Clinical Characteristics And Surgical Methods Of Cervical High Grade Squamous Intraepithelial Lesions In Postmenopausal Women

Objective:To analyze and discuss the clinical features of cervical high grade squamous intraepithelial lesion(HSIL)in postmenopausal women,the pathological upgrade(or missed diagnosis of cervical cancer)or positive margins after cervical conization or hysterectomy as well as the related influencing factors so as to provide a reasonable clinical diagnosis and treatment basis for the selection of initial treatment options for postmenopausal cervical HSIL patients.Methods:This study retrospectively analyzed 581 patients with cervical HSIL diagnosed pathologically by colposcopy biopsy from November 2017 to June 2020 who were hospitalized in the First Affiliated Hospital of Dalian Medical University for surgical treatment,including 104 postmenopausal cases and 477 non-menopausal cases(as control).Surgical methods include cervical conization[loop electrosurgical excision procedure(LEEP)or cold knife conization(CKC)]and hysterectomy.The pathological diagnosis of cervical cancer after cervical conization or hysterectomy is defined as pathological upgrade(or missed diagnosis of cervical cancer).Positive margin refers to the initial treatment of cervical conization after the pathology suggests that HSIL lesions are still visible on the cervical margin or the distance between the margin and the residual HSIL lesion is less than 1mm.The?~2test was used to compare the postmenopausal group and the non-menopausal group’s postoperative pathological upgrade and the positive rate of resection margins,and the univariate(?~2 test)and multivariate(logistic regression)analyses were used to analyze the high-risk factor of pathological upgrade and positive resection margins in postmenopausal women.Results:1.581 patients were enrolled,including 104 postmenopausal patients(17.90%of the total),of which 64 were initially treated with cervical conization(61.54%,LEEP 26cases and CKC 38 cases),40 cases(38.46%)were hysterectomy;477 non-menopausal patients(82.10%)taken as control,of which 454 were initially treated with cervical conization(95.18%,LEEP 27 cases and CKC 427 cases),23 cases(4.82%)were hysterectomy.There was a statistically significant difference in surgical methods between the postmenopausal and non-menopausal groups(P<0.001).2.The postoperative pathological upgrade rate of all patients was 6.71%(39/581),of which 15.38%(16/104)in the postmenopausal group and 4.82%(23/477)in the non-menopausal group.There was a difference in the postoperative pathological upgrade rate between the two groups,which was statistically significant(?~2=15.213,P<0.001),indicating that postmenopausal patients are at high risk of missed diagnosis of cervical cancer under colposcopy.Among the 40 patients in the postmenopausal group who were initially treated with hysterectomy,6 cases(15.00%)were pathologically upgraded after surgery and all were cervical squamous cell carcinoma(3cases of stage IA1,1 case of stage IA2,2 cases of stage IB1),and among them,1 patient of stage IA2 and 1 patient of IB1 had insufficient surgical range scope;among the 64patients in the postmenopausal group who were initially treated with cervical conization,10(15.63%)were pathologically upgraded to cervical cancer(1 case of adenocarcinoma,9 cases of squamous cell carcinoma),but the postoperative pathological upgrade rate of the two kinds of treatment was not statistically significant(?~2=0.007,P=0.932).3.A univariate analysis of postoperative pathological upgrade in the postmenopausal group found that there was no significant difference in menopausal time,preoperative TCT and HPV,pathological diagnosis of colposcopy biopsy and endocervical curettage(ECC)results(P>0.05).The multivariate(logistic regression)analysis found that there was a statistically significant difference in HPV16/18 infection before surgery(P<0.05).A univariate analysis of postoperative pathologically upgraded patients in the non-menopausal group found that there was a statistically significant difference in HPV16/18 infection before surgery,but there was no statistical significance in multivariate analysis.Therefore,compared with non-menopausal patients,the preoperative HPV16/18 infection in cervical HSIL patients in the postmenopausal group is an independent risk factor for postoperative pathological upgrade.4.The positive rate of the resection margins after cervical conization in all patients was6.56%(34/518),18.75%(12/64)in the postmenopausal group(6 cases in the LEEP group and 6 cases in the CKC group),and 4.85%in the non-menopausal group(22/454)(3 cases in the LEEP group and 19 cases in the CKC group),the difference in the positive rate of the resection margin between the two groups was statistically significant(?~2=15.488,P<0.001),indicating that the postmenopausal state is the risk factor for positive margins after cervical conization.Univariate and multivariate analyses of patients with positive margins in the postmenopausal group found that the preoperative TCT≥HSIL was statistically significant(P<0.05).A univariate analysis of patients with positive margins in the non-menopausal group found that the preoperative TCT≥HSIL difference was statistically significant,while the multivariate analysis had no statistical significance for the preoperative TCT≥HSIL.Therefore,preoperative TCT≥HSIL is an independent risk factor for positive margins after cervical conization in the postmenopausal group.Further analysis of the 12 patients in the postmenopausal group with positive margins after cervical conization,10 patients underwent secondary surgery within 6 months(all were hysterectomy),and 6 patients(60%)were found residual lesions(5 cases of HSIL,1 case of cervical squamous cell carcinoma stage IA1);of the22 patients in the non-menopausal group with positive margins after cervical conization,12 cases underwent secondary surgery within 6 months after surgery(1 case of cervical conization,11 cases of hysterectomy),of which 3 cases(25%)had residual lesions(all were HSIL),but the difference in the rate of residual lesions between the two groups was not statistically significant(P=0.192).Conclusions:1.Compared with non-menopausal patients,postmenopausal women with cervical HSIL pathologically diagnosed by colposcopy biopsy have a higher rate of pathological upgrade after cervical conization or hysterectomy.The preoperative HPV16/18 infection is the independent risk factor for postoperative pathological upgrade in postmenopausal women.2.Compared with non-menopausal patients,postmenopausal cervical HSIL patients have a higher rate of positive margins after cervical conization.The existence of HSIL and above lesions in TCT before surgery is an independent risk factor for positive margins.3.Cervical conization should still be the first choice for the treatment of postmenopausal cervical HSIL patients,and further diagnosis and treatment should be selected according to the pathological diagnosis after cervical conization.Hysterectomy is only the last resort for some patients who cannot use cervical conization as the first choice of treatment.