LEEP术后不同切缘阳性患者的分层管理及临床预后

Stratified management and clinical prognosis of patients with differently positive surgical margins after LEEP

目的:分析宫颈高级别上皮内病变行子宫颈环形电切除术(loop electrosurgical excision procedure,LEEP)术后切缘阳性患者病变残留的高危因素,探讨不同切缘阳性患者的分层管理。方法:收集宫颈LEEP术后病理证实切缘见宫颈上皮内病变,即切缘阳性患者305例。外切缘阳性患者随访观察术后转阴情况;非外侧缘(内切缘、基底)阳性患者行二次LEEP或全子宫切除术,分析术后病灶残留的高危因素。结果:112例外切缘阳性患者6个月随访转阴率为75.9%,已绝经及切缘累及多象限与转阴负相关;孕产次、术前薄层液基细胞学检查(thin-prep cytologic test,TCT)结果、病变累及腺体及切缘病变级别与转阴无相关性。193例非外切缘阳性患者中,已绝经、术前TCT结果为高级别鳞状上皮内病变不典型鳞状细胞(atypical squamous cell cannot exclude high grade squamous intraepithelial lesion,ASC-H)或高级别鳞状上皮内病变(high-grade squamous intraepithelial lesion,HSIL)、切缘病变累及多象限均与病变残留正相关;年龄、孕产次、术前人乳头瘤病毒(human papilloma virus,HPV)分型及切缘病变级别均与病变残留无相关性。结论:外切缘阳性患者术后转阴率高,可行常规随访。非外切缘阳性患者已绝经、术前TCT结果为ASC-H或HSIL及切缘累及多象限术后病变残留率高,建议行全子宫切除术。

Objective:This study aims to analyze the high risk factors of residual lesions in patients with positive cervical margin after loop electrosurgical excision procedure(LEEP)for high-grade intraepithelial cervical lesions,and to explore the stratified management of patients with different positive margins.Methods:A total of 305 patients with LEEP were collected.The postoperative specimens were pathologically confirmed to have residual cervical intraepithelial lesions at the margin of resection,namely,positive margin of conization.Routine postoperative follow-up was performed for patients with positive ectocervical margin to investigate the postoperative outcome.At the same time,all patients with positive non-ectocervical margins(endocervical margin and basal margin)were treated with a second LEEP or hysterectomy,and the high-risk factors for postoperative residual lesions in patients with positive non-ectocervical margins were analyzed.Results:The negative conversion ratio of 112 patients with positive surgical margin was75.9%during 6 months follow-up.Postmenopausal patients and multiple quadrants of margin involvement were inversely associated with positive ectocervical margin after conization.While the preoperative thin-prep cytology test(TCT)results,pregnancy and birth order,the degree of surgical margin lesions showed no correlation with the outcome of the patients.Among the 193 patients with positive non-ectocervical margin,menopausal status,preoperative TCT results including atypical squamous cell cannot exclude high grade squamous intraepithelial lesion(ASC-H)and high-grade squamous intraepithelial lesion(HSIL),and positive margin involved multiple quadrants,all of them were positively correlated with residual lesions.While the patient’s age,gestational order,preoperative human papilloma virus(HPV)type and preoperative lesion degree showed no correlation with lesion residual.Conclusion:Routine follow-up is feasible for patients with positive ectocervical margin for the high negative conversion ratio.The probability of postoperative residual lesions in patients with positive non-ectocervical margin is high in patients with menopause,the preoperative TCT show ASC-H or HSIL,and peripheral margin involved multiple quadrants,so hysterectomy is recommended.