目的 探讨附件扭转患者的特点及评估不同手术方式对卵巢储备功能的影响.方法 回顾性分析2016 年6 月至2020 年6 月在无锡市妇幼保健院行手术治疗的91 例附件扭转患者的临床特点、手术方式及术后恢复情况,根据手术方式分组,复位或囊肿剥除组为A组,附件切除组为B组.结果(1)91 例患者中90 例(98.90%)术前超声提示有附件包块,包块直径(8.76±3.12)cm,其中 69 例(77.53%)为卵巢良性肿瘤,12 例(13.48%)为生理性囊肿.(2)91 例患者中排除绝经期、单纯输卵管扭转以及病理为交界性肿瘤患者,余下74 例患者中,单纯复位2 例,卵巢囊肿剥除39 例,均纳入A组(41 例),附件切除33 例,纳入B组,两组从腹痛到手术时间、缺血等级比较,差异有统计学意义(P<0.05),均无任何并发症,A组16 例缺血等级3～4 级,在超声随访中,均显示卵泡和血管.(3)A、B两组术前血清AMH水平分别为(3.95±2.42)ng/mL、(2.92±1.82)ng/mL,差异无统计学意义(P>0.05),两组术后 1 周内血清AMH水平与术前比较差异有统计学意义(P<0.05),而术后1 月仅B组血清AMH水平(1.29±1.15)ng/mL与术前(2.92±1.82)ng/mL比较,差异有统计学意义(P<0.05).结论 临床中,通常根据缺血等级、腹痛到手术间隔时间,判断是否可保留卵巢;术后血清AMH水平提示,附件扭转保留卵巢是安全且不损害卵巢储备功能的手术方式.

Objective: To investigate the natural regression and related factors of high-grade squamous intraepithelial lesion (HSIL) in the cervix of childbearing age women, and to evaluate the applicability of conservative management for future fertility needs. Methods: This study included 275 patients of reproductive age with fertility needs, who were diagnosed as HSIL by biopsy from April 30, 2015 to April 30, 2022, including 229 cases (83.3%) cervical intraepithelial neoplasia (CIN) Ⅱ and 46 cases (16.7%) CIN Ⅱ-Ⅲ. They were followed-up without immediate surgery in the First Affiliated Hospital of Nanjing Medical University. The median follow-up time was 12 months (range: 3-66 months). The regression, persistence and progression of lesions in patients with HSIL were analyzed during the follow-up period, the influencing factors related to regression and the time of regression were analyzed. Results: (1) Of the 275 HSIL patients, 213 cases (77.5%, 213/275) experienced regression of the lesion during the follow-up period. In 229 CIN Ⅱ patients, 180 cases (78.6%) regressed, 21 cases (9.2%) persisted, and 28 cases (12.2%) progressed. In 46 CIN Ⅱ-Ⅲ patients, 33 cases (71.7%) regressed, 12 cases (26.1%) persisted, and 1 case (2.2%) progressed to invasive squamous cell carcinoma stage Ⅰ a1. There was no significant difference in the regression rate between the two groups (χ2=1.03, P=0.309). (2) The average age at diagnosis, age <25 years old at diagnosis were independent influencing factor of HSIL regression in univariate analysis (all P<0.05). There was no significant difference between HSIL regression and pathological grading, the severity of screening results, human papillomavirus (HPV) genotype, colposcopy image characteristics, number of biopsies during follow-up and pregnancy experience (all P>0.05). (3) The median regression times for patients aged ≥25 years and <25 years at diagnosis were 15 and 12 months, respectively. Kaplan-Meier analysis showed that age ≥25 years at diagnosis significantly increased the median regression time compared to <25 years (χ2=6.02, P=0.014). Conclusions: For HSIL patients of childbearing age, conservative management without immediate surgical intervention is preferred if CINⅡ is fully evaluated through colposcopy examination. Age ≥25 years at diagnosis is a risk factor affecting the prognosis of HSIL patients.

1 病例资料 患者,女性,58岁,因"阴道疼痛5年,阴道流血6天"入院,既往史及家族史无特殊.患者近5年感阴道刺痛,于2015年2月外院行前庭大腺囊肿造口术,术中见左侧大阴唇后部约3. 5 cm囊性包块,周围组织坚硬,未予活检.7月后出现阴道出血,妇检提示:左侧阴道内见约3 cm × 3 cm实质性肿块,肿块内见2 cm × 2 cm溃烂面,底部达左耻骨下支,组织学检查未见明显病理改变.遂予口服戊酸雌二醇(1 mg,1次/天),治疗2年,阴道刺痛症状逐渐改善.2018年1月患者感阴道疼痛加重,外阴可扪及无痛性包块,外院初步诊断为"前庭大腺脓肿",并予抗感染治疗,患者疼痛未好转.后至我院进一步诊治,入院前6天出现少量阴道出血,入院妇检:左侧前庭大腺肿大,覆盖皮肤正常,延伸至左阴道中下部表面1 cm糜烂,阴道前后侧及右侧壁,包括左穹窿、处女膜边缘、左侧盆腔壁、直肠未见明显侵犯.超声示左侧会阴部低回声肿瘤(见图1A).CT示左侧会阴部不规则软组织密度影,大小为5. 6 cm × 7. 2 cm.增强扫描提示增强不均匀,肿块侵蚀后左侧耻骨骨吸收破坏(见图1B).血液肿瘤标志物检查示CA12546. 81 U/mL,切除部分病灶,活检病理诊断为前庭大腺癌(见图2A～B).予环磷酰胺+顺铂化疗,4个周期后;顺铂+紫杉醇同步放疗,2个周期,后予培美曲塞+顺铂化疗,CT ( 2019 -12 -09 )扫描提示肿块缩小,但伴肺转移(3. 2 cm × 2. 5 cm,见图1C～D).患者未规律来院就诊,失访.