宫腔镜下病灶电切术联合高效孕激素在保留生育功能子宫内膜癌患者中的临床价值

The clinical value of hysteroscopic electrotomy combined with high effective progestins in patients with endometrial cancer with fertility preservation

目的探讨宫腔镜下病灶电切术联合高效孕激素治疗在保留生育功能子宫内膜癌(endometrial carcinoma,EC)患者中的临床应用价值。方法回顾性分析郑州大学第一附属医院2012年12月至2020年12月行保留生育功能治疗的Ⅰa期EC患者的临床资料,共53例行宫腔镜手术,其中31例患者为宫腔镜下病灶电切术联合高效孕激素治疗作为电切组,22例患者为宫腔镜下诊刮术联合高效孕激素治疗作为诊刮组,每3个月行子宫内膜病理检查,分析两组患者的治疗效果及妊娠结局,并评估宫腔镜电切的临床价值。结果(1)电切组与诊刮组的完全缓解率分别为87.1%(27/31)和72.7%(16/22),复发率分别为22.2%(6/27)、6/16,妊娠率分别为29.6%(8/27)、3/16,成功分娩率分别为5/8、2/3,宫腔粘连发生率分别为12.9%(4/31)、9.1%(2/22),均为轻中度粘连;两组患者的完全缓解率、复发率、妊娠率及宫腔粘连率比较,差异均无统计学意义(P>0.05)。logistic回归分析显示,宫腔粘连不是EC患者复发及妊娠的影响因素(P>0.05)。(2)电切组患者完全缓解中位时间小于诊刮组(3个月:6个月,P=0.004),并且其治疗前3个月的完全缓解率明显高于诊刮组(58.1%:9.1%,P=0.001)。(3)高分化EC患者的完全缓解率为85.1%(40/47)、复发率为27.5%(11/40)、妊娠率为25.0%(10/40);6例中分化EC患者中,完全缓解3例,复发1例,足月妊娠1例,两组患者的完全缓解率、完全缓解中位时间、复发率及妊娠率比较,差异均无统计学意义(P>0.05)。中分化EC患者中3例治疗3个月病理无缓解行子宫内膜癌全面分期手术,保守治疗期间,疾病均无深肌层浸润及远处转移等进展风险。结论对早期保留生育功能EC患者,宫腔镜下电切术联合高效孕激素治疗可在较短时间内达到较高的完全缓解率,其术后宫腔粘连发生率低且不影响EC患者的妊娠。

Objective To investigate the clinical value of hysteroscopic resection of lesions combined with megestrol acetate(MA)in the treatment of endometrial carcinoma(EC)with fertility preservation.Methods The clinical data ofⅠa EC patients who received fertility preservation therapy from December 2012 to December 2020 in the First Affiliated Hospital of Zhengzhou University were retrospectively analyzed.A total of 53 patients underwent hysteroscopic surgery,including 31 EC patients treated with hysteroscopic resection of lesions combined with MA as the hysteroscopic electrotomy group and 22 EC patients treated with hysteroscopy curettage combined with MA as the hysteroscopic curettage group.Endometrial pathological examination was performed every 3 months to analyze the treatment effect and pregnancy outcome of the two groups,and to evaluate the clinical value of hysteroscopic electrotomy.Results(1)The complete remission rate of hysteroscopic electrotomy group and the hysteroscopic curettage group were 87.1%(27/31)and 72.7%(16/22),the recurrence rate were 22.2%(6/27)and 6/16,the pregnancy rate were 29.6%(8/27)and 3/16,the successful delivery rate were 5/8 and 2/3,and the intrauterine adhesions rate which were mild and moderate were 12.9%(4/31)and 9.1%(2/22).There was no significant difference in them between the two groups(P>0.05).Logistic regression analysis showed that intrauterine adhesion was not a factor affecting recurrence and pregnancy of EC patients(P>0.05).(2)The median time of complete response in the hysteroscopic electrotomy group was shorter than that in the hysteroscopic curettage group(3 months:6 months,P=0.004).After 3 months of treatment,the rate of complete response in the hysteroscopic electrotomy group was significantly higher than that in the hysteroscopic curettage group(58.1%:9.1%,P=0.001).(3)The complete response rate,recurrence rate and pregnancy rate were 85.1%(40/47),27.5%(11/40)and 25.0%(10/40)in highly differentiated EC patients.Among the six case of moderately differentiated EC patients,3 had complete remission,1 had recurrence,and 1 had full-term pregnancy,and had no significant difference between them(P>0.05).Three moderately differentiated EC patients showed no pathological remission after 3 months of treatment,and underwent comprehensive staging surgery for endometrial cancer.During conservative treatment,there was no risk of disease progression such as deep muscle invasion and distant metastasis.Conclusions The patients who treated with hysteroscopic electrotomy combined with MA can achieve a higher complete remission rate in a relatively short time,and the probability of postoperative intrauterine adhesion is low and it does not affect the pregnancy of EC patients.