子宫恶性潜能未定的平滑肌肿瘤29例临床病理分析

Uterine smooth muscle tumors of uncertain malignant potential (STUMP):a clinicopathologic analysis of 29 cases

目的:分析子宫恶性潜能未定的平滑肌肿瘤(STUMP)的临床及病理学特点,探讨其诊断和治疗方法。方法:收集2008~2018年北京大学人民医院收治的病理科诊断为STUMP的29例患者的临床病理资料,回顾分析患者的临床表现、影像学检查、病理特征、治疗及预后。结果: 29例患者的平均年龄为42.3岁(26~76岁),最常见临床症状为月经紊乱(51.7%,15/29)。肿瘤平均最大直径7.24cm(2.50~16.10cm)。切面大部分呈灰白或淡黄色,质地较软、细腻,漩涡结构不清,偶见出血及水肿。镜下21例( 72.41%)全部由丰富的梭形细胞构成,6例(17.24%)伴有上皮样分化,2例(6.90%)伴有黏液样分化。肿瘤细胞有中-重度异型者9例(31.03%),核分裂象计数为3~20个/10HPF,其中3例可见病理性核分裂象。有5例(17.24%)出现坏死,包括3例不能明确类型坏死及2例可疑肿瘤细胞坏死。初次手术时19例行子宫肌瘤切除术、7例行全子宫切除术、2例行全子宫+双侧输卵管卵巢切除术、1例曾行全子宫切除术的患者行盆腔肿物切除术+双侧输卵管卵巢切除术。术后随访26例(89.7%),平均随访时间43.8个月(6~123个月),6例有生育要求者中2例术后自然妊娠并足月剖宫产分娩。2例( 6.9%)STUMP复发,复发仍均为STUMP;1例因心脑血管意外死亡,其余患者均存活未复发。结论: STUMP无特殊临床表现,确诊依靠术后病理及免疫组化检测,有生育要求者可严密随访下保留子宫,无生育要求者应切除子宫。

Objective: To analyze the clinical and pathological characteristics of uterine smooth muscle tumor of uncertain malignant potential (STUMP),and to explore its diagnostic and treatment methods. Methods: A total of 29 patients who were diagnosed as STUMP by the pathology department of Peking University People's Hospital from 2008 to 2018 were collected.Retrospectively analyze the patients' clinical manifestations,imaging findings,pathological features,treatment and prognosis. Results: The average age of the patients was 42.3(26~76years).The most common clinical symptom was abnormal menstrual period (51.7%,15/29).Average maximum diameter of the tumors was 7.24cm(2.50~16.10cm).The cut surface was usually grayish or yellowish,soft and fine,without typical whorled appearance of a leiomyoma.Areas of haemorrhage and edema may be seen occasionally.Microscopically,21 tumors( 72.41 %) were hypercellular,6 tumors (17.24%) with epithelioid differentiation,2 tumors(6.90%) with myxoid differentiation.Moderate to severe atypia were observed in 9 cases ( 31.03 %) and the mitotic counts were 3~20/10HPFs,atypical mitoses were found in 3 cases.5(17.24%) cases showed necrosis,including an uncertain type necrosis in 3 cases and doubtful tumor cell necrosis in 2 cases.At the time of initial operation,19 cases underwent hysteromyomectomy,7 cases underwent total hysterectomy,2 cases underwent total hysterectomy plus bilateral salpingoovariectomy,1 case who had hysterectomy previously underwent resection of pelvic tumor plus bilateral salpingoovariectomy.Follow-up of 26 cases (89.7%) were available after operation with 2 cases'recurrence.2 of 6 cases who had fertility desires got naturally pregnant,and both had full-term cesarean section.1 case died of cardiocerebral events while other patients all survived. Conclusions: No specific clinical manifestations were observed in STUMP.Pathological and immunohistochemical findings were the diagnositic golden standard for this disease.Those who have fertility desires could undergo fertility sparing operation with closely follow-up,however those who have no childbearing needs should undergo hysterectomy.