摘要
目的：通过分析子宫内膜癌临床分期与手术病理分期之间的差异，探讨影响子宫内膜癌预后的因素。
方法：收集1995年1月～2001年12月在青岛大学医学院附属医院妇科住院手术的198例子宫内膜癌患者的临床及病理资料，从临床分期、病理类型和组织学分级等三个方面，分别对子宫内膜癌术前与术后的差异进行分析与比较，并在此基础上初步研究了影响子宫内膜癌分期及预后的因素。
结果：
1 临床分期与手术病理分期之间存在着较大差异，平均差异率为46.4％(92／198)。其中，Ⅰ期差异率为24.5％(26／106)，Ⅱ期差异率为84.6％(62／78)，Ⅲ期10例子宫内膜癌患者中4例发生改变，Ⅳ期4例子宫内膜癌患者手术前后无改变。
2 病理类型：术前诊断为子宫内膜样腺癌者168例，术后9例改变为腺鳞癌，1例改变为腺棘癌，误差率为5.9％；术前诊断为子宫内膜腺鳞癌者15例，术后3例改变为内膜样腺癌，3例改变为腺棘癌，误差率为40.0％；术前诊断为子宫内膜腺棘癌者8例，术后1例改变为腺鳞癌，1例改变为内膜样腺癌；术前诊断为子宫内膜浆液性乳头状腺癌者4例，术后1例改变为内膜样腺癌；术前诊断为子宫内膜透明细胞癌者2例、子宫内膜未分化小细胞癌者1例，术后均未发生改变。
3 组织学分级：术前为高分化者120例，术后转为中分化者16例(占13.3％)，转为低分化者1例(占0.8％)；术前为中分化者60例，转为高分化者8例(占13.3％)，转为低分化者为9例(占15％)；术前为低分化者10例，术后转为中分化者2例；8例术前缺少组织学分级。
4 淋巴结转移：186例淋巴结切除标本中，17例患者发生盆腔淋巴结转移，转移率为9.1％。其中，临床Ⅰ期98例中有3例发生盆腔淋巴结转移(占3.0％)，临
中文摘要
床11期76例中有4例发生盆腔淋巴结转移(占5.2%)，临床111期9例中有7例发生
盆腔淋巴结转移，临床W期3例，术后发现盆腔淋巴结转移。68例腹主动脉旁淋巴
结活检中有7例发生淋巴结转移(I期4例、m期1例、W期2例)。
5子宫外盆腔转移:198例患者中，发生子宫外盆腔转移者(包括卵巢和盆腔
其他部位的转移)共35例，转移率为17.6%。研究中还发现，112例腹腔冲洗液中，
有9例细胞学阳性，占8.0%;4例行阑尾切除术的患者中，3例伴阑尾转移，(I期、
11期、111期各l例);32例大网膜标本中5例阳性，(I期、11期各l例，W期3例)。
通过以上调查研究，经单因素相关分析，临床分期、子宫肌层浸润、组织学分级、
病理类型均与盆腹腔转移有关护<0.01)。
6预后相关因素198例子宫内膜癌患者病例资料分析表明，随着手术病理分期
期别上升，肌层浸润深度增加，组织学分级增高，子宫内膜癌3年生存率显著下降，
经单因素分析，尸均<0.05;普通型腺癌3年存活率显著高于非普通型腺癌，尸<0.05。
结论:
1子宫内膜癌临床分期与手术病理分期相比存在着一定误差，尤其是临床n期
误差率较高，临床术前分期时应给予高度重视。
2子宫内膜癌盆腹腔转移及预后与分期、子宫肌层浸润深度、病理类型及组织
学分级均密切相关。
3子宫内膜癌手术病理分期较临床分期准确，能够客观判断预后，对术后进一
步治疗能够起到积极的指导作用。
OBJIECTIVE: To compare the differences between clinical (FIGO 1971) and surgical-pathologic (FIGO 1988) staging of endometrial carcinoma and to study the clinical value of clinical and surgical-pathological staging for endometrial carcinoma and to analyzed the prognologic factors of endometrial carcinoma.
METHODS: Clinical and pathological data of one hundred ninety-eight patients with endometrial carcinoma surgically treated from January 1995 to December 2001 were retrospectively reviewed in Affiliated Hospital Of Medical College Qing Dao Universty. The clinical staging , histologic grading and pathological type of these patients between preoperation and postoperation. The stagings were analyzed with regards to the prognologic factors of endometrial carcinoma.
