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Laparoscopy and/or Hysteroscopy in Differential Diagnosis and Treatment of Suspected Gestational Trophoblastic Neoplasia
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摘要:
目的 探讨腹腔镜和/或宫腔镜手术对于疑诊妊娠滋养细胞肿瘤(gestational trophoblastic neoplasia, GTN)的鉴别诊断和治疗价值及对其结局的影响。 方法 回顾性分析北京协和医院妇产科2005年1月至2013年12月收治的160例疑诊GTN而行腹腔镜和/或宫腔镜手术患者的临床资料, 分析患者的诊断和结局。 结果 160例患者中有26例诊断为GTN, 包括15例绒毛膜癌、6例侵蚀性葡萄胎和5例胎盘部位滋养细胞肿瘤; 134例诊断为非GTN疾病, 包括妊娠物残留106例(51例不全流产、52例宫角妊娠残留、2例胎盘残留、1例葡萄胎残留), 剖宫产瘢痕部位妊娠23例, 宫角妊娠3例, 子宫肌壁间妊娠2例。除末次妊娠性质(P < 0.001)外, GTN患者与非GTN患者之间的大部分临床资料差异无统计学意义。除1例患者治疗中失访外, 其他所有GTN和非GTN患者最终均通过手术或联合化疗获完全缓解或治愈。 结论 根据患者临床资料难以鉴别GTN时, 通过腹腔镜和/或宫腔镜手术有助于明确诊断, 手术对GTN患者结局无明显影响, 同时可以对非GTN疾病进行有效治疗。 Abstract:Objective To investigate the application of laparoscopy and/or hysteroscopy in differential diagnosis and treatment of suspected gestational trophoblastic neoplasia (GTN), and its potential impact on outcome. Methods From January 2005 to December 2013, 160 patients with a suspected diagnosis of GTN were admitted to Peking Union Medical College Hospital and underwent laparoscopy and/or hysteroscopy for it. The clinical data, diagnosis, and outcome of these patients were retrospectively analyzed. Results Among the 160 eligible patients, 26 were confirmed with GTN, including choriocarcinoma in 15 cases, invasive mole in 6 cases, and placental site trophoblastic tumor (PSTT) in 5 cases. The diagnosis of GTN was ruled out in the other 134 cases, including intrauterine gestational residues in 106 (51 cases of incomplete abortion, 52 cases of residues of cornual pregnancy, 2 cases of placental remnants, 1 case of residual hydatidiform mole), cesarean scar pregnancyin 23, cornual pregnancy in 3, intramural pregnancy in 2. There was no significant difference in most of the clinical data between GTN patients and non-GTN patients except for the type of last pregnancy (P < 0.001). All of the GTN and the non-GTN patients achieved complete remission or cure by subsequent chemotherapy or surgical therapy except one patient lost to follow-up during the course of the treatment. Conclusions Laparoscopy and/or hysteroscopy could be an effective strategy to facilitate diagnosis when it is difficult to differentiate GTN from non-GTN diseases by clinical data. Furthermore, that technique would not affect the outcome for GTN patients, while for non-GTN patients they could offer effective treatment. -
