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LEEP術(shù)在絕經(jīng)后高級(jí)別CIN患者診療的價(jià)值評(píng)估

2016-07-27 05:24:03陶恬闐江海燕
中國(guó)婦幼健康研究 2016年4期

陶恬闐,江海燕

(浙江省衢州市婦幼保健院,浙江 衢州 324000)

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LEEP術(shù)在絕經(jīng)后高級(jí)別CIN患者診療的價(jià)值評(píng)估

陶恬闐,江海燕

(浙江省衢州市婦幼保健院,浙江 衢州 324000)

[摘要]目的探討LEEP術(shù)在絕經(jīng)后高級(jí)別CIN患者中的診療價(jià)值。方法對(duì)2008年1月至2015年12月于浙江省衢州市婦幼保健院行子宮頸LEEP術(shù)的354例患者臨床資料進(jìn)行分析,以絕經(jīng)后患者36例為實(shí)驗(yàn)組,同期1:3選擇絕經(jīng)前患者108例為對(duì)照組,分析臨床癥狀、細(xì)胞學(xué)檢查、HR-HPV檢查、陰道鏡檢查及LEEP術(shù)后病理結(jié)果。結(jié)果實(shí)驗(yàn)組陰道鏡檢查滿意率顯著低于對(duì)照組(χ2=17.779,P=0.000)。以LEEP術(shù)后病理結(jié)果為診斷金標(biāo)準(zhǔn),實(shí)驗(yàn)組LEEP術(shù)后病理級(jí)別升級(jí)者顯著高于對(duì)照組(χ2=4.866,P=0.027),實(shí)驗(yàn)組陰道鏡下活檢病理的準(zhǔn)確性顯著低于對(duì)照組(χ2=3.992,P=0.046)。實(shí)驗(yàn)組患者行LEEP術(shù)后病理結(jié)果提示切緣陽(yáng)性率高于對(duì)照組,但兩組間無(wú)顯著性差異(χ2=3.416,P=0.065),其中實(shí)驗(yàn)組內(nèi)切緣陽(yáng)性率明顯高于對(duì)照組,兩組間差異有顯著性意義(χ2=5.797,P=0.016);實(shí)驗(yàn)組外切緣陽(yáng)性率高于對(duì)照組,但兩組間無(wú)顯著性差異(χ2=0.254,P=0.615)。結(jié)論絕經(jīng)后女性仍建議定期行宮頸癌篩查,包括宮頸TCT及HR-HPV檢測(cè)。絕經(jīng)后患者的陰道鏡檢查滿意率及準(zhǔn)確性均下降;對(duì)陰道鏡活檢后診為CIN的患者應(yīng)行LEEP進(jìn)一步確診診斷。

[關(guān)鍵詞]子宮頸鱗狀上皮內(nèi)瘤變;子宮頸線圈電切術(shù);高危型人乳頭瘤病毒;絕經(jīng)后

1資料和方法

1.1一般資料

2008年1月至2015年12月就診于衢州市婦幼保健院醫(yī)院接受LEEP術(shù)的高級(jí)別CIN患者共354例,其中絕經(jīng)后CIN患者36例為實(shí)驗(yàn)組,平均年齡約56歲(45~71歲);1:3選取同期接受LEEP術(shù)(手術(shù)時(shí)間±1周)的高級(jí)別CIN絕經(jīng)前患者108例為對(duì)照組,平均年齡約35歲(20~52歲)。患者行子宮頸LEEP術(shù)前均簽署知情同意書。

1.2方法

記錄患者術(shù)前子宮頸脫落細(xì)胞液基細(xì)胞學(xué)(liquid based cytology,LBC)及高危人乳頭瘤病毒(high risk-human palillomavirus,HR-HPV)檢查結(jié)果、陰道鏡檢查結(jié)果以及最終病理檢查結(jié)果,并進(jìn)行比較。HPV-DNA檢測(cè)采用亞能生物技術(shù)有限公司的HPV基因分型檢測(cè)試劑盒,采用雜交捕獲(HC-Ⅱ)技術(shù),檢測(cè)13種與宮頸癌相關(guān)的HR-HPV(包括16、18、3l、33、35、39、45、51、52、56、58、59、68),按試劑盒診斷標(biāo)準(zhǔn)HR-HPV DNA≥1.0pg/mL為陽(yáng)性。

