中华妇产科杂志
中華婦產科雜誌
중화부산과잡지
CHINESE JOUNAL OF OBSTETRICS AND GYNECOLOGY
2014年
9期
664-669
,共6页
子宫内膜肿瘤%子宫内膜增生%保留生育功能%治疗结果%病理学
子宮內膜腫瘤%子宮內膜增生%保留生育功能%治療結果%病理學
자궁내막종류%자궁내막증생%보류생육공능%치료결과%병이학
Endometrial neoplasms%Endometrial hyperplasia%Fertility preservation%Treatment outcome%Pathology
目的 对Ⅰa期子宫内膜样腺癌及子宫内膜复杂性不典型增生患者应用孕激素治疗的临床病理学变化及预后进行观察,探讨子宫内膜病理检查在孕激素治疗效果评估中的作用.方法 对2004年11月至2011年11月浙江大学医学院附属妇产科医院收治的40岁以下有强烈保留生育功能意愿的9例Ⅰa期子宫内膜样腺癌及21例子宫内膜复杂性不典型增生患者应用孕激素治疗,连续用药6～9个月,每3个月进行1次病理疗效评估,病理观察肿瘤性病变消退、变化情况以及子宫内膜对孕激素治疗的反应情况;并长期随访观察.结果 (1)用药6～9个月内9例子宫内膜样腺癌及21例子宫内膜复杂性不典型增生患者中,分别有5例(5/9)、18例(86％,18/21)达到完全反应(癌及癌前病变完全消退),2例、2例达到部分反应(残留增生过长的子宫内膜,无细胞不典型),2例、1例无反应或疾病进展;治疗全过程中分别有6例、20例共26例(87％,26/30)达到完全反应,中位完全反应时间6个月(3～21个月).中位随访时间55.5个月(24～104个月),所有患者均存活.6例完全反应的子宫内膜癌患者中有3例复发,中位复发时间10个月(6～51个月);20例达到完全反应的子宫内膜复杂性不典型增生患者中有7例复发,中位复发时间12个月(6～55个月),其中4例再次孕激素治疗后重新达到完全反应.26例完全反应患者中,8例进行了3～6个月的巩固治疗,有3例复发;18例未行巩固治疗,有7例复发;是否巩固治疗患者的复发率比较,差异无统计学意义(P=1.000).子宫内膜癌患者治疗后正常妊娠4例次,21例子宫内膜复杂性不典型增生患者正常妊娠10例次,共成功分娩16例健康新生儿.(2)镜下观察:肿瘤性病变在用药后达到部分反应或完全反应者病变范围明显缩小甚至消失,腺体密度下降,腺体结构简单清晰,腺上皮层次变薄,异型性减轻或消失.子宫内膜对孕激素治疗的反应:表现为子宫内膜间质水肿及蜕膜化,腺体狭小、迂曲;腺上皮单层,核变小,胞质变丰富;达到部分反应或完全反应者随着用药时间的延长,腺上皮萎缩明显,间质蜕膜化,表现为抑制性分泌反应.伴随的化生性改变:孕激素治疗后易发生鳞化,多表现为不成熟性鳞化.结论 Ⅰa期子宫内膜样腺癌及子宫内膜复杂性不典型增生病程进展缓慢,对孕激素治疗反应良好.治疗成功后复发率较高,大部分复发患者再次孕激素治疗安全、有效.保守治疗后需要长期随访观察.子宫内膜病理检查在保守治疗及长期随访中有重要作用.
目的 對Ⅰa期子宮內膜樣腺癌及子宮內膜複雜性不典型增生患者應用孕激素治療的臨床病理學變化及預後進行觀察,探討子宮內膜病理檢查在孕激素治療效果評估中的作用.方法 對2004年11月至2011年11月浙江大學醫學院附屬婦產科醫院收治的40歲以下有彊烈保留生育功能意願的9例Ⅰa期子宮內膜樣腺癌及21例子宮內膜複雜性不典型增生患者應用孕激素治療,連續用藥6～9箇月,每3箇月進行1次病理療效評估,病理觀察腫瘤性病變消退、變化情況以及子宮內膜對孕激素治療的反應情況;併長期隨訪觀察.結果 (1)用藥6～9箇月內9例子宮內膜樣腺癌及21例子宮內膜複雜性不典型增生患者中,分彆有5例(5/9)、18例(86％,18/21)達到完全反應(癌及癌前病變完全消退),2例、2例達到部分反應(殘留增生過長的子宮內膜,無細胞不典型),2例、1例無反應或疾病進展;治療全過程中分彆有6例、20例共26例(87％,26/30)達到完全反應,中位完全反應時間6箇月(3～21箇月).中位隨訪時間55.5箇月(24～104箇月),所有患者均存活.6例完全反應的子宮內膜癌患者中有3例複髮,中位複髮時間10箇月(6～51箇月);20例達到完全反應的子宮內膜複雜性不典型增生患者中有7例複髮,中位複髮時間12箇月(6～55箇月),其中4例再次孕激素治療後重新達到完全反應.26例完全反應患者中,8例進行瞭3～6箇月的鞏固治療,有3例複髮;18例未行鞏固治療,有7例複髮;是否鞏固治療患者的複髮率比較,差異無統計學意義(P=1.000).子宮內膜癌患者治療後正常妊娠4例次,21例子宮內膜複雜性不典型增生患者正常妊娠10例次,共成功分娩16例健康新生兒.(2)鏡下觀察:腫瘤性病變在用藥後達到部分反應或完全反應者病變範圍明顯縮小甚至消失,腺體密度下降,腺體結構簡單清晰,腺上皮層次變薄,異型性減輕或消失.子宮內膜對孕激素治療的反應:錶現為子宮內膜間質水腫及蛻膜化,腺體狹小、迂麯;腺上皮單層,覈變小,胞質變豐富;達到部分反應或完全反應者隨著用藥時間的延長,腺上皮萎縮明顯,間質蛻膜化,錶現為抑製性分泌反應.伴隨的化生性改變:孕激素治療後易髮生鱗化,多錶現為不成熟性鱗化.結論 Ⅰa期子宮內膜樣腺癌及子宮內膜複雜性不典型增生病程進展緩慢,對孕激素治療反應良好.治療成功後複髮率較高,大部分複髮患者再次孕激素治療安全、有效.保守治療後需要長期隨訪觀察.子宮內膜病理檢查在保守治療及長期隨訪中有重要作用.
