龚宇,罗爽,何佳,周春艳
GONG Yu,LUO Shuang,HE Jia,ZHOU Chunyan

• 1:遂宁市中心医院妇产科

摘要(Abstract)：

目的 建立高强度聚焦超声联合宫腔镜下清宫术对瘢痕妊娠疗效预测模型。方法 收集138例行高强度聚焦超声联合宫腔镜下清宫术治疗瘢痕妊娠患者的一般资料、妊娠相关指标及手术相关指标，根据疗效将患者分为手术成功组和手术失败组，比较2组患者一般资料、妊娠相关指标及手术相关指标；以LASSO回归筛选变量后行多因素logistic回归分析、筛选出独立性影响因素，根据logistic回归结果构建列线图模型。结果 138例高强度聚焦超声联合宫腔镜下清宫术患者中，有15例(10.87%)手术失败；LASSO回归筛选出5个潜在变量，多因素二元logistic逐步回归分析结果显示孕周≥6周、孕囊≥3 cm、术前血人绒毛膜促性腺激素(HCG)水平≥10~5 IU/L、瘢痕妊娠分型外生型为高强度聚焦超声联合宫腔镜下清宫术失败的危险因素，瘢痕厚度≥3 cm为保护性因素(P<0.05);以R软件构建列线图模型，ROC曲线下面积(AUC)为0.911,95%CI为0.827～0.999(P<0.05);以Bootstrap法对列线图进行内部验证、原始数据重复抽样1 000次，平均绝对误差为0.032,H-L拟合优度检验结果显示列线图模型预测概率与实际观察的手术失败率存在较好的一致性(P>0.05),列线图模型预测概率阈值为0.1～0.95时列线图模型临床获益率最高。结论 高强度聚焦超声联合宫腔镜下清宫术治疗瘢痕妊娠疗效受孕周、孕囊大小、术前血HCG水平等因素的影响，本研究构建的列线图模型对患者疗效具有较高的预测准确度与区分度，在预测概率阈值为0.1～0.95时列线图模型临床获益率最高。
Objective To establish a predictive model for the efficacy of high-intensity focused ultrasound(HIFU) combined with hysteroscopic hysterectomy on scar pregnancy so as to evaluate it. Methods One hundred and thirty-eight patients with scar pregnancy who underwent HIFU combined with hysteroscopic hysterectomy were selected for retrospective analysis. General data, pregnancy-related indicators, and surgery-related indicators were collected retrospectively. The patients were divided into 2 groups according to the curative effect: Successful Surgery Group and Failed Surgery Group. The general data, pregnancy-related indicators, and surgery-related indicators of the two groups were compared. The independent influencing factors were screened out by Multivariate logistic regression(MLR), and the nomogram model was constructed according to Logistic regression results. Results Fifteen cases(10.87%) of 138 patients with HIFU combined with hysteroscopic hysterectomy failed in the surgery. LASSO regression screened out 5 latent variables. The binary MLR showed that the risk factors for exogenous HIFU combined with hysteroscopic hysterectomy failure including gestational age ≥ 6 weeks, gestational sac ≥ 3 cm, preoperative blood HCG level ≥105 IU/mL, and scar pregnancy classified as exogenous type, while scar thickness ≥3 cm was a protective factor(P<0.05). The nomogram model was constructed with R software. The area under the curve(AUC) of the ROC method predicted by the model was 0.911, and the 95% CI was 0.827-0.999(P<0.05). The nomogram was verified internally by Bootstrap method, and the original data was repeatedly sampled 1000 times. The results showed that the mean absolute error was 0.032, and the H-L goodness-of-fit test showed that there was a good agreement between the predicted probability of the nomogram model and the observed failure rate(P>0.05). The decision curve showed that when the predicted probability threshold of the nomogram model was 0.1-0.95, the clinical benefit rate of the nomogram model was the highest. Conclusion The efficacy of HIFU combined with hysteroscopy in the treatment of scar pregnancy is mainly affected by the risk factors such as gestational age, gestational sac size, and preoperative blood HCG level. The nomogram model constructed in this study has high accuracy and discrimination for the prediction of curative efficacy. When the prediction probability threshold is 0.1-0.95, the nomogram model has the highest clinical benefit rate.

关键词(KeyWords)： 高强度聚焦超声;宫腔镜下清宫术;瘢痕妊娠;疗效预测;多因素分析;列线图模型
high-intensity focused ultrasound(HIFU);hysteroscopic hysterectomy;scar pregnancy;efficacy prediction;multi-factor analysis;nomogram model

Abstract:

Keywords:

基金项目(Foundation): 四川省医学会科研课题(S18025)