RESULTS: The total differences between clinical and surgical-pathologic staging were 46.4% (92/198), of which stage I was 24.5%, stage II 84.6%, stage III 4 of 10 cases, stage IV 0 of 4 cases. The total differences of pathological type between preoperation and postoperation were 9.5% (19/198), of which endometrioid adenocarcinoma was 5.9%, adenosquamous carcinoma 40.0%, adenoacanthoma 2 of 8 cases, papillary serous carcinoma 1 of 4 cases. The total differences of histologic grade were 18.9% (36/190), of which G1 was 14.1%, G2 28.3%, G3 2 of 10 cases. The metastasis rate of pelvic lymph nodes was 9.1% (17/186), in stage I 3.0%, stage II 5.2%. The positive rate of paraaortic lymph nodes was 10% (7/68). Thirty-five patients (17.6%) with extrauterine pelvic metastasis were found, of which stage I was 13.2%, stage II 14.1%. 8.0% with ovarian metastasis, in stage I 10.3%, in stage II 1.3%. The other pelvic metastasis rate were 9.5%, containing extrauterine infiltration, round ligament metastasis and pelvic periton
eum planting. The postive rate of peritoneal cytological was 8.0%. There were three postive in four appendixs excised and five postive in thirty-two omentum excised. By univariate analysis, stages, depth of myometrial invasions, histologic grade and pathological type were related to the metastasis of pelvic and abdominal cavity and prognosis (P<0.05).
CONCLUSIONS:
1 There are differences between clinical (FIGO 1971) and surgical-pathologic(FIGO 1988) staging of endometrial carcinoma, especially stage II. So we should attach importance to stage II in clinical staging.
2 Clinical stage, depth of myometrial invasion, histologic grade and pathological type were related to the metastasis of pelvic and abdominal cavity and prognosis.
3 The surgical-pathological staging is more accurate than the clinical staging. The surgical-pathological staging is able to define the real extent of endometrial carcinoma and assess prognosis objectively.
引文
1 连利娟主编．林巧稚妇科肿瘤学．北京：人民卫生出版社，2000，356．
2 Seung H K, Hong D K, Yong S S, et al. Deetection of Deep Myometrial Invasion in Endometrial Carcinoma: Comparison of Transvagina Ultrasound, CT, and MRI. J Comput Assist Tomogr, 1995; 19(5): 766-772.
3 Pete Ⅰ, Godeny M, Toth E, et al. Prediction of cervical infiltration in Stage Ⅱ endometrial cancer by different preoperative evaluation techniques(D&C, US, CT, MRI). Eur J Gynaecol Oncol, 2003; 24(6): 517-22
4 章文华，白萍，吴令英等．子宫内膜癌手术病理分期的临床意义．中华妇产科杂 志，2001；36(8)：479-482．
5 彭芝兰，刘兴会，张家文等．子宫内膜癌290例临床分期与手术-病理分期的比较．中华妇产科杂志，1997；32(10)：597-600．
6 Cowles TA, agerina JF, Masterson BJ, et al. Comparison of clinical and surgical staging inpatients with endometrial carcinoma. Obstet Gynecol, 1985; 66: 413.
7 Ruangvutilert P, Sutantawibul A, Sunsaneevithayakul P, et al. Accuracy of transvaginal ultrasound for the evaluation of myometrial invasion in endometrial carcinoma. J Med Assoc Thai, 2004 Jan; 87(1): 47-52
8 Kaku T, Tsukamoto N, Hachisuga T, et al. Endometrial carcinoma associated with hyperplasia. Gynecol Oncol, 1996; 60(1): 22-25.
9 Silberbery SB, Pathology of endometrial carcinoma. In: Sciarra JW, ed. Gynecology and obstetrics. 2nd ed. Philadelphia: Harper & Row, 1988. 1
10 阿克曼主编．阿克曼氏外科手术病理学．回允中译．沈阳：辽宁教育出版社，1999，1411．
11 Wierzchowski W, Szczepanski W, Dyduch G, et al. Department of Clinical and Experimental Pathomorphology, Collegium Medicum, Jagiellonian University, Krakow, Pol J Pathol, 2003; 54(3): 179-81.
12 Lampe B, Kurzl R, Hantschmann P. Reliability of tumor typing of endometrial carcinoma in prehysterectomy curettage. Int J Gynecol Pathol, 1995; 14: 2-6.
13 沈铿．子宫乳头状浆液性癌．中国实用妇科与产科杂志，2002，18(4)：213．
14 Chan JK, Loizzi V, Youssef M, et al. Significance of comprehensive surgical staging in noninvasive papillary serous carcinoma of the endometrium. Gynecol Oncol, 2003 Jul; 90(1): 181-5.
15 Demczuk S, Wierzchowski W, Szczepanski W, et al. The comparison of the agreement in determining the histological grade of uterine endometrial endometrioid carcinoma, using the three-grade FIGO classification and the two-grade system. Pol J Pathol. 2003; 54(3): 179-81.
