绝经后妇女子宫颈鳞状上皮内病变的临床分析

Clinical analysis of cervical intraepithelial lesion in postmenopausal women

目的探讨绝经后妇女子宫颈锥切术后病理升级（指子宫颈锥切术后病理检查结果较细胞学检查或阴道镜下活检病理检查结果严重）情况，并分析其影响因素。方法选择2013年7月至2015年1月在浙江大学医学院附属邵逸夫医院妇科门诊行子宫颈锥切术的患者共750例，其中绝经后129例，未绝经621例。收集所有患者的液基薄层细胞学检查（TCT）、HPV检测、阴道镜检查及其活检病理检查、子宫颈锥切术及其术后病理检查等结果，分析阴道镜下子宫颈活检与子宫颈锥切术后病理检查结果的符合情况及影响子宫颈锥切术后病理升级的相关因素，并进一步分析不同绝经状态患者的子宫颈锥切术后病理升级情况。结果（1）750例患者中，阴道镜下子宫颈活检与子宫颈锥切术后病理检查结果一致者329例，占43．9％（329／750）；子宫颈锥切术后病理升级者216例，占28．8％（216／750）。TCT检查结果、绝经状态与子宫颈锥切术后病理升级均明显相关（P〈0．05），而HPV感染状况与子宫颈锥切术后病理升级无关（P〉0．05）。（2）对于TCT检查的不同结果[包括未见上皮内病变或恶性细胞（NILM）、未明确诊断意义的不典型鳞状上皮细胞（ASCUS）、低级别鳞状上皮内病变（LSIL）、高级别鳞状上皮内病变（HSIL）]，绝经后患者子宫颈锥切术后病理升级的比例与未绝经患者分别比较，差异均无统计学意义（P〉0．05）。绝经时间〉5年患者的总子宫颈锥切术后病理升级比例明显高于绝经时间≤5年者（分别为40．3％、27．7％，OR=1．8，95％CI为1．1～2．8，P=0．029），其中，在TCT检查结果为LSIL时，绝经时间〉5年患者的子宫颈锥切术后病理升级比例明显高于绝经时间≤5年者（分别为6／10、26．3％，OR=4．2，95％CI为1．1～15．8，P=0．033）；而在TCT检查结果为NILM、ASCUS、HSIL时，两者分别比较，差异均无统计学意义（P〉0．05）。（3）TCT检查结果为LSIL的143例患者中，与阴道镜下活检结果比较子宫颈锥切术后病理检查结果升级为子宫颈癌的患者共9例，占6．3％（9／143），其中，绝经时间〉5年的10例患者中，2例（2／10）子宫颈锥切术后病理检查结果升级为子宫颈癌；绝经时间≤5年的133例患者中，7例（5．3％）子宫颈锥切术后病理检查结果升级为子宫颈癌。绝经时间〉5年患者的子宫颈锥切术后病理升级为癌的比例虽高于绝经时间≤5年者，但两者比较，差异无统计学意义（x2=0．460。P〉0．05）。结论绝经后妇女尤其是绝经时间〉5年者，阴道镜下活检后行子宫颈锥切术患者病理升级的比例升高，子宫颈锥切术后病理升级与TCT检查结果、绝经状态明显相关。故临床上应谨慎对待阴道镜下活检的病理检查结果，可以考虑结合TCT检查结果直接行小范围子宫颈环形电极切除（LEEP）术取材，以避免漏诊。

Objective To investigate the pathological escalation after cervical cone resection in postmenopausal women, and analyze the related influencing factors. Methods A retrospective cohort study was conducted at the Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University between July 2013 and January 2015. Seven hundred and fifty cases of cervical cone-cut were enrolled in this study, 129 cases of them were postmenopausal women, and 621 were premenopausal women. All results of patients＇ liquid-based thin-layer cytology （TCT）, HPV test, colposcopy and biopsy pathology, cervical cone resection and postoperative pathological examination were collected. Then the compliance with the pathological examination results after eolposcopic cervical biopsy and cervical cone resection, and the related factors affecting the pathological escalation after cervical cone resection were analyzed. The pathological escalation of patients with different menopausal conditions after cervical cone resection was also analyzed. Results （ 1 ） Of the 750 patients, there were 329 patients had the same pathological examination results after colposcopic cervical biopsy and cervical cone resection, which accounted for 43.9% （329/750）. And 216 cases demonstrated pathological escalation after cervical cone resection, which accounted for 28.8% （216/750）. The results of TCT examination and menopause were significantly correlated with the pathological escalation after cervical cone resection （P〈0.05）. However, the condition of HPV infection was unrelated to pathological escalation after cervical cone resection （P〉0.05）. （2） Compared with the different results of TCT examination [including non-intrusive load monitoring （NILM）, atypical squamous cell of undetermined signification （ASCUS）, low-grade squamous intraepithelial lesion （LSIL）, high-grade squamous intraepithelial lesion （HSIL）], the ratio of pathological escalation after cervical cone resection was not statistically significant difference between postmenopausal and non-menopausal patients （P〉0.05）. The proportion of pathological escalation of patients with 〉5 years of menopause was significantly higher than that of patients with menopause time ≤5 years （40.3% vs 27.7%, OR=1.8, 95%CI： 1.1-2.8, P=0.029）. Among them, when the result of TCT examination was LSIL, the rate of pathological escalation in patients 〉 5 years of menopause was significantly higher than that in menopause time ≤5 years （6/10 vs 26.3%, OR= 4.2, 95%CI： 1.1-15.8, P=0.033 ）. While the results of TCT examination were NILM, ASCUS or HSIL showed there was no statistically significant difference between two groups （P〉0.05）. （3） Among the 143 cases, of which the result of TCT examination was LSIL, 9 cases of the pathological examination results after cervical resection were escalated to cervical cancer, which accounted for 6.3% （9/143）. Among 10 cases of menopause time 〉5 years, 2 cases （2/10） of the pathological examination results after cervical cone resection were escalated to cervical cancer. Among 133 cases with menopause time ≤ 5 years, 7 cases （5.3%） were upgraded to cervical cancer after cervical cone resection. The ratio of pathological escalation to cancer in postmenopausal patients with 〉5 years was higher than that of menopause time ≤5 years. Due to the data volume limitation, the comparison was not statistically significant difference （X2=0.460, P〉0.05）. Conclusions In postmenopausal women, especially when menopausal time is 〉 5 years, the proportion of pathological escalation after cervical cone resection following colposeopic cervical biopsy is increased. And the pathological escalation after cervical cone resection is significantly correlated with the results of TCT examination and menopausal status. Therefore, doctors should treat the colposcopic biopsy pathological results with caution during clinic. Depending on TCT results, loop electrosurgical excision procedure （LEEP） sampling could be administrated directly in case of avoid missing diagnosis.