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子宫内膜癌分型的研究进展金明珠，狄文△【摘要】子宫内膜癌（endometrial carcinoma ）是妇科三大恶性肿瘤之一，以手术联合放、化疗为标准治疗方式；部分渴望保留生育能力的患者可经咨询后行保守治疗，待生育后进行手术。
1983年，Bockman 提出子宫内膜癌临床分型，将其分为Ⅰ型（雌激素依赖型）和Ⅱ型（非雌激素依赖型）；1994年，Poulsen 将子宫内膜癌按组织病理学分为腺癌、浆液性腺癌、黏液性腺癌、透明细胞癌、鳞状细胞癌、混合性癌和未分化癌；2013年，癌症基因组图谱（The Cancer Genome Atlas ，TCGA ）根据不同突变方式和拷贝数将子宫内膜癌分为4种，即POLE （DNA polymerase epsilon ）突变型、微卫星不稳定高突变型、低拷贝数型和高拷贝数型。
该分子分型对不同亚型患者的精准化治疗与预测患者预后具有重要指导意义。
本文总结了子宫内膜癌的3种分型的优势与局限性及其临床意义。
子宫内膜癌分型的不断完善，将有助于理解其预后的个体差异，指导治疗策略的选择，为精准医疗时代规范化、个体化、人性化的治疗奠定理论基础。
【关键词】子宫内膜肿瘤；癌；肿瘤分期；病理分型；免疫疗法；生育力Research Progress of Endometrial Cancer Classification JIN Ming -zhu,DI Wen.Department of Obstetrics and Gynecology,Renji Hospital,School of Medicine,Shanghai Jiao Tong University,Shanghai 200127,China (JIN Ming-zhu,DI Wen);School of Medicine,Shanghai Jiao Tong University,Shanghai 200025,China (JIN Ming-zhu)【Abstract 】Endometrial carcinoma is one of the three major malignant tumors in gynecology.The standard treatment is surgery with/without radiotherapy and chemotherapy;for those who desire to retain their fertility can be treated conservatively after consultation and accomplish the operation after childbirth.In 1983,Bockman proposed clinical classification of endometrial cancer,which was divided into type Ⅰ（estrogen-dependent ）and type Ⅱ（non-estrogen-dependent ）;in 1994,Poulsen classified endometrial cancer into adenocarcinoma,serous adenocarcinoma,mucinous adenocarcinoma,clear cell carcinoma,squamous cell carcinoma,mixed carcinoma,and undifferentiated carcinoma by histopathology;in 2013,endometrial carcinoma was divided into four types based on different mutation patterns and copy number by the Cancer Genome Atlas （TCGA ）:polymerase epsilon （POLE ）mutated,microsatellite instability,copy number-low and copy number-high.The molecular classification has important guiding significance for the precise treatment of patients with different subtypes and prognosis prediction of patients.In this review,we summarize three classifications of endometrial carcinoma,list their advantages and limitations,and highlight the clinical significance of endometrial cancer.The continuous improvement of classification of endometrial cancer will help to understand the heterogeneity in prognosis,guide the choice of treatment strategies,and lay a theoretical foundation for standardized,individualized and humanized treatment in the era of precision medicine.【Keywords 】Endometrial neoplasms;Carcinoma;Neoplasm staging;Pathological classification;Immunotherapy;Fertility（J Int Obstet Gynecol ，2020,47：15-18）基金项目：上海市重中之重临床重点学科-妇产科学（2017ZZ02016）；上海市临床重点专科建设项目-女性肿瘤作者单位：200127上海交通大学医学院附属仁济医院妇产科（金明珠，狄文）；上海交通大学医学院（金明珠）通信作者：狄文，E-mail ：diwen163@ △审校者·综述·我国子宫内膜癌发病率约为60/10万，死亡率约为20/10万[1]，发病率呈上升趋势。
