Lax S F, Tamussino K F, Lang P F
Institut für Pathologie, LKH Graz Süd-West, Standort West, Akademisches Lehrkrankenhaus der Medizinischen Universität Graz, Göstingerstrasse 22, 8020, Graz, Österreich.
Klinische Abteilung für Gynäkologie, Universitätsklinik für Frauenheilkunde, LKH-Universitätsklinikum Graz, Graz, Österreich.
Pathologe. 2016 Nov;37(6):549-556. doi: 10.1007/s00292-016-0243-z.
Malignancies of the uterus metastasize by direct invasion of neighboring structures, lymphatically or hematogenously. Endometrial and cervical cancers lymphatically spread to the pelvic and para-aortic lymph nodes. For endometrial cancer the depth of myometrial invasion, lymphosvascular space involvement (LVSI) and a microcystic, elongated and fragmented (MELF) glandular invasion pattern are predictors for lymph node metastases. Metastases to the pelvic lymph nodes occur in approximately 10 % of endometrial cancer patients and in 30 % of these cases the para-aortic lymph nodes are also involved. Sentinel lymph node biopsy is possible for clinical stage I endometrial cancer and early stages of cervical cancer but is not yet routine. The presence of LVSI is considered to be the strongest predictor of distant metastases, particularly if assessed by immunohistochemistry with antibodies against factor VIII-related antigen or CD31. Endometrioid and clear cell carcinomas can hematogenously metastasize to the lungs, bones, liver and brain and can rarely be manifested as a solitary metastasis. In contrast, serous carcinomas can show extensive peritoneal spread. To date molecular biomarkers cannot predict the occurrence of distant metastasis. Overexpression of P53, p16 and L1CAM have been identified as negative prognostic factors and are associated with the prognostically unfavorable serous tumor type. The metastatic spread of squamous cell cervical cancer is strongly associated with tumor volume. Microinvasive carcinomas have a very low rate of parametrial and lymph node involvement and do not require radical hysterectomy. In contrast, lymph node metastases occur in up to 50 % of bulky stages IB and II cervical cancers. Distant metastases can occur in the lungs, liver, bones and brain. Molecular biomarkers have not been shown to predict metastatic spread. In well-differentiated adenocarcinoma of the cervix the pattern of invasion is strongly predictive for the presence of lymph node metastases, irrespective of tumor size and depth of invasion.
子宫恶性肿瘤可通过直接侵犯邻近结构、经淋巴管或血行转移。子宫内膜癌和宫颈癌经淋巴管转移至盆腔和腹主动脉旁淋巴结。对于子宫内膜癌，肌层浸润深度、淋巴管间隙受累（LVSI）以及微囊状、细长和破碎（MELF）腺管浸润模式是淋巴结转移的预测指标。约10%的子宫内膜癌患者会发生盆腔淋巴结转移，其中30%的病例腹主动脉旁淋巴结也会受累。前哨淋巴结活检适用于临床I期子宫内膜癌和宫颈癌早期，但尚未成为常规检查。LVSI的存在被认为是远处转移的最强预测指标，尤其是通过抗VIII因子相关抗原或CD31抗体的免疫组化评估时。子宫内膜样癌和透明细胞癌可经血行转移至肺、骨、肝和脑，很少表现为孤立性转移。相比之下，浆液性癌可表现为广泛的腹膜播散。迄今为止，分子生物标志物尚不能预测远处转移的发生。P53、p16和L1CAM的过表达已被确定为不良预后因素，且与预后不良的浆液性肿瘤类型相关。宫颈鳞状细胞癌的转移扩散与肿瘤体积密切相关。微浸润癌的宫旁组织和淋巴结受累率极低，无需进行根治性子宫切除术。相比之下，高达50%的IB期和II期大体积宫颈癌会发生淋巴结转移。远处转移可发生在肺、肝、骨和脑。尚未发现分子生物标志物可预测转移扩散。在高分化宫颈腺癌中，浸润模式对淋巴结转移的存在具有很强的预测性，与肿瘤大小和浸润深度无关。
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