应用普通电刀的宫颈锥切术诊治宫颈上皮内瘤变和微小浸润癌的临床观察

背景与目的：高频电波刀电圈切除术和宫颈冷刀锥切术已经广泛应用于宫颈上皮内瘤变（cervical intraepithelial neoplasia，CIN）的诊治中。本研究旨在探讨普通电刀的宫颈锥切术在CIN和微小浸润癌的诊治中的临床应用价值。方法：回顾性分析2004年4月至2006年7月间在我院接受普通电刀的宫颈锥切术的173例患者的临床病理资料。记录手术时间、手术出血量，分析术后病灶残留、手术前后病理符合情况及再次手术情况。结果：173例患者平均年龄37．2岁（23～63岁），绝经3例，未生育者5例。手术中位时间为5min，中位出血量为5ml。锥切标本的病理诊断较阴道镜下活检或宫颈多点活检有降级或升级，各级别病变中手术前后的病理符合率为61．3％（25．0％～72．4％）。在163例术前诊为CIN的患者中，共发现9例微小浸润癌ⅠA1期，3例ⅠA2期。8例术前诊为微小浸润癌ⅠA1期中，3例间质浸润深度超过微小浸润癌范围被诊为局部早期浸润癌ⅠB1期。最后诊为ⅠA1期的14例患者中，1例切缘阳性者再次行锥切术，另有5例行次广泛全子宫切除术。所有ⅠA2期患者和ⅠB1期患者术后接受宫颈癌根治术。最后诊为CIN的151例患者中，3例切缘阳性，其中1例补充行全子宫切除术。2例术前活检阴性者锥切术后被证实为浸润性腺癌，另有3例CIN患者同时合并原位腺癌，术后均予再次手术。结论：应用普通电刀的宫颈锥切术是一种设备简单、手术时间短、出血少，且切净率高的诊治CIN和微小浸润癌的方法。其对宫颈微小浸润癌、局部早期浸润癌和腺癌的诊断率高。锥切术后为早期浸润癌或切缘阳性者，应根据具体情况进一步处理。     

宫颈锥切和子宫切除在子宫颈上皮内瘤变Ⅲ级治疗中的临床探讨

目的探讨宫颈锥切和子宫切除在子宫颈上皮内瘤变（CIN）Ⅲ级诊断和治疗中的价值。方法选择2006年1月至2008年12月间经阴道镜活检后诊断为CINⅢ级患者306例,年龄25～62岁,其中首选行宫颈锥切术者177例;首选行子宫切除术者129例,比较两种不同手术方法在诊断和治疗CINⅢ级的差异。结果行宫颈锥切术的177例患者术后病理结果：阴性为2例,CINⅠ级为8例,CINⅡ级为26例,CINⅢ级为97例,镜下浸润18例,早期浸润癌为26例。行子宫全切术的129例患者术后病检结果：阴性4例,CINⅠ级6例,CINⅡ级11例,CINⅢ级78例,镜下早侵13例,早期浸润癌为17例,两组患者术前术后病理结果比较差异无统计学意义（P=0.56）。宫颈锥切术的177例患者有效随诊率为88.1%,显著高于子宫全切术患者的有效随诊率（71.3%）（P〈0.05）。在对治疗结果的满意度调查上,宫颈锥切组明显优于子宫全切组。结论宫颈锥切是诊断和治疗CINⅢ级病变的合理方法,建议CINⅢ级患者可以先作宫颈锥切,切下宫颈组织作进一步的病理检查,明确病变程度,指导手术范围的选择。     

