伴奇异性核的子宫平滑肌瘤27例临床病理特征观察

Clinicopathologic observation of uterine leiomyomas with bizarre nuclei of 27 cases

目的 探讨伴奇异性核的子宫平滑肌瘤的临床病理特征、免疫表型、鉴别诊断、治疗及预后。方法 回顾性分析27例伴奇异性核的子宫平滑肌瘤的临床特点、病理形态学及免疫表型特征,并复习相关文献。结果 患者均为女性,年龄25~51岁,平均40岁。大多表现为异常子宫出血、腹部疼痛等特征。眼观：类似经典型平滑肌瘤,切面灰白色,偶有灰黄色,质硬韧。镜检：可见局灶或弥漫分布的奇异性细胞,这些奇异性细胞伴多核或多叶核（96.3%）、嗜酸性核仁（88.9%）,可见核内假包涵体（37.0%）及类似非典型核分裂象的破碎细胞核（25.9%）,核分裂象少见（0~4个/10HPF）;缺乏凝固性肿瘤坏死。免疫表型：p16在3例表现为局灶斑片状阳性,其余24例为阴性;p53在5例肿瘤细胞中表达,其中阳性细胞数小于10%;Ki-67增殖指数21例小于5%,5例为10%~20%,1例大于20%。22例获得随访资料,平均随访26个月（6~118个月）。1例术后52个月死于其他疾病,1例患者术后62个月复发,复发后的肿瘤形态类似第一次肿瘤,复发后行全子宫切除术,随访7个月无瘤生存,其余20例均为无瘤生存。结论 伴奇异性核的子宫平滑肌瘤是子宫平滑肌瘤的少见亚型,具有特殊的形态学特征和免疫表型,临床经过通常为良性病变,偶有复发,临床切除后应注意随访。

Purpose To investigate the clinicopathologic characteristics, immunophenotype, differential diagnosis, treatment and prog- nosis of uterine leiomyomas with bizarre nuclei. Methods 27 cases diagnosed as uterine leiomyomas with bizarre nuclei were retro- spectively analyzed for cfinicopathologic findings and immunophenotypes, followed with review of the literatures. Results 27 patients were all female, mean age 40 years, range 25 to 51 years. Clinical aspects including abnormal vaginal bleeding, pelvic pain, and so on. Macroscopically, the tumor had a solid white or yellow and whorled cut surface with a pushing margin. On mircroscopic evaluation, all cases contained cells with significant atypia with focal or diffuse distribution. The atypia cells had multiple nuclei （96.3%） , eosin- ophilic nucleoli （88.9%）, intranuclear pseudoniclusions （37.0%）, karyorrheetic nuclei （25.9%） which may mimic atypical mitotic figures. Mitotic figures were 0 to 4/10 HPF. All of these cases were lack of coagulate necrosis. Immnuohisochemical study showed that 3 cases were patched positive for p16, 5 cases were positive for p53 with less than 10% cells, the Ki-67 index were less than 5% in 21 cases, 10% to 20% in 5 cases and more than 20% in 1 case. Follow-up data were available in 22 cases, ranged from 6 to 118 months with mean 26 months. 1 patient died in other disease at 52 months later after surgery, 1 patient experienced local recurrence at 62 months after surgery, and then experienced hysterectomy, followed up 7 months with no disease, the other 20 cases were all alive with disease-free. Conclusion The uterine leiomyomas with bizarre nuclei is a rare subtype of uterine leiomyoma with notable morphologi- cal characters and inmmunophenotypes. Clinical behavior is a benign course with recurrence occassionaly, so follow up after surgery is necessary.