宫颈上皮内瘤变术后复发及残留高危因素分析

发布时间：2018-09-16 21:48

【摘要】：宫颈上皮内瘤变(CIN)是一组与子宫颈浸润癌的发生密切相关的子宫颈病变,该病变主要发生在25-35岁的妇女。低级别的CIN大部分是可以消退的,但高级别的CIN有癌变的可能,可以发展为浸润癌,被视为癌前病变。近年来CIN及宫颈癌的发病率在逐渐上升,而且发病的年龄也越来越趋向于年轻化。宫颈上皮内瘤变病理分级分三级:CIN1、CIN2、CIN3,其中CIN3包括重度不典型增生和原位癌,这三级反映了从宫颈病变发展成为宫颈癌的连续过程,从CIN发展成为宫颈癌大约需要10年的时间。所以做到CIN的早发、早诊、早治可以降低宫颈癌的发病率。临床上宫颈癌的诊断要遵循“三阶梯”原则:即宫颈细胞学检查、阴道镜检查和病理学检查,病理学检查是诊断宫颈癌的金标准。临床对CIN的治疗方法有激光治疗、电凝治疗、冷冻治疗等,但传统的方法创伤较大,患者术后并发症发生率较高且易复发,目前临床上主要应用宫颈环形电切术(LEEP)和冷刀锥切术(CKC)来治疗宫颈上皮内瘤变,有显著的治疗效果,但是仍有患者术后会复发。2013年美国阴道镜及宫颈病理协会(ASCCP)宫颈癌筛查新指南推荐:对于组织学诊断为CIN2、CIN3者,不建议采用表面破坏治疗,而推荐诊断性宫颈锥切术,但术后会有1%-25%患者治疗失败。CIN治疗失败可能会导致CIN术后的复发,也有发展为浸润癌的可能,所以,分析出宫颈锥切术后复发及残留的高危因素,区分出CIN治疗后复发的高危患者,这些患者术后要严密随访发现病变及时进一步治疗,可以达到早期预防CIN的复发的目的,这样能有效的控制疾病的复发和进展。本研究通过回顾性病例分析的方法,分析CIN患者临床病理资料与CIN术后复发残留之间的关系。目的:评估LEEP和CKC治疗CIN的临床疗效,通过对两种手术的术中出血量、术后并发症及术后复发率等方面进行比较,根据患者的病变级别为患者提供安全有效的治疗方式,减少患者术后的复发残留,提高患者的治愈率。分析CIN患者的临床病理资料,研究CIN患者术后病变复发、残留与患者年龄、孕次、产次、是否绝经、术前病理分级、cin3病变点数(≥3)、宫颈糜烂样改变程度、手术方式、术后病理切缘情况、腺体受累、术前及术后6个月hpv感染,scc、肿瘤家族史、吸烟及饮酒等因素之间的相关性,通过单因素多因素分析找出与cin患者术后复发及残留相关的高危因素,区分出cin治疗后容易复发的高危患者,对他们进行严密的术后随访,若发现病变及时进一步治疗,以达到早期预防cin的复发的目的,有效的控制疾病的复发和进展。材料与方法:收集大连医科大学2012年6月-2014年12月收治的256例cin患者的临床病理资料,使用spss19.0统计软件进行统计分析,采用t检验、pearsonx2检验和logistic回归分析等方法,回顾性分析leep和ckc在治疗cin上的临床疗效,分析2种手术方式对cin的治愈率、术后复发率等方面的差异,通过单因素及多因素分析cin患者术后复发、残留与患者的年龄、孕次、产次、绝经、术前病理分级、cin3病变点数、宫颈糜烂样改变程度、手术方式、术后病理切缘情况、腺体受累、术前及术后6个月hpv感染,scc、肿瘤家族史、吸烟及饮酒等因素的相关性。结果:本研究共纳入256例cin患者,其中100例患者于本院门诊行leep术,156例患者于本院手术室行ckc术,术后共随访24个月,共有20例患者术后复发,其中leep组有14例(14%),ckc组有6例(3.85%),leep组术后复发率明显高于ckc组(or=4.070,95%ci=1.509-10.979),所以ckc的治疗效果要明显高于leep组。将cin患者的临床病理资料通过单因素分析得出,cin术后复发残留与患者的产次(≥2)、绝经、术前病理分级、cin3病变点数(≥3点)、手术方式、术后切缘阳性、术后6个月hpv持续阳性显著相关(x2值分别为7.024;7.449;12.502;5.769;8.723;15.00;40.693),差异具有统计学意义(p≤0.05);而与患者的年龄、孕次、宫颈糜烂样改变程度、术前hpv感染、scc值、肿瘤家族史、吸烟饮酒史及术后腺体累及情况并无相关性(p0.05)。对cin术后复发残留相关的可能因素进行多因素logistic回归分析可见,绝经、cin3病变点数≥3、术后切缘阳性、术后6个月hpv持续阳性是cin患者术后复发的独立危险因素(or值分别为22.853;7.625;16.351;29.691),差异均有统计学意义(p≤0.05)。结论:对于cin的治疗,ckc的治疗效果优于leep,ckc的术后复发率明显低于leep。cin患者术后复发残留与患者的产次(≥2)、绝经、术前病理分级、cin3病变点数(≥3点)、手术方式、术后切缘阳性、术后6个月HPV持续阳性等因素显著相关,而与宫颈糜烂样改变程度、SCC、肿瘤家族史、吸烟、饮酒等情况无关。绝经、CIN3病变点数≥3、术后切缘阳性、术后6个月HPV持续阳性是CIN患者术后复发的独立危险因素。
[Abstract]:Cervical intraepithelial neoplasia (CIN) is a group of cervical lesions closely related to the occurrence of invasive cervical cancer, which mainly occurs in women aged 25-35. Most of the low-grade CIns can be regressive, but the high-grade CIns have the possibility of carcinogenesis, can develop into invasive cancer, and are considered as precancerous lesions. The pathological grading of cervical intraepithelial neoplasia is divided into three grades: CIN1, CIN2, and CIN3, in which CIN3 includes severe atypical hyperplasia and carcinoma in situ, reflecting the continuous process from cervical lesions to cervical cancer, which takes about 10 years to develop from CIN to cervical cancer. Therefore, early diagnosis and early treatment of CIN can reduce the incidence of cervical cancer. Clinically, the diagnosis of cervical cancer should follow the "three steps" principle: cervical cytology, colposcopy and pathological examination, pathological examination is the golden standard for the diagnosis of cervical cancer. Cryotherapy and so on, but the traditional method trauma is bigger, the patient's postoperative complication rate is higher and easy to recur, currently the clinical application of cervical loop electrosurgical excision (LEEP) and cold knife conization (CKC) to treat cervical intraepithelial neoplasia, has a significant therapeutic effect, but there are still patients with recurrence after surgery. ASCCP's new guidelines for cervical cancer screening recommend that for histologically diagnosed CIN2 and CIN3, surface destruction therapy is not recommended, but diagnostic cervical conization is recommended, but 1-25% of patients fail to treat after surgery. Failure of CIN treatment may lead to recurrence after CIN surgery, but may also develop into invasive cancer. Therefore, analysis of cervical conization The high risk factors of recurrence and residual after resection can be distinguished from