冰冻病理检查诊断宫颈上皮内瘤变Ⅲ级和评估锥切组织边缘状态的作用

目的 探讨冰冻病理检查方法用于诊断宫颈上皮内瘤变Ⅲ级(CINⅢ)和评估锥切组织边缘状态的作用.方法 对36例宫颈上皮内瘤变Ⅲ级患者(CINⅢ),进行宫颈锥切术或者子宫切除术,采用冰冻病理检查方法对患者的锥切标本进行诊断,术中对保留的宫颈取材组织行切片检查,分析并比较冰冻病理与石蜡病理检查的结果,同时评估锥切组织边缘状态,考察组织切缘病灶残留情况.结果 ①所有病患术中冰冻病理检查诊断结果:2例宫颈浸润癌,29例CINⅢ,3例CINⅡ,2例CINⅠ.术后石蜡病理检查诊断结果:30例CINⅢ,2例CINⅡ,2例CINⅠ以及2例宫颈浸润癌.②锥切标本、锥切后宫颈取材组织的冰冻病理检查和术后宫颈石蜡病理检查结果均提示3例患者锥切组织边缘状态为阳性,接受子宫切除术以后显示有残留病灶.33例患者锥切组织边缘状态为阴性,接受子宫切除术以后均显示无残留病灶.结论 冰冻病理检查能有效诊断CINⅢ,并能够准确评估锥切组织边缘状态是否还有残留病灶.     

宫颈锥切诊治CIN Ⅲ和宫颈癌ⅠA1期临床观察

[目的]探讨宫颈锥切对宫颈上皮内瘤变(CIN)Ⅲ及宫颈癌ⅠA1期的诊治作用。[方法]回顾性分析2002年1月至2004年12月行宫颈锥切术的114例患者的临床资料。[结果]宫颈锥切前多点活检准确率为87.7%(100/114)。宫颈粘连狭窄率为3.2%。21例患者补充全子宫切除术,切缘阳性者标本残留率为28.6%(2/7)、阴性者则为14.3%(2/14)。中位随诊16个月,仅行锥切术的93例患者(切缘阳性者2例、切缘阴性者91例),1例切缘阴性者复发(占1.1%)。11例患者有生育要求,已妊娠9例(81.8%),其中早产率为12.5%(1/8)。[结论]宫颈锥切是一种并发症少的手术方法,可提高CINⅢ、宫颈癌ⅠA1期的诊断准确性并有治疗作用。锥切治疗后复发率低,切缘阳性者易有残留,术后应适当处理及密切随诊。     

23例CIN宫颈锥切术后再处理的初步分析

目的探讨CIN宫颈锥切术后切缘阳性或高级别CIN病人的处理.方法回顾分析1999年1月至2004年5月23例CIN锥切术后再治疗的临床资料,并将锥切术后的病理与进一步治疗后病理进行分析比较.23例锥切病人中切缘阳性者10例(LEEP 9例、CKC 1例),切缘阴性者13例.再治疗者采用子宫切除术19例(82.6%),冷刀锥切(CKC)3例,局部切除1例.结果全组再次术后标本中无病变者6例(26.1%),降级者10例(43.5%),相符者7例(30.4%).锥切切缘阳性和阴性再次术后的宫颈残存病灶分别为80%(8/10)和69.2%(9/13),二者无统计学差异(P=1.0).锥切切缘为浸润癌(均为外院LEEP术后)的3例中2例术后为腺癌,且均有肌层浸润.锥切标本中发现3例早期浸润癌,术后1例降级,2例转阴.17例高级别CIN(CIN2～31例、CIN3 16例)术后23.5%相符,52.9%降级,23.5%转阴.结论CIN锥切术后为浸润癌者,必须及时处理.应严格掌握LEEP术的适应证,尤其怀疑腺癌时宜采用冷刀锥切术以明确诊断.术后为早期浸润癌和高级别的CIN、切缘阳性者,应根据具体情况进一步处理.     