诊断早期子宫内膜癌与宫腔镜手术相关不良预后因素研究进展韩璐;佟彤;毛奕文【摘要】宫腔镜技术已成为早期筛查子宫内膜癌不可或缺的方法,宫腔镜检查能否增加腹腔冲洗液肿瘤细胞(PWC)阳性率有着截然不同的结论,有研究者认为宫腔镜检查能够增加PWC阳性率,但也有资料说明并未增加内膜癌细胞腹腔播散的风险.宫腔镜检查的PWC阳性率与宫腔镜检查的条件、宫腔镜检查与获取腹腔冲洗液的间隔时间、是否同时行诊刮术、疾病程度、肿瘤本身的生物学特性等因素有关.大量临床研究资料显示,宫腔镜检查所致PWC阳性并不影响子宫内膜癌患者的生存预后及增加内膜癌复发的风险.宫腔镜检查建议应用于影像学检查提示宫内占位病灶<1~2 cm的病例,采用最低的膨宫压力和液体流量,避免扩张宫颈管和同时行刮宫术,以宫腔镜下定位活检为宜.%Hysteroscopy technology has become the indispensable method for early screening of endometrial carcinoma.There is still debate on whether hysteroscopy increases the positive rate of peritoneal washing cytology (PWC).Some physicians believe that hysteroscopy increases the positive rate of PWC;however, there are also data suggesting that hysteroscopy does not increase the risk of endometrial cancer cells spread in abdominal cavity.The positive rate of PWC associated with hysteroscopy is related to condition of hysteroscopy, time interval between hysteroscopy and acquisition of peritoneal washing liquid, whether performing simultaneous diagnostic curettage, stage of the disease, tumor biological characteristics, and other factors.A large amount of clinical research data have shown that positive PWC caused by hysteroscopy examination does not affect the survival of endometrialcancer patients and does not increase the risk of endometrial cancer recurrence.It has been suggested that hysteroscopy examination should be applied in cases with an intrauterine lesion <1~2 cm by imaging study, be performed with the lowest uterine pressure and liquid flow, and avoid the expansion of cervical canal and curettage surgery at the sametime.Hysteroscopy-guided biopsy is appropriate.【期刊名称】《大连医科大学学报》【年(卷),期】2017(039)003【总页数】4页(P296-299)【关键词】子宫内膜肿瘤;宫腔镜;预后因素【作者】韩璐;佟彤;毛奕文【作者单位】大连医科大学附属妇产医院暨大连市妇幼保健院妇科,辽宁大连116033;大连医科大学研究生院,辽宁大连 116044;大连医科大学研究生院,辽宁大连 116044【正文语种】中文【中图分类】R737.33子宫内膜癌(endometrial carcinoma)是女性三大生殖道恶性肿瘤之一，近年来发病率在世界范围内呈上升趋势，在美国、欧洲等发达地区目前已接近新发妇科恶性肿瘤的50%，据美国癌症协会报告，2015年美国子宫内膜癌的新发病例54870例，死亡病例10170例[1]。
妇产科名解作者：郭QQ 胎盘早剥（place ntal abruption）：妊娠20周以后或分娩期正常位置的胎盘在胎儿娩出前部分或全部从子宫壁剥离。
病理性缩复环（pathologic retraction ring);在胎先露下降受阻时，强有力的阵缩使子宫体更加增厚变短，而子宫下段逐渐变薄，子宫上下段肌壁厚薄相差悬殊，形成环状凹陷，并随宫缩逐渐升高，甚至可以高达脐上，形成病理缩复环。
子宫胎盘卒中（uteroplacental apoplexy)：又称库弗莱尔子宫（Couwelaire uterus），胎盘早剥发生内出血时，血液积聚于胎盘与子宫壁之间，随着胎盘后血肿压力的增加，血液浸入子宫肌层，引起肌纤维分离、断裂甚至变性，当血液渗透至子宫浆膜层时，子宫表面呈现紫蓝色瘀斑。
前置胎盘（placenta previa)：妊娠28周后，胎盘附着于子宫下段，下缘达到或覆盖宫颈内口，其位置低于胎先露部。
子宫内膜异位症（endometriosis,EMT)：具有活性的子宫内膜组织（腺体和间质）出现在子宫内膜以外部位时。
功血：即功能失调性子宫出血。
由于生殖内分泌轴功能紊乱引起的异常子宫出血，而全身及内外生殖器官无器质性病变存在。
分为无排卵性和有排卵性两种。
不孕症（infertility)：女性无避孕性生活至少12个月而未孕，称为不孕症，在男性则称为不育症。
产褥期（puerperium)：从胎盘娩出至产妇全身各器官除乳腺外恢复至正常未孕状态所需的一段时期。
通常为6周。
继发性闭经（second-ary amenorrhea)：指正常月经建立后月经停止6个月，或按自身原有月经周期计算停止3个周期以上者产后出血（postpartum hemorrhage)：指胎儿娩出后24小时内失血量超过500ml，剖宫产超过1000ml，为分娩期严重并发症。
据我国产妇死亡原因首位。
产褥病率（puerperal morbidity)：指分娩24小时以后的10日内，每日用口表测量体温4 次，间隔4小时，有2次体温≥38℃.鳞状上皮化生（squamous metaplasia)：暴露于宫颈阴道部的柱状上皮受阴道酸性影响，柱状上皮下未分化储备细胞（reserve cell)开始增殖，并逐渐转化为鳞状上皮，继而柱状上皮脱落，被复层鳞状细胞所代替。
