肺叶切除术治疗妊娠滋养细胞肿瘤肺转移的疗效分析

Pulmonary resection in the management of gestational trophoblastic neoplasia： a dinical study

目的评价肺叶切除术治疗妊娠滋养细胞肿瘤（GTN）肺转移的疗效。方法对1995年1月—2005年12月间北京协和医院收治的62例因GTN肺转移行肺叶切除术患者的临床病理资料进行回顾性分析。根据术前临床治疗情况将上述患者分为复发性GTN（A组，10例）、耐药性GTN（B组，28例）和化疗过程中血清人绒毛膜促性腺激素β亚单位（β-hCG）水平呈对数下降、化疗效果满意但肺部病灶持续存在者（C组，25例），其中1例患者分别因耐药与复发两次接受肺叶切除术治疗，故同时进入A组和B组。结果62例患者总的完全缓解率为89％（55／62），其中A、B、C组完全缓解率分别为90％（9／10）、79％（22／28）和100％（25／25），B组明显低于C组（P=0．024），其他组间比较，差拌则均无统计学意义（P〉0．05）。3组患者的复发率分别为2／8、15％（3／20）和0。3组高危[即国际妇产科联盟（FIGO）GTN评分≥7分]患者比例分别为90％（9／10）、82％（23／28）和44％（11／25），C组明显低于A、B组（P〈0．05）；B组患者术前化疗疗程数（7个疗程）明显多于A、C组（分别为3和5个疗程；P〈0．05）；A、B组患者术前血清β-hCG水平未达正常所占百分比[分别为50％（5／10）61％（17／28）]明显高于C组[为12％（3／25）；P〈0．05]；而3组术后病理阳性率分别为60％（6／10）、36％（10／28）和12％（3／25），C组明显低于A、B组（P〈0．05）。结论肺叶切除术对于GTN肺转移是一种有效的治疗方法。对于肺部病灶相对局限的耐药和复发患者，建议在化疗后适时行肺叶切除术；而对于化疗过程中血清β-hCG水平呈对数下降、化疗效果满意而肺部病灶持续存在的初治患者，可严密随诊，暂不必选择手术治疗。

Objective To investigate the effect of surgical resection in the management of gestational trophoblastic neoplasia （GTN） patients with pulmonary metastases. Methods A retrospective review of the medical records of 62 GTN patients who underwent pulmonary resection was carried out. The cases were divided into recurrent group （ group A, n = 10 ）, drug-resistant group （ group B, n = 28 ）, and the group with satisfactory response to chemotherapy but residual pulmonary lesion（s） （group C, n = 25 ）. One patient underwent lobectomy twice, and she was allocated simultaneously to groups A and B. The patients＇ median age, antecedent pregnancy, International Federation of Gynecology and Obstetrics （FIGO） risk score, number of preoperative chemotherapy courses, preoperative β-human chorionic gonadotrophin （β-hCG） titer, lesion size, number of lobes affected, positive rate of histology, follow-ups and prognosis were compared between the three groups. Results The proportion of high-risk patients in the three groups was 90% , 82% and 44% , respectively. The complete remission rates of the three groups were 90% , 79% and 100% , with relapse rates of 2/8, 15% and zero, respectively. Positive histology of the resected specimen was more frequently recognized in recurrent and drug-resistant groups （A 60% , B 36%, C 12% ）. In the drug-resistant group there were more preoperative chemotherapy sessions （A 3, B 7, C 5） and more patients with abnormal preoperative β-hCG titer （ A 50%, B 61% , C 12% ）. Conclusions Surgical resection is effective in the treatment of pulmonary metastases of GTN. Surgery is indicated when clinical evidence suggests that pulmonary metastatic disease causes relapse or drug-resistance and the lesions are relatively localized. Surgical resection is not recommended for patients with satisfactory response to chemotherapy but residual pulmonary lesions.