宫颈上皮内瘤变锥切术切缘阳性的相关因素分析

目的 宫颈上皮内瘤变(cervical intraepithelial neoplasia,CIN)是与宫颈浸润癌密切相关的一组癌前期病变.宫颈锥切术已成为CIN患者首选的治疗方法,手术病理切缘阳性是宫颈锥切术后病变复发的危险因素.本研究通过对接受宫颈冷刀锥切术(cold knifecone,CKC)或环形电切除术(loop electrosurgical excision procedure,LEEP)的CIN患者进行回顾性分析,探讨造成宫颈锥切术切缘阳性的原因,旨在降低切缘阳性率.方法 回顾性分析沈阳市妇婴医院2013-01-01-2014-12-31经阴道镜宫颈活检诊断为CIN并接受宫颈锥切术471例患者,对患者年龄、是否绝经、HPV感染、病变范围、手术方式、病变级别和术后病理提示宫颈上皮腺体受累等7种因素与宫颈锥切术后切缘阳性率做相关性分析.结果 471例宫颈锥切术患者中63例术后病理提示切缘阳性,阳性率为13.38％.单因素分析结果显示,宫颈锥切术后切缘阳性与HPV感染(x2=8.470,P＜0.05)、手术方式(x2=8.851,P＜0.01)、病变级别(x2=9.842,P＜0.05)及宫颈上皮腺体受累(x2=3.560,P＜0.05)有关,与患者年龄(t=1.293,P＞0.05)、是否绝经(x2=0.204,P＞0.05)及病变范围(x2 =0.498,P＞0.05)无关.多因素Logistic回归分析显示,HPV感染、LEEP和宫颈高级别病变是CIN锥切术后切缘阳性的危险因素.其中HPV感染因素,与HPV阴性组比较,HPV低危和高危组OR值分别为2.611(95％CI为1.214～5.615)和2.338(95％CI为1.100～4.968);病变级别因素,与CINⅠ比较,CINⅡ、CINⅢ和早期宫颈癌组OR值分别为7.903(95％CI为1.046～29.725)、27.852(95％CI为4.131～86.835)和21.548(95％CI为1.373～124.877).结论 HPV感染、LEEP及CIN高级别病变是造成宫颈锥切术切缘阳性的高危因素,在CIN制定宫颈锥切手术方式时应予以重视.     

宫颈锥切诊治CINⅢ宫颈癌ⅠA1期临床观察

[目的]探讨宫颈锥切对宫颈卜皮内瘤变（CIN）Ⅲ及宫颈癌ⅠA1期的诊治作用。[方法]回顾性分析2002年1月至2004年12月行宫颈锥切术的114例患者的临床资料。[结果]宫颈锥切前多点活检滞确率为87．7％（100／114）。宫领粘连狭窄率为3.2％。21例患者补允全子宫切除术，切缘阳性者标本残留率为28．6％（2／7）、阴性者则为14．3％（2／14）。中位随诊16个月．仅行锥切术的93例患者（切缘阳性者2例、切缘阴性者91例）。1例切缘阴性者复发（占1．1％）。11例患者有生育要求，已妊娠9例（81．8％），其中早产率为12．5％（1／8）。[结论]宫颈锥切是一种并发症少的手术方法，可提高CINⅢ、宫颔痛ⅠA1期的诊断准确性并有治疗作用。锥切治疗后复发牢低．切缘阳性者易有残留．术后应适当处理及密切随诊。     

宫颈上皮内瘤变锥切术后补充手术的临床分析

目的探讨宫颈上皮内瘤变(CIN)锥切术后切缘阳性或病理升级患者补充手术的必要性及合适的处理方法。方法回顾性分析2007年1月至2009年1月25例宫颈上皮内瘤变患者经冷刀锥切术(CKC)和宫颈环形电锥切术(LEEP)后再补充手术的临床资料,并将锥切术后的病理与补充手术后的病理进行比较分析。结果 25例行锥切术患者术后病理示切缘阳性5例,病理升级20例。25例均行补充手术,术后病理示13例(52%)无病变,9例(36%)病理降级,3例(12%)与补充手术前病理相符,无1例出现病理升级。结论宫颈锥切术后病理若为浸润癌者需补充手术治疗,切缘阳性者进行个体化治疗,而术后病理升级为更高级别的CIN或宫颈原位癌,可对其进行HPV和细胞学随访而不需补充手术治疗。     

