腹腔镜手术在以宫体占位为主的可疑妊娠滋养细胞肿瘤诊断中的价值

Value of laparoscopic surgery in the diagnosis of suspected gestational trophoblastic neoplasia cases with uterine mass

目的探讨腹腔镜手术在以宫体占位为主的可疑妊娠滋养细胞肿瘤（GTN）诊断中的价值。方法收集2009年11月1日至2014年11月1日中国医学科学院北京协和医院妇产科收治的以宫体占位为主的可疑GTN患者。本研究的纳入标准，需同时符合下列4项条件：（1）尚未达到2010年国际妇产科联盟（FIGO）的GTN临床诊断标准；（2）影像学检查提示存在以宫体占位为主的可疑GTN病灶；（3）接受了腹腔镜病灶切除术；（4）临床病理资料完整。本研究的排除标准，为符合下列任一条件：（1）存在明确转移病灶；（2）影像学检查提示病灶完全位于宫腔。根据术后病理诊断将纳入本研究的患者分为GTN组和非GTN组，回顾性分析并比较两组患者的临床特点，观察GTN组患者的治疗结局和预后。结果本研究符合纳入和排除标准的患者共62例，其中GTN组17例，包括绒毛膜癌（绒癌）8例、侵蚀性葡萄胎5例、胎盘部位滋养细胞肿瘤（PSTr）4例；非GTN组45例，包括宫角妊娠29例、子宫瘢痕妊娠6例、胎盘植入5例、子宫肌壁间妊娠4例、胎盘部位超常反应1例。（1）两组患者临床特点的比较：两组患者年龄[（31±8）、（34±5）岁]、术前血清B．hCG水平[（42365±85294）、（9732±29974）U／L]、术前血清B．hCG水平的变化趋势、病灶位置、病灶最大径[（4．3±2．1）、（4．4±1．4）cm]分别比较，差异均无统计学意义（P〉0．05）；而两组患者滋养细胞疾病史比例[5／17、4％（2／45）1、剖宫产史比例【1／17、38％（17，45）】分别比较，差异均有统计学意义（P〈0．05）。（2）GTN组患者的治疗结局和预后：GTN组17例患者术后诊断为绒癌I期高危型1例、绒癌I期低危型7例、侵蚀性葡萄胎I期低危型5例、PSTT I期4例。17例接受腹腔镜病灶切除术的CTN组患者，无围手术期严重并发症发生；1例（侵蚀性葡萄胎I期低危型）术后化疗过程中失访，16例术后予单药或联合方案化疗均获临床缓解，其中II例I期低危型患者随访11～66个月、1例绒癌I期高危型患者随访61个月、4例PSrrr患者随访13～66个月均无复发征象。结论以宫体占位为主的可疑GTN难以仅根据临床特点与妊娠相关的良性疾病鉴别，腹腔镜病灶切除术获取病理诊断是其可行、安全、有效的诊断方法。

Objective To evaluate the value of laparoscopic surgery in the diagnosis of suspected gestational trophoblastic neoplasia （GTN） cases with uterine mass. Methods The clinical characteristics of patients underwent laparoscopic surgery for a suspected diagnosis of GTN with uterine mass in Peking Union Medical College Hospital from November 2009 to November 2014 were retrospectively reviewed and analyzed. GTN and other pregnant-related disease were definitely diagnosed by pathological findings. The prognoses of the GTN cases were also investigated. Results Sixty-two patients with a suspected diagnosis of GTN with uterine mass were studied. Among them, 17 cases were definitely diagnosed as GTN, including 8 choriocarcinoma, 5 invasive mole and 4 placental site trophoblastic tumor（PSTT）. The other 45 cases were diagnosed as benign pregnancy-related diseases, including 29 cornual pregnancy, 6 cesarean scar pregnancy, 5 placenta accreta, 4 intramural uterine pregnancy and 1 exaggerated placental site. There were no significantly differences between the two groups in average age, preoperative value or tendency of 13-hCG, and location or size of lesions （P〉0.05）. More GTN patients showed a history of hydatidiform mole [5/17 vs 4% （2/45）, P〉0.05], and more patients with benign pregnancy-related disease showed a history of cesarean section [38% （17/45） vs 1/17, P〉0.05]. No serious perioperative complication was found in these patients received laparoscopic surgery. All GTN patients achieved complete remission by chemotherapy later. Except for 1 case loss, no recurrence was found in 11 low-risk stage I cases with an average follow-up period of 11- 66 months, 1 high-risk stage I case with a follow-up period of 61 months and 4 cases PSTT with a follow-up period of 13-66 months. Conclusions There were some atypical GTN cases with uterine mass, which were difficult to be differentiated from benign pregnancy-related diseases according to the clinical characteristics. Laparoscopic surgery with a pathologic diagnosis could be an essential way with efficiency and safety.