合并子宫腺肌病对子宫内膜癌进展、诊断及预后影响的研究进展

子宫内膜癌是女性生殖系统最常见的恶性肿瘤,其中部分病例合并子宫腺肌病。两者在疾病起源上均不同程度地受雌激素诱导,且子宫内膜细胞具有类似的生物学特征;子宫腺肌病不仅自身具有子宫内膜恶性转化潜能,也可能通过发挥屏障作用抑制原发子宫内膜癌进展。然而,子宫腺肌病的子宫多伴有形态结构失常,造成合并子宫腺肌病的子宫内膜癌灶累及肌层的影像学对比度下降,并给术后的病理诊断分期带来困扰和挑战。目前,针对合并子宫腺肌病的子宫内膜癌的预后情况仍无统一共识,但更多倾向子宫腺肌病合并症可能是Ⅰ型子宫内膜样腺癌的良好预后指标。本文从子宫内膜癌与子宫腺肌病在病因机制、进展转归等诸多方面存在相似性和相关性出发,探讨总结合并子宫腺肌病对子宫内膜癌进展转归、术前影像学诊断、术后病理分期和预后的影响,以期为临床处理两者共存的相关问题提供参考。     

子宫腺肌病诊治及其与子宫内膜癌关系的研究进展

子宫腺肌病(adenomyosis)是以子宫内膜腺体及间质侵入子宫肌层而导致的以月经过多和进行性痛经为主的一种临床常见疾病,严重影响患者的生活质量,多发生于育龄期经产妇。该病的发病机制尚不明确,目前存在子宫内膜损伤内陷学说、上皮间质转化学说和干细胞学说等各种学说。组织学检查是其诊断的金标准,但临床上常根据患者的临床表现及影像学检查作出初步诊断。子宫腺肌病可导致不孕,并且对整个妊娠过程产生不利影响。子宫腺肌病虽然是一种良性疾病,但近年越来越多报道证实了该病有恶变的风险。研究显示合并子宫腺肌病的子宫内膜癌患者,子宫腺肌病对癌症的侵袭浸润起到保护作用,这类患者往往临床预后更好。子宫腺肌病的治疗包括药物治疗和手术治疗,目前尚无根治性药物,手术是其主要的治疗手段。     

子宫内膜癌病理亚型与生物学行为探讨

本文分析了经我院手术治疗并经病理检查证实的子宫内膜癌173例的临床资料,占同期女性生殖道恶性肿瘤的26.3％。八类子宫内膜癌组织学亚型中以内膜样腺癌最多(73.4％)。内膜样腺癌、腺角化癌、分泌型腺癌、粘液型腺癌,其细胞分化好的,临床期别早的,病灶局限于内膜及浅肌层浸润的,淋巴脉管无转移的,其发生率显著高于腺鳞癌、透亮细胞癌及浆液乳头状腺癌(P<0.05～0.001)。而癌周内膜反应及淋巴细胞浸润,各病理亚型间无差异(P>0.05)。提示:内膜样腺癌、腺角化癌、分泌型腺癌、粘液型腺癌生物学行为较好,而腺鳞癌、透亮细胞癌、浆液乳头状腺癌具有不良的生物学行为,是内膜癌中具有高度危险性的三种亚型。     

子宫腺肌病恶变的研究进展

子宫腺肌病是一种子宫内膜异位性疾病,是妇科常见的良性疾病。子宫腺肌病在某些方面可表现出恶性肿瘤特征,如血管生成与侵袭行为,具有恶变潜能。子宫腺肌病恶变的病理类型以子宫内膜腺癌居多。其发病机制尚不明确,可能与平滑肌细胞异常、高雌激素状态、雌孕激素受体、代谢酶的异常、基因突变及表观遗传学等有关。临床表现不典型,主要症状为异常阴道出血及绝经后阴道出血。子宫腺肌病术前诊断比较困难,特别是早期诊断更为困难,临床上漏诊、误诊率较高,术后病理可诊断此病。治疗以手术为主,辅以放、化疗。预后尚不清楚,有待更多的病例证实。现就子宫腺肌病恶变的研究进展进行综述,旨在为早期诊治提供新思路。     

