LEEP治疗高级别宫颈上皮内瘤变远期疗效分析

发布时间：2018-08-10 19:50

【摘要】：目的：1.分析高级别宫颈上皮内瘤变（CINII、CINIII）随访对象的临床特点；评价宫颈环形电切术(LEEP)治疗高级别CIN的有效性与安全性；2.探讨TCT及HPV检测在随访过程中的价值；残留、复发的高危因素；手术对妊娠结局的影响。方法：1.选择2008年1月至2010年12月在皖南医学院第一附属医院妇产科阴道镜门诊接受LEEP保守治疗并病理诊断为CINII、CINIII持续有定期随访记录的患者共321例进行平均为期52.2月的定期随访。2.定期行薄层液基细胞学(TCT）和（或）人乳头瘤病毒(HPV)分型检测，当TCT诊断为ASCUS及其以上结果、持续性HPV感染或患者有可疑主诉均进行阴道镜检查，以病理结果为最终诊断。3.利用SPSS16.0对收集到的数据进行描述性分析；率的比较采用χ2检验；Logistic回归分析宫颈上皮内瘤变LEEP后残留、复发高危险因素；以α＜0.05为检验标准。结果：1：随访5年内发现术后3月残留1例，复发11例，盆腔淋巴结转移性鳞状细胞癌1例；309例5年内未发现病变，治愈率为96.26%，失败率为3.74%。2：TCT阳性患者17例，共计25次；其中HSIL2例，均证实复发（2/2）、LSIL(5/9)、ASC-H(1/4)、ASCUS(4/10),其阳性预测值分别为100%、55.56%、25.00%、40.00%。3：241例（受检率75.1%）患者术后接受HPV分型检测；HPV感染的有80例（1-5次），共计131次,HPV16、58、52、18阳性患者各23例、16例、14例、7例，对上述4种型别的感染通过联合TCT检查、定期复查或阴道镜检查误诊率为：5.6%、6.25%、14.29%、0%。对LEEP后HPV感染率的比较采用卡方检验，p值=0.01，即LEEP后随访人群随着时间的延长HPV感染率下降趋势有统计学意义。LEEP前HPV感染患者术后HPV清除率的比较采用卡方检验，p值0.01，即LEEP对感染人群的HPV清除效果明显。4：TCT检查、HPV分型检测以及两者联合检测的敏感性、特异性、阳性预测值、阴性预测值分别为：68.75%、99.27%、44.00%、99.73；92.00%、90.43%、17.16%、99.81%；90.00%、99.81%、81.81%、99.90%。5：采用Logistic回归分析示：绝经（p=0.001）、切缘阳性(p=0.035)、HPV感染（p=0.006）是LEEP后CINII、CINIII复发的危险因素;年龄（p=0.639）、病理分级（p=0.262）、累及腺体（p=0.496）与术后复发无统计学关系，不是其复发高危因素。6：随访五年内,术后有生育愿望的16例患者中15例均自然受孕，受孕率为93.75%，除1例孕36+4周早产，1例孕4月定期产检中，余均足月剖宫产分娩。妊娠41例计51次（1-3次），24例因非意愿怀孕行人工流产术29次（1-2次）；有生育史患者18例计19次（1-2次）；胎膜早破及早产率均为10.53%（2/19），择期剖宫产分娩。结论：1.LEEP治疗宫颈上皮内高度病变具有有效性与安全性。2.TCT联合HPV检测阳性、阴性预测值高，是术后随访的可靠方法。3.术后随访方案应根据每位病人的切缘情况、术后HPV检测情况、绝经状况及综合因素评估，加强高危病人的检测，制定个体化检查方案。4.LEEP对患者的受孕率、妊娠结局无明显影响。
[Abstract]:Objective: 1. To analyze the clinical characteristics of high-grade cervical intraepithelial neoplasia (CINII, CINIII) patients, evaluate the efficacy and safety of LEEP in the treatment of high-grade CIN, 2. To explore the value of TCT and HPV detection in the follow-up process, residual, high-risk factors of recurrence, and the impact of surgery on pregnancy outcome.
Methods: 1. From January 2008 to December 2010, 321 conservative LEEP patients with CINII and CINIII patients with CINII were selected from the vaginoscopy clinic of the First Affiliated Hospital of Southern Anhui Medical College. The average follow-up period was 52.2 months. Colposcopy was performed when TCT was diagnosed as ASCUS or above, persistent HPV infection or suspicious complaints were confirmed by pathology. 3. SPSS16.0 was used to analyze the collected data descriptively; _2 test was used to compare the rates; logistic regression was used to analyze LEEP of cervical intraepithelial neoplasia. Residual risk of recurrence was high, and alpha < 0.05 was the test standard.
Results: 1: Follow-up within 5 years found 1 residual case, recurrence in 11 cases, pelvic lymph node metastatic squamous cell carcinoma in 1 case; 309 cases within 5 years did not find lesions, the cure rate was 96.26%, the failure rate was 3.74%. 2: TCT positive patients 17 cases, a total of 25 times; HSIL 2 cases, confirmed recurrence (2/2), LSIL (5/9), ASC-H (1/4), ASCUS (4/10), the positive pre-diagnosis. 3:241 (75.1%) patients received HPV typing test after operation; 80 (1-5) patients with HPV infection, a total of 131 times, 23 HPV 16, 58, 52, 18 positive patients, 16 cases, 14 cases, 7 cases of the above four types of infection through combined TCT examination, regular review or colposcopy misdiagnosis rate: 5.6%, 6.6%. Chi-square test was used to compare the HPV infection rate after LEEP, P = 0.01, that is, the HPV infection rate of the follow-up group after LEEP decreased with the extension of time has statistical significance. The sensitivity, specificity, positive predictive value and negative predictive value of PV typing and combined detection were 68.75%, 99.27%, 44.00%, 99.73, 92.00%, 90.43%, 17.16%, 99.81%, 90.00%, 99.81%, 81.90% respectively. 5: Logistic regression analysis showed that menopause (p = 0.001), margin positive (p = 0.035), HPV infection (p = 0.006) was CINII after LEEP, CINII. CINIII recurrence risk factors; age (p = 0.639), pathological grade (p = 0.262), gland involvement (p = 0.496) and postoperative recurrence were not statistically related, is not a high risk factor for recurrence. Pregnancies were 51 times (1-3 times), artificial abortion 29 times (1-2 times) for unwanted pregnancy in 24 cases, 19 times (1-2 times) for 18 cases with childbearing history, premature rupture of membranes and premature delivery rate were 10.53% (2/19), selective cesarean section.
Conclusion: 1. LEEP is effective and safe in the treatment of high-grade cervical intraepithelial lesions. 2. TCT combined with HPV detection is positive, negative predictive value is high, is a reliable method for postoperative follow-up. 3. Follow-up program should be based on each patient's incision margin, postoperative HPV detection, menopausal status and comprehensive factors evaluation, strengthen the detection of high-risk patients. The individualized examination plan.4.LEEP had no significant effect on the pregnancy rate and pregnancy outcome of the patients.
【学位授予单位】：皖南医学院
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R737.33

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