1.3 LEEP術(shù)及病理檢查

普通電刀采用ERBE ICC 300(德國(guó)Elektromedizin Tubingen產(chǎn)品),頻率6~7MHz,電切功率設(shè)定為50~55W,電凝功率設(shè)定為45~50W。標(biāo)本自子宮頸12點(diǎn)處將子宮頸縱行打開(kāi),由左向右將其展開(kāi)、固定的子宮頸,根據(jù)組織體積取材8~20塊,順時(shí)針依次標(biāo)記。所有病理檢查均由專業(yè)病理醫(yī)師做出診斷。出血量評(píng)估方法:由術(shù)者和麻醉師共同評(píng)估負(fù)壓瓶中的出血量;術(shù)中紗布的出血量按大紗每塊濕透約50mL,小紗每塊濕透30mL估算、輔料的出血量按面積法估算,累計(jì)計(jì)算術(shù)中出血總量。

1.4統(tǒng)計(jì)學(xué)方法

TIAN Bing, WANG Tie-gong, YANG Peng-fei, YIN Wei, XU Bing, CHEN Lu-guang, LIU Qi, LIU Jian-min, LU Jian-ping

2結(jié)果

2.1兩組患者術(shù)前臨床特征

本研究實(shí)驗(yàn)組出現(xiàn)臨床癥狀者14例,其中異常陰道流血者9例(25.00%),白帶異常者3例(8.33%),不明原因腰酸者2例(5.56%);對(duì)照組出現(xiàn)臨床癥狀者51例,其中異常陰道流血者28例(25.93%),白帶異常者18例(16.67%),不明原因腰酸者5例(4.63%)。兩組間臨床癥狀比較無(wú)顯著性差異(χ2=0.757,P=0.384)。

2.2兩組患者術(shù)前實(shí)驗(yàn)室檢查

實(shí)驗(yàn)組中32例接受LBC檢查,其中細(xì)胞學(xué)檢查與LEEP術(shù)后病檢結(jié)果相符者為18例(56.3%);對(duì)照組中97例接受LBC檢查,其中59例與LEEP術(shù)后病檢結(jié)果相符(60.8%)。兩組間比較無(wú)顯著性差異(χ2=0.209,P=0.647)。實(shí)驗(yàn)組中25例接受HR-HPV檢查,陽(yáng)性率約80.0%,而對(duì)照組中接受HR-HPV者82例,其中陽(yáng)性率約為89.0%。兩組間比較無(wú)顯著性差異差(χ2=1.372,P=0.241)。

2.3兩組患者陰道鏡檢查滿意率及手術(shù)前后病理級(jí)別比較

實(shí)驗(yàn)組共29例接受陰道鏡檢查+活檢,其中提示宮頸慢性炎者3例,低級(jí)別CIN者4例,高級(jí)別CIN者22例;對(duì)照組中共92例接受陰道鏡檢查+活檢,提示宮頸慢性炎者4例,低級(jí)別CIN者5例,高級(jí)別CIN者83例。實(shí)驗(yàn)組陰道鏡檢查滿意率顯著低于對(duì)照組,兩組間差異有統(tǒng)計(jì)學(xué)意義(P=0.000)。以LEEP術(shù)后病理結(jié)果為診斷金標(biāo)準(zhǔn),實(shí)驗(yàn)組LEEP術(shù)后病理級(jí)別升級(jí)者顯著高于對(duì)照組,兩組間差異有統(tǒng)計(jì)學(xué)意義(P=0.027),其中實(shí)驗(yàn)組LEEP術(shù)后確診宮頸浸潤(rùn)癌2例,對(duì)照組術(shù)后確診宮頸浸潤(rùn)癌者1例;實(shí)驗(yàn)組陰道鏡下活檢病理的準(zhǔn)確性顯著低于對(duì)照組,兩組間差異有統(tǒng)計(jì)學(xué)意義(P=0.046),見(jiàn)表1。

表1絕經(jīng)前后陰道鏡檢查滿意率及病理級(jí)別一致性[n(%)]

Table1Satisfactory rate of colposcopy before and after menopause and the consistency of pathological grade[n(%)]