子宫内膜采集器取材与子宫切除术后病理结果的一致性分析

目的评价子宫内膜采集器在诊断子宫内膜病变中的临床应用价值。方法回顾性分析74例因子宫肌瘤、子宫腺肌病、子宫内膜癌行子宫切除患者的临床资料,术前采用SAP-I子宫内膜采集器（简称采集器）取子宫内膜组织行病理学检查,并与诊断性刮宫和子宫切除术后病理结果进行比较。结果 74例患者采集器取材均满意,采集器、诊断性刮宫与术后标本病理诊断结果的符合率分别是89.2%（66/74）和90.5%（67/74）,两者比较,差异无统计学意义（P〉0.05）。采集器取材诊断子宫内膜息肉和子宫内膜炎与术后标本的诊断符合率为84.0%（21/25）;15例单纯/复杂性增生诊断14例;8例不典型增生和4例子宫内膜样腺癌均与术后符合诊断。采集器取材无子宫穿孔、大出血等并发症的发生。结论子宫内膜采集器取材与诊断性刮宫及子宫切除术后病理诊断符合率较高,可用于筛查子宫内膜病变。     

E-cad、MMP-2在子宫腺肌病与子宫内膜癌中的表达及生物学行为相关性研究

目的:研究Ecad、MMP2在子宫腺肌病、子宫内膜癌中的表达,探讨其表达与子宫腺肌病发生及子宫腺肌病和子宫内膜癌生物学行为的相关性。方法:应用免疫组化SP染色法检测30例子宫腺肌病在位内膜、异位内膜,30例子宫内膜癌,16例对照组子宫内膜Ecad、MMP2的表达。结果:Ecad在子宫腺肌病在位内膜组和子宫内膜癌组中的表达显著低于对照组(P<0.05、P<0.01);Ecad在子宫腺肌病异位内膜组中的表达显著低于子宫腺肌病在位内膜组(P<0.01)。MMP2在子宫腺肌病异位内膜组中的表达显著高于子宫腺肌病在位内膜组及对照组(P<0.01、P<0.01);MMP2在子宫内膜癌组中的表达显著高于对照组(P<0.01)。Ecad、MMP2在子宫腺肌病异位内膜组与子宫内膜癌组中的表达差异均无显著性(P>0.05)。结论:Ecad、MMP2的异常表达可能与子宫腺肌病的发生有关;且可能与子宫腺肌病具有和子宫内膜癌相似的生物学行为有关。     

分段诊刮诊断子宫内膜癌临床价值分析

目的 评价分段诊刮诊断子宫内膜癌的临床价值.方法 回顾分析2000年1月至2002年11月在上海交通大学医学院附属仁济医院收治的52例子宫内膜癌患者,比较分析患者术前的分段诊刮和术后子宫病理,判断肿瘤细胞分级的符合率.结果 以术后子宫病理为标准,所有患者均为子宫内膜腺癌,分段诊刮和术后子宫病理在G1子宫内膜癌符合率为20%,G2肿瘤符合率为61.5%,G3内膜癌符合率为77.8%.G2和G3肿瘤病理诊断符合率同G1肿瘤相比较,差异均有统计学意义(G2对G1,x2=6.6,P=0.010;G3对G1,x2=7.726,P=0.005).14例患者分段诊刮病理提示为"子宫内膜非典型增生",而术后子宫病理均诊断为"子宫内膜腺癌".分段诊刮诊断细胞分级的准确率仅有50%(26/52),根据术后病理报告,48%(24/50)左右的患者肿瘤分级升级.当内膜癌浸润≥1/2子宫肌层深度时,病理诊断苻合率(75.0%)显著高于侵入内膜层者(22.2%),差异有统计学意义(x2=4.735,P=0.030).结论 分段诊刮和术后子宫病理在G3>和≥1/2子宫肌层浸润子宫内膜癌患者保持较高的符合率.与术后病理比较,分段诊刮诊断子宫内膜癌肿瘤细胞组织学级别被降低.临床上应重视分段诊刮的内膜癌病理报告.     

