66例子宫肉瘤患者的临床资料分析及未预料子宫肉瘤的研究探讨

发布时间：2018-08-11 09:38

【摘要】：目的:探讨子宫肉瘤的发生率、常见临床表现、影像学表现、治疗方法及预后,为更好的诊治子宫肉瘤提供临床依据;分析未预料子宫肉瘤的发生率,临床特点,探讨如何尽量避免未预料子宫肉瘤的发生及如何避免遇到未预料子宫肉瘤造成的不良后果。方法:1.收集2011年3月-2016年7月于天津中心妇产科医院住院的66例子宫肉瘤患者的临床资料,应用SPSS19.0统计学软件,对各组织学类型患者的临床特点(年龄、绝经情况、生育史、肿物大小、临床分期、临床表现、肿瘤标志物、术前诊刮、ER、PR及Ki-67的表达等)、影像学表现、治疗以及患者的预后进行分析比较,所有计数资料采用卡方检验,当单元格资料计数较小时,采用Fisher精确检验,Log-rank检验法单因素分析影响患者预后的相关因素,COX回归模型法对患者预后进行多因素分析,采用Kaplan-Meier乘积极限法绘制生存曲线图。2.收集在2011年3月-2016年7月因子宫肌瘤于天津中心妇产科医院住院的病人总数,术后病理诊断为子宫肉瘤患者45例,随机抽取同期住院的子宫肌瘤患者45例,分析未预料子宫肉瘤的发生率,以及未预料子宫肉瘤的临床特点,所有计数资料采用卡方检验。阅读文献,探讨粉碎器使用对子宫肉瘤预后造成的影响,如何尽量避免未预料子宫肉瘤的发生及未预料发生后如何避免造成不良影响。结果:1.构成比:子宫肉瘤占子宫体恶性肿瘤的4.7%,66例子宫肉瘤患者中:LMS:28例,ESS:25例,AS:13例。各组织类型中以子宫平滑肌肉瘤、子宫内膜间质肉瘤为主。2.年龄:66例子宫肉瘤患者中年龄最小的24岁,年龄最大68岁,平均年龄为:47.83±8.42岁,中位年龄49岁,子宫平滑肌肉瘤患者发病年龄较子宫内膜间质肉瘤高(P=0.008)。发病平均年龄:LMS:50.61±7.85岁,ESS:45.36±7.85。3.绝经状态及生育史:一半以上的患者于绝经前发病,绝大多数患者发病时已生育,各组织类型间的绝经状态、生育史无统计学差异。4.临床表现及分期:临床分期以I期为主,最常见的首发临床表现为阴道不规则出血,不同组织类型患者的临床表现及临床分期无统计学差异。5.肿物大小、病史:66例子宫肉瘤患者中,最长病史20年,最短的1月,肿物的大小2.5-25cm,各组织类型间肿物大小、病史有统计学差异(P=0.033)。6.术前检查:各组织类型间CA125阳性的差异无统计学意义。各组织类型间术前诊刮阳性率差异有统计学意义(P=0.001),子宫腺肉瘤术前诊刮阳性率较高(72.4%)。盆腔核磁诊断子宫肉瘤阳性率优于妇科超声(P=0.000)。7.雌孕激素ER/PR受体及Ki-67的表达:各组织类型中ER/PR受体的表达差异有统计学意义(P=0.042),雌孕激素受体在子宫内膜间质肉瘤中有较高的表达。各组织类型中Ki-67表达无统计学差异。8.预后:单因素分析中患者的发病年龄、临床分期、有无脉管癌栓是影响患者预后的相关因素(P=0.042 P=0.002 P=0.003),多因素分析中临床分期、脉管癌栓是影响患者预后的独立因素(P=0.014 P=0..008),ER/PR阳性表达、病理类型、治疗方式对患者预后的差异无统计学意义。9.未预料子宫肉瘤发生率为6.7‰,I期患者为主,主要是子宫平滑肌肉瘤,其次是子宫内膜间质肉瘤,腺肉瘤少见。10.未预料子宫肉瘤患者,发病年龄46.51±8.14岁,肌瘤平均病史2.89±1.79年,肌瘤个数≤3个;子宫肌瘤组发病年龄41.98±0.34岁,肌瘤病史4.32±2.28年,肌瘤个数3个,发病年龄、肌瘤病史、肌瘤个数有统计学差异(P=0.039 P=0.033P=0.003),两组患者间临床表现、绝经状态无统计学差异。11.子宫肉瘤与子宫肌瘤之间超声征象差异有统计学意义(P0.05),子宫肌瘤超声表现边界清晰、回声以低回声为主,瘤体内部血流分布规则,而未预料子宫肉瘤患者边界欠清、回声以蜂窝状或中高回声为主、血流分布不均。结论:1.子宫肉瘤发病率占子宫体恶性肿瘤的4.7%,多发生在绝经前女性患者中,无特异性临床表现,最常见的临床表现为阴道不规则出血。2.子宫肉瘤术前诊断困难。盆腔核磁在子宫肉瘤诊断中优于妇科超声,术前诊断性刮宫或宫腔镜检查能提高子宫腺肉瘤术前诊断率,雌孕激素受体在子宫内膜间质肉瘤中有较高的表达。3.单因素分析中患者的发病年龄、临床分期、有无脉管癌栓是影响患者预后的相关因素,多因素分析中临床分期、脉管癌栓是影响患者预后的独立因素,ER/PR阳性表达、病理类型、治疗方式对患者预后的差异无统计学意义。4.未预料子宫肉瘤发生率为6.7‰,早期患者为主,主要是子宫平滑肌肉瘤,其次是子宫内膜间质肉瘤,腺肉瘤少见。5.未预料子宫肉瘤与子宫肌瘤患者相比比较,具有发病年龄大、肌瘤病史短、肌瘤个数少的特点。两组患者绝经状态、临床表现无统计学差异。6.子宫肌瘤超声表现边界清晰、回声以低回声为主,瘤体血流分布规则,而未预料子宫肉瘤患者边界欠清、回声以蜂窝状或中高回声为主、血流分布不均。
[Abstract]:Objective: To investigate the incidence, common clinical manifestations, imaging manifestations, treatment methods and prognosis of uterine sarcoma, and to provide clinical evidence for better diagnosis and treatment of uterine sarcoma. Methods: 1. The clinical data of 66 cases of uterine sarcoma hospitalized in Tianjin Central Obstetrics and Gynecology Hospital from March 2011 to July 2016 were collected. The clinical characteristics (age, menopause, birth history, tumor size, clinical stage, clinical manifestations, tumor markers, preoperative diagnosis) of each