葡萄胎清宫前发生侵蚀性葡萄胎肺转移患者的临床分析

目的 探讨葡萄胎清宫前发生侵蚀性葡萄胎肺转移患者的临床特点及治疗效果.方法 回顾性分析2004年1月至2006年1月间,北京协和医院诊治的葡萄胎患者及侵蚀性葡萄胎肺转移患者的病历资料.首先将葡萄胎清宫前无肺转移患者的临床特点与葡萄胎清宫前发生侵蚀性葡萄胎肺转移的患者进行比较;然后,将葡萄胎清宫前发生侵蚀性葡萄胎肺转移患者的治疗效果与葡萄胎清宫后进展为侵蚀性葡萄胎肺转移的患者进行比较.结果 葡萄胎清宫前有胸部CT检查的37例初治葡萄胎患者中,发现存在肺部转移灶的患者有11例,占30%.葡萄胎清宫前有肺转移患者的停经时间[(15.0±4.0)周]、完全性葡萄胎所占的比例(91%),均显著高于葡萄胎清官前无肺转移的患者[(10.0±2.5)周和50%],两者分别比较,差异均有统计学意义(P值分别为0.026、0.027);而年龄、子宫体积较相应停经时间大4周、卵巢黄素化囊肿直径≥6 cm、葡萄胎清宫前血人绒毛膜促性腺激素β亚单位(β-hCG)水平等比较,差异均无统计学意义(P＞0.05).葡萄胎清宫前发生侵蚀性葡萄胎肺转移患者的血β-hCG水平降至正常水平距第1次清宫术的时间间隔,明显短于葡萄胎清宫后发生侵蚀性葡萄胎肺转移的患者,分别为(83±18)、(126±31)d,两者比较,差异有统计学意义(P＜0.01);而血β-hCG水平降至正常水平的化疗疗程数、肺部转移灶完全消失或明显吸收后不再改变所需的化疗疗程数、治疗所需总化疗疗程数以及完全缓解率等比较,差异均无统计学意义(P＞0.05).结论 葡萄胎一经诊断应尽早行清宫术,清宫术实施的时间越晚,发生侵蚀性葡萄胎肺转移和需要进行化疗的概率就越大.若葡萄胎清宫前发生了侵蚀性葡萄胎肺转移,其治疗效果与葡萄胎清宫后发生侵蚀性葡萄胎肺转移的相同,均可治愈.     

A case with multiple gynecological malignancies

A patient with cervical non-Hodgkin lymphoma was treated with chemotherapy. Fourteen months after the diagnosis of the lymphoma, an endometrial adenocarcinoma was detected as a secondary malignant tumor. The patient was treated with surgery followed by radiotherapy. Approximately 7 years after the diagnosis of endometrial cancer, vaginal invasive squamous cell carcinoma was diagnosed as the third primary malignancy, and a second-line palliative radiotherapy was applied. Seven months after the last radiotherapy, postradiational sarcoma in the vagina was diagnosed. Congenital and acquired immune system disorders, viral oncogenes, and various human leukocyte antigen (HLA) types were investigated. Total blood count and lymphocyte subset analysis were performed, and CD4+ lymphopenia was detected. Serologic tests were carried out for human immunodeficiency virus, hepatitis B virus, human papillomavirus, Epstein-Barr virus, and herpes simplex virus infection. Epstein-Barr virus viral capsid antigen IgG was found positive. Low-risk human papillomavirus panel was detected by Hybrid Capture method in the cervical smear. The HLA investigation revealed HLA-A2, HLA-A3, HLA-B57, HLA-B35, HLA-B4, HLA-B6, HLA-DR3, HLA-DR1, HLA-DR51, HLA-DR52, HLA-DQ6(1), and HLA-DQ7(3). The patient died because of the disease.     

Death from pulmonary embolism associated with hydatidiform mole

This case is being reported first to call attention to the somewhat neglected aspects of trophoblastic invasion and deportation. With the increased invasiveness of the trophoblasts in a benign mole the chance of emboli formation would seem to be increased appreciably, particularly when associated with repeated manipulation and examination or attempted induction.It is felt that a more acute awareness of the likelihood of pulmonary emboli brings up the question of the advisability of early operative interference as against the long accepted, more conservative therapy of abortion of the mole followed by curettage.     