the high risk patients of recurrence after CIN treatment. These patients should be followed up closely to find the lesions and further treatment in time to achieve the purpose of early prevention of recurrence of CIN, so as to effectively control the recurrence and progress of the disease. Objective: To evaluate the clinical efficacy of LEEP and CKC in the treatment of CI N, and to compare the intraoperative bleeding volume, postoperative complications and postoperative recurrence rate of the two kinds of surgery. The clinical and pathological data of patients with CIN were analyzed to study the relapse of CIN and its relationship with age, pregnancy, parity, menopause, preoperative pathological grading, CIN 3 lesion number (> 3), cervical erosion-like changes, surgical methods, postoperative pathological margin, gland involvement, preoperative and postoperative 6. Correlation among monthly HPV infection, scc, family history of tumor, smoking and alcohol consumption was studied. High risk factors associated with postoperative recurrence and residue of CIN patients were identified by univariate and multivariate analysis. High risk patients who were prone to recurrence after CIN treatment were identified and followed up closely. If further treatment was found, the patients would be treated promptly. Materials and methods: the clinical and pathological data of 256 patients with CIN admitted to Dalian Medical University from June 2012 to December 2014 were collected and analyzed by SPSS 19.0 statistical software. t test, Pearson x2 test and logistic regression analysis were used to review the data. Sexually analyze the clinical efficacy of LEEP and CKC in the treatment of cin, and analyze the difference of the cure rate and recurrence rate of CIN between the two surgical methods. Univariate and multivariate analysis was used to analyze the postoperative recurrence of cin, residual and age, pregnancy, parity, menopause, preoperative pathological grading, CIN 3 lesion points, cervical erosion-like changes, surgery. Results: A total of 256 patients with CIN were enrolled in this study. 100 of them underwent LEEP in the outpatient department of our hospital, 156 underwent CKC in the operating room of our hospital. A total of 20 patients were followed up for 24 months. Postoperative recurrence was found in 14 cases (14%) in LEEP group, 6 cases (3.85%) in CKC group, and the recurrence rate in LEEP group was significantly higher than that in CKC group (or = 4.070, 95% CI = 1.509-10.979), so the therapeutic effect of CKC was significantly higher than that in LEEP group. Pathological grading, CIN 3 lesion points (> 3 points), surgical methods, positive incision margin, 6 months after surgery, HPV persistent positive significantly correlated (x2 values were 7.024; 7.449; 12.502; 5.769; 8.723; 15.00; 40.693), the difference was statistically significant (p < 0.05); but with the patient's age, pregnancy, cervical erosion-like changes, preoperative HPV infection, SCC value, tumor home There was no correlation between family history, smoking and drinking history and postoperative gland involvement (p0.05). multivariate logistic regression analysis showed that postmenopausal, CIN3 lesion number (> 3), positive incision margin and persistent positive HPV 6 months after operation were independent risk factors for postoperative recurrence of CIN (or value was 22.85, respectively). Conclusion: For the treatment of cin, the curative effect of CKC is better than that of leep, and the recurrence rate of CKC is lower than that of leep. The recurrence rate of CKC is lower than that of leep. cin. The recurrence rate of CKC is lower than that of leep. The persistent positive rate of HPV was significantly correlated with the degree of cervical erosion, SCC, family history of cancer, smoking and alcohol consumption. Positive incision margin, CIN3 lesion number (>3) and persistent positive rate of HPV 6 months after operation were independent risk factors for recurrence of CIN.
【学位授予单位】：大连医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R737.33

【参考文献】