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作者：Caroline Helwick  
出處：WebMD醫學新聞

　　【24drs.com】November 3, 2009(芝加哥) — 第1型子宮內膜癌病患一般有不錯的預後，偶爾在兩到三年內死於該病。伊利諾大學醫學院的研究者發現，切片樣本中出現壞疽可以用來預測此結果。
　　
　　Marsha A. Apushkin醫師在美國臨床病理協會(American Society for Clinical Pathology，ASCP)2009年會中表示， 雖然第1型子宮內膜癌的分期和治療決策是根據手術分期，切片樣本中出現壞疽可能代表有超乎一般預期之侵犯型行為的可能。
　　
　　她表示，研究動機來自資深作者Carey Z. August醫師，August醫師觀察一名患有此症的朋友，原本預期會完全復原，但是她的腫瘤卻變得更像第2型腫瘤(例如乳突漿液癌[papillary serous carcinoma])，而有不佳預後。
　　
　　Apushkin醫師表示，這些病患一般不會這麼快死亡。該研究中，我們在第1型腺癌病患中找尋可以預測惡化病程的特徵。
　　
　　Apushkin醫師等人尋找「Advocate Illinois Masonic Medical Center Tumor Registry」登記中心在1998至2008年間，第1型類子宮內膜子宮內膜腺癌(type I endometrioid endometrial adenocarcinoma)診斷的紀錄。5個案例確認為發生遠端轉移(1例失去追蹤)。比較組包括6個沒有發生轉移的第1型子宮內膜癌病患。
　　
　　Hemoxylin-及eosin-染色玻片切片檢體或手術樣本進行以下評估：腺狀組成的構造等級；腺狀和鱗狀組成的細胞核等級；出現未分化的腫瘤、肌肉侵犯、壞疽、與其他變異類型。檢視p16、突觸蛋白、雌激素受體、與Ki67的免疫染色，比較腺狀、鱗狀與未分化之組成。
　　
　　她指出，因為樣本數少，預期我們的發現不會達統計上的顯著意義，但是作為一篇描述性研究，是很有趣的議題。
　　
　　出現遠端轉移且顯示為第3或4期疾病的所有案例，都使用子宮切除術。只有五分之一案例使用化療治療，反映出用這種方法治療認為預後好的病患；五分之三使用放射線治療。
　　
　　追蹤的4個案例中，所有病患都在追蹤期間死於此病。治療後的存活為7、10、14和32個月。有1名病患在17個月時失去追蹤。
　　
　　Apushkin醫師報告指出，這些案例和控制組案例的切片，在組織學參數上的唯一差異是，案例組出現壞疽。在任何免疫組織化學標記的表現上，沒有一致的差異。
　　
　　羅徹斯特大學Strong紀念醫院的Julietta Fiscella醫師表示，她發現這些研究發現相當有關，她認為，以現有的科技，可能會忽略了微小的轉移。
　　
　　她表示，我做了很多婦科病理檢查，或許我應該回頭檢視我那些第1型病患的臨床病程，追蹤她們一定相當有趣。我也認為，以大型研究確認這些發現是重要的。
　　
　　Apushkin醫師表示，此發現可能會造成術前與術中分期步驟、以及治療第1型疾病上的改變。
　　
　　Apushkin醫師宣告沒有相關財務關係。
　　
　　美國臨床病理協會2009 年會：摘要37。發表於2009年10月29日。

Necrosis in Biopsy Specimen Heralds Poor Prognosis for Type I Endometrial Carcinoma Patients

By Caroline Helwick
Medscape Medical News

November 3, 2009 (Chicago, Illinois) — Type?I endometrial cancer patients, who normally have a good prognosis, occasionally succumb to their disease within 2 to 3 years. Investigators from the University of Illinois School of Medicine, in Chicago, found that the presence of necrosis in the biopsy specimen might predict this outcome.

"Although staging and treatment decisions in type?I endometrial cancer patients are made on the basis of surgical staging, the presence of necrosis in biopsy specimens may indicate the potential for more aggressive behavior than we usually expect," said Marsha A. Apushkin, MD, at the American Society for Clinical Pathology (ASCP) 2009 Annual Meeting.

She said the impetus for the study came from senior author Carey Z. August, MD, who observed this curious disease course in a friend who was expected to make a full recovery but whose tumor behaved more like type?II tumors (such as papillary serous carcinoma), which have a poor prognosis.

"These patients usually don't die so soon," Dr. Apushkin said. "In this study, we looked for features that might predict a more aggressive course among the type?I adenocarcinomas."

Dr. Apushkin and colleagues searched the records of the Advocate Illinois Masonic Medical Center Tumor Registry for cases of type?I endometrioid endometrial adenocarcinoma diagnosed between 1998 and 2008. Five cases were identified in which distant metastases developed (1 was lost to follow-up). The comparison group consisted of 6 cases of type?I endometrial cancer in which metastases were not observed.

Hemoxylin- and eosin-stained slides of the biopsy or surgical specimen were evaluated for the following: architectural grade of glandular component; nuclear grades of glandular and squamous components; and presence of undifferentiated tumor, myoinvasion, necrosis, and other forms of differentiation. Immunostains for p16, synaptophysin, estrogen receptor, and Ki67 were examined, and the glandular, squamous, and undifferentiated components were compared.

"Because of the small sample size, we anticipated that our findings would not achieve statistical significance but would be of interest in a descriptive study," she noted.

All cases that resulted in distant metastases showed stage?III or IV disease at hysterectomy. Only 1 of the 5 was treated with chemotherapy, reflecting the approach to treating patients believed to have good prognosis; 3 of 5 were treated with radiotherapy.

Of the 4 cases with follow-up, all patients were dead of disease at follow-up. Survival after treatment was 7, 10, 14, and 32 months. One patient was lost to follow-up at 17 months.

The only difference in histologic parameters between the biopsies of these cases and the control cases was the presence of necrosis in the former, Dr. Apushkin reported. There were no consistent differences in level of expression of any of the immunohistochemical markers.

Julietta Fiscella, MD, from the University of Rochester's Strong Memorial Hospital, in Minnesota, said she found the findings very concerning. She suggested that micrometastases might be missed with current techniques.

"I do a lot of gynecologic pathology. Maybe I should go back and examine the clinical course of my type?I patients," she said. "It would be absolutely interesting to follow them. I also think it is important to confirm these findings in a larger study."

Dr. Apushkin said the findings could lead to changes in preoperative and intraoperative staging procedures, and in treatment for type?I disease.

Dr. Apushkin has disclosed no relevant financial relationships.

American Society for Clinical Pathology (ASCP) 2009 Annual Meeting: Abstract 37. Presented October 29, 2009.