목적 대Ⅰa기자궁내막양선암급자궁내막복잡성불전형증생환자응용잉격소치료적림상병이학변화급예후진행관찰,탐토자궁내막병리검사재잉격소치료효과평고중적작용.방법 대2004년11월지2011년11월절강대학의학원부속부산과의원수치적40세이하유강렬보류생육공능의원적9례Ⅰa기자궁내막양선암급21례자궁내막복잡성불전형증생환자응용잉격소치료,련속용약6～9개월,매3개월진행1차병리료효평고,병리관찰종류성병변소퇴、변화정황이급자궁내막대잉격소치료적반응정황;병장기수방관찰.결과 (1)용약6～9개월내9례자궁내막양선암급21례자궁내막복잡성불전형증생환자중,분별유5례(5/9)、18례(86％,18/21)체도완전반응(암급암전병변완전소퇴),2례、2례체도부분반응(잔류증생과장적자궁내막,무세포불전형),2례、1례무반응혹질병진전;치료전과정중분별유6례、20례공26례(87％,26/30)체도완전반응,중위완전반응시간6개월(3～21개월).중위수방시간55.5개월(24～104개월),소유환자균존활.6례완전반응적자궁내막암환자중유3례복발,중위복발시간10개월(6～51개월);20례체도완전반응적자궁내막복잡성불전형증생환자중유7례복발,중위복발시간12개월(6～55개월),기중4례재차잉격소치료후중신체도완전반응.26례완전반응환자중,8례진행료3～6개월적공고치료,유3례복발;18례미행공고치료,유7례복발;시부공고치료환자적복발솔비교,차이무통계학의의(P=1.000).자궁내막암환자치료후정상임신4례차,21례자궁내막복잡성불전형증생환자정상임신10례차,공성공분면16례건강신생인.(2)경하관찰:종류성병변재용약후체도부분반응혹완전반응자병변범위명현축소심지소실,선체밀도하강,선체결구간단청석,선상피층차변박,이형성감경혹소실.자궁내막대잉격소치료적반응:표현위자궁내막간질수종급세막화,선체협소、우곡;선상피단층,핵변소,포질변봉부;체도부분반응혹완전반응자수착용약시간적연장,선상피위축명현,간질세막화,표현위억제성분비반응.반수적화생성개변:잉격소치료후역발생린화,다표현위불성숙성린화.결론 Ⅰa기자궁내막양선암급자궁내막복잡성불전형증생병정진전완만,대잉격소치료반응량호.치료성공후복발솔교고,대부분복발환자재차잉격소치료안전、유효.보수치료후수요장기수방관찰.자궁내막병리검사재보수치료급장기수방중유중요작용.
Objective To assess the efficacy and pathological change of fertility-sparing treatment with progestin for endometrial carcinoma (EC) of stage Ⅰ a and complex atypical hyperplasia (CAH) and to observe the prognosis of the treatment.Methods Nine EC patients of stage Ⅰ a and 21 CAH patients aged under 40 years who desired childbearing and retaining their fertility were enrolled into this study.All patients were given a daily oral high-dose of progestin with duration of treatment ranging from 6 to 9 months.Diagnostic curettage was performed every 3 months as a modality for seeing the histologic change of neoplastic tissues and endometrial tissue.A careful and long-term follow-up is necessary for patients with complete response (CR).Results During the first period of fertility-sparing management,according to histologic change,5 EC patients and 18 CAH patients showed CR with no evidence of endometrial adenocarcinoma or hyperplasia,2 EC patients and 2 CAH patients showed partial response with a regression to complex or simple hyperplasia without atypia,2 EC patients and 1 CAH patient showed stable disease or progressive disease.Accordingly,a total of 26 patients showed CR (26 of 30 patients).The median time to CR was 6 months (range,3 to 21 months) of progestin treatment.The median follow-up time was 55.5 months (range,24 to 104 months) and all patients were alive.During follow-up,among the 26 patients with CR,3 of 6 EC patients achieved CR recurred disease after a median time interval of 10 months (range,6 to 51 months),7 of 20 CAH patients achieved CR had recurrent disease after a median time interval of 12 months (range,6 to 55 months).Four of 7 CAH with recurrent disease achieved CR to progestin retreatment.Eight of 26 patients achieved CR continued a further 3 or 6 months of consolidation therapy,3 of them had recurrent disease,the remaining 18 stopped progesterone treatment after CR and 7 patients had recurrent disease; there was no significant statistical difference between the two groups (P=1.000).EC patients succeeded in 4 pregnancies,CAH patients succeeded in 10 pregnancies,they gave birth to 16 healthy babies in all.Conclusions EC of stage Ⅰ a and CAH had slow progression of symptoms.Progestin treatment in EC of stage Ⅰ a and CAH patients was effective.A careful and long-term follow-up is required because of the substantial high rate of recurrence.Progestin re-treatment in most patients with recurrent endometrial cancer is effective and safe.