子宫颈锥形切除术相关问题探讨(附390例临床分析)

目的:探讨子宫颈锥形切除术(宫颈锥切)在宫颈疾病诊治中的价值、手术方法、指征、范围和锥切后再处理问题.方法:对北京协和医院2005年11月～2007年10月的390例宫颈锥切资料进行回顾分析,其中210例为普通电刀锥切,180例为冷刀锥切.结果:1)患者的宫颈活检诊断包括宫颈上皮内瘤样变3级(CIN3)311例(79.7%),不排除早期宫颈浸润癌39例(10.0%),CIN2 31例(7.9%),CIN,和非CIN病变9例(2.3%).2)全组平均锥切高度(锥高)1.95cm,其中81例(20.8%)切缘阳性,电刀锥切组的锥高和切缘阳性率与冷刀锥切组相近,但手术时间短,出血少.3)锥切病理诊断包括CIN:或以下病变110例,CIN3 242例,宫颈浸润癌38例,3组的切缘阳性率分别为4.5%,22.5%和57.9%(P＜0.05).4)锥切后再处理包括随诊278例(71.3%),全子宫切除95例(24.4%),广泛子宫切除术15例(3.8%),再次锥切2例(0.5%).结论:锥切是诊治CIN和早期宫颈癌的重要手术,不能被阴道镜多点活检取代;电刀锥切是一种可行的手术方法;切缘状况与宫颈病变严重程度有关.锥切后再处理的选择需根据锥切病理、患者年龄、生育要求和切缘状况综合考虑.     

宫颈上皮内瘤变315例手术前后病理分析

背景与目的:宫颈上皮内瘤变(cervical intraepithelial neoplasia, CIN)是宫颈癌的癌前期病变.近年来,越来越多的年轻女性被诊断出CIN,如何正确而适度的处理CIN是临床处理的目标.本文通过对宫颈上皮内瘤变患者手术治疗前后病理情况分析,探讨治疗宫颈上皮内瘤变的合理方式.方法:对2004年4月至2006年11月间我院收治的315例行宫颈锥切术或子宫切除术的CIN 患者进行回顾性分析.比较不同手术治疗前后组织病理诊断,并随访治疗后复发情况.结果:315例患者中,232例(73.65%)行锥切治疗,26例(8.25%)行全子宫切除,57例(18.1%)行次广泛子宫切除.232例锥切治疗患者,术后病理转阴22例,级别升高36例,其中浸润癌20例.锥切术后继续手术治疗15例,其中5例证实有病灶残留.在子宫切除的83例患者中,病理阴性4例,微早浸润癌ⅠA1期3例,浸润癌1B1期4例,该4例接受再次手术或放射治疗.214例锥切为最终治疗,术后未再治疗的CIN患者中,随访中发现5例(2.4%)再次出现宫颈病变.结论:宫颈锥切是一种能准确诊断宫颈病变并能较好治疗CIN的方法.建议对于CIN患者应尽量先行宫颈锥切,根据锥切后病理情况及患者对保留生育功能的要求再决定进一步的处理方案.     

宫颈癌及癌前病变相关危险因素分析

目的分析宫颈癌及癌前病变的相关危险因素。方法选取2010年12月至2013年12月间收治的宫颈上皮瘤样变和宫颈癌患者1 876例,其中宫颈上皮内瘤样变Ⅰ级、Ⅱ级、Ⅲ级和宫颈癌患者分别为776例、401例、482例和217例。另选取同期接受健康检查的育龄期妇女1239例作为对照组,对其进行阴道镜检查并病理检查证实未出现宫颈上皮瘤样变,调查并分析两组人群的临床资料。结果与对照组相比,宫颈上皮内瘤样变Ⅰ级、Ⅱ级与HPV感染、生产次数、文化程度、户籍等相关。宫颈上皮瘤样变Ⅲ级和宫颈癌与HPV感染、生产次数、初次性生活年龄、户籍、性生活年限等相关。结论宫颈癌的发生发展与HPV感染、初次性生活年龄及生产次数等相关,临床工作者在宫颈癌防治工作中应将其作为重点,加强宣教及随访管理。     

Reversal of cervical dysplasia with hyperthermia

Purpose: Patients with recurrent cervical carcinoma within a previously irradiated area respond poorly to chemotherapy. We have treated these patients with simultaneous cisplatin and hyperthermia (CDDP?+?HT) and investigated response, toxicity, palliative effect and survival.

