자궁경부 원추절제술 후 병변의 중증도 및 절제연 양성 부위에 따른 잔류종양의 분석
Analysis of residual tumor based on pathologic severity and site of positive margin after cold-knife conization of the uterine cervix
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목적: 원추절제술 후 절제연 양성 부위와 잔류종양과의 연관성 및 처치에 대해 알아보고자 하였다. 방법: 1993년 1월부터 2006년 6월까지 만 14년 6개월간 인제대학교 부산백병원 산부인과에 입원하여 cold-knife 원추절제술을 시행한 후 조직검사상 CIN I, CIN II, CIN III 및 미세침윤암으로 진단된 599명 중 절제연 양성 소견을 보인 환자는 144명 (24%)이었으며, 이들 중 12개월 이상 추적관찰이 되지 않았던 31명을 제외한 113명을 대상으로 병변의 중증도 및 절제연 양성 부위에 따른 잔류종양을 비교하였다. 결과: 병변의 중증도에 따른 절제연 양성률은 CIN I에서는 15명 중 1명 (6.7%), CIN II는 37명 중 8명 (21.6%), CIN III는 450명 중 95명 (21.1%), 미세침윤암은 97명 중 40명 (41.7%)으로 나타나 병변의 중증도가 증가할수록 절제연 양성의 빈도가 증가하 였다 (P=0.0001). 원추절제술 후 12개월 이상 경과 관찰을 시행한 113명의 절제연 양성 환자들 중 잔류종양은 31명 (27.4%)에 서 조사되었는데, CIN I에서는 한명도 없었으나, CIN II는 1명 (12.5%), CIN III는 14명 (18.9%), 미세침윤암의 경우에는 16명 (53.3%)에서 존재하는 것으로 나타나 병변의 중증도가 증가할수록 잔류종양의 빈도가 높았다 (P=0.0028). 절제연 침범 위치 와 잔류종양과의 상관관계를 분석한 결과, 내자궁경부와 외자궁경부 양쪽 절제연 모두를 침범한 환자들의 경우 8명 중 7명 (87.5%)에서 잔류종양이 확인되었고 내자궁경부 절제연 양성 환자는 70명 중 26명 (37.1%)에서 잔류종양이 있었으나, 외자궁 경부 절제연 양성 환자 35명 중에서는 한 명도 잔류종양이 존재하지 않아 내자궁경부 절제연 양성이 잔류종양과 높은 관련 성이 있었다 (P<0.0001). 결론: 원추절제술 후 절제연 양성이라도 잔류종양이 없을 가능성이 많으므로 추가적인 수술을 바로 시행하기보다는 정기적인 추적관찰을 하되, 병변의 중증도가 심하거나 내자궁경부 절제연이 침범된 경우에는 파파니콜로바른표본검사, 인유두종바이 러스검사, 질확대경 등을 통해 잔류종양의 유무를 면밀히 확인해야 한다.
Abstract
Objective: To evaluate correlation of sites of positive margin and residual tumor and to establish management after conization. Methods: Of 599 cold-knife conizations [15 (2.6%) with cervical intraepithelial neoplasia (CIN) I, 37 (6.1%) with CIN II, 450 (75.1%) with CIN III, 97 (16.2%) with microinvasion] performed at our institution from January, 1993 to June, 2006, 144 patients (24.0%) had positive margins and 113 patients were included in the retrospective study excluding 31 cases that were not followed more than 12 months. Correlation of conization pathology and residual tumor according to sites of positive margin were evaluated. Results: The prevalence rates of positive margins were 6.7% (1/15) in CIN I, 21.6% (8/37) in CIN II, 21.1% (95/450) in CIN III, and 41.2% (40/97) in microinvasion. The prevalence rate of positive margin increased with severity of conization pathology (P=0.0001). Of 113 patients followed more than 12 months, 27.4% (31/113) had residual tumor [0.0% (0/1) in CIN I, 12.5% (1/8) in CIN II, 18.9% (14/74) in CIN III, and 53.3% (16/30) in microinvasion]. The prevalence rate of residual tumor increased with severity of conization pathology (P=0.0028). Residual tumor was more common in patients in whom both endocervical and exocervical margins or in whom only the endocervical margin were involved than in those in whom only exocervical margin was involved [87.5% (7/8) or 35.3% (24/68) versus 0% (0/37), respectively]. Conclusions: Expectant management is reasonable for patients with positive margin after conization. However, careful follow-up of these patients is essential, particularly in endocervical involvement.
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