孕激素治疗增生子宫内膜和高分化子宫内膜样癌后的临床病理形态观察

The observation of histological features after progestin treatment for endometrial hyperplasia and well-differentiated endometrioid carcinoma

目的：显微镜下观察孕激素治疗对不同增生子宫内膜和高分化子宫内膜样腺癌的组织病理学影响,为临床更好地管理孕激素治疗提供依据。方法：收集2010年至2014年86例增生不伴有非典型增生（包括简单型增生、复杂型增生）和非典型增生及高分化子宫内膜样癌患者在我院经孕激素正规治疗刮宫至少两次以上病例,其中刮宫次数最多者达11次,时间2个月到5年。两个高年资病理医师双盲法显微镜下观察激素治疗前后病理改变。结果：简单型增生50名,基本转归为正常子宫内膜;复杂型增生18名,治疗约半年后转为正常子宫内膜;但其中2例有复发或恶化。非典型增生不伴/伴癌变18例,孕激素治疗后刮宫,10例镜下显示好转或完全缓解。好转病例显示组织结构依然复杂,但腺体间质比例降低,间质蜕膜样变或者玻璃样变;高倍镜下腺上皮细胞核变温和,核膜光滑,核仁不明显,核浆比例降低,胞浆丰富,伴嗜酸性变、鳞状细胞化生或粘液化生。该类病例继续治疗后,转化为正常周期宫内膜。但有4例（22.2%）在1-2年后复查,又出现非典型增生,甚至癌变。另有2个病例,治疗3个月后刮宫,镜下依然为非典型增生改变,证明孕激素治疗无效。结论：1）简单型增生过孕激素治疗效果好,3-6个月后刮宫,基本恢复正常周期。2）对非典型增生及癌变患者,因容易复发和恶化,按2014NCCN诊疗规范治疗坚持用药并定期复查非常有必要。3）非典型增生伴/不伴癌变病例,细胞学好转先于组织学。4）对治疗无效者,需要根据患者生育要求及时手术治疗。5）根据孕激素治疗效果评价,增生不伴非典型增生患者,区分简单型和复杂型增生依然有必要性。

Objective： To observe the pathological impact of progestin on endometrial hyperplasia and well-differentiated endometrioid carcinoma（WDC）, and provide evidence for clinical administration to progestin treatment. Methods： A total of 86 cases of endometrial hyperplasia（including hyperplasia without atypia, atypical hyperplasia） and high differentiated endometrioid carcinomas with at least 2 curettage biopsies（most up to 11, from 2 months to 5 years） in our hospital and being given regular therapy were collected. Every slide was observed under microscope by two experienced pathologists. Results： There were 50 cases of simple hyperplasia and almost of them changed into normal endometrium. In 18 cases of complex hyperplasia, most of them were transformed into the normal, while 2 cases recurred or developed. In 18 cases of atypical hyperplasia and WDC, 10 got better or complete remission after about 3 months. These cases appeared decreased gland-to-stroma ratio with stroma decidual or hyaline changes. At higher power, cell changes were seen decreased nucleo-to-cytoplasmic ratio, mild gland cell nuclei, smoothened karyotheca, and eosinophilic, squamous or mucinous metaplasia. These cases eventually changed into normal endometrium after about several months to years＇ treatment. However, there were 4 cases（22.2%） arose to atypical hyperplasia even carcinoma again after 1-2 years. Another 2 atypical hyperplasia given progestin for 3 months had few changes which proofed the treatment was not effective. Conclusion： 1） The effect of progestin for simple hyperplasia was good; 2） for atypical hyperplasia and carcinoma, the standard and long-standing treatment according to NCCN guidance is necessary since these diseases are easily recurred or progressed; 3） during progestin treatment, for atypical hyperplasia and carcinoma, cellular changes are prior to that of architecture; 4） for those progestin non-effective cases, immediate operation is needed; 5） since progestin effect is different, for hyperplasia without atypical it is necessary to distinguish simple and complex hyperplasia.