［摘要］ 目的：探讨宫腔镜检查在子宫内膜癌诊断中的价值。方法：经手术治疗的子宫内膜癌共102例分为两组：（1）宫腔镜检查组(39例)，在宫腔镜下行分段诊刮术；（2）单纯分段诊刮组(63例)。比较两组术前后宫颈受累情况的诊断符合率及开腹手术时腹水细胞学检查的结果。结果：两组患者的年龄、临床分期、病理分级及组织学类型差异无显著性，宫腔镜检查组诊断宫颈受累的准确率为97.4%(38/39)，明显高于单纯分段诊刮组 (76.2%,48/63) ，其假阳性率(0/35) 明显低于单纯分段诊刮组(21.6%,11/55)（P值均＜0.01），两组患者均无腹水，有84.3%(86/102)在开腹手术时行腹腔洗液细胞学检查。宫腔镜检查组腹腔洗液细胞学阳性率为8.8%(3/34), 单纯分段诊刮组为13.5%(7/52)，两组差异无显著性（P＞0.05）。结论：宫腔镜检查可提高子宫内膜癌诊断的准确性，能较确切地了解宫颈是否受累，同时可能并不增加肿瘤细胞扩散的机会，对可疑宫内病变者应在宫腔镜检查下分段诊刮。

［中图分类号］ R737.33［文献标识码］ A

［文章编号］ 1000-1530（2000）03-0272-03

The value of hysteroscopy in the diagnosis of endometrial cancer

WEN Hong-Wu，LIU Yun-Ming

（Department of Obstetrics and Gynecology, the First Hospital,

Peking University, Beijing100034, China；）

WANG Jie

（Center Hospital of China National Petroleum Corporation）

ABSTRACTObjective: To evaluate the value of hysteroscopy in the diagnosis of endometrial cancer. Methods: One hundred and two patients with endometrial cancer were diagnosed and the operations were performed in our department from Jan. 1990 to June 1997. They were divided into two groups. There were 39 patients in the first group who were diagnosed by hysteroscopy and fractional curettage, and the other 63 patients were in the second group who were diagnosed only by fractional curettage. The accuracy rates for diagnosis of cervical canal involvement and peritoneal cytology at the time of laparotomy were compared between the two groups. Results: There was no statistic difference in patients' age, stage, grade and histological type of the disease between the two groups. The accuracy rate for diagnosis of cervical canal involvement was higher in the first group (97.4%, 38/39) than in the second group (76.2%,48/63), P＜0.01, and the false positive rate for diagnosis of cervical canal involvement was lower in the group with hysteroscopy (0, 0/35) than in the group without hysteroscopy (21.6%, 11/55), P＜0.01. No ascites was found in the patients of the two groups. Peritoneal washing cytology was examined in eighty-six patients (84.3%, 86/102) at the time of laparotomy. The positive peritoneal cytology was found in 3 patients (8.8%, 3/34) in the first group and 7 patients (13.5%, 7/52) in the second group, and the positive rate of peritoneal cytology was no difference between the two groups. Conclusion: Hysteroscopy is valuable for the diagnosis of endometrial cancer and cervical canal involvement, but might have no effect on cytological malignancy in the peritoneal cavity. Hysteroscopy should be used in the diagnosis of uterine cavity diseases.

KEYWORDSHysteroscopy; Endometrial neoplasms/diag; Dilatation and curettage▲

分段诊断性刮宫术是子宫内膜癌诊断及术前分期的主要手段，但单纯的分段诊刮术对诊断子宫内膜癌宫颈受累的假阳性率较高^［1］，从而造成手术范围不必要的扩大。而宫腔镜下分段诊刮又有导致癌细胞向腹腔内扩散的危险^［2］。本文对宫腔镜下分段诊刮和单独分段诊刮诊断并手术治疗的子宫内膜癌病例进行对比分析，以探讨宫腔镜检查在子宫内膜癌诊断中的价值。

1资料与方法

1.1资料来源

我院从1990年1月～1997年6月共诊断子宫内膜癌110例，本文对其中在我院经手术治疗的102例(92.7%)患者进行分析。患者年龄26～80岁，平均55.3岁。根据FIGO 1989年手术-病理分期标准，Ⅰ期75例，Ⅱ期9例，Ⅲ期15例，Ⅳ期3例。