16 Scholten AN, Smit VT, Beerman H, et al. Prognostic significance and interobserver variability of histologic grading systems for endometrial carcinoma. Cancer, 2004 Feb 15; 100(4): 764-72.
17 Morrow CP, Bundy NB, Kurman RJ, et al. Relationship between Surgical pathological risk factors and outcome in clinical stage Ⅰ and Ⅱ carcinoma of the endometrium: a Gynecology Oncology Group study. Gynecol Oncol, 1991; 40(1): 55.
18 Chee JJ, Ho TH, Tay EH, et al. Endometrioid adenocarcinoma of the uterus: surgico-pathological correlations and role of pelvic lymphadenectomy. Ann Acad Med Singapore. 2003 Sep; 32(5): 670-5.
19 Buckers TE, Anderson B, Sorosky JI, et al. Significance of patho-logic patterns of pelvic lymphnode metastases in endometrial cancer. Gynecol Oncol, 2001; 80: 85-88.
20 Yenen MC, Dilek S, Dede M, et al. Pelvic-paraaortic lymphadenectomy in clinical Stage Ⅰ endometrial adenocarcinoma: a multicenter study. Eur J Gynaecol Oncol, 2003; 24(3-4): 327-9.
21 Todo Y, Sakuragi N, Nishida R, et al. Combined use of magnetic resonance imaging, CA 125 assay, histologic type, and histologic grade in the prediction of lymph node metastasis in endometrial carcinoma. Am J Obstet Gynecol, 2003 Aug; 189(2): 567.
22 Hsieh CH, ChangChien CC, Lin H, et al. Can a preoperative CA 125 level be a criterion for full pelvic lymphadenectomy in surgical staging of endometrial cancer? Gynecol Oncol, 2002 Jul; 86(1): 28-33.
23 Niikura H, Okamura C, Utsunomiya H, et al. Sentinel lymph node detection in patients with endometrial cancer. Gynecol Oncol, 2004 Feb; 92(2): 669-74
24 Kennedy AW, Peterson GL, et al. Experience with pelvic washings in stage Ⅰ and Ⅱ endometrial carcinoma. Gynecol Oncol, 1987; 28: 50-60.
25 郎景和，子宫内膜癌诊治的几个问题．中华妇产科杂志，2000；35(5)：261-263．
26 Hirai Y, Takeshima N, Kato T, et al. Malignant potential of positive peritoneal cytology in endometrial cancer. Obstet Gynecol, 2001; 97(5Pt 1): 725-728.
27 Ebina Y, Hareyama H, Sakuragh N, et al. Peritoneal cytology and its prognostic value in endometrial carcinoma, int Surg, 1997; 82: 244-248.
28 Steiner E, Eicher O, Sagemuller J, et al. Multivariate independent prognostic factors in endometrial carcinoma: a clinicopathologic study in 181 patients: 10 years experience at the Department of Obstetrics and Gynecology of the Mainz University. Int J Gynecol Cancer, 2003 Mar-Apr; 13(2): 197-203.
29 刘新民，万晶，赵小平．子宫内膜癌手术范围的前瞻性临床研究．中华妇产科杂志，1996；31(9)：548-550．
30 Lindauer J, Fowler JM, Manolitsas TP, et al. Is there a prognostic difference between depth of myometrial invasion and the tumor-free distance from the uterine serosa in endometrial cancer? Gynecol Oncol, 2003 Dec; 91(3): 547-51.
31 reasman WT, Morrow CP, Bundy BN. Surgical pathologic spread patterns of endometrial cancer: a gynecology oncology group study. Cancer, 1987; 60(8:) 2035.
32 33Caroll K. FIGO stage, histology, histologic grade, age and race asprognostic factors in determing survival for cancer of the female gynecological system: an analysis of 1973-87 SEER cases of cancers of the endometrium, cervix, ovary, vulua, and vagina. Semin Surg Oncol, 1994; 10(1): 31.
33 Zaino RJ, kurman RJ, Diana KL, et al. Pathologic models to predict outcome for women with endometrial adenocarcinoma: the importance of the distinction between surgical stage and clinical stage- agynecologic oncology group study. Cancer, 1996; 77(6): 1115.
34 arducci F, Lambaudie E, Sonoda Y, et al. Endometrial cancer: what's new? Gynecol Obstet Fertil, 2003 Jul-Aug; 31(7-8): 581-96.
35 Bremond A, Bataillard A, Thomas L, et al. Standards, Options and RecommendAtions 2000: non metastatic endometrial cancer. Bull Cancer, 2002 Jul-Aug; 89(7-8): 697-706.