基于磁共振指导的宫腔镜精准一步电切诊断早期子宫内膜癌可疑肌层浸润的价值

Application of MRI-guided hysteroscopic one-step resection in the diagnosis of suspected myometrial invasion in early endometrial cancer patients

目的开发一种基于MRI指导的宫腔镜精准一步电切评估早期子宫内膜癌(endometrial cancer,EC)影像学疑似子宫肌层浸润(myometrialinvasion,MI)的综合方案,评估其诊断价值,探讨影像学可疑肌层浸润对保育治疗结局的影响。方法纳入65例有保留生育功能需求的早期内膜癌患者,其中41例经MRI检查排除肌层浸润(参照组),24例提示可疑肌层浸润并进行病灶定位,通过宫腔镜下一步电切术(整体切除内膜病灶、下方基底层和3~5 mm肌层)进行病理检查。病理排除肌层浸润的患者,接受保育治疗,其临床特征和保育治疗结局与参照组进行对比。结果利用基于MRI指导的宫腔镜精准一步电切的诊断方案,24例疑似肌层浸润的患者中6例经电切病理证实肌层浸润,纳入MI组,接受手术治疗;余18例电切病理未见肌层浸润证据的患者被纳入非MI组,接受保育治疗。非MI组的累积完全缓解率在治疗早期与参照组无明显差异,在保育治疗第8个月(27.8%vs.61.0%,P=0.024)和第18个月(82.5%vs.94.8%,P=0.037)低于参照组。非MI组完全缓解后随访12个月的累积复发率高于参照组(50.0%vs.0,P<0.001),3例非肌层浸润复发患者经再次保育治疗后全部再次完全缓解。非MI组和参照组的妊娠率差异无统计学意义,非MI组有1例成功妊娠并足月分娩。结论MRI指导下的宫腔镜精准一步电切联合病理检查是综合评估早期内膜癌肌层浸润的有效手段,与MRI评估相比,帮助了约75%的患者得以保留生育能力,但临床对待这类病例应当谨慎诊治、密切随访。

Objective To evaluate the role of MRI-guided hysteroscopic precise one-step resection in the diagnosis of suspected myometrial invasion(MI)of endometrial cancer(EC)in patients desiring fertility preservation and the effects of suspected MI on the outcome of fertility-preserving treatment.Methods Sixty-five patients with early endometrial cancer who desiring fertility perservation were included,of which 41 myometrial infiltration patients were excluded by MRI imaging(reference group).EC patients with suspected MI on MRI(n=24)were prospectively enrolled and evaluated.Suspected MI was identified on MRI and resected via an en bloc resection technique(resecting the endometrial lesion,basal layer,and underneath myometrium en bloc)under hysteroscopy for pathological examination.Patients with negative pathological findings received progestin-based conservative therapy.The clinical characteristics and fertility-preserving outcomes of these patients were compared with those of patients without any evidence of MI on MRI.Results Through MRI-guided hysteroscopic one-step resection,6 out of 24 patients were confirmed of myometrial invasion and included in the MI group for surgical treatment.Among patients with suspected MI on MRI,MI was pathologically excluded in 18 patients(non-MI group)with fertility-preserving treatment.The cumulative complete response rate were lower in the non-MI group than those in the reference group at the 8th month(27.8%vs.61.0%,P=0.024)and the 18th month(82.5%vs.94.8%,P=0.037)of follow-up.The cumulative recurrence rate of the Non-MI group after 12 months of CR was higher than that of the Reference group(50.0%vs.0,P<0.001).All 3 Non-MI recurrent patients achieved complete remission after re-treatment.There was no statistical difference in pregnancy rate between the Non-MI group and the Reference group,with 1 successful pregnancy and full-term delivery in the Non-MI group.Conclusion The MRI-guided hysteroscopic precise one-step resection is an effective method for comprehensively evaluating the MI of early EC.Compared with MRI evaluation,it helps about 75%of patients preserve fertility,who need more careful treatment and more close follow-up.