子宫颈锥切术中子宫颈管搔刮诊断子宫颈管病变残留的临床价值

The clinical value of endocervical curettage during loop electrosurgical excision procedure in diagnosing persistent endocervical lesions

目的评估宫颈环形电切术(LEEP)中应用宫颈管搔刮(ECC)预测宫颈管病变残留的可行性及其诊断宫颈管病变残留的准确性和预测价值。方法回顾性分析2018年9月至2019年11月重庆医科大学附属第一医院宫颈门诊阴道镜检查和(或)ECC诊断宫颈管高级别鳞状上皮内病变(HSIL)及以上病变者行LEEP手术,宫颈锥切后立即对残留宫颈管行ECC的患者176例的临床资料。分析ECC、LEEP内切缘与LEEP术后宫颈管病变残留的相关性,并比较内切缘与ECC预测宫颈管病变残留的准确性。结果 LEEP术中ECC样本的不合格率为8.5%(15/176),ECC的阳性率为25.5%(41/161)。35例患者因LEEP内外切缘和(或)ECC阳性后续行子宫切除术。以子宫切除术宫颈管病理结果为金标准,ECC灵敏度为90.9%,特异度为45.8%;内切缘灵敏度为81.8%,特异度为62.5%。两者的灵敏度和特异度比较,差异无统计学意义(P>0.05)。评估内切缘联合ECC对宫颈管病变残留的预测效能的ROC曲线下面积为0.786,联合预测的灵敏度为81.8%,特异度为75%。排除LEEP病理确诊的16例宫颈癌和2例原位腺癌患者,LEEP术后宫颈管病变残留率为7.7%(11/143)。ECC阳性和内切缘阳性与LEEP术后宫颈管病变残留显著相关(χ^(2)=28.088,χ^(2)=29.095, P <0.001)。结论 LEEP术中ECC阳性和内切缘阳性均为宫颈管病变残留的重要预测因子。在高度怀疑宫颈管HSIL或者更严重病变的患者中,LEEP术中应用ECC,联合内切缘状态对宫颈管病变残留进行综合评估,可增加对宫颈管病变残留预测的准确性。

Objective To evaluate the feasibility of endocervical curettage(ECC) during loop electrosurgical excision procedure(LEEP) in predicting persistent endocervical lesions, and to evaluate the accuracy and predictive value in the diagnosis of persistent cervical lesions. Methods The study included 176 patients who underwent ECC during LEEP for endocervical HSIL or worse diagnosis by cervical biopsy and/or ECC at the cervical clinic of the First Affiliated Hospital of Chongqing Medical University from September 2018 to November 2019. The correlation between ECC, internal margins and persistent endocervical lesions was analyzed. The accuracy of predicting persistent cervical lesions by the internal margin and ECC were compared. Results The failure rate of ECC samples was 8.5%(15/176). The positive rate of ECC during LEEP was 25.5%(41/161). There were 35 patients underwent hysterectomy because of positive margins and/or positive ECC. Regarding the pathological results of cervical canal after hysterectomy as gold standard, the sensitivity of ECC was 90.9%, and the specificity was 45.8%. The sensitivity of internal margin was 81.8%, and the specificity was 62.5%. The difference was not significant(P > 0.05). Furthermore, the sensitivity of internal margin combined with ECC was 81.8%, and the specificity was 75%, the area under the ROC curve was 0.786. Excluding 16 patients with cervical cancer and 2 patients with adenocarcinoma in situ, the residual rate of endocervical lesions after LEEP was 7.7%(11/143). The positive ECC and positive internal margin were significantly correlated with persistent endocervical lesions(χ^(2)=28.088, χ^(2)=29.095, P < 0.001). Conclusions The positive ECC during LEEP and positive internal margin were important predictors of persistent endocervical lesions. It is recommended that ECC during LEEP should be used to increase the detection of persistent endocervical lesions in patients highly suspected of endocervical diseases. And ECC combined with internal margin to evaluate the persistent endocervical lesions can increase the accuracy of prediction.