Materials and methods: Between 1992 and 2005 47 patients received CDDP?+?HT. Response was evaluated by gynaecologic examination and CT-scan. The Common Toxicity Criteria (CTC) were used for evaluation of toxicity and palliative effect. The Kaplan-Meier method was used to estimate survival, and Cox regression analysis to evaluate the influence of prognostic factors.

Results: The objective response rate was 55%, palliation was achieved in 74% and operability in 19% of patients. Two patients are currently disease free at 9 years and 18?+?months following treatment and 2 remained disease free until death by other causes. The median survival was 8 months and was influenced by duration of disease free interval and tumour diameter. Grade 3–4 haematological toxicity was observed in 36% of patients and renal toxicity was maximum grade 2.

Conclusion: CDDP?+?HT results in a high response rate and acceptable toxicity in patients with recurrent cervical cancer.     

Prevention of cervical cancer with vaccines

Worldwide, cervical cancer is one of the most common cancers in women. This is especially true in developing countries, where Papanicolaou smear screening, an effective preventive measure against cervical cancer, is insufficiently implemented. With growing evidence for human papillomavirus as a central etiologic factor in cervical neoplasia, development of a vaccine against this virus has emerged as an important objective in prevention of cervical cancer. International efforts in vaccine development have culminated in advancement of various vaccine strategies and initiation of human clinical trials. Reports from animal vaccine trials and early phase I human trials indicate markedly enhanced immune response through vaccination. However, the clinical significance of these results requires confirmation from long-term human trials.     

Long-term survival with thorotrast cervical granuloma

Thorium dioxide, a radioactive contrast material, was commonly used for cerebral angiography prior to recognition of its radiation hazard. Extravasation of the material into the extravascular tissue in the neck results in granuloma formation, thorotrastoma, long-term morbidity, and an increased incidence of benign and malignant tumors. We report our experience with the management of 2 patients who underwent cerebral angiography with thorotrast more than 25 years ago. Aggressive surgical excision of involved tissue is warranted to ameliorate symptoms and diminish the risk of malignancy.     

Serum retinol level and risk of subsequent cervical cancer in cases with cervical dysplasia

We followed up on 134 women who had been diagnosed with cervical dysplasia to examine the relationship of dietary and serum vitamin A to subsequent cervical cancer. The subjects were women attending the Papanicolaou test screening for residents in Miyagi, Japan and histologically diagnosed as having cervical dysplasia between October 1987 and September 1988. Personal interviews were carried out, and blood samples were taken on the date of diagnosis of cervical dysplasia. The subjects were followed-up with cervical smear and colposcopy at about 3-month intervals from the date of interview until the end of February 1995. During the follow-up, 8 women (5.9%) developed cancer in situ or invasive cervical cancer and 106 (79.1%) reverted to normal. The rate of progression of the cancer in situ or invasive cervical cancer was 4.5 times higher in women with lower serum retinol levels than those with higher serum retinol levels (p = 0.08). The results suggest an association of low serum retinol level with development of cervical cancer.     

High-risk human papilloma virus and cervical abnormalities in HIV-infected women with normal cervical cytology

Background

The prevalence of High-Risk Human papilloma virus (HR-HPV), a necessary cause of invasive cervical cancer (ICC) is relatively high in HIV infected women. Gaps exist in our knowledge of the optimal approaches for managing women who have HR-HPV with normal cervical cytology (NCC) particularly in settings of HIV infection.

