子宫内膜癌治疗应关注的几个问题

子宫内膜癌是常见的妇科恶性肿瘤,关于其诊断和治疗国内外均有诊治指南,但是在治疗方面还存在一些问题,应引起广大妇科肿瘤工作者关注。如,早期子宫内膜癌患者子宫切除范围和淋巴结是否有必要切除,子宫内膜癌内分泌治疗的必要性,年轻的早期子宫内膜癌患者能否保留生育功能等。针对上述问题进行简要论述。     

子宫内膜癌手术治疗的进展

2009年FIGO修订了子宫内膜癌手术病理分期。FIGO分期已推行20年但仍有问题和不足。手术治疗存在以下争议:是否要求所有患者均行盆腔及腹主动脉旁淋巴结切除术、淋巴结切除的范围,年轻低危早期者能否保留卵巢。2010年NCCN子宫内膜癌指南推荐所有可行手术者均行盆腔、腹主动脉旁淋巴结切除。前哨淋巴结检测可用于诊断早期子宫内膜癌。     

子宫内膜癌患者保留生理功能的治疗

子宫内膜癌是妇科常见恶性肿瘤之一,约75%的患者为早期病例,对于Ⅰ期子宫内膜癌的首选治疗方法为筋膜外全子宫切除、双附件切除及盆腔、腹主动脉旁淋巴结取样和（或）清扫术,术后5年存活率达83%～93%,预后较好.但标准的手术治疗使年轻的子宫内膜癌患者失去了生育机会及卵巢内分泌功能,严重影响患者的生存质量.因此,子宫内膜癌患者保留生理功能的治疗,包括保留年轻子宫内膜癌患者的生育功能或卵巢内分泌功能,以及对手术治疗后的子宫内膜癌患者进行激素替代治疗,成为近年较为关注的问题.     

早期子宫内膜癌保留生育功能的治疗

子宫内膜癌是常见的妇科恶性肿瘤,多数发生在绝经后女性。传统治疗方法切除了全子宫及双附件,使患者丧失生育功能。目前,文献报道了较多关于子宫内膜癌保守治疗成功的案例,使得年轻的早期患者保留了生育功能。但保留子宫存在肿瘤复发的风险。且药物的剂量、治疗时间,患者的入选标准、随访等尚未达成共识。现就保守治疗的可行性及这些相关问题做一综述。     

年轻早期子宫内膜癌患者的治疗研究进展

近年来子宫内膜癌的发病年龄有年轻化趋势,年轻早期子宫内膜癌患者是否能保留其卵巢功能、生育功能,以及全子宫及双附件切除后给予激素替代治疗存有争议,尚不能得出肯定的结论,对这一问题还需深入研究和评价。     

早期子宫内膜癌腹膜后淋巴结转移的相关因素探讨

目的:研究临床早期子宫内膜癌腹膜后淋巴结转移的相关因素,为子宫内膜癌有选择实施腹膜后淋巴结切除寻找依据。方法:回顾分析2012年6月至2017年3月于我院行手术治疗的335例临床早期子宫内膜癌患者的术后病理资料,采用卡方检验进行单因素分析,Logistic回归进行多因素分析。结果:335例临床早期子宫内膜癌中,24例腹膜后淋巴结转移,淋巴结转移率7.16%。单因素分析提示,子宫肌层浸润深度、宫颈管浸润、脉管癌栓与早期子宫内膜癌的腹膜后淋巴结转移有关;Logistic多因素分析提示,宫颈管累及、脉管癌栓是临床早期子宫内膜癌腹膜后淋巴结转移的独立高危因素。结论:宫颈管浸润和脉管癌栓是早期子宫内膜癌腹膜后淋巴结转移的重要高危因素,是早期子宫内膜癌实施腹膜后淋巴结切除的重要依据。     

子宫内膜癌患者保留生育功能治疗的研究进展

子宫内膜癌好发于绝经前后的妇女,40岁以下者相对少见,只占所有病例的2.1%～14.4%.其治疗方法主要为子宫双附件切除,或同时行腹膜后淋巴结切除.此种手术治疗尽管对早期肿瘤的治愈率高,但患者却丧失了生育能力.一般情况下,年轻的子宫内膜癌患者多为有不孕史的未孕妇女,渴望保留生育功能.现已有早期子宫内膜癌采用反复子宫内膜诊刮及激素（通常为孕激素）治疗成功且保留生育功能的报道.保守性治疗尽管可行,但仍有许多问题存在争议,诸如恰当的治疗前评估,孕激素治疗的期限及剂量,完成生育后子宫切除的必要性等.因此,本文复习近年的国内外文献,就子宫内膜癌患者保留生育功能治疗的治疗前评估、治疗方法及结局的研究进展综述如下.     