子宫内膜切除术治疗子宫腺肌病32例分析

子宫腺肌病是妇科临床较常见的疾病，治愈的主要手段是全子宫切除术。近年来有报道子宫内膜切除术可用于治疗子宫腺肌病及超过6个月以上的月经过多的患者。我院行子宫内膜切除术（TCRE）治疗超过6个月以上的月经过多、术后病理证实子宫腺肌病患者32例。现将治疗及随访情况报告如下。     

子宫内膜切除术治疗子宫腺肌病28例分析

子宫内膜切除术是通过去除子宫内膜，达到减少经血量目的的腔内手术，主要适应症为功血，可同时切除突向宫腔的肌瘤。腺肌病因有进一步手术的指征，故非适应症。在１９９０年５月至１９９３年４月所施２０８例子宫内膜切除术中，经术中镜下所见，Ｂ超监视示灌流液进入肌层及病理证实，发现子宫腺肌病２８例。经术后３～３４个月随访，２例子宫切除，２６例疗效满意，成功率９２．８６％，月经均有改善，贫血治愈，１８例术前痛经者７７．８％术后痛经消失，２２．２％减轻。文中就子宫内膜切除术能治疗子宫腺肌病的机制进行了探讨，提出子宫腺肌病多发生于育龄妇女，子宫切除的治疗原则常使患者望而却步，若术前能对此病正确诊断，选择轻症患者行子宫内膜切除术，有可能成为代替子宫切除治疗子宫腺肌病的全新方法。     

阴道超声对诊断治疗卵巢子宫内膜异位囊肿及子宫腺肌病的价值

目的探讨阴道超声及血清CA125测定对诊断治疗卵巢子宫内膜异位囊肿及子宫腺肌病的价值。方法对卵巢子宫内膜异位囊肿及子宫腺肌病患者631例进行回顾性分析，术前均经阴道超声检查，部分患者进行了血清CA125测定。结果阴道超声检查卵巢子宫内膜异位囊肿符合率98．7％；子宫腺肌病符合率91．7％；卵巢子宫内膜异位囊肿合并子宫腺肌病符合率95．1％。血清CA125检查卵巢子宫内膜异位囊肿，阳性率39．4％；子宫腺肌病阳性率52．2％；卵巢子宫内膜异位囊肿合并子宫腺肌病阳性率59．2％。结论阴道超声可做为较准确诊断卵巢子宫内膜异位囊肿及子宫腺肌病的首选方法。阴道超声下囊肿穿刺是治疗卵巢子宫内膜异位囊肿的简便、有效的方法之一。血清CA125测定可做为卵巢子宫内膜异位囊肿及子宫腺肌病的协助诊断方法，应进一步完善对照组的研究。     

子宫内膜癌合并子宫肌瘤或（和）子宫腺肌病临床病理分析

目的：分析子宫内膜癌合并子宫肌瘤或（和）子宫腺肌病患者的临床病理特征,比较合并子宫肌瘤或（和）子宫腺肌病的子宫内膜癌与单纯子宫内膜癌的高危因素情况。方法：回顾性分析天津市中心妇产科医院2010年8月—2012年3月收治的298例子宫内膜癌患者的临床病理资料,其中合并子宫肌瘤者106例（35.6%,A组）,合并子宫腺肌病者37例（12.4%,B组）,同时合并子宫肌瘤与子宫腺肌病者48例（16.1%,C组）,单纯子宫内膜癌者107例（35.9%,D组）。结果：A组、C组比D组的手术-病理分期早（Zc分别为2.10和2.06）,肌层浸润浅（Zc分别为1.99和2.23）,雌激素受体（ER）、孕激素受体（PR）阳性检测率高（χ2分别为10.83、5.78;7.75、4.13）,差异均有统计学意义（均P＜0.05）,A组、B组比D组的组织分化好（Zc分别为2.18和2.01）,B组PR阳性检出率高于D组（χ2=3.86）,差异有统计学意义（均P＜0.05）,其他指标与D组比较差异无统计学意义（均P＞0.05）。而A组、B组和C组间比较差异无统计学意义（均P＞0.05）。4组间的腹水细胞学阳性、淋巴结转移、病理类型比较差异无统计学意义（均P＞0.05）。结论：子宫内膜癌合并子宫肌瘤多属雌激素依赖性肿瘤,组织分化好,肌层浸润浅,高危因素较少。单纯性子宫内膜癌高危因素较多。     

Clinicopathologic study of eight cases of uterine body cancers associated with endometriosis interna (uterine adenomyosis)

Among 30 cases of uterine body cancers, in eight cases (Stage IA, two cases; Stage IB, six cases) uterine adenomyosis was demonstrated microscopically. The age range was from 46 to 66 years with a median of 56. When these eight cases were compared with the 12 cases of Stage I endometrial cancer without adenomyosis, there was no difference in either menstrual history or family history, although past histories of hypertension and diabetes mellitus were found in these eight cases. The mean obesity index was 127 in eight cases and 116 in 12 cases. Seven of these eight cases were pure tubular adenocarcinoma. From the standpoint of early myometrial infiltration of the endometrial cancer, these eight cases not only provided a good model to survey early endometrial cancer but also suggested a common stimulus, such as estrogen, in both endometrial cancer and uterine adenomyosis.     

