Moore B C, Higgins R V, Laurent S L, Marroum M C, Bellitt P
Department of Obstetrics and Gynecology, Carolinas Medical Center, Charlotte, USA.
Am J Obstet Gynecol. 1995 Aug;173(2):361-6; discussion 366-8. doi: 10.1016/0002-9378(95)90253-8.
The optimal management of cervical intraepithelial neoplasia after cold knife conization remains controversial. Reliable predictors of residual dysplasia in the cervix after cold knife conization have not been consistently identified. This study was initiated to examine the accuracy of the traditional factors used to predict residual dysplasia in hysterectomy specimens after cold knife conization.
A retrospective 10-year chart review identified a cohort of 1272 patients who underwent cold knife conization, of whom 311 had a subsequent hysterectomy within 1 year of conization. Residual disease was defined as cervical intraepithelial neoplasia or cancer in the hysterectomy specimen. All cone specimens were completely submitted for pathologic examination, and the following factors were analyzed for their predictive value: degree of dysplasia, margin involvement, endocervical gland involvement, and status of the endocervical curettage. The predictive value of age, race, gravidity, parity, socioeconomic status, cigarette smoking, and marital status were also examined. The chi 2 test, t test, and logistic regression were used for statistical analysis.
Dysplasia or cancer were identified in 1066 (84%) of the 1272 patients who underwent cold knife conization. Of the 311 patients having a subsequent hysterectomy, 106 (34%) had residual disease in their hysterectomy specimen. By multivariate analysis only increasing age and degree of dysplasia were predictive of residual disease. The odds ratio of residual disease in the hysterectomy specimen for a 25-year-old woman was 2.7 (95% confidence interval 1.6 to 4.4) compared with a 40-year-old woman whose odds ratio was 4.9 (95% confidence interval 2.2 to 10.8). The presence of dysplasia in the cold knife conization specimen conferred an odds ratio of 12.1 (95% confidence interval 2.7 to 54.5) of identifying residual disease. Dysplasia involving the ectocervical margin, endocervical margin, and endocervical glands was not predictive of disease in the hysterectomy specimens. Endocervical curettage was not performed in 44% of the patients, preventing reliable statistical evaluation. Further analysis indicated that residual disease was found in 32% of the hysterectomy specimens with negative margins, in 31% with no endocervical gland involvement, and in 23% with a negative endocervical curettage sample.
The presence or absence of dysplasia in the cold knife conization ectocervical margin, endocervical margin, and endocervical glands was not predictive of residual dysplasia in post-cold knife conization hysterectomy specimens. Increasing age and severity of disease in the cone specimen were the only factors that accurately predicted residual dysplasia. The traditional factors used to justify hysterectomy after cold knife conization may not be valid on the basis of these results.
冷刀锥切术后宫颈上皮内瘤变的最佳管理仍存在争议。冷刀锥切术后宫颈残留发育异常的可靠预测指标尚未得到一致确定。本研究旨在检验用于预测冷刀锥切术后子宫切除标本中残留发育异常的传统因素的准确性。
一项为期10年的回顾性图表审查确定了一组1272例行冷刀锥切术的患者，其中311例在锥切术后1年内接受了子宫切除术。残留疾病定义为子宫切除标本中的宫颈上皮内瘤变或癌症。所有锥切标本均完整送检病理检查，并分析以下因素的预测价值：发育异常程度、切缘受累情况、宫颈管腺体受累情况以及宫颈管刮除术结果。还检查了年龄、种族、妊娠次数、产次、社会经济地位、吸烟状况和婚姻状况的预测价值。采用卡方检验、t检验和逻辑回归进行统计分析。
1272例行冷刀锥切术的患者中，1066例（84%）被诊断为发育异常或癌症。在311例随后接受子宫切除术的患者中，106例（34%）子宫切除标本中有残留疾病。多因素分析显示，只有年龄增长和发育异常程度可预测残留疾病。25岁女性子宫切除标本中残留疾病的优势比为2.7（95%置信区间1.6至4.4），而40岁女性的优势比为4.9（95%置信区间2.2至10.8）。冷刀锥切标本中存在发育异常使识别残留疾病的优势比为12.1（95%置信区间2.7至54.5）。宫颈外口切缘、宫颈管切缘和宫颈管腺体的发育异常并不能预测子宫切除标本中的疾病。44%的患者未进行宫颈管刮除术，无法进行可靠的统计学评估。进一步分析表明，切缘阴性的子宫切除标本中32%发现残留疾病，无宫颈管腺体受累的标本中31%发现残留疾病，宫颈管刮除样本阴性的标本中23%发现残留疾病。
冷刀锥切宫颈外口切缘、宫颈管切缘和宫颈管腺体中发育异常的有无不能预测冷刀锥切术后子宫切除标本中的残留发育异常。年龄增长和锥切标本中疾病的严重程度是准确预测残留发育异常的唯一因素。基于这些结果，冷刀锥切术后用于证明子宫切除合理的传统因素可能无效。