早期子宫内膜癌诊治中淋巴结切除价值的争议

淋巴转移是子宫内膜癌最主要的转移途径.目前对早期子宫内膜癌患者是否常规行盆腹腔淋巴结切除尚有争议.高危因素与淋巴转移密切相关,术前和术中检查手段均无法准确判断是否有淋巴结转移,淋巴结切除不能改变低危早期内膜癌患者的生存结局,但对合并中高危因素的早期子宫内膜癌患者,淋巴结切除可提高5年生存率,改善预后.     

子宫内膜癌保留生育功能的治疗进展

子宫内膜癌是最常见的妇科恶性肿瘤之一,5%发生在40岁以下的妇女,年轻子宫内膜癌患者常强烈要求保留生育功能。生育年龄子宫内膜癌患者症状(月经异常)出现早,多为早期、分化程度好、且多数为性激素依赖型,预后较好。现已有早期子宫内膜癌采用保守手术及激素(通常为孕激素)治疗成功且保留生育功能、成功分娩的报道,现就子宫内膜癌保留生育功能治疗的现状做一综述。     

晚期子宫内膜癌患者手术治疗的价值

目的 探讨手术治疗在晚期(Ⅲ～Ⅳ期)子宫内膜癌患者中的应用价值.方法 对1997年1月1日至2007年12月31日间在山东省肿瘤医院妇瘤科住院行手术治疗的78例晚期子宫内膜癌患者的临床资料进行回顾性分析.其基本手术方式为子宫全切除+双侧附件切除+部分大网膜切除+阑尾切除+盆腹腔内转移灶切除术,以残留灶直径≤2 cm者为手术满意.评价晚期子宫内膜癌手术治疗的效果(随访满1、3、5年者分别为67、51、36例),并分析影响患者预后的因素.结果 78例患者中,肉眼无残留灶者23例,残留灶直径≤2 cm者42例,残留灶直径＞2 cm者13例,手术满意率为83%(65/78).患者1年生存率为91%(61/67),3年生存率为55%(28/51),5年生存率为28%(10/36).单因素分析显示,肿瘤侵及范围、有无腹水、术后残留灶大小、术后化疗疗程数明显影响患者的预后(P＜0.05);而病理类型、有无术后放疗对患者预后无明显影响(P＞0.05).结论 手术治疗在晚期子宫内膜癌患者的治疗中有重要价值,应提倡最大限度切除病灶,在此基础上给予多疗程的联合化疗,而放疗的意义不大.     

早期子宫内膜癌术后补充治疗及晚期患者非手术治疗

子宫内膜癌以手术为主,但放疗及化疗等非手术治疗也具有不可低估的作用。文章重点就早期子宫内膜癌手术后的补充治疗及晚期患者的非手术治疗选择和实施原则做一阐述。     

子宫内膜癌保留生育功能的治疗

对于年轻未生育子宫内膜癌患者的治疗目前存在较多争议。文章结合临床实践体会和文献报道,重点就其适应证选择、治疗前评估、治疗方案、疗效评价、病情监测、治疗后的生育问题、完成生育后的处理等做一阐述。     

Assisted reproductive technologies in conjunction with conservatively treated endometrial adenocarcinoma. A case report

This case report illustrates the successful use of assisted reproductive technologies (ARTs) in a patient receiving conservative treatment for endometrial adenocarcinoma. A 31-year-old infertile woman, diagnosed as FIGO stage Ia endometrial adenocarcinoma (grade 1), received oral medroxyprogesterone acetate 400 mg/day for 12 weeks. Endometrial curettage was performed and the absence of endometrial carcinoma was confirmed. A single pregnancy was achieved with in vitro fertilization and embryo transfer. A healthy female infant was born via cesarean section at 42 weeks' gestation. The carcinoma has not recurred, and the patient now desires a second child. We conclude that ART combined with progesterone treatment might be a powerful option for the treatment of infertile patients with early stage, well-differentiated endometrial adenocarcinoma.     

年轻早期高分化子宫内膜样腺癌患者保守治疗新进展

子宫内膜癌（EC）是常见的妇科恶性肿瘤,对年轻未生育的早期高分化子宫内膜样腺癌患者来说,保守治疗显得尤为重要。传统保守治疗药物包括孕激素、促性腺激素释放激素类似物（GnRHa）和芳香化酶抑制剂（AIs）等。宫腔镜电切术联合孕激素治疗是年轻子宫内膜样腺癌患者保留生育功能的新型治疗方式,在缓解率、妊娠率、不良反应发生率和复发率等方面优于传统保守治疗,但目前关于手术操作及术后激素治疗尚无统一标准。肥胖EC患者应治疗肥胖以降低复发风险,其中以减重手术效果最为显著、持久。现已证实减重手术对体质量指数（BMI）≥35 kg/m2的早期高分化子宫内膜样腺癌患者是有效干预。建议BMI≥35 kg/m2或BMI≥30 kg/m2且合并代谢综合征/2型糖尿病的年轻早期高分化子宫内膜癌患者,若经非手术治疗肥胖疗效不佳,可考虑以减重手术作为辅助治疗     

Is there a role for neoadjuvant chemotherapy in the treatment of stage IV serous endometrial carcinoma?

