灶残留和无病灶残留患者的LEEP锥切标本，锥体的中位长度分别为1.5、1.5 cm，两者经秩和检验无明显差异（Z=-1.55，P〉0.05），而两者的中位周长（分别为2.5、2.8 cm）、宽度（分别为0.6、0.6 cm）分别比较均有明显差异（Z=-3.17、Z=-2.88，P均〈0.01）；切缘阳性者术后病灶残留率明显高于切缘阴性者[分别为6.77%（18/266）、2.43%（30/1 236）；χ2=13.30，P〈0.01]，其中内切缘阳性、一侧切缘阳性者[分别为16.07%（9/56）、7.29%（7/96）]也均明显高于切缘阴性者（χ2=26.99，P〈0.01；χ2=4.24，P〈0.05）；术后随访中，TCT检查结果为异常者术后病灶残留率明显高于正常者[分别为6.00%（6/100）、1.29%（14/1 083；χ2=9.50，P〈0.01]，而HR-HPV检测结果为阳性者术后病灶残留率与阴性者比较无明显差异[分别为2.91%（6/206）、0.96%（7/727）；χ2=3.10，P〉0.05]。多因素logistic回归分析显示，随访中TCT检查异常为影响LEEP术后病灶残留的独立危险因素（OR=3.75，P〈0.05）。结论子宫颈HSIL患者行LEEP锥切术后存在病灶残留情况；高龄（≥50岁）、切缘阳性尤其是内切缘阳性、术后TCT检查异常是术后病灶残留的危险因素，其中术后TCT检查异常是术后病灶残留的独立危险因素。阴道镜下子宫颈活检和（或）ECC对于发现LEEP锥切术后HSIL病灶残留、疾病进展具有不可或缺的价值。

ObjectiveTo analyze clinical outcome of high-grade squamous intraepithelial lesion （HSIL） half a year after loop electrosurgical excision procedure （LEEP） and explore the high risk factor of residual cervical HSIL.MethodsThe retrospective study was carried out on 1 502 patients who underwent LEEP, with HSIL in the LEEP histopathology from January 2011 to December 2013 at Obstetrics and Gynecology Hospital of Fudan University to confer the difference between residual group and non-residual group after 6 months of the leep conization. Patients were followed with ThinPrep cytologic test （TCT）, high risk HPV （HR-HPV） test, colposcopy guided biopsy （CBD） and endocervical curettage （ECC）. The high risks of residual cervical HSIL was analyzed.ResultsAmong 1 502 cases, 48 （3.20%, 48/1 502） cases suffered HSIL residual disease. Forty cases were diagnosed by CBD, 4 cases were diagnosed by ECC. The other 4 cases were both positive in CBD and ECC. Residul rate were different among different age groups. The residual rate was higher in the age ≥50 years old compared to the age below 50 [9.70% （16/165）, 2.39% （32/1 337）; χ2=25.33, P〈0.01]. For post-LEEP specimens, both circumference （2.5, 2.8 cm; Z=-3.17, P〈0.01） and width [0.6, 0.6 cm; Z=-2.88, P〈0.01） were less in HSIL lesion residual group than those in non-residual group, though length showed no obvious difference [1.5, 1.5 cm; Z=-1.55, P〉0.05） . The residual rate of leep positive margin was obviously higher than that in the negative margin group [6.77% （18/266） vs 2.43% （30/1 236） ; χ2=13.30, P〈0.01]. Different positive margin had diverse residual rate, as positive endocervical margin was 16.07% （9/56）, positive margin undetermined was 7.29%（7/96） and positive ectocervical margin was 3.33%（4/120）. Both positive endocervical margin and positive margin undetermined had a higher residual rate than residual rate （χ2=26.99, P〈0.01; χ2=4.24, P〈0.05）. Abnormal cytology showed higher residual rate than the non-residual with significant difference [6.00% （6/100） vs 1.29% （14/1 083） , χ2=9.50, P〈0.01]. In terms of the post-LEEP HR-HPV test follow-up, HR-HPV positive′s residual rate was higher than that in the negative group [2.91% （6/206） vs 0.96% （7/727）], while there was no statistical significance （χ2=3.10, P〉0.05）. Multivariate logistic analysis showed that abnormal cytology in 6 month′s follow-up post-LEEP conization was an independent risk factor on residual lesion （OR=3.75, P〈0.05）.ConclusionsPatient with age ≥50 years old and positive endocervical margin are high risk factors for the residual HSIL lesion after LEEP conization,especially for abnormal cytology during follow up is independent risk factor for residual lesion. Colposcopy directed biopsy and （or） ECC still play an indispendsable role in finding the HSIL residual lesion.