CIN宫颈锥切术后病变残留临床处理

【摘 要】 目的:探讨引起宫颈上皮内瘤变宫颈锥切术后病变残留的因素及处理。方法:2007年1月~2009年6月在我院因CIN行宫颈锥切手术的患者中切缘残留20例,无切缘残留121例。分析CIN锥切术后病变残留与切缘阳性、病变程度,以及是否专科手术者的关系。结果:141例中切缘残留20例(14.1%),重度宫颈糜烂研究组16例(80%),对照组无切缘残留121例,重度宫颈糜烂13例(10.7%)。141例宫颈锥切患者,由普通医生实施手术操作的54例,切缘阳性13例,切缘阳性率24%;由专科医生实施手术操作的87例,切缘阳性7例,切缘阳性率为8%。结论:宫颈锥切术后病变残留应行HPV DNA检测和阴道镜随诊,来确定是否行二次锥切术。

【关键词】 宫颈上皮内瘤变; 宫颈锥切术; 切缘残留

Clinical treatment on residues after CIN conization

SUN Jinmiao, XI Lijun, ZHU Fenglan

Department of Gynaecology and Obstetrics, Daqin Longnan Hospital, Daqin 163453, China

【Abstract】 Objectives: To explore on the factors and clinical treatment of residues after CIN conization surgery. Methods: We studied 20 patients with excision margin residues and 121 patients without excision margin residues who have received CIN conization surgery in our hospital between January 2007 and December, 2009, to understand the relationship between CIN conization residues and positive excision margins, degree of pathological changes and expertise of the surgeon. Results: Among 141 studied cases, 20 cases showed excision margin residues(14.1%) of which 15 cases having severe cervical erosion (32%), while 121 cases indicated no margin residues of which 42 cases having severe cervical erosion (15.2%). General surgeon performed 54 conization among the 141 cases. There are 13 cases of positive excision margin, the rate being 24%. Specialized surgeon performed 87 cases of conization, with 7 cases of positive excision margin (8%). Conclusion: CIN conization residues should be detected with HPV DNA and vaginoscopy to determine whether the secondary conization is necessary.

【Key words】 Cervial intraepithelial neoplasia; Cervical conization surgery; Excision margin residues

近年来随着宫颈癌筛查的开展,宫颈上皮内瘤变(CIN)呈上升趋势,宫颈锥切术已经广泛应用于CIN的治疗.但宫颈锥切术后病变残留的处理仍是一个棘手的问题。现就我院141例宫颈锥切术后切缘残留20例患者进行分析。

1 资料与方法

1.1一般资料

2007年1月~2009年6月在我院行宫颈锥切的患者141例,年龄21岁～58岁,平均39.5岁。已生育者103例,占73%;有接触性出血者34例,占24%;有白带增多者88例,占62%。

1.2宫颈锥切及病理检查方法

141例全部采用LEEP刀锥切。根据患者阴道镜图像、活检提示之病变位置及有无生育要求,沿病灶外0.5~1cm实施锥切,锥高2～3cm,病理检查按常规方法进行。对切缘的取材采取先将外切缘切一圈,再将锥顶切一块分别作病理检查,对可疑部位行连续切片检查。锥切切缘见CIN或切缘与CIN距离

2 结果

2.1残留与切缘阳性的关系

术前活检CINIII 141例,锥切标本术后病理诊断CINI 8例,CINII 35例,CINIII 94例,微小浸润癌4例。术后切缘残留20例,阳性率14.1%。其中内切缘残留4例,外切缘残留14例,内外切缘都残留2例。

2.2残留与宫颈病变程度的关系

CINIII锥切术后切缘阳性20例患者轻度宫颈糜烂1例(5%) ,中度宫颈糜烂3例(15%) ,重度宫颈糜烂16例(80%)。切缘阴性组121例患者中轻度宫颈糜烂45例(37.1%),中度宫颈糜烂63例(52.0%),重度宫颈糜烂13例(10.7%)。