Abstract.   Despierre E, Moerman P, Vergote I, Amant F. Is there a role for neoadjuvant chemotherapy in the treatment of stage IV serous endometrial carcinoma? Int J Gynecol Cancer 2006; 16(Suppl. 1): 273–277.
Serous endometrial carcinoma (SEC) is an uncommon variant of endometrial carcinoma that is notorious for its aggressive clinical course. Similar to its ovarian counterpart, it has a propensity for early intraabdominal and lymphatic spread. We present two cases of advanced SEC, who were left with no residual tumor after neoadjuvant chemotherapy. After three courses of chemotherapy, both patients underwent interval debulking surgery, resulting in no residual disease. The documentation of chemosensitivity might enable the clinician to select a subpopulation of patients with widespread SEC that might benefit from interval debulking surgery.     

子宫内膜癌的手术治疗

手术治疗是子宫内膜癌各种治疗的基石,尽管有诸多争议,但早期子宫内膜癌手术依然以全面分期手术为主,而晚期则行最大程度的肿瘤细胞减灭术。文章就早期、晚期和复发性子宫内膜癌手术治疗的情况进行阐述。     

Stage I endometrial carcinoma. Role of omental biopsy and omentectomy.

A prospective, routine histologic assessment of the omentum during primary surgery was conducted on 84 women with stage I endometrial carcinoma between February 1986 and June 1989. The purpose of the study was to determine the true incidence of omental involvement in early endometrial cancer and to detect risk variables associated with such metastases. Omental metastases were found in 7 (8.3%) of 84 patients with stage I endometrial carcinoma. A majority of the metastases (five) consisted of microscopic disease. Factors statistically significantly associated with omental metastasis were adnexal spread, cul-de-sac implantation, papillary serous carcinoma, a positive retroperitoneal lymph node and grade 3 tumor. The study indicated that silent metastases to the omentum frequently are neglected clinically in patients with stage I endometrial carcinoma during primary surgery and that a routine omental biopsy should be part of the procedure. Furthermore, for patients with high-risk variables, a complete omentectomy ought to be considered.     

Evaluation of the sensitivity, specificity, positive and negative predictive values of preoperative magnetic resonance imaging for staging endometrial cancer. A prospective study of 100 cases at the Dorset Cancer Centre

OBJECTIVES: The objectives were to evaluate the sensitivity and specificity of preoperative magnetic resonance imaging (MRI) in predicting myometrial invasion and disease stage in cases of endometrial carcinoma. STUDY DESIGN: Prospective analytic study in 100 sequential cases of endometrial carcinoma referred to the Dorset Cancer Centre between January 1999 and July 2004. The study included 100 women with histologically proven endometrial malignancy, the mean age of the studied population being 68.6 years +/-2S.D. The preoperative MRI findings were compared with final surgical and histological staging; the latter was taken as the gold standard. The main outcome measures were the sensitivity and specificity of preoperative MRI for staging endometrial cancer. RESULTS: A total of 100 consecutive cases of endometrial cancer were analysed, of which 62 cases were classified as stage Ia/Ib (early disease) by histology. MRI accurately predicted the degree of invasion in 54 cases and overestimated in 8, giving a sensitivity of 87% and specificity of 90%. In stage Ic disease the sensitivity and specificity of MRI were 56 and 86%, respectively. However, MRI showed significantly reduced sensitivity for predicting stage II endometrial cancer at 19% but was found to be both sensitive and specific for predicting advanced endometrial cancer (stages III and IV); the sensitivity and specificity were 100 and 99%, respectively. CONCLUSIONS: The accuracy of MRI scanning in predicting early and advanced endometrial disease is very good, but there is reduced accuracy with stage Ic and stage II disease. MRI is a valuable imaging modality in the preoperative assessment of cases of endometrial cancer.     

Synchronous primary neoplasms of the female reproductive tract

A histopathologic review of synchronous primary neoplasms of the female reproductive tract is presented. During a 30-year period, 3863 patients with female genital malignancies were accessioned to the UCLA Tumor Registry: 958 had ovarian cancer, 776 endometrial cancer, 1556 cervical cancer, and 573 other gynecologic malignancies. Twenty-six (0.7%) patients with invasive synchronous primary cancers were identified. The most frequent synchronous genital lesions were ovarian and endometrial cancers in 11 patients (0.3%). No association was documented between genital and extragenital cancers. Patients with synchronous ovarian and endometrial cancers each were low stage and low grade, and the prognosis was excellent. Their detection in a relatively early stage suggests diagnosis may be facilitated by early symptoms from the endometrial carcinoma, and that these lesions are biologically of relatively low grade. These data support the conclusion that there is an association between low-stage epithelial carcinoma of the ovary and endometrial carcinoma.