子宫腺肌病对子宫内膜癌的作用及相关机制的研究进展

子宫内膜癌是最常见的妇科恶性肿瘤之一,子宫腺肌病亦是常见的良性妇科疾病,均病因不明.两者既是两种独立的妇科疾病,又存在着错综复杂的联系.从流行病学以及临床病理特征来看,子宫腺肌病可能是子宫内膜癌发生的危险因素,但同时又是抑制子宫内膜癌进展的保护性因素.在疾病发生发展中,两者在分子信号通路、雌激素及其受体作用以及错配修复...     

子宫肌腺症的临床病理特点及手术指征的探讨

目的:探讨子宫肌腺症的临床病理特点及手术指征。方法:2004年1月至12月手术治疗且病理证实为子宫肌腺症340例,其中全子宫切除284例,保守手术(子宫肌腺症病灶切除术)56例,回顾分析其临床病理特点并探讨手术方式及指征。结果:340例子宫肌腺症中合并子宫内膜异位囊肿95例(27.94%),合并子宫肌瘤148例(43·5%),合并贫血95例(27.9%),合并子宫内膜息肉20例(5.9%)。痛经组与无痛经组患者合并不孕症差异无统计学意义(P>0.05),两组合并内膜息肉有显著的统计学差异(P<0.01),痛经者合并内膜息肉是非痛经组的5倍,95%CI为0.079~0.509。两组合并子宫内膜异位囊肿有显著的统计学差异(P<0.01)。痛经患者合并卵巢子宫内膜异位症的风险是无痛经患者的3.369倍,95%CI为1.699~6.681。多因素Logistic回归分析表明,绝经前、月经量多和子宫大的患者易并发卵巢子宫内膜异位囊肿;年轻、分娩次数多和痛经重的患者易并发子宫内膜息肉;绝经前年轻女性和子宫体积大的患者易并发子宫肌瘤。分析不同手术途径表明:腹腔镜组年龄偏低,贫血、不孕比例明显增高。结论:对年轻合并性交痛、肛门坠痛等症状,伴有贫血或不孕患者首选腹腔镜检查/手术;子宫较大、B超提示合并肌瘤或既往有剖宫产史,估计盆腔粘连重者选择开腹手术;合并子宫脱垂、尿失禁等盆底组织缺陷性疾病选择阴式途径完成。保留子宫的手术可以根据患者主要症状、手术医师的技能和仪器来选择术式。对年龄大且无生育要求,合并贫血、子宫肌瘤,服药有严重副作用或无明显疗效的可行全子宫切除术。     

Utilidad de la histeroscopia en el manejo del sangrado uterino anormal

Hysteroscopy is currently considered the test that enables not only the diagnosis but also the treatment of intrauterine pathology in patients with symptoms of abnormal uterine bleeding caused by structural abnormalities such as polyps, adenomyosis, submucosal fibroids, endometrial hyperplasia, or endometrial cancer. The miniaturization of the diameter of hysteroscopes with working channels, the bipolar mini-resector, and the hysteroscopic morcellation systems have allowed outpatient treatment, sometimes at the same time as hysteroscopic diagnosis, providing greater satisfaction, reducing surgical and/or anaesthesia risks and enabling rapid cost-effective resolution of symptoms. This article reviews the usefulness of hysteroscopy for the diagnosis and treatment of intrauterine structural pathology causing abnormal uterine bleeding.     

