保留生育功能法治疗年轻早期高分化子宫内膜癌和复杂性不典型增生

Fertility-sparing Treatment for Young Patients With Early Stage Well Differentiated Endometrial Cancer or Complex Atypical Hyperplasia

目的探讨宫腔镜病灶切除、促性腺激素释放激素类似物(GnRHa)联合左炔诺孕酮宫内节育系统(曼月乐)或来曲唑治疗早期高分化子宫内膜癌和复杂性不典型增生的年轻患者的有效性和安全性。方法对2013年1月~2018年10月34例小于42岁的早期高分化子宫内膜腺癌(局限于黏膜内,无明显肌层侵犯,16例)或复杂性不典型增生(18例),行宫腔镜双极电刀病灶切除术,术后戈舍瑞林3.75 mg皮下注射28天一次共3次。19例手术结束时置入曼月乐,另15例术后口服来曲唑2.5 mg每天一次。所有患者每隔3个月复查阴道超声、宫腔镜诊刮术。结果随访9~68个月,平均34.6月。完全反应率子宫内膜癌为87.5%(14/16),复杂性不典型增生为100%(18/18);疾病稳定2例,均为子宫内膜癌。完全反应的子宫内膜癌和复杂性不典型增生各有1例复发。2例复发和2例疾病稳定者均行子宫切除术。随访期间11例获得12次妊娠。结论宫腔镜病灶切除、GnRHa联合曼月乐或来曲唑的保留生育功能方法治疗早期高分化子宫内膜癌和复杂性不典型增生安全、有效。完成生育后应该行子宫切除,尤其子宫内膜癌患者。

Objective To evaluate the efficacy and safety of hysteroscopic lesionectomy and gonadotropin-releasing hormone agonist(GnRHa)combined with levonorgestrel-releasing intrauterine system(Mirena)or letrozole in young women with early stage well-differentiated endometrial carcinoma(EC)or complex atypical hyperplasia(CAH).Methods We performed a retrospective analysis on the clinical characteristics of 34 patients younger than 42 years old with early stage well-differentiated EC(localized in the mucosa without obvious muscularis invasion,16 cases)or CAH(18 cases)from January 2013 to October 2018.All the patients underwent hysteroscopic bipolar electrosurgical resection,and received goserelin 3.75 mg subcutaneous injection once every 28 days for 3 times.A total of 19 cases were treated with Mirena at the end of the operation,while the other 15 cases were given letrozole 2.5 mg once a day.All the patients underwent follow-ups with endometrial sampling by hysteroscopy and curettage and transvaginal ultrasound(TVS)for every 3 months.Results The patients were followed up for 9-68 months(mean,34.6 months).The complete response(CR)rate of EC was 87.5%(14/16)and that of CAH was 100%(18/18);the disease was stable in 2 cases,both of which were endometrial carcinoma.Among the women who achieved CR,1 case of CAH and 1 case of EC had relapsed.Hysterectomy was performed in 2 patients with recurrence and 2 patients with stable disease.During the follow-up period,11 cases got 12 pregnancies.Conclusions Hysteroscopic lesionectomy and GnRHa combined with levonorgestrel intrauterine hormonal system or letrozole is an effective fertility-sparing strategy for young women with early stage well-differentiated EC or CAH.Hysterectomy should be performed after childbirth,especially in patients with EC.