[Discussion on the diagnosis and treatment of high-grade squamous intraepithelial lesions in post-menopausal women].

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 type Ⅲ transformation 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 type Ⅲ TZ (6.4%, 59/925) compared with type Ⅰ and(or) Ⅱ TZ (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.目的： 探讨绝经后子宫颈活检诊断为高级别鳞状上皮内病变（HSIL）患者的阴道镜下表现及其诊治特点。 方法： 回顾性分析南京医科大学第一附属医院2015年11月至2017年10月期间，阴道镜下子宫颈活检诊断为HSIL，并接受子宫颈环形电切术（LEEP）或筋膜外子宫全切除术治疗的1 449例患者的临床病理资料，比较绝经组[已绝经者，213例（14.7%，213/1 449）]与未绝经组[未绝经者，1 236例（85.3%，1 236/1 449）]患者的阴道镜表现、诊断和处理方法。 结果： （1）接受LEEP或筋膜外子宫全切除术后，绝经组阴道镜下活检漏诊子宫颈癌的比例高于未绝经组，分别为9.4%（20/213）和3.8%（47/1 236），两组比较，差异有统计学意义（χ(2)=12.860，P<0.05）。（2）绝经组阴道镜下图像评估≥HSIL的比例与未绝经组比较，差异无统计学意义[分别为76.1%（162/213）和78.2%（967/1 236），P=0.479]；绝经组Ⅲ型转化区的比例高于未绝经组[分别为91.1%（194/213）和59.1%（731/1 236），P<0.05]；Ⅲ型转化区者阴道镜下活检漏诊子宫颈癌的比例高于Ⅰ~Ⅱ型转化区者[分别为6.4%（59/925）和1.5%（8/524），P<0.05]；绝经组单独由子宫颈管搔刮术（ECC）检出HSIL的比例高于未绝经组[分别为9.9%（21/213）和2.6%（32/1 236），P<0.05]。（3）初始治疗采用LEEP的患者：绝经组的内切缘阳性率高于未绝经组[分别为20.5%（36/176）和10.5%（130/1 236），P<0.05]；初始治疗采用LEEP并诊断为HSIL的患者中，绝经组的内切缘阳性率[分别为15.4%（25/162）和8.8%（105/1 189），P=0.008]及病变残留率[分别为52.0%（13/25）和26.7%（28/105），P=0.014]均高于未绝经组。（4）37例绝经组患者初始治疗采用筋膜外子宫全切除术，术后诊断子宫颈癌Ⅰa1期5例（13.5%，5/37）。 结论： （1）与未绝经者相同，绝经后阴道镜下活检诊断为HSIL的患者，其阴道镜图像仍具有明确的≥HSIL病变表现。同时，绝经后ECC能增加HSIL的检出；相比未绝经者，绝经后HSIL患者合并子宫颈癌的风险增加，且易被阴道镜下活检漏诊。（2）LEEP具有诊断与治疗双重效果，仍是绝经后HSIL推荐的处理方式，缺点是内切缘阳性率及病变残留率增加，需进一步干预。（3）对于绝经后无法将锥切术作为初始治疗的HSIL患者，子宫切除术的类型选择有待更加深入的研究。.