宫颈HSIL患者初次锥切术后切缘阳性相关因素分析与补充手术必要性探讨

Analysis of factors related to positive margins after primary conization in patients with cervical HSIL and discussion on the necessity of supplementary surgery

目的通过回顾性分析宫颈高级别鳞状上皮内病变(high-grade squamous intraepithelial lesions,HSIL)行初次宫颈锥切术后切缘阳性相关因素、切缘状态与病变残留、复发的关系,探讨宫颈HSIL锥切术后切缘阳性的高危因素及补充二次手术的必要性.方法收集广州医科大学附属第三医院妇科2014年1月至2018年12月因宫颈HSIL住院行宫颈锥切的患者共501例,统计分析:①首次锥切切缘阳性率及高危因素;②78例补充二次手术者初次锥切术后病灶残留率(术后病理为HSIL及以上)与切缘状态的关系;③(规范随访)113例初次锥切术后复发率与切缘状态的关系.结果①501例HSIL患者初次锥切后切缘阳性116例,切缘阳性率23.15%,多因素分析显示锥切方式为宫颈电环切除(loop electrosurgical excision procedure,LEEP)(P=0.003,OR=4.227,95%CI=1.631-10.955)、锥切高度≤1.6 cm(P=0.005,OR=2.674,95%CI=1.348-5.301)、病变累及点数(P<0.001,OR=1.206,95%CI=1.094-1.330)是宫颈锥切术后切缘阳性的高危因素;②78例二次手术(二次锥切或子宫切除)患者中,切缘阳性组与切缘阴性组病变复发率相比较(40%vs 13.95%),差异有统计学意义(P=0.0018).③113例初次锥切术后病变复发率在切缘阳性组与切缘阴性组两组之间(8%vs 6.8%)差异无统计学意义(P=0.811).结论宫颈锥切方式为LEEP、锥切高度≤1.6 cm、病变累及点数为切缘阳性的高危因素;切缘阳性是病变残留的高危因素,但与病变复发无显著性相关,要认识到切缘阳性并不等同于病变残留,是否补充二次手术需结合个体化因素选择,避免诊疗过度.

Objective Through a retrospective analysis of the factors associated with positive resection margins after primary cervical conization for high-grade squamous intraepithelial lesions(HSIL),the relationship between resection margin status and residual and recurrence of lesions,to explore the risk factors for positive margins after cervical HSIL conization and the necessity of supplementary secondary surgery.Methods A total of 501 patients who underwent cervical conization in Department of Gynecology of the Third Affiliated Hospital of Guangzhou Medical University from January 2014 to December 2018 were collected and analyzed;②The positive rate and high-risk factors of the first conization margin;①The relationship between the residual rate of lesions after primary conization(postoperative pathology was HSIL or above)and the status of the incisal margin in 78 patients who underwent secondary surgery;③The relationship between the recurrence rate and the status of the incision margin after the primary conization in 113 cases(standard follow-up).Results①Among the 501 HSIL patients,116 had positive margins in the initial conization,with a positive rate of 23.15%.Multivariate analysis showed that the coning method was LEEP(P=0.003,OR=4.227,95%CI=1.631-10.955),and the coning height≤1.6 cm(P=0.005,OR=2.674,95%CI=1.348-5.301),the number of lesions involved(P<0.001,OR=1.206,95%CI=1.094-1.330)were high risk factors for positive margins after cervical conization;②Among 78 patients with secondary surgery(secondary conization or hysterectomy),the recurrence rate of lesions between the positive margin group and the negative margin group was compared(40%vs 13.95%),and the difference was statistically significant(P=0.0018).③In 113 cases of primary conization,there was no significant difference in the recurrence rate between the positive margin group and the negative margin group(8%vs 6.8%),the difference was not statistically significant(P=0.811).Conclusion The cervical conization method is LEEP,the conization height:gl.6 cm,and the number of lesions involved are high-risk factors for positive margins;positive margins are high-risk factors for residual disease,but there is no significant correlation with disease recurrence.It is not equivalent to residual disease.Whether to supplement secondary surgery should be selected in combination with individual factors to avoid excessive diagnosis and treatment.