早期葡萄胎的临床特点及诊断方法探讨

Clinical characteristics and diagnosis of early hydatidiform mole

目的探讨早期葡萄胎(停经时间≤12周)的临床特点及诊断方法。方法收集2013年2月—2018年2月在大连市妇幼保健院行第1次清宫术并经病理检查确诊的葡萄胎患者526例,其中停经时间≤12周者484例(早期葡萄胎组)、停经时间>12周者42例(晚期葡萄胎组),比较两组患者的临床特点,探讨早期葡萄胎的诊断方法,并进一步分析清宫术前超声诊断与术后病理诊断的符合情况。结果(1)两组患者临床特点的比较:与晚期葡萄胎组比较,早期葡萄胎组患者的临床特点趋于不典型,葡萄胎的典型临床表现如阴道流血、子宫异常增大、卵巢黄素化囊肿(直径>6 cm)、妊娠并发症的发生率均显著下降(P均<0.05)。早期葡萄胎组清宫术前血清β-hCG水平显著低于晚期葡萄胎组(Z=-2.382,P=0.017)。早期葡萄胎组、晚期葡萄胎组患者清宫术前超声诊断为葡萄胎的检出率分别为53.5%(259/484)、66.7%(28/42),两组比较,差异无统计学意义(x^2=2.697,P=0.101)。526例葡萄胎患者中,515例完成随诊,其中38例(7.4%,38/515)发生恶变,手术或化疗后均治愈;早期葡萄胎组、晚期葡萄胎组的葡萄胎恶变率分别为7.0%(33/473)、11.9%(5/42),两组比较,差异无统计学意义(x^2=0.745,P=0.388)。(2)早期葡萄胎的诊断:484例早期葡萄胎患者中,病理形态学检查结合细胞周期蛋白依赖性激酶抑制因子p57(p57KIP2)免疫组化法检测,诊断为完全性葡萄胎(CHM)302例,部分性葡萄胎(PHM)179例,未明确病理类型葡萄胎(UHM)3例。(3)早期葡萄胎患者清宫术前超声诊断与术后病理诊断的符合情况:与术后病理诊断对照,清宫术前超声检查诊断为葡萄胎者259例,超声检出率为53.5%(259/484);其中CHM和PHM的检出率分别为78.1%(236/302)、11.7%(21/179),CHM的超声检出率显著高于PHM(x^2=199.224,P<0.01)。随着停经时间的延长,超声检查对葡萄胎的检出率与诊断孕周呈弱负相关(r=-0.211,P<0.01)。早期PHM的中位停经时间较CHM显著延长(分别为68.0、58.5 d;Z=-8.048,P<0.01)。结论早期葡萄胎的临床特点不典型,约1/2患者的超声征象不典型,但超声检查仍是重要的辅助检查手段,通过病理形态学检查结合p57KIP2免疫组化法检测可有效诊断早期葡萄胎,以减少葡萄胎的漏诊。

Objective To evaluate the clinical characteristics and diagnostic strategies of early hydatidiform mole.Methods A retrospective cohort study was conducted of 526 women with hydatidiform mole who underwent suction curettage and were confirmed by histopathology in Dalian Maternal and ChildHealth Care Hospital from Feb.2013 to Feb.2018,including 484 women with gestational age less than or equal to 12 weeks(the early group)and 42 women with gestational age greater than 12 weeks(the late group).The clinical characteristics between the two groups were compared,and the pathological diagnosis and pre-evacuation ultrasound examination of the early group were further discussed.Results Compared with the late group,the clinical characteristics of the early group tended to be atypical,and the incidence of vaginal bleeding,excessive uterine size,theca lutein cysts(>6 cm)and pregnancy complications decreased significantly(all P<0.05).The serum level ofβ-hCG in the early group was significantly lower than that in the late group(Z=-2.382,P=0.017).While there was no significant difference in the pre-evacuation ultrasound detection rate between the two groups(53.5%vs 66.7%;x^2=2.697,P=0.101).Five hundred and fifteen patients completed the follow-up,and 38 patients with post-mole neoplasia were all cured.There was no significant difference in the malignant transformation rate of hydatidiform mole between the two groups(7.0%vs 11.9%;x^2=0.745,P=0.388).In the early group,302 cases of complete hydatidiform mole(CHM),179 cases of partial hydatidiform mole(PHM)and 3 cases of unclassified hydatidiform mole(UHM)were histologically diagnosed,according to pathological morphology combined with p57KIP2 immunohistochemical staining.Compared with pathological diagnosis,the overall pre-evacuation ultrasound detection rate in the early hydatidiform mole was 53.5%(259/484),which was significantly better for complete(78.1%,236/302)versus partial(11.7%,21/179)hydatidiform moles(x^2=199.224,P<0.01).There was significantly weak negative correlation between the overall ultrasound detection rate and gestational age of hydatidiform mole(r=-0.211,P<0.01).The gestational age of early PHM was significantly longer than that of CHM(68.0 vs 58.5 days;Z=-8.048,P<0.01).Conclusions The clinical presentations of early hydatidiform mole are not typical.Although ultrasound examination identifies only about half of hydatidiform moles,ultrasonography is still an important auxiliary examination method.Morphological examination combined with p57KIP2 immunohistochemical staining could effectively diagnose early hydatidiform mole,so as to reduce the missed diagnosis of hydatidiform mole.