項(xiàng)目實(shí)驗(yàn)組(n=29)對(duì)照組(n=92)χ2P陰道鏡滿意情況17.7790.000 滿意7(24.14)63(68.48) 不滿意22(75.86)29(31.52)確診病理升級(jí)4.8660.027 升級(jí)8(27.59)10(10.87) 未升級(jí)21(72.41)82(89.13)陰道鏡活檢與LEEP病理一致性3.9920.046 一致15(51.72)66(71.74) 不一致14(48.28)26(28.26)

2.4兩組患者LEEP術(shù)后切緣陽(yáng)性情況比較

實(shí)驗(yàn)組患者行LEEP術(shù)后病理結(jié)果提示切緣陽(yáng)性率(22.22%)高于對(duì)照組(10.18%),但兩組間無(wú)顯著性差異(χ2=3.416,P=0.065),其中實(shí)驗(yàn)組內(nèi)切緣陽(yáng)性率(11.11%)明顯高于對(duì)照組(1.85%),兩組間差異有顯著性意義(χ2=5.797,P=0.016);實(shí)驗(yàn)組外切緣陽(yáng)性率(11.11%)高于對(duì)照組(8.33%),但兩組間無(wú)顯著性差異(χ2=0.254,P=0.615)。

2.5兩組患者手術(shù)的損傷情況比較

出血是LEEP手術(shù)的最常見(jiàn)并發(fā)癥。本研究中實(shí)驗(yàn)組、對(duì)照組均無(wú)宮頸周邊臟器的損傷。實(shí)驗(yàn)組患者術(shù)中出血>10mL 2例(5.56%),對(duì)照組患者術(shù)中出血>10mL 9例(8.33%),兩組間差異無(wú)統(tǒng)計(jì)學(xué)意義(χ2=0.295,P=0.587),兩組出血多的患者均可見(jiàn)病變位置深、淺表血管豐富。

3討論

3.1宮頸細(xì)胞學(xué)檢查及HR-HPV檢測(cè)在絕經(jīng)后女性宮頸癌疾病篩查的價(jià)值

宮頸細(xì)胞學(xué)檢查及HR-HPV檢測(cè)是宮頸癌疾病篩查的最主要兩項(xiàng)檢測(cè)手段。本研究中,實(shí)驗(yàn)組(絕經(jīng)后)與對(duì)照組(絕經(jīng)前)患者宮頸細(xì)胞學(xué)檢查及HR-HPV檢測(cè)陽(yáng)性率無(wú)顯著性差異(P>0.05),這提示常規(guī)的宮頸癌疾病篩查手段同樣適用于絕經(jīng)后女性。故本研究選擇的兩組間術(shù)前臨床特征、實(shí)驗(yàn)室檢查一致,具有可比性。

3.2陰道鏡下活檢在絕經(jīng)后女性宮頸癌疾病篩查的價(jià)值

陰道鏡下活檢是診斷子宮頸癌及癌前病變的一項(xiàng)精準(zhǔn)檢查。但絕經(jīng)后女性宮頸轉(zhuǎn)化區(qū)上移、宮頸萎縮,陰道鏡檢查的滿意率及準(zhǔn)確性均較絕經(jīng)前患者下降。Suram等[5]學(xué)者提出陰道鏡檢查前使用雌激素或米索前列醇可增加陰道鏡檢查的滿意率,從而佐證這一理論。

