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자궁경부암의 임상 및 병리조직학적 연구

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 Clinical and histopathological studies on carcinoma of the cervixv 
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[한글] 한국인의 악성 종양중 자궁 경부 악성조양의 실태를 파악하기 위하여 연세대학교 외과대학 병리학 교실에서 1971년 1월부터 1975년 12월말까지 만 5년간 검색한 생검 혹은 자궁적출술로 얻어진 자궁경부 악성종양 총 1295예중 병리표본이 불충분하거나 검색이 불가능한 52예를 제외한 1243예를 대상으로 연령분포, 임상증상, 결혼연령, 초경연령, 폐경상태, 출산 및 임신 횟수, 임상기별분포(clinical stage) 및 병리 조직학적 검색를 통하여 외국문헌과 비교하고 나아가서는 예후에 영향을 미치는 병리 조직학적 유형을 알아보고자 본 연구에 착수하였다. 자궁경부 편평상피암중 상피내암 및 침윤이 의심되던가 현미경적 침윤암에 대하여는 상피내암을 구성하는 종양세포의 형태를 small round cell, small elongated cell, large cell 및 mixed type의 4형으로 분류하였으며(Rubio etal, 1974), 침 윤암에 대하여서는 분화 정도에 따른 Broders' 분류와 세포 형태에 따라 large cell non-keratinizing type, keratinizing type 및 small cell non-keratinizing type으로 대별하였고(Broders', 1925; Ng & Atkin, 1973), 이들과 clinical stage을 비교 관찰하여 다음과 같은 결과를 얻었다. 1. 자궁경부 악성종양 1243예중 편평상피암이 1187예로 96.5%, 선암이 48예로 3.9%였다. 2. 연령분포는 41∼50세까지가 총 1243예중 546예(43.9%)로 가장 높았으며 다음이 50대, 30대 순이었다. 이중 편평상피암에서는 40대에 총 1187예중 527예로 44.4%, 다음이 30대와 50대로 각각 21.7%를 점하고 있었다. 편평상피암중 상피내암이 평균연령 42.9세, 침윤이 의심되던가, 현미경적 침윤암이 45.0세, 침윤암이 47.9세였다. 3. 편평상피암의 주소는 부정기 자궁출혈이 35.9%로 가장 많았고 다음이 냉, 접촉성출혈의 순위였으며 병력 기간은 5개월 이내가 66.1%로 가장 많았다. 4. 편평상피암의 초경 연령은 16세가 28.1%로 가장 많았고 초혼 연령은 19-21세가 37.9%로 가장 많았다. 또한 침윤암의 폐경 상태는 53.3%가 폐경기 이후였다. 5. 편평상피암의 임신 및 출산 횟수는 임신이 5∼8회가 45%, 출산이 5∼8회가 47%로 가장 높았고 평균 임신 및 출산 횟수는 각각 7회 및 4.7회 였다. 6. 편평상피 침윤암의 임상 각 기별 분포를 보면 stage Ⅰ, Ⅱ 및 Ⅲ가 각각 12.3%, 48.6% 및 8.3%였다. 7. 편평상피내암 및 침윤이 의심되던가 현미경적침윤암의 종양세포유형을 보면 small round cell이 43.7%로 가장 많았고 다음이 large cell, small elongated 및 mixed type의 순이었다. 8. 편평상피 침윤암을 Broder's grade Ⅰ, Ⅱ 및 Ⅲ로 구분하면 각각 2.5%, 37.4% 및 59.1%였고 세포형에 따라 large cell non-keratinizing type, Keratinizing type 및 small cell non-keratinizing type로 구분하며 각각 83.3%, 11.6% 및 4.1%였다. 9. 편평상피 침윤암에서 Broder's grade 및 cell type과 clinical stage를 비교 분석하여보면 Broder's Grade는 Clinical stage와 큰 연관이 없었으나 cell type과는 연관이 있어 large cell non-keratinizing type이 stage Ⅰ과 Ⅱ에서 비교적 자주 출현하였다.
