经阴道彩色多普勒超声联合血浆肿瘤标志物检测在子宫内膜癌诊断中的应用

The value of transvaginal color Doppler sonography combined with serum tumor markers in diagnosing endometrial cancer

目的总结子宫内膜癌经阴道彩色多普勒超声(TVCDS)声像图特征及血浆肿瘤标志物CA125+CA199在子宫内膜癌辅助诊断中的作用。方法对2006年1月至2012年10月就诊于广州市妇女儿童医疗中心的14 027例患者行经阴道彩色多普勒超声检查,发现子宫内膜可疑癌病灶的131例患者均辅以血浆肿瘤标志物CA125+CA199检测,与手术病理诊断结果对照,对子宫内膜癌患者的声像图特征及血浆肿瘤标志物联合检测结果进行分析。结果 131例超声疑诊子宫内膜癌的患者术后病理诊断为早期子宫内膜癌64例(原位癌2例),中晚期子宫内膜癌67例。131例患者超声及血浆肿瘤标志物检测结果与病理诊断结果对照显示:术前超声诊断早期和中晚期子宫内膜癌与病理诊断符合率为56.3%(36/64)和100%(67/67);术前超声辅以血浆肿瘤标志物CA125+CA199联合诊断早期和中晚期子宫内膜癌与病理诊断符合率为78.1%(50/64)和100%(67/67)。术前超声漏误诊28例(43.8%,6例子宫内膜息肉误诊为子宫内膜癌,15例误诊为子宫内膜增殖症,7例误诊为黏膜下肌瘤),均为早期子宫内膜癌。131例子宫内膜癌超声声像图特征:(1)64例早期子宫内膜癌主要超声表现为子宫增大(59.4%,38/64)和子宫内膜不规则增厚(82.8%,53/64),子宫最大径平均为(69.8±9.7)mm,子宫内膜平均厚度为(37.1±9.7)mm。其中9例子宫内膜病灶呈不均匀低回声,55例子宫内膜与肌层交界面的弱回声晕不完整;56例病灶浸润子宫肌层(浸润浅肌层31例,浸润深肌层25例),13例浸润宫颈,均无宫旁浸润。61例病灶内见彩色血流信号;3例病灶内未见血流信号;64例均无引流区域或远处淋巴结转移。(2)67例中晚期子宫内膜癌主要超声表现为子宫明显增大和子宫内膜明显增厚(91.0%,61/67),子宫最大径(81.9±10.8)mm,子宫内膜平均厚度为(41.8±13.5)mm。其中61例子宫内膜癌病灶浸润扩散至子宫外,宫旁或膀胱壁可探及与子宫分界不清的低回声包块,阴道壁局部增厚;67例病灶内显示网状或树枝状血流信号;53例盆腔和(或)主动脉旁、腹腔和(或)腹股沟区显示低回声转移淋巴结。131例子宫内膜癌血浆肿瘤标志物检测结果:(1)术前早期子宫内膜癌患者中31例(48.4%,31/64)CA125(测值>37 U/ml),27例CA199测值升高(测值>37 U/ml,占42.2%,27/64),24例(37.5%,24/64)CA125+CA199检测值升高。(2)术前中晚期子宫内膜癌患者中61例(91.0%,61/67)CA125或59例CA199(88.1%,59/67)测值明显升高,56例(83.6%,56/67)CA125+CA199测值均升高。经阴道彩色多普勒超声辅以血浆肿瘤标志物CA125+CA199联合检测诊断早期子宫内膜癌(78.1%,50/64)和中晚期子宫内膜癌(100%,67/67)与病理诊断符合率高于单纯经阴道彩色多普勒超声诊断符合率,经阴道彩色多普勒超声检查与超声辅以血浆肿瘤标志物联合检测诊断符合率比较,差异有统计学意义(χ2=6.95,P=0.01)。结论经阴道彩色多普勒超声显示子宫增大、子宫内膜增厚、子宫内膜病灶回声不均、子宫内膜与肌层交界面的弱回声晕不完整、病灶内出现点条网状血流信号为早期子宫内膜癌特征性超声表现;超声检查发现可疑子宫内膜癌病灶并辅以血浆肿瘤标志物CA125+CA199联合检测,有助于尽早提示早期子宫内膜癌,减少漏误诊。

Objective To summarize the ultrasonic features of endometrial carcinoma in transvaginal color Doppler sonography（TVCDS）, and to analyze the supplementary function of serum CA125 and CA199 in diagnosing endometrial carcinoma. Methods From January 2006 to October 2012, fourteen thousand and twenty-seven women underwent TVCDS in GZ Women Children Medical Centre, serum CA125 and CA199 were determined by chemiluminescence immunoassay. The ultrasound characteristics of 131 cases of endometrial carcinoma（including 64 cases of early-stage and 67 cases of advanced endometrial carcinoma） who were accurately diagnosed by pathology and the value of serum CA125 and CA199 were analyzed. Results In groups 131 patients were accurately confirmed by pathology, including 64 cases early-stage and 67 cases advanced carcinoma. The diagnositic coincidence of ultrasound and ultrasound combined with serum tumor markers was 56.3%（36/64） and 78.1%（50/64） respectively. On ultrasonography, 64 patients with early stage endometrial carcinoma showed uterine enlargement in 38 cases and endometrial thickening in 53 cases. In 9 cases, endometrial lesions were heterogeneously hypoechoic. In 55 cases, the halo between endometrium and muscle was interrupted and disappeared. In 56 cases, endometrial lesions had muscular layer infiltration. In 13 cases, endometrial lesions had cervical infiltration. In 61 cases, sparse punctuate or reticular flow signals were detected within lesions. In 3 cases, there was no blood flow signal in lesions. All these patients had not lymph node metastasis. Sixty-seven cases with advanced endometrial carcinoma showed more obviously uterine enlargement and significant endometrial thickening. In 61 patients, tumor spread outside the uterus. Reticular or dendritic flow signals were detected in 67 cases lesions. There were hypoechoic lymph node mestastasis in 53 cases. In 31 cases of early stage endometrial carcinoma, preoperative CA125 increased. In 27 cases of early stage endometrial carcinoma, preoperative CA199 increased. In 24 cases CA125 and CA199 increased meanwhile. In 61 cases of advanced endometrial carcinoma, preoperative CA125 increased. In 59 cases of advanced endometrial carcinoma, preoperative CA199 increased. In 56 cases CA125 and CA199 increased meanwhile. Sixty-four cases of early-stage endometrial carcinoma were diagnosed by TVCDS assisted with CA125 and CA199 and were confirmed by pathology. The detective rate was 78.1%（50/64）. To compared with TVCDS, the difference was statistical significance（χ2=6.95,P=0.01）. Conclusions The ultrasonic features of early-stage endometrial carcinoma in TVCDS were uterine enlargement, endometrial thickening, heterogeneous hypoechoic endometrial lesions, interrupted or disappeared hypoechoic halo between endometrium and musclar layer, and sparse punctuate or reticular flow signals within lesions. Serum CA125 and CA199 may be helpful in improving diagnosis coincidence rate when early-stage endometrial cancer is find or suspected on ultrasonography.