作者(Author): 龚宇,罗爽,何佳,周春艳
GONG Yu,LUO Shuang,HE Jia,ZHOU Chunyan

参考文献(References)：

• [1]王超，李蓉，乔杰，等．剖宫产瘢痕妊娠的流行病学与临床诊治[J]．中华生殖与避孕杂志，2020(2):161-165．
• [2]欧阳振波，罗凤军，钟碧婷，等．美国母胎医学会关于剖宫产瘢痕妊娠指南的解读[J]．现代妇产科进展，2021,30(1):54-57．
• [3]HUO X,XIE Y,YANG L,et al.Doppler ultrasound evaluation of the efficacy of high intensity focused ultrasound in treatment of cesarean section scar pregnancy[J].J Coll Physici,2020,30(3):240-244．
• [4]WANG W,JIANG J,CHEN Y,et al.The effect of ultrasound-guided high-intensity focused ultrasound treatment for cesarean scar pregnancy on ovarian reserve[J].Int JHyperther,2021,38(1):1409-1414．
• [5]YIN Y,PAN F,HE M,et al.High intensity focused ultrasound combined with ultrasound-guided suction curettage treatment for cesarean scar pregnancy:a comparison of different HIFU sonication strategies[J].Int J Hyperther,2022,39(1):390-396．
• [6]LEGRIS M L,GABRIELE V,HOST A,et al.Cesarean scar pregnancy:Two case report and therapeutic management algorithm[J].J Gynecol Obstet Hum,2021,50(4):102056-102059．
• [7]王超，姚颖，李蓉，等．剖宫产瘢痕妊娠的流行病学研究:现状与展望[J]．中国妇产科临床杂志，2021,22(4):444-445．
• [8]朱小刚，石丘玲，邓新粮，等．聚焦超声消融手术联合负压吸引术治疗包块型CSP的临床效果及影响因素分析[J]．中华妇产科杂志，2022,57(4):253-258．
• [9]HE S,XUE M,JIANG J.Early versus late hysteroscopic resection after high-intensity focused ultrasound for retained placenta accreta[J].Int J Hyperther,2021,38(1):257-262．
• [10]MO R,KALBURGI S,THAKUR Y,et al.Successful hysteroscopy and curettage of a caesarean scar ectopic pregnancy[J].BMJ Case Reports CP,2021,14(4):241183-241186．
• [11]LIU L,ROSS W T,CHU A L,et al.An updated guide to the diagnosis and management of cesarean scar pregnancies[J].Curr Opin Obstet Gyn,2020,32(4):255-262．
• [12]TANG Q,QIN Y,ZHOU Q,et al.Hysteroscopic treatment and reproductive outcomes in cesarean scar pregnancy:experience at a single institution[J].Fertil Steril,2021,116(6):1559-1566．
• [13]MILLER R,TIMOR-TRITSCH I E,GYAMFI-BANNER-MAN C,et al.Society for Maternal-Fetal Medicine(SMFM) consult series#49:cesarean scar pregnancy[J].Am J Obstet Gynecol,2020,222(5):2-14．
• [14]ABD ELAZEEM H A S,SAAD M M,AHMED I A,et al.High-intensity focused ultrasound in management of placenta accreta spectrum:a systematic review[J].Int JGynecol Obstet,2020,151(3):325-332．
• [15]LIU X,TANG J,LUO Y,et al.Comparison of high-intensity focused ultrasound ablation and secondary myomectomy for recurrent symptomatic uterine fibroids following myomectomy:a retrospective study[J].BJOG J Obstet Gy,2020,127(11):1422-1428．
• [16]TSAI M C,CHANG L T,TAM K W.Comparison of high-intensity focused ultrasound and conventional surgery for patients with uterine myomas:a systematic review and meta-analysis[J].J Minim Invas Gyn,2021,28(10):1712-1724．
• [17]WANG Y,LIU X,WANG W,et al.Long-term clinical outcomes of US-guided high-intensity focused ultrasound ablation for symptomatic submucosal fibroids:a retrospective comparison with uterus-sparing surgery[J].Acad Radiol,2021,28(8):1102-1107．
• [18]SORRENTINO F,DE FEO V,STABILE G,et al.Cesarean scar pregnancy treated by artery embolization combined with diode laser:a novel approach for a rare disease[J].Medicina,2021,57(5):411-413．
• [19]SHE C,LI S,WANG X,et al.High-intensity focused ultrasound ablation as an adjuvant surgical salvage procedure in gestational trophoblastic neoplasia chemotherapy with chemoresistance or recurrence:two case reports[J].Int J Hyperthermia,2021,38(1):1584-1589．
• [20]WU G,LI R,HE M,et al.A comparison of the pregnancy outcomes between ultrasound-guided high-intensity focused ultrasound ablation and laparoscopic myomectomy for uterine fibroids:a comparative study[J].Int J Hyperthermia,2020,37(1):617-623．
• [21]QU W,LI H,ZHANG T,et al.Comparison of different treatment strategies in the management of endogenic caesarean scar pregnancy:a multicentre retrospective study[J].BMC Pregnancy Childb,2022,22(1):1-7．
• [22]LI Y,SU Y,KONG F,et al.The value of transvaginal sonography in predicting salvage use of laparoscopy for cesarean scar pregnancy[J].Clin Exp Obstet Gyn,2021,48(6):1368-1373．
• [23]ZHANG Y,ZHANG C,HE J,et al.The impact of gestational sac size on the effectiveness and safety of high intensity focused ultrasound combined with ultrasoundguided suction curettage treatment for caesarean scar pregnancy[J].Int J Hyperther,2018,35(1):291-297．
• [24]LIANG W,YANG P,HUANG R,et al.A combined nomogram model to preoperatively predict histologic grade in pancreatic neuroendocrine tumorspreoperative prediction of histologic grade in p NETs[J].Clin Cancer Res,2019,25(2):584-594．
• [25]WANG S,YANG L,CI B O,et al.Development and validation of a nomogram prognostic model for SCLC patients[J].J Thoracic Oncol,2018,13(9):1338-1348.

文章评论(Comment)：