绝经后反复宫腔大量积脓合并子宫内膜样腺癌1例诊治分析并文献复习

doi:10.3760/cma.j.cn441417-20250417-17025

摘要/Abstract

摘要：

目的　探讨子宫内膜癌在绝经后宫腔积脓患者中的占比及漏诊原因，增强临床医生对绝经后宫腔积脓疾病的认识，提高对此类患者的诊断及治疗水平，减少漏诊。方法　选择2024年3月由南方医科大学珠江医院驻点帮扶的仁化县人民医院收治的1例以绝经后反复宫腔大量积脓为首发症状的子宫内膜样腺癌患者为研究对象。对本例患者的临床病例资料，包括病史、临床表现及实验室检查、分子分型检测结果与诊治过程等进行分析。以“绝经后宫腔积液”“宫腔反复积脓”“绝经后子宫内膜样腺癌”为中、英文关键词，对万方数据知识服务平台、中国知网等中文数据库以及PubMed等英文数据库2015年1月至2025年1月收录的绝经后宫腔积液/积脓合并子宫内膜癌的相关文献进行检索，总结绝经后宫腔积脓患者合并子宫内膜癌的发生比例，分析漏诊原因。结果（1）本例患者女，79岁，因“绝经28年，反复阴道流脓1年”2024年3月23日就诊于仁化县人民医院妇科，患者近1年反复出现间歇性下腹痛及不规则阴道流脓。妇科超声及盆腔MRI均提示宫腔大量积液。引流脓液培养出粪肠球菌，糖类抗原（CA）19-9 287.15 U/ml，入院诊断宫腔积脓，尝试保守治疗无效，经与患者及家属沟通，于2024年5月15日行腹腔镜下全子宫+双侧附件切除术，患者家属术前术中均拒绝行术中冰冻病理，拒绝扩大手术范围；术后病理提示子宫内膜样腺癌，诊断：子宫内膜样腺癌IB_NSMP期，术后一般情况良好，建议术后8周开始补充阴道近距离放疗。截至2024年12月14日，患者已结束放疗半年，复诊指标及影像学检查均无异常。（2）文献复习结果：关于绝经后宫腔积脓的相关研究文献9篇，涉及251例绝经后宫腔积脓患者，其中71例（28.3%）患有妇科恶性肿瘤［子宫内膜癌43例（17.1%），宫颈癌27例（10.7%），子宫平滑肌肉瘤1例（0.4%）］，子宫内膜癌排名第一，且在首次就诊时漏诊的患者多达11例（4.3%）。结论妇科恶性肿瘤是宫腔积脓的原因之一，以子宫内膜癌和子宫颈癌为主，对于绝经后合并宫腔积脓的患者一定要引起重视，避免漏诊，在无法明确病因及保守治疗无效时建议积极手术治疗来缓解症状并明确病因。

关键词:

反复宫腔积脓, 子宫内膜样腺癌, 绝经后女性, 阴道近距离放疗, 临床表现, 漏诊, 子宫内膜癌分子分型

Abstract:

Objective　To explore the proportion of endometrial cancer in postmenopausal patients with pyometra and the causes of missed diagnosis, enhance clinicians' understanding and attention to postmenopausal pyometra, improve the diagnosis and treatment level for such patients, and reduce missed diagnosis. Methods　A patient with endometrioid adenocarcinoma, whose initial symptom was recurrent massive pyometra in the uterine cavity after menopause, was admitted to Renhua County People's Hospital, which was supported by the stationed medical team from Zhujiang Hospital of Southern Medical University in March 2024. A retrospective analysis method was used to study the patient's clinical case data, including medical history, clinical manifestations, laboratory tests, molecular typing test results, and the diagnosis and treatment process. Using "postmenopausal uterine cavity effusion" "recurrent pyometra in the uterine cavity" "postmenopausal endometrioid adenocarcinoma" as Chinese and English keywords, the relevant literatures on postmenopausal uterine cavity effusion and pyometra combined with endometrial cancer included in Chinese databases such as Wanfang Data Knowledge Service Platform and China National Knowledge Infrastructure (CNKI), as well as English databases such as PubMed from January 2015 to January 2025 were retrieved. The incidence proportion of endometrial cancer in postmenopausal patients with pyometra was summarized, and the causes of missed diagnosis were analyzed. Results (1) The patient was a 79-year-old woman who was admitted to the Department of Gynecology of Renhua County People's Hospital on March 23, 2024 due to "28 years of menopause and recurrent vaginal purulent discharge for 1 year". The patient had recurrent intermittent lower abdominal pain and irregular vaginal purulent discharge in the past year. Both gynecological ultrasound and pelvic MRI suggested a large amount of effusion in the uterine cavity. Enterococcus faecalis was cultured from the drained pus, and the carbohydrate antigen (CA) 19-9 was 287.15 U/ml. The admission diagnosis was pyometra, and conservative treatment was tried but ineffective. After communication with the patient and her family members, laparoscopic total hysterectomy + bilateral adnexectomy was performed on May 15, 2024. The patient's family members refused intraoperative frozen pathology and refused to expand the scope of the surgery before and during operation. The postoperative pathology suggested endometrioid adenocarcinoma, and the diagnosis was: endometrioid adenocarcinoma stage IB_NSMP. The patient's general condition was good after operation, and it was recommended to start supplementary vaginal brachytherapy 8 weeks after operation. As of December 14, 2024, the patient had completed radiotherapy for half a year, and the reexamination indicators and imaging examinations were all normal. (2) Results of literature review: there were 9 relevant research literatures on postmenopausal pyometra, involving 251 postmenopausal patients with pyometra, among whom 71 (28.3%) had gynecological malignancies [43 cases of endometrial cancer (17.1%), 27 cases of cervical cancer (10.7%), and 1 case of uterine leiomyosarcoma (0.4%)]. Endometrial cancer ranked the first, and as many as 11 patients were missed diagnosed during the first visit, accounting for 4.3%. Conclusions Gynecological malignancies are one of the causes of pyometra, mainly endometrial cancer and cervical cancer. Great attention should be paid to postmenopausal patients with pyometra to avoid missed diagnosis. When the cause of the disease cannot be determined and conservative treatment is ineffective, active surgical treatment is recommended to relieve the symptoms and clarify the causes of the disease.

Key words:

Recurrent pyometra in the uterine cavity, Endometrioid adenocarcinoma, Postmenopausal women, Vaginal brachytherapy, Clinical manifestations, Missed diagnosis, Molecular typing of endometrial cancer

刘翔宇龙汝玲.

绝经后反复宫腔大量积脓合并子宫内膜样腺癌1例诊治分析并文献复习 [J]. 国际医药卫生导报, 2025, 31(17): 2945-2950.

Liu Xiangyu, Long Ruling.

Postmenopause recurrent pyometra complicated with endometrioid adenocarcinoma: a case report and literature review [J]. International Medicine and Health Guidance News, 2025, 31(17): 2945-2950.

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