histological type of uterine sarcoma were analyzed by SPSS 19.0 statistical software. Scraping, ER, PR and Ki-67 expression, imaging findings, treatment and prognosis of patients were analyzed and compared. Chi-square test was used for all counting data. Fisher exact test was used for small cell data. Log-rank test was used for univariate analysis of related factors affecting the prognosis of patients. COX regression model was used for multiple prognosis of patients. Factor analysis, Kaplan-Meier multiplying positive limit method was used to draw survival curve. 2. The total number of patients admitted to Tianjin Central Obstetrics and Gynecology Hospital from March 2011 to July 2016 were collected. 45 patients with uterine sarcoma were pathologically diagnosed. 45 patients with uterine sarcoma were randomly selected from the same period of hospitalization. The incidence of unexpected uterine sarcoma was analyzed. Chi-square test was used to determine the incidence of unexpected uterine sarcoma and the clinical characteristics of unexpected uterine sarcoma. Of the 66 patients with uterine sarcoma, 28 were LMS, 25 ESS, and 13 AS. Most of them were leiomyosarcoma and endometrial stromal sarcoma. The average age of onset was LMS: 50.61 [7.85], ESS: 45.36 [7.85.3]. Menopausal status and fertility history: more than half of the patients had premenopausal onset, the vast majority of patients had fertility at the time of onset, and there was no statistical difference in the state of menopause and fertility history between different tissue types. Stage I: The most common clinical manifestation was irregular vaginal bleeding. There was no significant difference in clinical manifestation and staging between different tissue types. 5. Tumor size, medical history: 66 cases of uterine sarcoma patients, the longest history of 20 years, the shortest 1 month, the size of the tumor 2.5-25 cm, the size of the tumor between tissue types, disease. Preoperative examination: There was no significant difference in the positive rate of CA125 among different tissue types. The positive rate of preoperative curettage was statistically significant (P = 0.001). The positive rate of preoperative curettage for uterine adenosarcoma was higher (72.4%). Progesterone ER/PR receptor and Ki-67 expression: There was significant difference in ER/PR receptor expression among different tissue types (P = 0.042), estrogen and progesterone receptor expression was high in endometrial stromal sarcoma. There was no significant difference in Ki-67 expression among different tissue types. 