RESUMO
Objective To analyze the performance of colposcopy and investigate the diagnosis and treatment characteristics of high-grade squamous intraepithelial lesion (HSIL) diagnosed by cervical tissue sampling in post-menopausal women. Methods A retrospective study was performed on 1 449 patients with HSIL diagnosed by cervical tissue sampling under colposcopy and treated by loop electrosurgical excision procedure (LEEP) or extrafascial hysterectomy as the primary therapy at the First Affiliated Hospital of Nanjing Medical University, from November 2015 to October 2017. In order to investigate the diagnosis and treatment of HSIL in post-menopausal women, a case-control study was conducted to compare the difference in performance of colposcopy and treatment modality between 213 post-menopausal patients (14.7%, 213/1 449) and 1 236 pre-menopausal patients (85.3%, 1 236/1 449). Results (1)The proportion of cases pathologically upgraded to cervical cancer was significantly greater in post-menopausal patients (9.4%, 20/213) compared with pre-menopausal patients (3.8%, 47/1 236; P<0.05). (2) The proportion of ≥HSIL diagnosed by colposcopy showed no significant difference between post-menopausal patients (76.1%, 162/213) and pre-menopausal patients (78.2%, 967/1 236; P=0.479). The proportion of typeⅢtransformation zone (TZ) was significantly greater in post-menopausal patients (91.1%, 194/213) compared with pre-menopausal patients (59.1%, 731/1 236; P<0.05). The rate of missed diagnosis of cervical cancer was significantly higher in typeⅢTZ (6.4%, 59/925) compared with typeⅠand(or)ⅡTZ (1.5%, 8/524; P<0.05). The proportion of HSIL detected by endocervical curettage alone was greater in post-menopausal patients (9.9%, 21/213) compared with pre-menopausal patients (2.6%, 32/1 236; P<0.05). (3)Initial treatment with LEEP: the positive rate of endocervical margin was significantly greater in post-menopausal patients (20.5%, 36/176) compared with pre-menopausal patients (10.5%, 130/1 236;P<0.05); in patients who were diagnosed as HSIL after LEEP, the positive rate of endocervical margin and the residual rate were both greater in post-menopausal patients compared with pre-menopausal patients [15.4% (25/162) versus 8.8% (105/1 189), P=0.008; 52.0% (13/25) versus 26.7% (28/105), P=0.014]. (4)Thirty-seven post-menopausal patients were treated by extrafascial hysterectomy as the primary therapy, 5 cases (13.5%, 5/37) were diagnosed as cervical cancer (stage Ⅰa1) after the surgery. Conclusions (1) The lesions of HSIL in post-menopausal patients still have definite features under colposcopy as same as pre-menopausal patients. Endocervical curettage could help detect more HSIL in post-menopausal patients. Compared with pre-menopausal patients, post-menopausal HSIL patients have an increased risk of cervical cancer and are more likely missed by cervical tissue sampling. (2) LEEP has the dual effects of diagnosis and treatment, and is still the recommended treatment for post-menopausal HSIL patients. However, the increase in positive rate of endocervical margin and residual rate requires further active intervention. (3) Considering those post-menopausal HSIL patients who cannot accept conization as the initial treatment, the selection of hysterectomy type requires more thorough study.
RESUMO
Objective To observe the missed diagnosis of invasive carcinoma under the microscope (ICUM) in high grade squamous intraepithelial neoplasia (HSIL), and analyze associated factors influencing missed ICUM. Methods A retrospective study was performed on patients diagnosed with HSIL by colposcopy-guided biopsy and treated with loop electrosurgical excision procedure(LEEP)at the First Affiliated Hospital of Nanjing Medical University, from December 2014 to December 2016. They were non-pregnant, ≤50 years old and the cervical volume without obvious enlargement and exogenous surface without and ulcerative lesions. A total of 283 cases with early cervical cytology results, never received cervical traumatic treatment or cervical biopsy in another hospital before, and their colposcopic images were clear enough to reevaluate. The ultimate pathological diagnosis was based on the higher-level pathological diagnosis between the results of cervical biopsy and LEEP to evaluate ICUM missed in HSIL and the risk factors. Results (1) Among the 283 cases with HSIL diagnosed by colposcopy-directed biopsy,44 cases (15.5％,44/283) were missed diagnosis of ICUM, which consisted of 29 cases Ⅰa1, 4 cases Ⅰa2 and 11 cases Ⅰb1 in the ultimate pathology.(2)Analysis of associated factors for missed ICUM:univariate analysis showed that,as the age increased, the risk of missed ICUM also increased(the rates of missed diagnosis for<30, 30-39, 40-50 years were 7.7％, 11.5％, 22.0％, respectively;χ2=6.254, P=0.012 by trend test). The more the number of high-grade features, the higher risks(the rates of missed diagnosis for 1, 2, 3, 4 high-grade features were 10.2％, 17.6％, 23.8％, 30.8％, respectively;χ2=7.686,P=0.006 by trend test). The locations of HSIL were only endocervical, only ectocervical and mixed, the risk increased by this sequence(2.8％, 5.1％, 28.7％; χ2=26.193,P<0.01 by trend test). The rate of missed diagnosis for not completely visible squamocolumnar junction(SCJ)was higher than that of the completely visible one(22.3％ vs 2.1％;χ2=19.680, P<0.01). The rate of missed diagnosis was higher for existing atypical vessels than those without(60.7％ vs 10.6％;χ2=48.279, P<0.01). The rate of missed diagnosis for visible lesion size≥40 mm2 was higher than that of<40 mm2(27.3％vs 4.2％;χ2=28.921, P<0.01). The rate of missed diagnosis for the proportion of visible lesion size in ectocervical size ≥0.75 was higher than that of <0.75 (83.3％ vs 14.1％;P<0.01). The rate of missed diagnosis for the maximum linear length of visible lesion≥10 mm was higher than that of<10 mm(46.9％vs 9.0％;χ2=44.473, P<0.01). But the different severity of cervical cytology before colposcopy was not associated with missed ICUM(P>0.05). Multivariable analysis found that visibility of SCJ, atypical vessels, visible lesion size and maximum linear length of visible lesion were associated with missed diagnosis of ICUM(all P<0.05). Conclusions The diagnostic value of HSIL by colposcopy is limited. Meanwhile, for the patients who are ≤50 years old with HSIL diagnosed by cervical biopsy, invisibility of SCJ, atypical vessels, visible lesion size and maximum linear length of visible lesion evaluated by colposcopy are the independent risk factors of missed ICUM. Thereby, it is necessary to take active intervention for HSIL with these risk factors.