2. 3残留与临床手术者关系

141例宫颈锥切患者,由普通医生实施手术操作的54例。切缘阳性13例,切缘阳性率24%。由专科医生实施手术操作的87例,切缘阳性7例,切缘阳性率为8%。

2. 4随 访

20例切缘阳性患者,在宫颈门诊定期随访,随访时间最长38个月,最短10个月,平均24个月。术后随访均液基细胞学(LCT)、HPV-DNA、电子阴道镜三者相结合。第1年每3个月随诊;第2年每6个月随诊;以后每年1次。16例宫颈LCT结果持续无异常,2例不能明确意义的非典型鳞状细胞(ASCUS),2例低度鳞状上皮内病变(LSIL),3例HPV-DNA阳性。经电子阴道镜检查组织病理,3例CINI,1例CINII,3例慢性宫颈炎。4例CIN患者均再次行LEEP术。LEEP术后病理3例CINI。1例为慢性炎症。

3 讨论

3.1 宫颈锥切的切缘阳性与病变残留

目前普遍认为,锥切术后切缘阳性是CIN病灶残留的高危因素,当切缘阳性时病变残留的危险性明显增加[1~3]。Jakus[4]发现宫颈锥切切缘阳性患者术后行全子宫切除,术后残留发生率达8%～84.8%。本文141例宫颈CINIII患者,术后切缘阳性20例,阳性率14.1%,与戴志琴[9]报道的16.1%相似。随访18个月,4例阴道镜组织病理CIN患者均再次行LEEP术。术后病理3例CINI,1例为慢性炎症,提示20例切缘阳性有3例病变持续存在,病变残留率15%。Tillmans等[5]对248例宫颈锥切的CIN患者随访观察中发现,66例切缘阳性者有33例复发或病变持续存在,而182例切缘阴性者仅12例发生CIN。当颈管切缘阳性时病变残留率可达53.1%,单纯宫颈切缘阳性者为11.8%[6,7]。

1.2宫颈病变性质与病变残留

Barvara[8]报道病变的严重程度是预示宫颈锥切后病变残留的因数。LSIL锥切术后的残留病变率是无病变的5倍,HSIL的残留病变率升至7.6倍。戴志琴[9]报道:肉眼病变累及宫颈的范围越广,发生病变残留的可能性越大。本文CINIII锥切术后切缘阳性20例患者轻度宫颈糜烂1例(5%) ,中度宫颈糜烂3例(15%) ,重度宫颈糜烂16例(80%)。Lapaquette等[10]提出,低度宫颈上皮内病变、高度上皮内病变锥切后切缘阳性率分别为0%,18.6%,说明病变残留率随病变的严重程度而增加,这与将来复发率的高低有极其密切的关系。

3.2 宫颈病变残留处理

当Leep切缘阳性、颈管活检阳性、组织病理检查有假腺形成、病灶呈球形生长、有中心性坏死时,大多数学者主张应予子宫全切或补充二次锥切[11,12]。虽Leep切缘阴性,但有上述病理发现时应提高警惕,密切监测,因为颈管切缘阳性者,复发率达25.0%～50.0%[10]。Milojkovic[13]也认为手术切缘阳性不是再次手术的指征。CIN切除后再次手术的指征是:(1)手术切缘阳性,且随访不能保证;(2)随访过程中宫颈细胞学、阴道镜和组织学检查发现异常。近年来,高危型HPV DNA检测作为一种新方法用于CIN III锥切术后的随访,大量研究表明,90%以上的高级别病变伴有高危型HPV感染,锥切可能切除不典型增生病灶而治愈CIN,但不能切除所有感染的上皮而消灭HPV,因为HPV感染是多中心性的[14]。切缘阳性患者,如治疗后HPV阴性,则残留病灶的风险可以忽略。而HPV持续阳性有46%~73%的复发或病灶残留,提示HPV检测可作为预测那些治疗后将会复发的CIN残留病灶的标记物[15,16]。因此大多数学者认为,对于锥切缘阳性但希望保留子宫的患者,最好采用HPV DNA检测和阴道镜随诊[15],如随访中HPV DNA阳性且阴道镜检查有异常,在充分告知的情况下,权衡患者的年龄、随访条件、个人意愿,然后选择继续随诊、再次采取宫颈锥切、宫颈部分切除、全子宫切除等不同处理手段[17]。

综上所述,须高度重视和正确处理残留病灶问题,做好密切随访。既要防止过度治疗,也不能遗漏病变可能进一步发展的严重后果。

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[收稿日期:2010-05-25]