【作者】 应伟雯；

【导师】 谢幸； 叶大风；

【作者基本信息】 浙江大学 ， 妇产科学， 2003， 硕士

【摘要】 前言 子宫内膜癌是女性生殖道最常见的恶性肿瘤，近年来发病率有明显上升趋势。2/3子宫内膜癌患者在初次诊断时处于早期，但估计五年生存率比70年代下降4个百分点。因此，对早期子宫内膜癌患者需要根据高危因素进行分层治疗。1988年国际妇产科联盟(FIGO)在新颁布的分期体系中，纳入了子宫肌层浸润深度这一因素，但此分期体系是建立在术后切除子宫的组织学检查基础上。至今无一可靠的非组织学手段判断子宫肌层浸润。 目前，临床应用的判断子宫肌层浸润的非组织学手段包括手术中剖检子宫肉眼观和术前影像学检查。影像学方法有MRI、CT、经阴道二维超声和彩色多普勒超声。MRI因其良好的软组织对比分辨力，对肌层浸润的诊断准确性较高，但由于设备条件等的限制，尚难普及。CT的准确性不如MRI，与阴道超声相似，而费用较阴道超声高。彩色多普勒超声在评估肌层浸润的价值存在争论。阴道超声具 2003年浙江大学硕士学位论文有比腹部超声更高的分辨力，而且检查方法简便，无创伤，目前己成为术前了解肌层浸润深度最常用的检查手段。但由于二维超声只能显示两个平面的信息，而且缺乏一个客观的量化诊断指标，诊断的敏感性和特异性较低。因此有必要寻找更为有效的超声诊断手段。本研究的目的是1、探讨三维超声的多平面成像技术诊断于宫内膜癌肌层浸润的价值，筛选影响三维超声诊断准确性的超声和临床病理因素。2、评估三维超声测定于宫和肿瘤体积在诊断子宫内膜癌深肌层浸润中的价值。3、建立诊断深肌层浸润的综合评分系统。材料与方法 收集2002年1月至2003年3月间经诊刮确诊并在我院接受手术治疗的子宫内膜癌患者53例，术前一周内作经阴道二维超声和三维超声检查，经阴道三维超声启用多平面成像和体积测量功能。参考Olnya等的肌层浸润判断标准分别对肌层浸润深度做出判断。应用三维超声分别测量于宫体积和肿瘤体积。同时记录患者（l）临床参数：年龄，有无绝经，绝经年限，体重指数，血清CA－125；（2）术前组织学参数：组织分类，细胞分化；（）术后组织学参数：组织分类，细胞分化，有无宫颈浸润或淋巴浸润或脉管浸润，有无合并子宫肌瘤或腺肌症；（4）术后组织免疫组化染色结果：雌激素受体（ER），孕激素受体（PR）尸53，增殖细胞核抗原（PCNA）。以术后病理组织学诊断为金标准，分别比较三维超声多平面成像和二维阴道超声两种方法评估肌层浸润深度的结果；比较深肌层浸润和浅肌层浸润两组患者的子宫体积和肿瘤体积；建立肿瘤体积和深肌层浸润的回归方程；筛选影响超声诊断的因素和与深肌层浸润相关的因素；建立包括三维超声参数的诊断子宫内膜癌深肌层浸润的综合评分系统。根据资料性质分别采用卡方检验，Mannwhitmp U检验，LOgistic回归，ROC曲线等统计方法，显著性检验水准a＝0刀5（双侧人所有数据用 SPSS 10．0软件包处理。 2 2003年浙江大学硕士学位论文结果：l、术后组织学诊断结果：深肌层浸润18例，浅肌层浸润引例，无肌层浸 润4例。 2、H维超声结果： （）三维超声多平面成像法：图象特征为：无肌层浸润时局部内膜增厚， 回声增强，内膜基底线光滑清晰；有肌层浸润时基底线模糊呈锯齿状改 变或基底线消失，肿瘤向肌层延续呈指状突起。在诊断浅肌层浸润中 三维超声多平面成像优于二维超声，其差异有统计学意义 （X’－24．115，p＝0．001），但在诊断深肌层浸润上两者差异无显著性 ／－6厂85，p＝l．000）。在纳入研究的所有参数中，未发现有能影响三维 超声多平面成像诊断子宫内膜癌肌层浸润的参数（P＞0刀50）。 （2）三维超声子宫和肿瘤体积：深、浅肌层浸润的子宫体积中位数分 别为 50（Q，。。。一108．5－46） Cm3和 46（Q，。。。。108－24）Cm3，两者差异无显著 性（Z—1．409，厂l．000）：深、k肌层浸润的肿瘤体积分别为 9．16（Q75． 。。一23二2－3二45Xm3和1．12（Q，。。。＝4．49－1．12）Cm’，两者差异有显著性 （Z—3厂2，p＝0刀00）。肿瘤体积和深肌层浸润的lOgistiC回归方程模型有 显著性差异，方程为：IOgitp＝－1．318＋0刀72X，对方程进行回代，当肿瘤 体积为 48．82。m3，42．40 Cm3，37．56 Cm3，18．31 Cm3，深肌层浸润的概率分 另u为 90％，85％，80％，50O。 3、综合评分体系的建立：将可能与深肌层浸润有关的因素，包括年龄、 体重指数、三维超声子宫和肿瘤体积、肿瘤生长部位、生长方式、血 清CA－125，术后组织类型、细胞分化、ER、PR、P53、PCNA的表达 进行进一步分析，发现细胞分化、三维超声下肿瘤体积，组织类型，更多还原