adenocarcinoma||腺管上皮: 腺癌adrenal cortical carcinoma||肾上腺皮质: 肾上腺皮质癌American Joint Committee on Cancer Staging; AJCC||美国癌症分期联合委员会angiosarcoma||血管内皮: 血管肉瘤basal cell carcinoma||基底细胞: 基底细胞癌calcitonin||抑钙素carcinoembryonic antigen; CEA||癌胚抗原carcinoma||恶性上皮肿瘤Carcinoma in situ||原位癌catecholamine||儿茶酚胺chondrosarcoma||软骨: 软骨肉瘤choriocarcinoma||胎盘上皮: 绒毛膜癌direct extension||直接蔓延dysgerminoma||恶性胚胎瘤Dysplasia||异生fetoprotein; AFP||胎蛋白fibrosarcoma||纤维组织: 纤维肉瘤FIGO: International Federation of Gynecology and Obstetrics||国际妇产科学联盟glioma||神经胶细胞: 神经胶细胞瘤hematogenous metastasis||血行转移hepatocellular carcinoma; hepatoma||肝细胞: 肝细胞癌histopathological grading||组织病理分化human chorionic gonadotropin; HCG||人类绒毛膜促性腺素immature teratoma||全能细胞: 未成熟畸胎瘤International Union against Cancer; UICC||国际防癌联盟Invasive carcinoma||侵袭癌leiomyosarcoma||平滑肌: 平滑肌肉瘤leukemia||造血细胞: 白血病liposarcoma||脂肪组织: 脂肪肉瘤lymphangiosarcoma||淋巴管内皮: 淋巴管肉瘤lymphatic metastasis||淋巴转移lymphoma||类淋巴组织: 淋巴瘤malignant melanoma||神经外胚层: 恶性黑色素瘤malignant meningioma||脑膜: 恶性脑膜瘤malignant mesothelioma||间皮: 恶性间皮瘤malignant mixed tumor||唾液腺: 恶性混合瘤malignant peripheral nerve sheath tumor, malignant schwannoma||神经鞘: 恶性周边神经鞘肿瘤malignant pheochromocytoma||肾上腺髓质: 恶性嗜铬细胞瘤malignant phyllodes tumor||乳房: 恶性叶状瘤malignant teratoma||恶性畸胎瘤metastasis||远处转移Microinvasive carcinoma||微侵袭癌mild dysplasia||轻度异生moderate dysplasia||中度异生moderately differentiated||中度分化myeloma||浆细胞: 骨髓瘤neuroblastoma||神经节细胞: 神经母细胞瘤neuroblastoma||神经母细胞瘤neuron-specific enolase; NSE||神经特异性烯醇node||淋巴结oma||良性肿瘤osteosarcoma||硬骨: 骨肉瘤poorly differentiated||分化不良prostate-specific antigen; PSA||前列腺特异性抗原prostatic acid phosphatase; PAP||前列腺酸性磷酸renal cell carcinoma||肾脏上皮: 肾细胞癌rhabdomyosarcoma||横纹肌: 横纹肌肉瘤sarcoma||恶性间叶肿瘤seminoma||生殖细胞: 精细胞瘤severe dysplasia||重度异生squamous cell carcinoma||鳞状上皮: 鳞状细胞癌stage||期别synovial sarcoma||滑膜: 滑膜肉瘤thymic carcinoma||胸腺上皮: 胸腺癌transitional cell carcinoma||泌尿道上皮: 过渡细胞癌tumor marker||临床检验: 含肿瘤标记undifferentiated||未分化well differentiated||分化良好mscarriage--patent tretament自然流产recurrent miscarriage: 习惯性流产late miscarriage晚期流产incompetent cervix宫颈机能不全ectopic pregnancy宫外孕Ectopic pregnancy removement with laparoscopy,saving tube.腹腔镜治疗宫外孕，保留输卵管recurrent spontanoeus abortion反复自然流产blighted ovum胎停育missed abortion稽留流产molar pregnancy葡萄胎water birth水中分娩Vagina reconstruction by minimal access surgery 微创阴道重建手术absence of vagina无阴道vaginal aplasia先天性无阴道primordial uterus 始基子宫vagina reconstruction 阴道重建congenital absence of vagina and uterus 先天性无子宫无阴道Uterine Myoma子宫肌瘤Polycystic ovaries多囊卵巢.Certification in medical oncology and gynecologic oncology first offered.首次授予内科肿瘤学和妇科肿瘤学资格.2.The American Cancer Society and the Society of Gynecologic Oncologists[ on Collagists] also were involved.美国癌症协会与妇科肿瘤学家们也参与其中。
子宫内膜癌150例临床病例分析目的：探讨与子宫内膜癌术后生存率相关的因素。