Methods

Between May 2012 and June 2013 we conducted a colposcopic assessment of HIV-infected women with prior (NCC) and known HR-HPV status to compare cervical abnormalities in women with and without HR-HPV. Colposcopic examinations were done at the Operation Stop Cervical Cancer (OSCC) unit of the Jos University Teaching Hospital (JUTH), Jos, Nigeria. Abnormal colposcopic finding (ACF) was defined as areas of aceto-white epithelium involving the squamo-coulumnar junction, areas of punctation, mosaic pattern or atypical vessels. We compared proportions of ACF as well as histologic grades of cervical intra-epithelial neoplasia (CIN) in women with or without HR-HPV. Statistical analysis was done on STATA.

Results

We conducted colposcopic examinations in 78 out of 89 (86.5%) eligible women. The mean age of the cohort was 32.4 years (SD ±4.6) with a median 32 years (IQR 29–36). After a mean follow up time of 20.1 months from the initial cervical pap cytology and HR-HPV testing, we found 12 of 78 (15.4%) women with ACF. The odds for an ACF was statistically higher [OR = 4.0 (95% CI: 1.1-14.7)] in women with HR-HPV compared to those without. Of the twelve women with ACF, subsequent histologic examination of colposcopically directed cervical biopsies confirmed CIN 1 in 4 cases (33.3%), CIN 2 in 1 case (8.3%), CIN 3 in 2 cases (16.7%), carcinoma-in-situ (CIS) in 2 cases (16.7%), and normal cervix in 3 (25.0%). Overall, the proportion of women detected with any grade of CIN was 11.5% (9/78) and 6.4% (5/78) were CIN 2 or greater lesion (CIN2+).

Conclusion

HIV-infected women with NCC and HR-HPV had a four-fold higher likelihood for an ACF. The practice of early colposcopic examination of HIV-infected women with prior NCC and HR-HPV may increase early detection of higher grade CIN and CIS cancer stages in our setting.

     

Ovarian metastasis in patients with cervical cancer

The study included a total of 634 patients with cervical cancer; 311 were in stage I b and 323 were in stage II. All patients received radical hysterectomy at the Department of Obstetrics and Gynecology, Kinki University, between May 1975 and December 1986. One out of 311 patients in stage I b (0.3%) and eight out of 323 patients in stage II (2.5%) had ovarian metastases confirmed histologically. Nine patients who had ovarian metastases were investigated about stages, histological types of the cervical cancer (WHO and CPL classification), incidence of metastases in pelvic lymph nodes, corpus infiltration, parametrial infiltration, and peritoneal cytology. Results obtained were as follows: 1. As to histological types, patients with adenocarcinoma and/or PL type in CPL classification had high incidence of ovarian metastases. 2. Patients with corpus infiltration had high incidence of ovarian metastases. 3. Metastases to both ovary and pelvic lymph nodes tended to occur on the same side, but ovarian metastases and parametrial infiltration did not necessarily occur on the same side. We suggest removal of ovaries, even before menopause, in patients with cervical cancer who have cervical adenocarcinoma, or corpus infiltration, or are suspicious for metastases in more than two pelvic lymph nodes.     

Survival of patients with untreated cervical carcinoma

Patients infrequently present with advanced-stage cervical malignancy in the United States, where access to care and aggressive screening, detection, and treatment regimens are the standard. Neglected cancer is more likely in countries with underdeveloped healthcare delivery systems; yet in this new millennium, we foresee not only an aging population with modern medicine able to prolong life expectancy, but also attentive screening regimens even amid the older old. Taking into account common comorbid illness from which patients used to die, informed consent in making a treatment in the robust and frail elderly becomes a new challenge. Recognizing an ever-growing population in today's culture of patient-directed care, clinicians may find patients choosing alternative modalities or simply declining conventional therapies. The difficult dilemma then arises about how to inform a patient most accurately of her prognosis in an untreated condition. In the past, virtually all patients in the United States traditionally received some treatment for cervical cancer on diagnosis; thus, review was made of archival published literature to document survival of patients with untreated cervical cancer.