子宫内膜癌患者腹腔细胞学阳性的临床意义及对预后的影响

Clinical implications of positive peritoneal cytology in endometrial cancer

目的探讨子宫内膜癌患者腹腔细胞学阳性的临床意义及对预后的影响。方法对1996年1月至2008年12月复旦大学附属肿瘤医院收治的315例子宫内膜癌患者的临床病理资料进行回顾性分析，所有患者均行手术治疗，且均行术中腹水或腹腔冲洗液细胞学检查。对与腹腔细胞学阳性相关的因素，采用相关分析法进行分析；对影响子宫内膜癌患者预后的因素，采用log—rank检验进行单因素分析，采用Cox回归法进行多因素分析。结果（1）315例子宫内膜癌患者中，30例（9．5％）患者腹腔细胞学阳性。腹腔细胞学阳性与多个子宫内高危因素包括病理类型（P=0．013）、手术病理分期（P=0．000）、肌层浸润（P=0．012）、脉管浸润（P=0．012），以及多个子宫外转移危险因素包括子宫浆膜层侵犯（P=0．004）、宫颈受累（P=0．016）、附件转移（P=0．000）和大网膜转移（P=0．000）明显相关，而与病理分级（P=0．152）、淋巴结转移（P=0．066）无明显相关性。（2）315例子宫内膜癌患者的3年总生存率和3年无疾病进展生存率分别为93．0％和85．5％。单因素分析显示，腹腔细胞学阳性及不同手术病理分期、病理类型、肌层浸润深度、病理分级和脉管浸润是影响子宫内膜癌患者预后的危险因素（P〈0．05）；多因素分析显示，手术病理分期、肌层浸润深度是影响子宫内膜癌患者预后的独立危险因素（P〈0．05）。30例腹腔细胞学阳性患者中，无高危因素患者的3年生存率和3年无疾病进展生存率均显著高于有高危因素者（P〈0．05）；进一步分析显示，腹腔细胞学阳性是影响晚期（Ⅲ～Ⅳ期）子宫内膜癌患者预后的独立危险因素（P=0．006）。结论腹腔细胞学阳性与多个子宫内高危因素和子宫外转移危险因素密切相关，是影响晚期子宫内膜癌患者预后的独立危险因素。因此，腹水细胞学检查应继续作为全面分期手术的步骤之一，并将结果单独进行报告，是十分有必要的。

Objective To evaluate the clinical significance of positive peritoneal cytology in patients with endometrial cancer. Methods The records of 315 patients with endometrial cancer who were operated at Cancer Hospital, Fudan University between January 1996 and December 2008 were reviewed. Peritoneal cytology were performed and diagnosed in all patients. Factors related with peritoneal cytology were analyzed by correlation analysis. Log-rank test and Cox regression test was used for the analysis of prognosis, respectively. Results （ 1 ） Peritoneal cytology were positive in 30 （ 9.5% ） patients. Positive peritoneal cytology was associated with pathological subtype （P = 0. 013 ）, stage （P = 0. 000 ）, myometrial invasion （ P = O. 012）, lymph-vascular space invasion （ P = 0. 012 ）, serosal involvement （ P = 0. 004 ）, cervical involvement （ P = 0. 016 ）, adnexal involvement （ P = O. 000 ）, and omental involvement （ P = 0. 000 ）, with no association with grade （P = 0. 152） and lymph node metastasis （ P = 0. 066 ）. （ 2 ） Three-year overall survival （OS） and progression-free survival（PFS） were 93.0% and 85.5% ,respectively. Positive peritoneal cytology, surgical stage, pathological subtype, myometrial invasion, grade, and lymph-vascular space invasion were significantly associated with worse prognosis by univariate analysis （ P 〈 0. 05 ）, while only surgical-pathology stage and myometrial invasion were independent prognostic factors by multivariate analysis （P 〈 0. 05）. For 30 cases with positive peritoneal cytology, the patients with no high risk factors shown significantly prognoses better than those with any risk factors. The results shown that for patients with late stage （stage Ⅲ～Ⅳ） endometrial cancer with positive peritoneal cytology was significantly associated with the worse OS and PFS by multivariate analysis （P = 0. 006）. Conclusions Positive peritoneal cytology was associated with serosal involvement, cervical involvement, adnexal involvement, omental involvement, and late stage. Therefore, peritoneal cytology should be performed and reported separately as a part of full surgical staging procedure.