方法：选择2004年2月-2011年12月北京朝阳医院经手术治疗术后病理确诊为子宫内膜癌的患者150例，分析与子宫内膜癌术后生存率相关因素。
结果：年龄大于等于56岁的患者3年、5年生存率低于年龄小于56岁的患者（P＜0.05）；早期（Ⅰ期、Ⅱ期）患者的3年、5年生存率明显高于晚期（Ⅲ期、Ⅳ期）患者（P＜0.05）；组织分化较好的（G1、G2）患者的3年、5年生存率高于组织分化差的（G3）患者（P ＜0.05）；肌层浸润深度小于1/2的患者的3年、5年生存率高于肌层浸润深度大于等于1/2的患者（P＜0.05）。
结论：子宫内膜癌术后患者的生存率与年龄、手术-病理分期、组织分化、肿瘤肌层浸润深度密切相关。
故早期发现并诊治子宫内膜癌能明显提高患者术后生存率。
[Abstract] Objective：To explore the factors related to postoperative survival rate of endometrial carcinoma.Method：A total of 150 patients with endometrial carcinoma underwent primary surgical treatment and confirmed by pathology from Feb 2004 to Dec 2011 in Beijing Chaoyang Hospital were selected，and the factors related to postoperative survival rate of endometrial carcinoma were analyzed.Result：The postoperative survival rates in 3 and 5 years of patients whose ages were greater than or equal to 56 years-old were lower than that of patients whose ages were less than 56 years-old（P＜0.05）.The postoperative survival rates in 3 and 5 years of patients in the early stage（phase Ⅰand phase Ⅱ）were higher than that of patients in the latter period（P＜0.05）.The postoperative survival rates in 3 and 5 years of patients whose degrees of tissues differentiation（G1 and G2）were better were higher than that of patients whose degrees of tissues differentiation（G3）were bad（P＜0.05）.The postoperative survival rates in 3 and 5 years of patients whose muscular infiltration depth were less than 1/2 were higher than that of patients whose muscular infiltration depth were greater than or equal to 1/2（P＜0.05）.Conclusion：Age，surgical-pathologic stage，tissue differentiation and the depth of tumor invasion are closely related to the postoperative survival rate of patients with endometrial carcinoma.So early discovery，early diagnosis and early treatment of patients with endometrial carcinoma can raise the postoperative survival rate.[Key words] Endometrial carcinoma；Postoperative survival rate子宫内膜癌（endometrial carcinoma）是原发于子宫内膜的上皮性恶性肿瘤，为女性生殖器官常见的恶性肿瘤，在经济发达国家其发病率居妇科恶性肿瘤首位。
子宫内膜癌癌症基因组图谱分子分型临床价值2024在妇科三大恶性肿瘤中，子宫内膜癌（endometrialcarcinoma,EC）由于被临床医生普遍认为是恶性程度较低，预后较好的肿瘤，故关注度不如子宫颈癌和卵巢癌。
其实，子宫内膜癌在临床诊治中经常有"出乎意料"的情况。
传统组织学分型和分级存在重复性低、对应性差、未考虑肿瘤异质性，对临床指导性差，越来越不能满足临床诊治的需求。
随着基因检测技术的发展，以及对肿瘤分子特征研究的深入，临床医生逐渐认识到,每种肿瘤的分子特性是恶性肿瘤精准诊治及预后的重要指标物。
2013年子宫内膜癌癌症基因组图谱（TCGA）分子分型的提出，以及2020年美国国立综合癌症网络（NCCN）指南第1版推荐了TCGA分子分型，推动了子宫内膜癌分子分型的临床应用。
国内相关的临床指南及专家共识也建议，在子宫内膜癌的病理报告、风险评估、诊疗流程中加入TCGA分子特征。
同时，分子分型还存在很多误区，临床实践中还存在诸多未厘清的问题。
因此，子宫内膜癌TCGA分子分型在临床应用中面临：机遇，挑战与突破。
1、子宫内膜癌TCGA分子分型在临床应用中面临的机遇1.1子宫内膜癌传统分型及病理学的局限性1983年Bohkman将流行病学、病理和临床特征联系起来，提出子宫内膜癌的两型分类模式,I型雌激素依赖型和II型非雌激素依赖型，二元分类成为过去30多年区分子宫内膜癌的重要框架。
但在实践中发现，根据子宫内膜癌组织形态学和免疫组化进行的I型和II型分类，患者预后与病理分型并不完全一致,给临床治疗带来很大困扰，比如：20%左右的肿瘤难以归纳到工型或者H型，另有约10%的肿瘤形态上是典型的子宫内膜样癌，但其生物学行为则是非子宫内膜样癌；透明细胞癌虽然在传统上被认为是口型子宫内膜癌,但是某些病例却表现出良好的预后和极低的复发率，而且，相当比例的透明细胞癌并无TP53的突变［1］β因此，二元分类法及组织病理学越来越显示出其局限性。
