자궁경부상피내종양의 원추절제술 후 절제 변연부 상태에 영향을 미치는 인자 분석
THE ANALYSIS OF FACTORS WHICH AFFECT RESECTION MARGIN STATUS AFTER CONIZATION FOR CERVICAL INTRAEPITHELIAL NEOPLASIA
1
조회
0
다운로드
0
인용
0
참고문헌
키워드
초록
목적자궁경부 원추절제술 후 절제 변연부 침범 소견을 보일 때 병변의 중증도가 이에 미치는 영향에 대하여 살펴보고 절제 변연부 침범과 재발 및 잔류종양의 연관성에 대하여 알아보고자 하였다. 연구방법2003년 11월부터 2011년 2월까지 자궁경부 원추절제술을 시행 받은 후 cervical intraepithelial neoplasia (CIN)으로 진단된 환자 202명을대상으로 후향적 연구를 시행하였다. 원추절제술 후 환자는 자궁절제술을 시행 받거나 3-6개월 간격으로 자궁경부세포검사를 통한 추적관찰을 시행하였으며 이상 소견을 보이는 경우 질확대경하에 조직검사를 시행하였다. 재발은 CIN I 이상의 조직 소견을 보이는 경우로 정의하였다. 결과CIN으로 진단된 환자 202명 중 CIN I은 46명(22.8%), CIN II는 35명(17.3%), CIN III는121명(59.9%)이었다. 절제 변연부 침범 소견을 보인 환자는 67명(33.2%)이었고 CIN I은 7명(10.4%), CIN II는 14명(20.9%), CIN III는 46명(68.7%)으로 CIN의 중증도가 심할수록 절제 변연부의 침범 빈도가 증가하였다(P = 0.009). 자궁절제술을 시행 받은 환자는 28명(13.9%)으로 절제 변연부 침범이 없었던 환자는 13명, 절제 변연부침범이 있었던 환자는 15명이었고 각각 7명(53.8%)과 5명(33.3%)에서 잔류 병변이 존재하여 절제 변연부의 침범 여부와 잔류종양의 유무는 통계학적으로 유의한 상관관계를 보이지 않았다(P = 0.445). 보존적 치료를 시행한 환자는 174명으로 이 중 절제 변연부 침범을 보인3명(3/52, 5.7%)과 절제 변연부 침범을 보이지 않은 2명(2/122, 1.6%)의 환자에서만 재발을 보였다(P = 0.335). 결론CIN 환자에 있어 병변의 중등도가 심할수록 절제 변연부 침범이 있을 가능성이 크지만 절제 변연부의 침범이 있다 하더라도 실제적으로잔류 병변이 없는 경우가 더 많으며 절제 변연부의 침범 여부가 재발과는 유의한 상관관계가 없는 것으로 나타났다. 따라서 변연부 침범소견을 보이는 경우라도 지속적 추적관찰만 잘 이루어 질 수 있다면 CIN의 치료로 충분하다 할 수 있겠다. 또한 절제 변연부의 침범이 없는 경우에도 잔류종양이 남아 있을 가능성이 있으므로 주의 깊은 추적관찰이 필요할 것으로 생각된다.
Abstract
Objective The aim of this study was to evaluate the correlation between resection margin status after conization and severity of dysplasia and to evaluate the risk of residual disease and recurrence for positive resection margin after conization. Methods We retrospectively reviewed the medical and histopathological records of 202 patients who underwent conization that revealed cervical intraepithelial neoplasia (CIN) at Myongji Hospital, Kwandong University College of Medicine between November 2003and February 2011. Patients were followed up every three to six months with cervicovaginal smears, and suspected cases of recurrence were subjected to colposcopy and biopsy. Results A total of 202 patients underwent conization (46 [22.8%] with CIN I, 35 [17.3%] with CIN II, 121 [59.9%] with CIN III) and were enrolled this study. The cone resection margin involved in 33.2% (67/202) of the patients (7/67 [10.4%] with CIN I, 14/67 [20.9%]with CIN II, 46/67 [68.7%] with CIN III). The frequency of resection margin involvement after conization was higher with increasing severity of CIN (P = 0.009). Hysterectomy was performed in 28 patients (13.9%). The incidence of residual disease was 53.8% (7/13)in resection margin free group and 33.3% (5/15) in resection margin involvement group (P = 0.445). There were three (3/52, 5.7%)recurrence in resection margin involvement group and two (2/122, 1.6%) recurrence in resection margin free group (P = 0.335). Conclusion The risk of resection margin involvement after conization increased with increasing severity of CIN. However, the women with involvement of resection margin after conization often have no residual disease and there was no difference in recurrence between the resection margin status. Therefore, patients whose resection margins were involved after conization could be managed conservatively.