Cardiac metastases associated with gynecologic malignancies

Metastasis to the heart of malignancies arising within the pelvis is a rarely reported phenomenon. In fact, review of the literature and personal experience demonstrate that cardiac metastases occur more frequently than expected. Clinical suspicion would enable its antemortem diagnosis in many patients and would permit appropriate therapy in carefully selected individuals.     

Doppler color flow mapping of an invasive mole

We report here Doppler color flow mapping carried out before and after chemotherapy for an invasive mole. This mapping revealed an abnormal color blood flow within the echo-free space in the uterine myometrium, and pulsed Doppler ultrasound showed a prominent arteriovenous shunt flow. Similar features were obtained by pelvic angiography (PAG). After 4 courses of chemotherapy, the area of abnormal colored flow was reduced and findings on the PAG were supportive. The patient is being closely followed, using Doppler color flow mapping.     

Multiple primary cancers associated with gynecologic malignancies

Seventeen multiple primary cancers including 16 double cancers and one triple cancer were found in 316 patients with gynecologic malignancies who were treated in our department from 1984 to 1988. All pathologic slides but one were reviewed, and cases with possible metastasis or recurrence were not included in this study. The incidence of multiple primary cancers in gynecologic malignancies was 5.4%. Multiple primary cancers were encountered in 4.4% of 205 cervical cancers (including carcinoma in situ), 15.2% of 33 endometrial cancers, and 8.6% of 58 ovarian cancers (including low potential malignancy), respectively. The most frequent sites of other cancers were seen in the large intestine and rectum (5/17), breast (4/17), and gynecologic organs (3/17). Higher incidences were seen in our study that in those in domestic literature. This is probably because detailed anamnesis and gastrointestinal series were obtained in most gynecologic malignancies (especially in endometrial or ovarian cancer).     

Partial mole with lung metastases and multiple abnormalities of the fetus

The authors report on a patient with partial mole, multiple malformations and lung metastases requiring chemotherapy. This case shows that the partial hydatidiform mole must therefore be carefully monitored by serial beta-hCG titres following evacuation to ensure the achievement of complete sustained remission.     

A case of multiple malignancies

A case of fourfold cancer: of the vulva and larynx diagnosed synchronously and the breast and lung diagnosed metachronously is presented.     

Second primary genital malignancies associated with endometrial cancer

Epidemiological data on Israeli patients with second primary genital malignancies associated with endometrial cancer is presented. During the 7 years of study, 29 (2.9%) of 1,007 patients with endometrial cancer had additional primary malignancy involving the genital organs. Of these, there were 25 (2.5%) ovarian and 4 (0.4%) cervical malignancies. The occurrence of a second malignancy was related to ethnic origin. The ratio of European/American to Asian/African Jewish descendants was 8.7 to 1. A significantly greater than expected incidence of ovarian and cervical malignancy was detected in the endometrial cancer patient (P less than 0.0001). The prognosis was mainly influenced by the clinical staging of disease at the time of diagnosis. Recognition of the fact that second primary cancers occur at a higher than expected frequency in patients with endometrial cancer, offers an opportunity for their early detection.     

侵蚀性葡萄胎和绒癌的临床与病理诊断

本文通过２２７例恶性妊娠性滋养叶细胞肿瘤的病理学诊断，评价了侵蚀性葡萄胎和绒癌的临床诊断标准。根据末次妊娠性质，①足月产组：４１例（１００％）均为绒癌；②流产值：５１／５４例（９４．４％）为绒癌；③葡萄胎组：自葡萄胎排出至病理确诊时间，６个月以内，７１／８０例（８８．８％）为恶葡；１２个月以上，３４／３５例（９７．１％）为绒癌；６￣１２个月，１４／１７例（８２．４％）为绒癌。     

Evaluation of hysterography in the diagnosis of choriocarcinoma and invasive mole

From 1963 through 1985, 181 hysterography were performed for 101 patients. The diagnostic accuracy of hysterography was 92.3%. There were no false positive findings, though a negative result may be obtained in patients whose intramural lesion does not communicate with the uterine cavity, as proved by operative findings. Three types of abnormalities were observed on the hysterogram: (1) filling defect, (2) intramural invasion of the uterine wall by the contrast medium and (3) extravasation of the contrast medium into the pelvic veins. The filling defect was usually observed in patients with (1) residual molar tissue in the uterine cavity, (2) intramural lesion and (3) intrauterine adhesions. The above three conditions can be differentiated by the characteristic shape of the filling defect. If it is used in combination with either or both of the other two procedures, ie., B-ultrasound and pelvic arteriography the accuracy of diagnosis will be further improved.     

