中间型滋养细胞肿瘤诊断与鉴别诊断

中间型滋养细胞肿瘤(ITTs)包括胎盘部位滋养细胞肿瘤(PSTT)和上皮样滋养细胞肿瘤(ETT),是比较罕见的妊娠滋养细胞疾病。PSTT主要表现为不规则阴道流血和闭经;ETT主要表现为不规则阴道流血。影像学和血清学等辅助检查在诊断ITTs中起一定作用,病理是确诊的金标准。手术是主要的治疗方式,根据具体病情联合放化疗。早期诊断和合理治疗可明显改善预后。     

Placental site trophoblastic tumors (trophoblastic pseudotumors): pathology and clinical importance

Placental site trophoblastic tumor (PSTT), which can be regarded as a subtype of gestational trophoblastic neoplasia is discussed. The histopathological features include trophoblastic proliferation without the typical organization of the bilamelar cyto and syncytiotrophoblastic villus. Ultrastructural investigation has demonstrated a clone structural relationship between the infiltrating cells and those of the trophoblastic components of the normal human placenta. Clinical management should be based on the complete surgical resection of the mass and a follow-up by measuring the serum levels of beta-human chorionic gonadotropin fractions.     

妊娠合并卵巢肿瘤及瘤样病变58例临床分析

目的探讨妊娠合并卵巢肿瘤及瘤样病变患者的临床特征和处理对策。方法回顾性分析2009年1月至2010年12月福建省妇幼保健院收治的58例经手术病理诊断的妊娠合并卵巢肿瘤及瘤样病变患者的临床资料。结果 58例妊娠合并卵巢肿瘤及瘤样病变患者占同期妊娠的0.24%(58/23756),其中卵巢良性肿瘤及瘤样病变56例(96.6%),卵巢恶性肿瘤2例(3.4%)。妊娠前首次发现者5例(8.6%);孕早期发现者22例(37.9%),孕中期发现者18例(31.0%),孕晚期发现者13例(22.4%);孕早、中期均为超声检查发现,孕晚期均为剖宫产术中发现。56例卵巢良性肿瘤及瘤样病变患者中,50例(89.3%)行卵巢囊肿切除术,6例(10.7%)行附件切除术,随访8～18个月未见复发。2例妊娠合并卵巢恶性肿瘤患者中,1例卵巢浆液性囊腺癌行肿瘤细胞减灭术,术后辅助化疗8个疗程,随访12个月无瘤生存;1例卵巢肿瘤切除术后病理诊断卵巢幼年性颗粒细胞瘤,拒绝再次手术及化疗,术后2个月死亡。58例患者中,妊娠合并卵巢肿瘤蒂扭转行急诊手术8例,发生率为13.8%。58例患者的病理类型为成熟畸胎瘤24例(41.4%),浆液性囊腺瘤22例(37.9%),黄体囊肿10例(17.2%),颗粒细胞瘤1例(1.7%),浆液性乳头状囊腺癌1例(1.7%)。结论超声检查可以诊断和监测妊娠期卵巢肿瘤及瘤样病变,而剖宫产术中常规行双侧附件探查亦很重要。妊娠合并卵巢肿瘤蒂扭转患者以成熟畸胎瘤为最多见。     

Current topic: trophoblastic pathology.

Selected topics in trophoblastic pathology which are arousing current interest are briefly reviewed. These include the concept of villitis as a non-specific immunological lesion, changing views on the distinction between partial and complete hydatidiform mole, a reconsideration of the role of inadequate placentation in pregnancy hypertension and in spontaneous abortion, the significance of confined placental mosaicism and the importance of infection and defective collagen synthesis in premature rupture of the membranes.     

滋养细胞肿瘤患者子宫病灶大小与化疗疗程的关系

目的探讨滋养细胞肿瘤患者子宫病灶大小与化疗疗程的关系。方法应用彩色多普勒超声诊断仪探测了滋养细胞肿瘤２９例子宫病灶的大小、子宫血流情况，并与治愈时化疗疗程数作比较。结果随着子宫上病灶的增大，子宫动脉的搏动指数（ＰＩ）及阻力指数（ＲＩ）逐渐下降，病灶周围血流的搏动指数及阻力指数也逐渐下降，而治愈所需的疗程数逐渐增加，表明子宫病灶的大小、子宫血流情况与化疗效程之间有一定关联，而血清β－ｈＣＧ水平不能反映子宫病灶的大小及病情的严重程度。结论应用彩超测定子宫病灶及血流情况有助于估计滋养细胞肿瘤患者的预后，而β－ｈＣＧ水平与病情严重程度、预后不平行。     

恶性滋养细胞肿瘤面临的临床问题

妊娠滋养细胞肿瘤（gestational trophoblastic neoplasia，GTN）又称妊娠滋养细胞疾病（gestational trophoblastic disease，GTD），是指胚胎的滋养细胞发生恶性变而形成的肿瘤。滋养细胞肿瘤包括：葡萄胎，侵蚀性葡萄胎，绒毛膜癌及中间型滋养细胞肿瘤。由于其独特的组织学来源及生物学行为，     

Management of low-risk metastatic gestational trophoblastic tumors.