참고문헌 (31)
- The Korea Central Cancer Registry, National Cancer Center, "Annual report of cancer statistics in Korea in 2008" (2010), Ministry of Health and Welfare
- Wright TC Jr, "2006 consensus guidelines for the management of women with cervical intraepithelial neoplasia or adenocarcinoma in situ", Am J Obstet Gynecol, 197, pp.340~345 (2007)
- Murta EF, "Importance of surgical margins in conization for cervical intraepithelial neoplasia grade III", Arch Gynecol Obstet, 263, pp.42~44 (1999)
- Schermerhorn TJ, "Clinicopathologic variables predictive of residual dysplasia after cervical conization", J Reprod Med, 42, pp.189~192 (1997)
- Skjeldestad FE, "Residual and recurrent disease after laser conization for cervical intraepithelial neoplasia", Obstet Gynecol, 90, pp.428~433 (1997)
- 이은주, "자궁 경부 원추 생검 상 자궁 경부 상피내 종양 Ⅲ이면서 절제면 양성인 환자들의 처치", Obstetrics & Gynecology Science, 44(9), pp.1664~1670 (2001), 대한산부인과학회
- Ostör AG, "Natural history of cervical intraepithelial neoplasia: a critical review", Int J Gynecol Pathol, 12, pp.186~192 (1993)
- Mitchell MF, "Cervical human papillomavirus infection and intraepithelial neoplasia: a review", J Natl Cancer Inst Monogr, pp.17~25 (1996)
- Martin-Hirsch PL, "Surgery for cervical intraepithelial neoplasia", Cochrane Database Syst Rev, (2), pp.CD001318~ (2000)
- Nuovo J, "Treatment outcomes for squamous intraepithelial lesions", Int J Gynaecol Obstet, 68, pp.25~33 (2000)
- Kalliala I, "Cancer free survival after CIN treatment: comparisons of treatment methods and histology", Gynecol Oncol, 105, pp.228~233 (2007)
- Mitchell MF, "A randomized clinical trial of cryotherapy, laser vaporization, and loop electrosurgical excision for treatment of squamous intraepithelial lesions of the cervix", Obstet Gynecol, 92, pp.737~744 (1998)
- Fine BA, "The pre- and postoperative value of endocervical curettage in the detection of cervical intraepithelial neoplasia and invasive cervical cancer", Gynecol Oncol, 71, pp.46~49 (1998)
- 정선영, "자궁경부 상피내종양 및 미세침윤암의 원추절제술 후 잔류병변에 관한 고찰", Obstetrics & Gynecology Science, 45(11), pp.7~7 (2002), 대한산부인과학회
- Kalogirou D, "Predictive factors used to justify hysterectomy after loop conization: increasing age and severity of disease", Eur J Gynaecol Oncol, 18, pp.113~116 (1997)
- Bertelsen B, "Laser conization of cervical intraepithelial neoplasia grade 3: free resection margins indicative of lesion-free survival", Acta Obstet Gynecol Scand, 78, pp.54~59 (1999)
- Moore BC, "Predictive factors from cold knife conization for residual cervical intraepithelial neoplasia in subsequent hysterectomy", Am J Obstet Gynecol, 173, pp.361~366 (1995)
- Lu CH, "Prediction of persistence or recurrence after conization for cervical intraepithelial neoplasia III", Obstet Gynecol, 107, pp.830~835 (2006)
- 송승훈, "자궁경부 원추절제술 후 절제연 양성인 환자에서 잔류병변의 예측인자", Obstetrics & Gynecology Science, 47(12), pp.2397~2402 (2004), 대한산부인과학회
- Monk A, "Conservative management of options for patients with dysplasia involving endocervical margins of cervical cone biopsy specimens", Am J Obstet Gynecol, 174, pp.1695~1699 (1996)
- 이은숙, "자궁경부 원추절제술 후 병변의 중증도 및 절제연 양성 부위에 따른 잔류종양의 분석", Obstetrics & Gynecology Science, 51(11), pp.1295~1301 (2008), 대한산부인과학회
- Abdul-Karim FW, "Cervical intraepithelial neoplasia after conization: a study of 522 consecutive cervical cones", Obstet Gynecol, 65, pp.77~81 (1985)
- Buxton EJ, "Residual disease after cone biopsy: completeness of excision and follow-up cytology as predictive factors", Obstet Gynecol, 70, pp.529~532 (1987)
- Husseinzadeh N, "Predictive value of cone margins and post-cone endocervical curettage with residual disease in subsequent hysterectomy", Gynecol Oncol, 33, pp.198~200 (1989)
- Hellberg D, "20-year experience of follow-up of the abnormal smear with colposcopy and histology and treatment by co nization or cryosurgery", Gynecol Oncol, 38, pp.166~169 (1990)
- White CD, "Infl ammatory cell infi ltrate in the cervix as a predictor of residual cervical intraepithelial neoplasia after conization", J Reprod Med, 37, pp.799~802 (1992)
- White CD, "Cervical intraepithelial neoplasia extending to the margins of resection in conization of the cervix", J Reprod Med, 36, pp.635~638 (1991)
- Lapaquette TK, "Management of patients with positive margins after cervical conization", Obstet Gynecol, 82, pp.440~443 (1993)
- Reich O, "Cervical intraepithelial neoplasia III: long-term outcome after cold-knife conization with clear margins", Obstet Gynecol, 97, pp.428~430 (2001)
- Paterson-Brown S, "The significance of cone biopsy resection margins", Gynecol Oncol, 46, pp.182~185 (1992)
- Reich O, "Cervical intraepithelial neoplasia III: long-term follow-up after cold-knife conization with involved margins", Obstet Gynecol, 99, pp.193~196 (2002)