Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT; CooperSurgical Inc, Trumbull, CT.
Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY.
Am J Obstet Gynecol. 2019 Jul;221(1):39.e1-39.e14. doi: 10.1016/j.ajog.2019.02.051. Epub 2019 Mar 7.
Occult uterine cancer at the time of benign hysterectomy poses unique challenges in patient care. There is large variability and uncertainty in estimated risk of occult uterine cancer in the literature and prior research often did not differentiate/include all subtypes.
To thoroughly examine the prevalence of occult uterine cancer in a large population-based sample of women undergoing hysterectomy for presumed benign indications and to identify associated risk factors.
Using the New York Statewide Planning and Research Cooperative System database, we identified 229,536 adult women who underwent an inpatient or outpatient hysterectomy for benign indications during the period October 1, 2003 to December 31, 2013 at civilian hospitals and ambulatory surgery centers throughout the state. Diagnosis of corpus uteri cancer within 28 days after the index hysterectomy was determined using linked state cancer registry data. We estimated the prevalence of occult uterine cancer (overall and by subtype) and developed and validated risk prediction models using a random split sample approach.
Overall, 0.96% (95% confidence interval: 0.92-1.00%) of the women had occult uterine cancer, including 0.75% (95% confidence interval: 0.71-0.78%) with endometrial carcinoma and 0.22% (95% confidence interval: 0.20-0.23%) with uterine sarcoma. The prevalence of leiomyosarcoma was 0.15% (95% confidence interval: 0.13-0.17%). Seventy-one percent of the endometrial carcinomas and 58.0% of the uterine sarcomas were at localized stage. The risk for occult uterine cancer ranged from 0.10% in women aged 18-29 years to 4.40% in women aged ≥75 years; and varied from 0.14% in women undergoing hysterectomy for endometriosis to 0.62% for uterine fibroids and 8.43% for postmenopausal bleeding. The risk of occult uterine cancer was also significantly associated with race/ethnicity, obesity, comorbidity, and personal history of malignancy. Prediction models incorporating these risk factors had high negative predictive values (99.8% for endometrial carcinoma and 99.9% for uterine sarcoma) and good rule-out accuracy despite low positive predictive value.
In women undergoing hysterectomy for presumed benign indications, 0.96% had unexpected uterine cancer. Patient characteristics such as age, surgical indication, and medical history may help guide risk stratification.
在良性子宫切除术时发现隐匿性子宫癌给患者治疗带来了独特的挑战。文献中隐匿性子宫癌的风险估计存在很大的变异性和不确定性，并且既往研究往往没有区分/包括所有亚型。
在接受良性指征子宫切除术的大型基于人群的妇女样本中，彻底检查隐匿性子宫癌的患病率，并确定相关的危险因素。
我们利用纽约州全州规划和研究合作系统数据库，确定了 2003 年 10 月 1 日至 2013 年 12 月 31 日期间，在全州各地的民用医院和门诊手术中心接受择期住院或门诊子宫切除术治疗良性疾病的 229,536 名成年女性。通过链接州癌症登记处数据，确定索引子宫切除术 28 天内诊断出的子宫体癌。我们使用随机分割样本方法估计隐匿性子宫癌（总体和亚型）的患病率，并建立和验证风险预测模型。
总体而言，有 0.96%（95%置信区间：0.92-1.00%）的妇女患有隐匿性子宫癌，其中 0.75%（95%置信区间：0.71-0.78%）患有子宫内膜癌，0.22%（95%置信区间：0.20-0.23%）患有子宫肉瘤。平滑肌肉瘤的患病率为 0.15%（95%置信区间：0.13-0.17%）。71%的子宫内膜癌和 58.0%的子宫肉瘤处于局限性阶段。隐匿性子宫癌的风险范围从 18-29 岁妇女的 0.10%到≥75 岁妇女的 4.40%；从子宫内膜异位症接受子宫切除术的妇女的 0.14%到子宫肌瘤的 0.62%和绝经后出血的 8.43%。隐匿性子宫癌的风险也与种族/民族、肥胖、合并症和个人恶性肿瘤史显著相关。纳入这些危险因素的预测模型具有较高的阴性预测值（子宫内膜癌为 99.8%，子宫肉瘤为 99.9%），尽管阳性预测值较低，但具有良好的排除准确性。
在因疑似良性指征而接受子宫切除术的妇女中，有 0.96%的妇女患有意外的子宫癌。患者特征，如年龄、手术指征和既往病史，可能有助于指导风险分层。