Ultrasound-guided local injection of methotrexate to treat an invasive hydatidiform mole

A 28-year-old Japanese woman had an invasive hydatidiform mole which was diagnosed by means of transvaginal ultrasonography. After the two initial courses of systemic methotrexate (MTX) therapy given over a period of weeks, the tumor was 14 mm in diameter and the surrounding blood supply remained rich. In addition to the two initial courses of systemic MTX therapy, local ultrasound-guided injection of MTX therapy was given three times, once per week. After the local MTX treatment, the betahCG level, which had been as high as 240 ng/mL, dropped to less than 0.1 ng/mL. We then gave two additional courses of systemic MTX therapy (once per week). More than 3 years have passed since the final systemic MTX therapy, and the patient's serum betahCG levels continue to be less than 0.1 ng/mL. An invasive mole can be treated with an ultrasound-guided local injection of MTX in addition to the established systemic MTX treatment.     

Forty-five year's experience of the treatment of choriocarcinoma and invasive mole

Our work was begun in 1949, through many yera's effort, several chemicals (such as 6 MP, 5 FU and others) were found to be effective for the treatment of choriocarcinoma (C.C.) and invasive mole (I.M.). From 1959 through 1985, 1500 patients were consecutively treated. The mortality rate of CC was reduced from > 90% to < 20%. No more death occurred in IM. All Survivors followed up for 10–38 years showed no evidence of residual disease. 80% of the young patients treated with chemotherapy alone conceived after recovery. The pregnancy outcome showed no deviation from that of the general population. All children are growing up normally many married and gave birth to normal third generations. The results indicated that chemotherapy with 5 FU achieves not only a complete remission, but also a cure, even with wide-spread metastases. The results of choriocarinoma and invasive mole treated with mainly 5 FU were reported. The clinical experience in the management of metastases at different sites were also summarized.     

经阴道彩色多普勒技术对侵蚀性葡萄胎的诊断价值

为探讨经阴道彩色多普勒超声（ＴＶＣＤ）对侵蚀性葡萄胎的早期诊断，对１９例侵蚀性葡萄胎行ＴＶＣＤ血流检测，以９１例正常早孕、３５例正常非孕子宫、１３例良性葡萄胎作为对照组。结果：侵蚀性葡萄胎肌壁血流丰富，子宫动脉和螺旋动脉ＰＳ值明显增高（ｐ〈０．００５），ＲＩ、ＰＩ值明显降低（ｐ〈０．００５）。以肌壁血窦〉５ｍｍ作为侵蚀性葡萄胎的诊断标准，其敏感性９５％，特异性１００％。表明ＴＶＣＤ是检测侵蚀性葡萄     

A study on ultrasound imaging of invasive mole and choriocarcinoma with regard to clinical significance

In order to establish the value of ultrasonography in the diagnosis and management of trophoblastic tumor, we have performed ultrasonic examination on 32 patients. In 24 out of 32 cases, the focal echo could be detected within the uterus. The ultrasonically estimated volume of the focus was correlated with the level of urinary hCG. Concerning 17 hysterectomized cases, the ultrasound imaging of focuses was quite consistent with the post-operative findings. The echo patterns of these focuses could be classified into 4 types, that is, Type I, massive echogenic; Type II, multiple echo free; Type III, solitary echo free; and Type IV, subserous cystic. Type I echoes were macroscopically recognized to be clot, molar tissue and cancer tissue. In Types II, III and IV, multifarious hemorrhages were proven to be echo sources. The histopathological results showed that it is difficult to discriminate choriocarcinoma from invasive mole clearly by this echo pattern analysis. A notable decrease in focal size and change in echo pattern could be observed after chemotherapy, but these echographic changes were much slower than the rapid response in the urinary hCG value.