Key words:
- gestational trophoblastic neoplasia /
- laparoscopy /
- hysteroscopy /
- diagnosis
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表 1 GTN患者与非GTN患者临床资料比较
组别 年龄
（x±s岁）孕次
（x±s）产次
（x±s）入院距末次妊娠
终止时间
（x±s, d）术前β-hCG
（x±s, U/L）超声病变
血流信号
丰富肺部CT
异常末次妊娠性质 足
月
产流
产异
位
妊
娠葡
萄
胎非GTN患者（n=134） 32.9±5.6 3.5±1.6 0.9±0.7 370.4±971.7 8553.6±28 318.9 66/126 14/38 9 121 1 3 GTN患者（n=26） 31.1±7.1 2.7±2.0 0.6±0.8 589.3±949.1 31 012.5±71 277.0 10/23 7/21 2 15 1 8 P 0.233 0.069 0.092 0.302 0.125 0.432 0.788 ＜0.001 GTN：妊娠滋养细胞肿瘤；β-hCG：人绒毛膜促性腺激素 
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表 2 26例GTN患者的治疗和随诊情况
病例 诊断 初次手术后治疗 β-hCG降至
正常的时间随诊时间
（月）结局 1 绒毛膜癌 Act-D化疗5程 化疗1程后 44 无病存活 2 绒毛膜癌 FAV化疗6程 化疗3程后 55 无病存活 3 绒毛膜癌 FAV化疗1程后行TAH，术后FAV化疗2程 化疗2程后 25 无病存活 4 绒毛膜癌 FAV化疗3程后行开腹子宫病灶切除术，术后FAV化疗3程 化疗2程后 40 无病存活 5 绒毛膜癌 FAV化疗5程 化疗2程后 26 无病存活 6 绒毛膜癌 FAV化疗5程 化疗2程后 66 无病存活 7 绒毛膜癌 FAV化疗5程 化疗2程后 14 无病存活 8 绒毛膜癌 EMA-CO化疗3程 化疗1程后 15 无病存活 9 绒毛膜癌 FAV化疗4程 化疗1程后 12 无病存活 10 绒毛膜癌 FAV化疗4程 化疗2程后 15 无病存活 11* 绒毛膜癌 FAV化疗4程 化疗2程后 28 无病存活 12 绒毛膜癌 FAV化疗4程 化疗1程后 38 无病存活 13 绒毛膜癌 EMA-CO化疗6程 化疗2程后 39 无病存活 14 绒毛膜癌 FAV化疗6程 化疗2程后 22 无病存活 15 绒毛膜癌 Act-D+VP16化疗1程，FAV化疗1程后行TAH，术后FAV化疗3程 化疗3程后 37 无病存活 16 IM FAV化疗5程 化疗3程后 75 无病存活 17 IM FUDR化疗4程 化疗2程后 55 无病存活 18 IM FAV化疗3程 化疗1程后 28 无病存活 19 IM FAV化疗4程 化疗2程后 34 无病存活 20 IM Act-D+VP16化疗1程，FAV化疗2程后失访 未降至正常 失访 21 IM FAV化疗3程后行腹腔镜子宫病灶切除术，术后FAV化疗3程 化疗3程后 44 无病存活 22 PSTT Act-D+VP16化疗1程后行腹腔镜全子宫切除术，术后EMA-EP化疗3程 化疗1程后 31 无病存活 23 PSTT FAEV化疗2程后行腹腔镜子宫病灶切除术，术后化疗3程 化疗1程后 15 无病存活 24 PSTT FAEV化疗4程 化疗前正常 12 无病存活 25 PSTT FAV化疗1程，FAEV化疗1程后行TAH，术后EMA-CO化疗2程 化疗2程后 54 无病存活 26 PSTT LAVH 术前正常 13 无病存活 *初次治疗停药2个月后复发，FAEV化疗2程后行TAH，术后FAEV化疗1程，Act-D+VP16化疗2程，此后随诊无病存活；GTN、β-hCG：同表 1；IM：侵蚀性葡萄胎；PSTT：胎盘部位滋养细胞肿瘤；Act-D：放线菌素D；FAV：氟脲苷+放线菌素D+长春新碱；TAH：开腹全子宫切除术；EMA-CO：依托泊苷+氨甲蝶呤+放线菌素D、环磷酰胺+长春新碱；FAEV：氟脲苷+放线菌素D+依托泊苷+长春新碱；Act-D+VP16：放线菌素D+依托泊苷；FUDR：氟脲苷；EMA-EP：依托泊苷+氨甲蝶呤+放线菌素D、依托泊苷+顺铂；LAVH：腹腔镜辅助阴式全子宫切除术
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