子宫内膜癌高危因素对淋巴结切除临床决策的指导意义

Application value of high risk factors for clinical decision making to lymphadenectomy in endometrial carcinoma

目的 Ⅰ期子宫内膜癌手术范围是否应常规包括淋巴结切除国内外专家意见尚未统一。本研对临床Ⅰ期子宫内膜癌高危因素手术前后的诊断符合率进行分析,探讨临床Ⅰ期子宫内膜癌行淋巴结切除的指征。方法 回顾性分析2010-05-10-2013-05-10青岛市立医院收治的127例Ⅰ期子宫内膜癌患者临床资料,所有患者均行腹腔镜下筋膜外全子宫＋双附件切除＋盆腔淋巴结清除术（其中55例同时行腹主动脉旁淋巴结清除术）。比较手术前后组织学分级、病理类型、肌层浸润深度和淋巴结转移的诊断符合情况,分析其与淋巴结转移的相关性。结果 手术前后组织学分级诊断符合率为76.4%（97/127）,8.1%（9/111）的患者新增为高危因素合并者;病理类型诊断符合率为89.8%（114/127）,10.2%（13/127）的患者新增为高危因素合并者;肌层浸润诊断符合率为74.8%（95/127）,20.4%（20/98）的患者新增为高危因素合并者;淋巴转移诊断符合率为89.0%（113/127）,11.0%（14/127）的患者新增为高危因素合并者。14例淋巴结有转移,其中盆腔淋巴结转移10例,腹主动脉旁淋巴结转移1例,盆腔及腹主动脉旁淋巴结共同转移3例。2例术后病理确诊侵犯宫颈间质,其中1例伴有盆腔淋巴结转移。11.8%（15/127）的患者术后手术病理分期升高。淋巴结转移与组织学分级相关,χ^28.444,P=0.015;与肌层浸润相关,χ^27.601,P=0.004;而与病理类型无关,χ^20.995,P=0.156。病理确诊的低危患者（中、高分化子宫内膜样腺癌且肌层浸润〈1/2）淋巴结转移率为2.7%（2/75）。结论 子宫内膜癌高危因素术前判断准确性不高,低危患者也可发生淋巴结转移,因此主张对临床Ⅰ期子宫内膜癌患者行全面的分期手术,更好地指导术后辅助治疗方案选择,从而改善患者预后。

OBJECTIVE It has not been unified that lymph node excision should be routine included in stage I endometrial carcinoma. To analysis the coincidence of high risk factors before and after surgery, and explore the necessity of lymphadenectomy in clinical stage I endometrial carcinoma. METHODS The clinical data of 127 patients with stage I endometrial carcinoma in the Qingdao Municipal Hospital from May 10th 2010 to May 10th 2013 were analyzed retrospectively. All patients underwent laparoscopic extrafascial hysterectomy＋ bilateral oophorectomy ＋ pelvic lymphadenectomy （55 cases underwent para-aortic lymphadenectomy at the same time）. The coincidence rate before and after surgery was observed in histological grade. Pathological type, depth of myometrial invasion and lymph node metastasis as well as the correlation to lymph node metastasis were analyzed. RESULTS Before and after operation,the coincidence rate of diagnosis in histological grade was 76.4% （97/127）, the additional risk factors was 8.1% （9/111）. The coincidence rate of diag- nosis in pathological type was 89.8%（114/127）, the additional risk factors was 10.2%（13/127）. The coincidence rate of diagnosis in myometrial invasion was 74.8O//oo （95/127）, the additional risk factors was 20.4% （20/98）. The coincidence rate of diagnosis in lymph node metastasis was 89.0~ （113/127）, the additional risk factors was 11.0% （14/127）. For teen cases were with lymph node metastasis, including 10 cases with pelvic lymph node metastasis, 1 cases with para-aortic lymph node metastasis and 3 cases with pelvic and para-aortic lymph node metastasis. Two cases were pathologically confirmed violated cervical stroma in post-operation,including 1 case with pelvic lymph node metastases. 11.8%（15/127） of patients had increased in postoperative surgical stage. Histological grade was associated with Lymph node metastasis （X2 = 8. 444, P= 0. 015）, tissue myometrial invasion was associated with Lymph node metastasis（x2 = 7. 601, P=0. 004）, but pathological type was not related with Lymph node metastasis（x2 =0. 995,P=0. 156）. The rate of lymph node me tastasis in Low risk patients （with well-moderately differentiated, adenocarcinoma endometrium and superficial myometrial invasion） was 2.7%（2/75）. CONCLUSIONS The diagnostic accuracy of high risk factors in endometrial carcinoma is not satisfactory. Lymph node metastasis can also occur in patients with Low-risk factors. We advocate comprehensive staging operation on patients with clinical stage I endometrial carcinoma, to provide prognostic information more accurately, and help to formulate adjuvant therapy of postoperative.