1.2研究方法

将102例病例分为两组：第1组为宫腔镜检查组，39例，患者均在宫腔镜下行分段诊刮术；第2组为单纯分段诊刮组，63例。比较两组术前、后宫颈受累情况的诊断符合率及开腹手术时腹水细胞学检查的结果。

1.3宫腔镜下分段诊刮的适应证、禁忌证及手术方法

1.3.1适应证绝经后出血及绝经前不规则阴道出血、阴道排液可疑子宫内膜病变者。

1.3.2禁忌证子宫活动性出血及盆腔急性炎症。

1.3.3手术方法宫颈扩张器扩至7号。缓慢插入电视宫腔镜（德国Storz公司生产，5%（质量分数）的葡萄糖液加压膨宫），先检查宫底和输卵管开口，再逐渐向外退出检查宫腔前、后、左、右壁，最后检查宫颈管。根据检查所见，刮取病变或可疑病变组织送病理检查。单纯分段诊刮时，先刮颈管,再扩宫颈刮宫腔，刮出物送病理。

2结果

2.1两组临床病理资料比较

第1组患者平均年龄(56.7±8.9)岁，第2组(54.4±10.6)岁，经t检验，差异无显著性。两组临床病理资料比较见表1。

两组患者的临床分期、病理分级及组织学类型经χ²检验，χ²值分别为0.37，1.05和0.004，差异也无显著性，P值均大于0.05。

两组患者的所有病例均较好地耐受了诊断时的手术操作，无1例出现并发症。

表1两组临床病理资料比较

Table 1Comparison of clinical and pathological data between group 1 and group 2

Groups n Stages Grades Histological type Ⅰa Ⅰb Ⅰc Ⅱ Ⅲ Ⅳ Ⅰ Ⅱ Ⅲ Endometrioid Others Group 1 39 6 20 4 3 5 1 11 25 3 36 3 Group 2 63 7 32 6 6 10 2 28 26 9 58 5^ Total 102 13 52 10 9 15 3 39 51 12 94 8

1 patient for adeno-squamous carcinoma, 2 patients for clear cell carcinoma；  1 patient for serous papillary adenocarcinoma， 2 patients each for adeno-squamous carcinoma and clear cell carcinoma.2.2两组患者宫颈受累情况诊断符合率

宫腔镜检查组诊断宫颈受累的3例患者，其手术切除的子宫标本均可见宫颈受累，诊断宫颈未受累的36例患者，有1例切除的子宫标本见宫颈受累，其它35例与诊断相符。而单纯分段诊刮组诊断宫颈受累的19例患者，其手术切除的子宫标本仅8例确有宫颈受累，其它11例并未见宫颈受累。诊断宫颈未受累的44例患者，有40例切除的子宫标本未见宫颈受累，有4例实际上有宫颈受累。

两种诊断方法对宫颈受累情况诊断的敏感性、假阳性、准确性、阴性预测值和阳性预测值见表2。

经χ²检验，第1组诊断宫颈受累的准确率明显高于第2组，χ²=8.22，其假阳性率明显低于第二组，χ²=8.65，P值均＜0.01。两种方法诊断宫颈受累的敏感性、阴性预测值无差异，第1组阳性预测值似高于第2组，但经确切概率计算差异无显著性(P＞0.05)。

第2组宫颈受累假阳性的11例中，有10例实际为Ⅰ期的患者行广泛性子宫切除术及盆腔淋巴结剔除术，另1例行次广泛性子宫切除术。

2.3两组腹腔洗液细胞学检查结果比较

两组患者均无腹水，有84.3%(86/102)在开腹手术时行腹腔洗液细胞学检查。开腹手术距诊断性刮宫的时间为5～10 d。第1组有34例行腹腔洗液细胞学检查，结果3例阳性，阳性率为8.8%。第2组有52例行腹腔洗液细胞学检查，其中7例阳性，阳性率为13.5%，经χ² 检验，χ²=0.43，两组差异无显著性（P＞0.05）。

表2两种方法对宫颈受累情况诊断的比较（%）