生殖医学杂志

目的探讨乳腺癌患者术后因可疑子宫内膜病变行宫腔镜诊治的病理类型构成及其影响因素。方法回顾性分析2015年6月至2020年6月北京协和医院妇科收治的因异常子宫出血或超声提示子宫内膜增厚等原因行宫腔镜诊治,且同时合并乳腺癌手术病史的291例患者的临床病理资料,不同分组间进行统计学分析。结果 (1)子宫内膜病变中以子宫内膜息肉最常见(63.23%),恶性病变(EIN/ECa)占比9.62%。(2)异常子宫出血对于预测内膜病变的良恶性比子宫内膜厚度更具有临床意义(P=0.017);恶性病变的宫腔深度较良性病变更深(P=0.014)。(3)选择性雌激素受体调节剂(SERMs)治疗组(包括他莫昔芬和托瑞米芬)内膜恶性病变率(7.51%)显著低于未用药组(19.23%)[OR(95%CI)=0.34(0.14,0.80),P=0.014];就单药而言,托瑞米芬具有保护效应[OR(95%CI)=0.28(0.10,0.70),P=0.011]。芳香化酶抑制剂组的恶变率(9.52%)也低于未用药组,但无统计学差异[OR(95%CI)=0.44(0.08,2.21),P=0.489]。(4)23.73%(42/177)保留子宫的患者在宫腔镜手术后接受口服或宫腔释放孕激素预防子宫内膜病变复发,与无用药组相比复发率显著降低(11.90%vs. 26.67%)[OR(95%CI)=0.37(0.14,1.02),P=0.048]。结论乳腺癌患者术后因医学指征行宫腔镜检查,最常见的病理类型是子宫内膜息肉,恶性病变率约10%;异常子宫出血、宫腔深度对于预测良恶性具有较明确的临床意义;选择性雌激素受体调节剂似乎不是导致子宫内膜癌的显著危险因素,托瑞米芬反而显示有保护性效应,值得扩大样本进一步研究。良性病变者采用孕激素制剂预防复发是有效的。

Objective:To investigate the pathological types and influencing factors of suspected endometrial lesions treated by hysteroscopy in the postoperative breast cancer patients.Methods:A retrospective analysis was performed on the clinical and pathological data of 291 patients who received hysteroscopy due to abnormal uterine bleeding or endometrial thickening indicated by ultrasound, and who also had a history of breast cancer surgery in the Department of Gynecology of Peking Union Medical College Hospital from June 2015 to June 2020. Statistical analysis was conducted among different groups.Results:Endometrial polyp was the most common lesion type(63.23%),malignant lesion(EIN/ECa) accounted for 9.62%. Abnormal uterine bleeding had more clinical significance in predicting benign and malignant endometrial lesions than endometrial thickness(P=0.017). The uterine depth of malignant lesions was deeper than that of benign lesions(P=0.014). The incidence of endometrial malignant lesions in selective estrogen receptor modulators(SERMs) treatment group(including tamoxifen and toremifene)(7.51%) was significantly lower than that in non-endocrine treatment group(19.23%)[OR(95%CI)=0.34(0.14,0.80),P=0.014]. In terms of single drug, toremifene had a protective effect[OR(95%CI)=0.28(0.10,0.70),P=0.011]. The rate of malignancy in the aromatase inhibitor group(9.52%) was also lower than that in the no-medication group, but there was no significant difference[OR(95%CI)=0.44(0.08,2.21),P=0.489]. 23.73%(42/177) of patients received oral progestin or intrauterine release of progestin to prevent recurrence of endometrial lesions after hysteroscopic surgery, with a significantly lower recurrence rate compared with the no-medication group(11.90% vs. 26.67%)[OR(95%CI)=0.37(0.14,1.02),P=0.048].Conclusions:The most common pathological type of breast cancer patients underwent hysteroscopy after medical indications was endometrial polyps. The rate of malignant lesions was about 10%. Abnormal bleeding and the depth of uterine cavity had a clear clinical significance in predicting benign and malignant. Selective estrogen receptor modulator does not appear to be a significant risk factor for endometrial cancer. Toremifene, however, has even shown a protective effect, and it is worth expanding the sample to further investigation. The efficacy of progestin agents in preventing disease recurrence was definite.