[영문] Garcinoma of the uterine cervix is the most common malignant tumor of women in area through carcinoma of the cervix occur at the age from the second decade of life to senility, the peak incidence of clinical obvious lesion occurs around 50 years of age, but in situ lesions have their peak 10 to 15 years earlier (Ng and Atkin, 1973). (Hertig and Gore, 1960). Although many investigators in this area have suffered faults of experimental design that have confronted the interpretation of the result, the combined weight of the evidence has led to claims that one or a combination of the factors listen below are statistically significantly associated with the incidence of cervical neoplasia: 1. Age at first coitus 2. Frequency of coitus 3. Age at first pregnancy 4. No. of sexual partners 5. Circumcision status of partness 6. No. of pregnancies 7. Time between termination of pregnancy and resumption of coitus 8. Socioeconomic status 9. Race 10. Religion 11. Method of contraception 12. Other demographic, familial and environmental factors (Martin, 1967 Christopherson and Parker, 1965) Squamous cell carcinoma and adenocarcinoma comprises 90-95% and 5-10% of all malignant cervical neoplasms, respectively. (Anderson, 1971 : Guido and Lindo, 1974). Squamous cell carcinoma devided in to carcinoma in situ, microinvasive carcinoma and invasive carcinoma and the average age of carcinoma in situ was 38 years, early stromal invasive was 42.2 years and clinically unsuspected invasive cervical carcinoma was 48.5 years(Herting and Gore, 1960). In 1959. Wentz and Reagan proposed a classification for invasive squamous cell carcinoma of the uterine cervix based on histological cell type. The squamous cell carcinomas were devided into 3 distinct groups which included large cell non-keratinizing, keratinizing and small cell cancer. The important features of this classification compared with other grading systems, such as modified Broder's grade is a morphological classification premitting correlation between tissue and cellular specimens, a significant difference in the clinical stage and 5 years survival among the 3 cell types(Ng and Atkin, 1973). There are several reports on cervical malignancies among Korean based on clinical and statistical aspects but there is a few report on cervical cancer, especially based on the histopathological aspects. The present study is an attempt to investigate clinical histopathological aspects and characteristics, such as histologic cell types, modified Broder's grade, and relationship between histologic types and clinical stage. Materials and methods The materials used in this study consists of 1243 cases of malignancies of uterine cervix for 5 years from 1971 to 1975. All specimens were fixed in 10% formalin. For histologic examination, paraffin embedded blocks were cut in 6μ thickness and sections were stained by hematoxylin-eosin method. Histopathological studies on all cases of invasive squamous cell carcinoma are performed as follow. 1. Classification of invasive carcinoma by modified Broder's grade and histologic cell type. 2. Relationship between histologic types and clinical stage carcinoma in situ, microinvasive carcinoma and other malignant cervical tumors were also examined. For the all cases of squamous cell carcinoma whose clinical records were available, age, chief complaints, duration, age of status menarche and marriage, menopause, Gravity and parity and clinical stage were reviewed. Result and Summary Clinical and histopathological studies were made on 1243 cases malignancies of uterine cervix, that were submitted to the department of pathology, Yonsei University, College of Medicine, during the period of 5 years form 1971 to 1975. 1. Malignancies of the uterine cervix were 26.3% of total cancer of either sexes and 42.8% o female total malignancies. 2. Among 1243 cases, 1187 cases (95.5%) were squamous cell carcinoma, in which 194 cases (15.6%) in situ, 72 cases (5.8%) suspected or microinvasive carcinoma and 921 cases (74.1%) invasive carcinoma were included. 3. The average age of squamous cell carcinoma was 46.9 year old, in which in situ 42.9, suspected or micro-invasive 45.0 and invasive 47.9 year old were included. The adeno carcinoma was 49.2 year old. 4. Clinical symptoms of the squamous cell carcinoma in order of frequency were as follows : irregular vaginal bleeding (56.5%), vaginal discharge (31.1%) and postcoital bleeding (24.8%). The duration of chief complaints were most common within 6 months (66.1%) and the average duration was 5.8 months. 5. Among 260 clinical history available cases of squamous cell carcinoma, the most common age of menarche was 16 year old (28.1%) and among 132 cases, the most common age of marriage was between 19-21 year old (37.9%). the majority of the patient (53.3%) in this series were post menopausal. Gravity & parity between 5 to 8 times were 45.0% and 47.0%, and it's average numbers were 6.7 and 4.8 times respectively. 6. Subdivision of 350 cases of invasive squamous cell carcinoma was made according to the clinical stage: Stage Ⅰ : 43 cases (12.3%), Stage Ⅱ : 170 cases (48.6%), Stage Ⅲ : 108 cases (30.8%), Stage Ⅳ : 29 cases (8.3%). 7. The predominant nuclear configuration in the carcinoma in situ and suspected or microinvasive carcinoma was small rounded in 119 cases (43.7%), small elongated in 30 cases (11.3%), large in 41 cases (15.4%) and mixed in 53 cases (19.9%). 8. The distribution of invasive squamous cell carcinoma, when considered in relation to modified Broder's grade and histological cell types were as follows. Broder's grade Ⅰ (25%), Ⅱ (37.4%) and Ⅲ (59.1%), large cell non-keratinizing (83.3%), keratinizing (11.6%) and small cell (4.1%). 9. The histological cell types were well correlated with clinical stage, but no correlation between Broder's modified grade and clinical stage was identified. In conclusion based on above findings it can be stated that uterine cervical carcinoma were most common malignant tumors among Koreans. The histological cell types of invasive squamous cell carcinoma was well correlated with clinical stage and prognosis.
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