The clinical course of 48 patients with low-risk metastatic gestational trophoblastic tumors (GTTs) treated with primary single-agent chemotherapy was reviewed. All patients achieved sustained remission, although 25 (51%) required a second single-agent regimen, and 7 (14%) needed combination chemotherapy to achieve it. An average of 3.4 courses of chemotherapy were necessary to achieve remission, and 6 patients (12%) underwent resection of resistant tumor foci. Primary single-agent chemotherapy is a reasonable treatment option in patients with low-risk metastatic GTT.     

Extrauterine lesions of intermediate trophoblast.

Lesions of intermediate trophoblast arising in the uterus include exaggerated placental site, placental site nodule, placental site trophoblastic tumor (PSTT), and epithelioid trophoblastic tumor. Only 12 examples of extrauterine lesions of intermediate trophoblast (ELIT) have been previously reported; 7 new cases are described herein. Six lesions were located in the fallopian tube or paratubal region and one in the ovary. The patients were 25 to 47 (average 36) years of age. The lesions ranged from 0.6 to 4 cm in diameter; four were cystic. The four placental site nodules (three tubal, one paratubal) were composed of small, sharply circumscribed nodules of intermediate trophoblast with no mitotic activity. The three PSTTs (two tubal, one ovarian) exhibited irregular stromal infiltration by intermediate trophoblast, mitotic activity, and necrosis. Chronic salpingitis was seen in the six tubal/paratubal cases, and endometriosis was seen in four cases. Immunoreactivity for human placental lactogen, human chorionic gonadotropin, and cytokeratin in two cases was consistent with an origin from intermediate trophoblast. ELITs presumably arise from previous ectopic pregnancies, a history of which was present in two of these patients. Follow-up, available on two of the three patients with PSTT, was uneventful at 6 and 12 years, but study of additional cases is necessary to reliably determine the behavior of extrauterine PSTTs.     

Pathology of gestational trophoblastic tumors

Gestational trophoblastic tumours result from an abnormal proliferation of different types of trophoblasts. The morphological pattern, together with the immunohistochemical aspect, the cytogenetic data and the clinical profile, helps identify each pathological entity. Hydatiform moles represent malformed placentas caused by genetic aberrations of the villous trophoblast. A complete hydatiform mole displays an hydropic degeneration of all the chorionic villi with a more or less marked proliferation of trophoblasts. A partial hydatiform mole is made up of molar vesicles interspersed with normal chorionic villi. In an invasive hydatiform mole or chorioma destruens, molar vesicles penetrate the myometrium giving rise to a mass distorting the uterine wall. A choriocarcinoma is a malignant proliferation of atypical villous trophoblasts without villi formation. Necrosis, haemorrhage, vascular invasion and distant metastases strongly compromise its outcome. A trophoblastic implantation site tumor, clearly less frequent, results from a proliferation of extravillous trophoblasts, particular for their secretion of human placental lactogen hormone (hPL). This tumour, exceptionally malignant, should be differentiated from the exaggerated placental site and its variants. Except for the placental site trophoblastic tumour, and whatever the outcome (benign or malignant), all gestational trophoblastic tumours secrete the beta-subunit of the chorionic gonadotropic hormone (beta-hCG) more or less abundantly. The serum or urinary level of this unit is proportional to the tumour volume and represents a fundamental basis for the follow-up of these tumours. Multidisciplinary care of high-risk cases allows us to cure the disease, and helps the patient recover her reproductive uterine function.     

Mesenchymal tumors and tumor-like lesions of the female genital tract: a selective review with emphasis on recently described entities.

The diverse mesenchymal tumors and tumor-like lesions that occur within the female genital tract include a number of lesions that have only been recently characterized and others about which there is new information. In this group are the aggressive angiomyxoma, angiomyofibroblastoma, and cellular angiofibroma. Criteria for the distinction of these lesions are reviewed, as are the pathologic features of prognostic significance in assessing smooth muscle tumors of the vulva. The diagnostic problems that the epithelioid variant of smooth muscle tumors, both benign and malignant, may pose when they occur in various areas of the genital tract are discussed, particularly with regard to problems encountered in the ovary, a site where the diagnosis often is not considered. Recent information expanding the morphologic spectrum of fibroepithelial polyps of the genital tract is presented, and important non-neoplastic entities, including nodular fasciitis and the postoperative spindle cell nodule, are reviewed. Mesenchymal tumors of the various types seen in the soft tissues may be encountered anywhere in the female genital tract and have been the subject of particular recent interest in the ovary; issues relevant to differential diagnosis are reviewed.