3.3LEEP術(shù)在絕經(jīng)后女性宮頸癌疾病診療中的價(jià)值

針對(duì)絕經(jīng)后高級(jí)別CIN患者的診療規(guī)范目前尚未統(tǒng)一。既往國(guó)內(nèi)外多數(shù)醫(yī)院選擇針對(duì)絕經(jīng)后患者行全子宮切除術(shù),但往往過(guò)度治療,且并不降低患者的死亡率。目前,越來(lái)越多絕經(jīng)后患者接受子宮頸錐形切除術(shù)作為診療手段。本研究中絕經(jīng)前后患者行LEEP手術(shù)的損傷出血無(wú)顯著性差異,出血因素多見(jiàn)于與病變位置深、淺表血管豐富的患者。同時(shí)相應(yīng)文獻(xiàn)也提示絕經(jīng)后患者切緣陽(yáng)性率明顯高于絕經(jīng)前人群。Cheng等[6]學(xué)者發(fā)現(xiàn)101例絕經(jīng)后且接受子宮頸錐切術(shù)的患者中約20.8%出現(xiàn)切緣陽(yáng)性,相比于絕經(jīng)前患者(10.9%)有顯著性差異。在本研究中,實(shí)驗(yàn)組患者切緣陽(yáng)性率(22.22%)高于對(duì)照組(10.18%),但兩組間差異無(wú)統(tǒng)計(jì)學(xué)差異(P>0.05),考慮為樣本量不足的可能,今后可擴(kuò)大研究樣本進(jìn)一步討論。但其中絕經(jīng)后患者內(nèi)切緣陽(yáng)性率(11.11%)明顯高于絕經(jīng)前(1.85%),兩組間差異有統(tǒng)計(jì)學(xué)意義(P<0.05),這與絕經(jīng)后宮頸管萎縮及轉(zhuǎn)化區(qū)上移的生理變化相關(guān),提示臨床操作中對(duì)于絕經(jīng)后患者需高度警惕,必要時(shí)需加大錐形切除柱高。但通過(guò)與陰道鏡活檢的比較,可發(fā)現(xiàn)絕經(jīng)后宮頸LEEP術(shù)后病理級(jí)別升級(jí)率顯著增加。

綜上所述,陰道鏡下活檢診斷ClN,目前尚不能完全替代高頻電刀手術(shù)。陰道鏡是一種視覺(jué)技術(shù),有賴于檢查者有嚴(yán)格的訓(xùn)練和豐富的經(jīng)驗(yàn)。由于炎性反應(yīng)和HPV感染也可產(chǎn)生陰道鏡下異常圖象,因此陰道鏡診斷CIN的敏感性高而特異性低,對(duì)陰道鏡活檢后診為CIN的患者應(yīng)行LEEP進(jìn)一步確診診斷,以盡量避免過(guò)度治療以及漏診。

[參考文獻(xiàn)]

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[專業(yè)責(zé)任編輯:韓曉兵]

[收稿日期]2016-02-29

[作者簡(jiǎn)介]陶恬闐(1979-),女,主治醫(yī)師,主要從事婦產(chǎn)科臨床工作。

[通訊作者]江海燕,副主任醫(yī)師。

doi:10.3969/j.issn.1673-5293.2016.04.037

[中圖分類號(hào)]R711.7

[文獻(xiàn)標(biāo)識(shí)碼]A

[文章編號(hào)]1673-5293(2016)04-0527-03

Significance evaluation of LEEP for post menopausal women with high grade cervical intraepithelial neoplasia

TAO Tian-tian, JIANG Hai-yan

(Quzhou Maternal and Child Health Hospital, Zhejiang Quzhou 324000, China)

[Abstract]Objective To evaluate the significance of LEEP in the diagnosis and treatment of high-grade cervical intraepithelial neoplasia (CIN) in post-menopausal women. Methods Clinical data of 354 patients undergoing LEEP in Quzhou Maternal and Child Health Hospital were analyzed, including 36 post-menopausal women in experimental group and 108 pre-menopausal patients in control group. Clinical manifestations, cytological examination, HR-HPV examination, colposcopy and pathological results after LEEP were analyzed. Results The satisfaction rate of colposcopy in the experimental group was significantly lower than in the control group (χ2=17.779,P=0.000). The postoperative pathological results after LEEP were taken as gold standards for diagnosis. The pathological levels in the experimental group were significantly higher than those in the control group (χ2=4.866,P=0.027). The accuracy of biopsy under colposcopy was significantly lower in the experimental group than in the control group (χ2=3.992,P=0.046). After LEEP, the positive rate of the cutting edge in the experimental group was higher than in the control group, but no significant difference between two groups was found (χ2=3.416, P=0.065). The positive rate of internal margin in the experimental group was higher, and there was significant difference between two groups (χ2=5.797,P=0.016). The experimental group had higher positive rate of external margin than the control group, but no significant difference was indicated (χ2=0.254,P=0.615). Conclusion Post-menopausal women are suggested to take cervical cancer screening regularly, including TCT and HR-HPV test. Both the satisfaction rate and accuracy of colposcopy decline for post-menopausal women. LEEP is needed for further confirm diagnosis among cases diagnosed with CIN after colposcopic biopsy.

[Key words]cervical intraepithelial neoplasia (CIN); loop electrosurgical excision procedure (LEEP); high risk-human papillomavirus (HR-HPV); post-menopause

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