Division of Gynecologic Oncology, Department of Obstetrics/Gynecology, The Ohio State University College of Medicine, Columbus, OH.
Division of Gynecologic Oncology, Department of Obstetrics/Gynecology, University of Missouri-Kansas City School of Medicine, Kansas City, MO.
Am J Obstet Gynecol. 2020 Jan;222(1):60.e1-60.e7. doi: 10.1016/j.ajog.2019.08.002. Epub 2019 Aug 8.
Endometrial intraepithelial neoplasia, also known as complex atypical hyperplasia, is a precancerous lesion of the endometrium associated with a 40% risk of concurrent endometrial cancer at the time of hysterectomy. Although a majority of endometrial cancers diagnosed at the time of hysterectomy for endometrial intraepithelial neoplasia are low risk and low stage, approximately 10% of patients ultimately diagnosed with endometrial cancers will have high-risk disease that would warrant lymph node assessment to guide adjuvant therapy decisions. Given these risks, some physicians choose to refer patients to a gynecologic oncologist for definitive management. Currently, few data exist regarding preoperative factors that can predict the presence of concurrent endometrial cancer in patients with endometrial intraepithelial neoplasia. Identification of these factors may assist in the preoperative triaging of patients to general gynecology or gynecologic oncology.
To determine whether preoperative factors can predict the presence of concurrent endometrial cancer at the time of hysterectomy in patients with endometrial intraepithelial neoplasia; and to describe the ability of preoperative characteristics to predict which patients may be at a higher risk for lymph node involvement requiring lymph node assessment at the time of hysterectomy.
We conducted a retrospective cohort study of women undergoing hysterectomy for pathologically confirmed endometrial intraepithelial neoplasia from January 2004 to December 2015. Patient demographics, imaging, pathology, and outcomes were recorded. The "Mayo criteria" were used to determine patients requiring lymphadenectomy. Unadjusted associations between covariates and progression to endometrial cancer were estimated by 2-sample t-tests for continuous covariates and by logistic regression for categorical covariates. A multivariable model for endometrial cancer at the time of hysterectomy was developed using logistic regression with 5-fold cross-validation.
Of the 1055 charts reviewed, 169 patients were eligible and included. Of these patients, 87 (51.5%) had a final diagnosis of endometrial intraepithelial neoplasia/other benign disease, whereas 82 (48.5%) were ultimately diagnosed with endometrial cancer. No medical comorbidities were found to be strongly associated with concurrent endometrial cancer. Patients with endometrial cancer had a thicker average endometrial stripe compared to the patients with no endometrial cancer at the time of hysterectomy (15.7 mm; standard deviation, 9.5) versus 12.5 mm; standard deviation, 6.4; P = .01). An endometrial stripe of ≥2 cm was associated with 4.0 times the odds of concurrent endometrial cancer (95% confidence interval, 1.5-10.0), controlling for age. In all, 87% of endometrial cancer cases were stage T1a (Nx or N0). Approximately 44% of patients diagnosed with endometrial cancer and an endometrial stripe of ≥2 cm met the "Mayo criteria" for indicated lymphadenectomy compared to 22% of endometrial cancer patients with an endometrial stripe of <2 cm.
Endometrial stripe thickness and age were the strongest predictors of concurrent endometrial cancer at time of hysterectomy for endometrial intraepithelial neoplasia. Referral to a gynecologic oncologist may be especially warranted in endometrial intraepithelial neoplasia patients with an endometrial stripe of ≥2 cm given the increased rate of concurrent cancer and potential need for lymph node assessment.
子宫内膜上皮内瘤变，又称复杂不典型增生，是一种子宫内膜癌前病变，与子宫切除时同时患有子宫内膜癌的风险为 40%相关。尽管大多数在子宫切除时诊断为子宫内膜上皮内瘤变的子宫内膜癌为低风险和低分期，但约 10%的最终诊断为子宫内膜癌的患者将患有高危疾病，需要进行淋巴结评估以指导辅助治疗决策。鉴于这些风险，一些医生选择将患者转介给妇科肿瘤医生进行明确治疗。目前，关于术前因素可预测患有子宫内膜上皮内瘤变的患者同时患有子宫内膜癌的信息很少。识别这些因素可能有助于对患者进行术前分诊，决定是否转至普通妇科或妇科肿瘤学治疗。
确定术前因素是否可预测患有子宫内膜上皮内瘤变的患者在子宫切除时同时患有子宫内膜癌；并描述术前特征预测哪些患者可能存在更高风险的淋巴结受累，需要在子宫切除时进行淋巴结评估。
我们对 2004 年 1 月至 2015 年 12 月因病理证实的子宫内膜上皮内瘤变而行子宫切除术的患者进行了回顾性队列研究。记录患者的人口统计学、影像学、病理学和结局。使用“Mayo 标准”确定需要进行淋巴结切除术的患者。使用两样本 t 检验估计连续协变量与进展为子宫内膜癌之间的未调整关联，使用逻辑回归估计分类协变量之间的未调整关联。使用 5 折交叉验证的逻辑回归为子宫切除时的子宫内膜癌建立了多变量模型。
在回顾的 1055 份图表中，有 169 份符合条件并纳入研究。在这些患者中，87 例（51.5%）最终诊断为子宫内膜上皮内瘤变/其他良性疾病，而 82 例（48.5%）最终诊断为子宫内膜癌。未发现任何合并症与同时患有子宫内膜癌有很强的关联。与同时患有子宫内膜癌的患者相比，子宫内膜癌患者的平均子宫内膜带更厚（15.7 毫米；标准差，9.5），而无子宫内膜癌的患者为 12.5 毫米；标准差，6.4；P =.01）。子宫内膜带厚度≥2 厘米与同时患有子宫内膜癌的几率增加 4.0 倍相关（95%置信区间，1.5-10.0），控制年龄因素后。在所有子宫内膜癌病例中，87%为 T1a 期（Nx 或 N0）。与子宫内膜带厚度<2 厘米的子宫内膜癌患者相比，约 44%的子宫内膜带厚度≥2 厘米且诊断为子宫内膜癌的患者符合“Mayo 标准”的淋巴结切除术指征，而子宫内膜带厚度<2 厘米的子宫内膜癌患者为 22%。
子宫内膜带厚度和年龄是子宫内膜上皮内瘤变患者子宫切除时同时患有子宫内膜癌的最强预测因素。鉴于子宫内膜带厚度≥2 厘米的子宫内膜上皮内瘤变患者同时患有癌症的风险增加，以及潜在的淋巴结评估需求，可能特别需要向妇科肿瘤医生转介。