8. Prognosis: Univariate analysis of the patient's age, clinical stage, presence or absence of vascular vessels. Tumor thrombus is a related factor affecting the prognosis of patients (P = 0.042 P = 0.002 P = 0.003). In multivariate analysis, vascular tumor thrombus is an independent factor affecting the prognosis of patients (P = 0.014 P = 0.008), positive expression of ER / PR, pathological types, treatment methods have no significant difference on the prognosis of patients. 9. Unexpected incidence of uterine sarcoma is 6.7, stage I. The patients were mainly leiomyosarcoma of uterus, followed by endometrial stromal sarcoma and adenosarcoma. 10. Unexpected patients with uterine sarcoma were 46.51 (+ 8.14) years old, with an average history of 2.89 (+ 1.79) years, and the number of leiomyomas (< 3); 41.98 (+ 0.34) years old, 4.32 (+ 2.28) years old, and 3 years old. Age, history of leiomyoma, the number of leiomyomas were statistically significant (P = 0.039 P = 0.033 P = 0.003), clinical manifestations between the two groups, no statistical difference in menopausal status. Conclusion: 1. The incidence of uterine sarcoma accounted for 4.7% of uterine malignancies, mostly occurred in premenopausal women, without specific clinical manifestations, the most common clinical manifestation was vaginal irregular bleeding. 2. Uterine sarcoma surgery. Pelvic MRI is superior to gynecological ultrasound in the diagnosis of uterine sarcoma. Preoperative diagnostic curettage or hysteroscopy can improve the preoperative diagnosis rate of uterine adenosarcoma. Estrogen and progesterone receptors are highly expressed in endometrial stromal sarcoma. 3. Univariate analysis of the patient's age of onset, clinical stage, presence or absence of vascular tumor thrombus is an influence. Multivariate analysis of the clinical stage, vascular tumor thrombus is an independent factor affecting the prognosis of patients, ER/PR positive expression, pathological types, treatment methods of patients with prognosis of the difference was not statistically significant. 4. Unexpected incidence of uterine sarcoma was 6.7, early patients mainly uterine leiomyosarcoma, followed by son. Endometrial stromal sarcoma, adenosarcoma is rare. 5. Unexpected uterine sarcoma compared with myoma patients, with the onset of age, myomatosis history is short, the number of myomas is small. Two groups of patients with menopausal status, clinical manifestations are not statistically significant. 6. Myoma ultrasound manifestations of clear borders, echo mainly hypoechoic, tumor blood flow distribution rules. In the case of unexpected uterine sarcoma, the margin was poorly defined, the echoes were mainly honeycomb-like or medium-high echoes, and the blood flow was uneven.
【学位授予单位】：天津医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R737.33

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