【Abstract】 Preface Endometrial carcinoma(EC) is the most commom malignancy of the female genital tract .The incidence has been increasing in recent years.Although two thirds patients with endometrial cancer are diagnosed as early stage ,the five-year survival was decreased 4% compared with that in 1970’s.So,the patients with early stage should be treated according to high risk factors. The depth of myometrial invasion was involved in the staging system of the International Federation of Gynecology and Obstetrics(FIGO) in 1988. But it was based on staging surgery and postoperative histological examination .By far there is no reliable non-histological means for evaluating the depth of myometrial2003invasion.At present, non-histological means for evaluating the depth of myometrial invasion include a gross evaluation and imaging techniques.The imaging techniques include MRI ,CT, transvaginal sonography(TVS) and color Doppler flowing image(CDFI).MRI is the most effective due to its excellent resolution of contrast of soft tissue.But it can’t be used widely because of its higher cost-effective.CT is expensive and less effective than MRLThere is controversy of CDFI in evaluating the depth of myometrial invasion.TVS is a simple and non-invasive method, which has high discrimination. So it has been widely used to assess the depth of MI.However TVS could only provide the information of two planes and was lack of objective quantity parameters, so it has low sensitivity and specificity to detect the depth of myometrial invasion of endometrial cancer.Therefore , it is necessary to study a more effective sonographic method. The objectives of the study are:1. To investigate the value of multiplanar mode reconstruction of three dimensional transvaginal sonography(3D-TVS) in diagnosis of depth of MI2. To evaluate the role of measurements of uterine and tumor volume by 3D-TVS in detection of deep MI.3.To set up a combined score system to diagnose deep MI.2003Materials and Methods Fifty-three patients with apostoperative histological-proven endometrial carcinoma from Women’s Hospital, Zhejiang University between 2002 to 2003 were included in the study. All Patients underwent primary surgery and submitted to TVS and 3D-TVS within 7 days before operation.The diagnosis of the depth of MI by TVS and 3D-TVS was made according to the criteria of Olaya. The uterine and tumor volume were obtained based on 3D-TVS. In the meantime, the following parameters were recorded:1) Clinical parameters:age,weight index,menopause,the duration of postmenopause,FIGO stage and serum CA125.2) Preoperative histological parametersrhistological type ,tumor grade.3) Postoperative parameters:histological type,tumor grade,cervical involvement,lymph-vascular space involvement.complicated with myoma and adenomyosis.4) Postoperative immunohistochemistry parameters: estrogen receptor (ER), progesterone receptor (PR), P53, and proliferating cell nuclear antigen (PCNA)The Postoperative histological diagnosis was used as the gold standard for diagnosis of the depth of MI. X2 test, Mann-Whitney U test,Receiver operating characteristic(ROC) curve,Logisticregression were used to compare the advantages of 2D-TVS and 3D-TVS in detection of the depth of MI.To compare the difference of uterine volume and tumor volume between superficial and deep MI, a logistical regression equation of tumor volume and deep MI was established. All the data were statistically managed with SPSS 10.0 for windows. By analyzing the parameters that affected the accuracy of 3D-TVS or were related to deep MI, a combined score system was established. Results 1 .postoperative histological resultsEighteen of the patients were deep MI,thirty-one superficial MI and four no myometrial involvement. 2.3D-TVS results(1) Imaging features were observed by 3D-TVS multiplanar mode reconstruction. The endometrium-myometrium interphase was clearly outlined and local endometrium was thick更多还原