绝经后女性子宫颈高级别鳞状上皮内病变的诊治

Diagnosis and treatment of high-grade cervical squamous intraepithelial lesions in postmenopausal women

目的探讨绝经后女性子宫颈高级别鳞状上皮内病变(HSIL)患者的诊治方式。方法回顾性分析2018年1月-2019年12月在复旦大学附属华东医院妇科经阴道镜下宫颈活检或宫颈管搔刮(ECC)病理确诊为HSIL的186例患者的临床资料,其中绝经组64例,未绝经组122例,收集2组患者的液基细胞学检查(LCT)、人乳头状瘤病毒(HPV)、阴道镜下宫颈活检病理结果、宫颈锥切术或全子宫切除术后病理结果、切缘病变情况等,并将上述结果进行组间比较。结果(1)2组术前细胞学检查结果及HPV感染情况比较,差异无统计学意义。(2)绝经组阴道镜下宫颈活检病理与术后病理符合率(60.94%,39/64)低于未绝经组(77.05%,94/122),2组比较差异有统计学意义(χ^(2)=5.348,P=0.021)。绝经组漏诊宫颈癌的比例(15.63%,10/64)高于未绝经组(6.56%,8/122),2组比较差异有统计学意义(χ^(2)=3.949P=0.047)。(3)采用子宫颈环形电切术(LEEP)的患者:绝经组术后切缘阳性率(33.33%,16/48)高于未绝经组(18.85%,23/122),2组比较差异有统计学意义(χ^(2)=4.086,P=0.043)。切缘阳性患者中,绝经组术后病变残留率(62.5%,10/16)高于未绝经组(30.43%,7/23),2组比较差异有统计学意义(χ^(2)=3.946,P=0.047)。(4)绝经组中,有16例直接采用全子宫切除术,术后诊断为子宫颈癌4例。结论绝经后HSIL患者阴道镜下宫颈活检漏诊宫颈癌的风险明显增高,应强调ECC的重要性。LEEP是绝经后HSIL患者的首选治疗方式,术后切缘阳性患者推荐进一步积极干预。对于子宫颈萎缩严重的绝经后HSIL患者,是否可在严格术前评估后首选全子宫切除术,有待进一步研究证实。

Objective To discuss the diagnosis and treatment of cervical high-grade squamous intraepithelial lesions(HSIL)in postmenopausal women.Methods The clinical data of 186 patients with HSIL diagnosed by colposcopic cervical biopsy or endocervical curettage in the Department of Gynecology,Huadong Hospital Affiliated to Fudan University from January 2018 to December 2019 were retrospectively analyzed,including 64 cases in postmenopausal group and 122 cases in nonpostmenopausal group.All results of patients’liquid-based cytology test(LCT),human papillomavirus(HPV)test,pathological results of colposcopic cervical biopsy,pathological results after cervical conization or hysterectomy,pathological results of resection margin were collected and compared between the two groups.Results(1)There was no significant difference in the results of preoperative cytology and HPV infection between the two groups.(2)The coincidence rate of colposcopic cervical biopsy pathology and postoperative pathology in the postmenopausal group(60.94%,39/64)was lower than that in the non-postmenopausal group(77.05%,94/122),and the difference was statistically significant(χ^(2)=5.348,P=0.021).The rate of missed diagnosis of cervical cancer in the postmenopausal group(15.63%,10/64)was higher than that in the non-postmenopausal group(6.56%,8/122),and the difference was statistically significant(χ^(2)=3.949,P=0.047).(3)In patients undergoing LEEP:the positive rate of postoperative resection margin in the menopausal group(33.33%,16/48)was higher than that in the nonmenopausal group(18.85%,23/122),and the difference was statistically significant(χ^(2)=4.086,P=0.043).In patients with positive resection margin,the residual rate of postoperative lesions in the postmenopausal group(62.5%,10/16)was higher than that in non-menopausal group(30.43%,7/23),and the difference was statistically significant(χ^(2)=3.946,P=0.047).(4)In the postmenopausal group,16 cases received hysterectomy directly,and 4 cases were diagnosed as cervical cancer after the surgery.Conclusion Postmenopausal HSIL patients have a significantly higher risk of missed diagnosis of cervical cancer by cervical biopsy under colposcopy,and the importance of ECC should be emphasized.LEEP is the first choice for postmenopausal patients with HSIL,and further intervention is recommended for patients with positive resection margins.For postmenopausal HSIL patients with severe cervical atrophy,whether hysterectomy can be the first choice after strict preoperative evaluation remains to be confirmed by further studies.