宫腔镜和腹腔镜在妊娠滋养细胞肿瘤鉴别诊断中的价值

目的探讨宫腔镜和腹腔镜用于妊娠滋养细胞肿瘤（GTN）鉴别诊断中的价值。方法回顾性分析北京协和医院2003年9月至2006年3月收治的外院疑诊为GTN或外院诊断为GTN并已接受化疗、转人北京协和医院后因不能确诊而进行宫腔镜和（或）腹腔镜检查及治疗的27例患者的临床资料,并分析官腔镜和腹腔镜在GTN、不全流产和异位妊娠鉴别诊断中的价值。27例患者,年龄为24～46岁,平均年龄（36±7）岁;主要表现为清宫术后（53±37）d仍有反复阴道流血;血清人绒毛膜促性腺激素p亚单位（p-hCG）水平异常（3．6～112469.0 U／L）,中位数为235．5U／L;超声检查提示官腔、一侧宫底或子宫肌层内有占位性病变,其病变内或子宫肌层见丰富的血流;肺部CT或胸部x线检查无异常发现。宫腔镜下清宫术11例;腹腔镜检查和手术治疗10例;官腔镜联合腹腔镜检查及治疗6例。结果最终诊断只有4例患者为GTN,且均为绒毛膜癌;23例为非GTN疾病,包括子宫角妊娠12例、子宫残角妊娠1例和不全流产10例。23例非GTN患者,通过宫腔镜或腹腔镜手术治疗或术后辅助单次甲氨蝶呤肌内注射,均于术后6周内治愈;4例GTN患者,经过以氟尿嘧啶为主的化疗后,均获得完全缓解。结论妊娠终止后阴道异常流血的主要原因有不全流产、异位妊娠和GTN。当通过临床病史、超声检查和血清B-hCG水平检测等综合分析,仍不能明确诊断时,宫腔镜和（或）腹腔镜检查是可供选择的诊断方法,并能同时进行有效的手术治疗。

Value of hysteroscopy and laparoscopy in differential diagnosis of gestational trophoblastic neoplasia

OBJECTIVE: To determine the efficacy of hysteroscopy and laparoscopy in differential diagnosis of pregnancy-related diseases, including gestational trophoblastic neoplasia (GTN), incomplete abortion and ectopic pregnancy. METHODS: Twenty-seven patients with a suspected diagnosis of GTN were transferred to Peking Union Medical College Hospital from September 2003 to March 2006, and underwent hysteroscopy and laparoscopy. Clinical data of patients were reviewed retrospectively. Most patients had abnormal vaginal bleeding and persistently elevated plasma beta human chorionic gonadotropin (beta-hCG) level for a median (53 +/- 37) days (range, 15 - 125 days) after evacuation. Ultrasound revealed a lesion with affluent blood flow in intrauterine, unilateral horn of uterus, or myometrium. No positive findings were revealed by computerized tomography or X-ray of the chest in all patients. Eleven patients underwent evacuation under hysteroscope, 10 patients were diagnosed and treated by laparoscopy, and 6 by hysteroscopy and laparoscopy. RESULTS: Choriocarcinoma was diagnosed in 4 patients, who achieved complete remission by chemotherapy later. The diagnosis of GTN was ruled out in the other 23 patients, including cornual pregnancy in 12, pregnancy in rudimentary horn in 1, and incomplete abortion in 10, who were cured by hysteroscopic and laparoscopic surgery and postoperative adjuvant single dose methotrexate. CONCLUSIONS: The major causes of pregnancy-related abnormal bleeding include incomplete abortion, ectopic pregnancy, and GTN. Hysteroscopy and laparoscopy are effective alternative of diagnosis for differentiation of GTN from non-GTN and can also offer therapeutic treatment.