Abscess in adenomyosis mimicking a malignancy in a 54-year-old woman

BACKGROUND: Although there are a few reports describing abscess formation in endometriotic foci no report of abscess formation arising de novo within adenomyosis appears in the literature. Preoperative diagnosis of adenomyosis is frequently difficult because of non-specific signs and symptoms. Synchronous pelvic pathologies such as leiomyoma, endometrial polyp, endometrial hyperplasia, as well as endometrial cancer may cause differential diagnostic problems. CASE: A 54-year-old postmenopausal woman complaining of inguinal pain, nightsweats and hot flashes is presented. Radiologic examinations of the pelvis revealed a 95 x 85 mm leiomyoma-like lesion including a 53 x 43 mm cystic space and 9 x 6 mm papillary formation within the uterus raising clinical suspicion of malignancy. A total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed accompanied by a frozen section diagnosis. The frozen section revealed an abscess formation arising in a focus of adenomyosis. The postoperative period of the patient was uneventful. CONCLUSION: The present case, to our knowledge, is the first report representing abscess formation in adenomyosis. Abscess arising within adenomyosis can strongly raise the suspicion of endometrial cancer, particularly if the patient is postmenopausal. If endometrial cancer cannot be ruled out with definitive histopathological diagnosis in the preoperative period, a frozen section becomes mandatory during surgical intervention.     

Incidence of adenomyosis uteri in a Greek population.

The reported incidence of adenomyosis based on unselected hysterectomies varies so widely that conclusions regarding the influence of any factor on that incidence are difficult to reach, although the relation of adenomyosis uteri to endometrial carcinoma has been the subject of only a few studies. In a 5-year period at the General Hospital of Athens, 646 hysterectomies were performed. All data were retrieved from the surgical pathology laboratory files concerning adenomyosis uteri with either simultaneous endometrial carcinoma or endometrial hyperplasia. A control population was selected from patients operated upon for a variety of benign pelvic diseases. Adenomyosis was found in association with endometrial carcinoma in 17.5% of 40 cases, and in association with endometrial hyperplasia in 21.6% of 60 cases. The control series of 546 patients had a 26% incidence of adenomyosis. The results of our study do not indicate any correlation between adenomyosis uteri and endometrial carcinoma.     

Tamoxifen and giant endometrial polyps

Tamoxifen is a synthetic non-steroid anti-estrogen that has been used effectively for several years in the adjuvant treatment of breast cancer. Although its therapeutic effect is due to its anti-estrogenic properties, the drug also shows modest type B estrogen-receptor agonist activity during the menopausal period in which estrogens are at a low level. Owing to the fall in estrogen levels in menopause, tamoxifen provokes an up-regulation of both estrogen and progesterone receptors at an endometrial tissue is a direct consequence of this. This proliferation, which is the result of an inappropriate response of the basal layer and the basis for the onset of hyperplasia and polyps in the tissue. At standard therapeutic dosages, tamoxifen in postmenopausal women is associated with the onset of alterations in the vaginal and endometrial epithelium. Cases of endometrial hyperplasia, endometrial polyps, adenomyosis, endometriosis and fibromyomas are described in the literature. Endometrial polyps represent the most common pathology associated with TAM in women with previous breast cancer in menopause. The estrogenic stimulus to polyps following TAM treatment may be considerable, resulting in their growth to sizeable proportions, causing metrorrhagia and suspected neoplastic pathology. Two cases of patients receiving adjuvant treatment with tamoxifen for previous breast cancer, who presented two giant endometrial polyps of uncommon dimension, are reported.     

Spectrum of MR features in adenomyosis

Magnetic resonance (MR) imaging is a highly accurate non-invasive technique for the diagnosis of adenomyosis. Typical MR features include either diffuse or focal thickening of the junctional zone or an ill-defined area of low signal intensity in the myometrium on T2-weighted MR images. Occasionally, the islands of ectopic endometrial tissue can be identified as punctate foci of high signal intensity. Less commonly, adenomyosis can present as a well-circumscribed form known as adenomyoma, adenomyotic cyst characterized by the presence of haemorrhagic cyst, or adenomyomatous polyp protruding into the uterine cavity. The MR appearances of adenomyosis may occasionally fluctuate in response to hormonal stimulation and treatment. MR imaging is helpful not only in monitoring the treatment effect of hormonal therapy, but also in predicting therapeutic effect. In cases of endometrial cancer in the uterus with adenomyosis, evaluation of myometrial invasion may become difficult. Rarely, endometrial cancer may arise directly from adenomyosis resulting from malignant transformation of endometrial glands, creating diagnostic challenges. Differential diagnosis of adenomyosis on MR imaging include physiological myometrial contraction and almost all myometrial lesions, and they should be carefully differentiated from adenomyosis by identifying typical clinical and MR features in these lesions. Precise knowledge of the spectrum of MR features in adenomyosis greatly helps in determining an accurate diagnosis and appropriate management of the patients.