妊娠滋养细胞疾病-hyd.ppt

,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,妊娠滋养细胞疾病,成都市第五人民医院,黄远东,像天上美丽的繁星，像地上散落的珍珠，,像春天美丽的花环，像冬天飘零的白雪，,是冷酷的杀手！,妊娠滋养细胞疾病,(gestational trophoblastic disease,GTD),是一组来源于胎盘滋养细胞的疾病，包括,(including),：,葡萄胎,(hydatidiform mole),侵蚀性葡萄胎,(Invasive mole),绒毛膜癌,(Choriocarcinoma),胎盘部位滋养细胞肿瘤,(placental site trophoblastic tumor,）,Conception,侵蚀性葡萄胎、绒癌和胎盘部位滋养细胞肿瘤，统称为妊娠滋养细胞肿瘤,(gestational trophoblastic neoplasia,GTN),Conception,一 相关因素,(,pathogenic factors),1.,地域或种族因素,(area or race factor),亚洲和拉丁美洲国家的发生率 ，北美和欧洲国家的发生率,2.,细胞遗传异常,(abnormal cell heredity),完全性葡萄胎的染色体核型为二倍体,(the chromosome karyotype of complete HM is diploid),均来自父系。,90%,为,46XX,，,10%,为,46XY,。,完全性葡萄胎,（,complete hydatidiform mole,）,一 相关因素,(,pathogenic factors),3.,其他因素,(other factors),营养因素,(nutration factor),食物中缺乏维生,素,A,(vitamin A,）,、胡萝卜素,(carotene),和动物,脂肪,(animal fat),者，机会增多。,年龄因素,(age factor),前次妊娠葡萄胎史,(case history of HM in,revious pregnancy),有过,1,次葡萄胎史者再次妊娠的发生率为,1%,有过,2,次葡萄胎史者再次妊娠的发生率为,1520,%,完全性葡萄胎,（,complete hydatidiform mole,）,一 相关因素,(,pathogenic factors),部分性葡萄胎,(partial hydatidiform mole),发生率远低于完全性葡萄胎,有关部分性葡萄胎高危因素,(,high riskb factor,),的报道很少,部分性葡萄胎的核型,90%,以上为三倍体,(,more than 90%of the karyotype of partial,hydatidiform mole is triploid,),，,最常见的,核型是,69XXY(the most common karyotype,is 69XXY,),，其余为,69,XXX,或,69,XYY,。,一 相关因素,(,pathogenic factors,),部分性葡萄胎,(partial hydatidiform mole),由,1,个单倍体卵子,(,ovum,),和两个正常单倍,体,精子,(,sperm,),或一个减数分裂缺陷的双,倍体精子结合形成。,多余的父源基因是造成滋养细胞增生,的主,要原因,(,principle cause,),二、病理,(pathology),完全性葡萄胎,Complete hydatidiform mole,二、病理,(pathology),肉眼观,(macroscopic observation),形如葡萄串，水泡直径,(diameter),由数毫米至数厘米不等，水泡由纤细的纤维素相连。,葡萄胎组织中常混有血块及蜕膜碎片,(often mixed with blood clot and the pieces of deciduas),完全性葡萄胎,镜下观,(microscopic observation),可见绒毛体积增大，间质水肿，绒毛内血管消失,(the blood vessels in villa are disappeared),，还可见弥漫性滋养细胞增生,(diffuse proliferation of trophocyte),二、病理,(pathology),完全性葡萄胎,完全性葡萄胎,二、病理,(pathology),超声图像,二、病理,(pathology),完全性葡萄胎,CT,图像,二、病理,(pathology),部分性葡萄胎,肉眼观,(macroscopic observation),仅部分绒毛变为水泡，常合并有胚胎或胎儿组织,(embryonic or fetal tissue),。胎儿多数已死亡，少数幸存胎儿常合并宫内生长迟缓,(intrauterine growth retardation),或多发性畸形,(multiple malformations),二、病理,(pathology),部分性葡萄胎,二、病理,(pathology),部分性葡萄胎,二、病理,(pathology),部分性葡萄胎,二、病理,(pathology),部分性葡萄胎,镜下观,(,microscopic observation,),可见滋养细胞,(,trophocyte,),增生程度较轻,间质内,可见胎源性血管、胚,胎,(,embryo,),和胎膜,(,fetal membranes,),的组织结构,三、临床表现,(,clinical manifestations,),完全性葡萄胎,是最常见的症状,(,mostly common symptom,),停经时间一般在,812,周,(,the period of menolipsis is about 8 to 12 weeks,),长期反复出血可导致贫血和继发感染,(,may cause,anemia and secondary infection,),大量流血可引起失血性休克,(,hemorrhagic shock,),1.,停经后阴道流血,(,vaginal bleeding after menolipsis),三、临床表现,(,clinical manifestations,),完全性葡萄胎,2.,子宫异常增大,(,abnormal enlargement of uterus,),约半,数以上患者子宫大于停经月份,3.,血清人绒毛膜促性腺激素,(,human chorionic gonadotrophin,HCG,),水平异常升高,(,the serum level of HCG is abnormally elevated,),4.,腹痛,（,abdominal pain,）,子宫收缩痛,（,uterotonic pain,）,卵巢黄素囊肿蒂扭转或破裂,（,pediculotorsion or rupture of theca lutein ovarian cyst,）,5.,妊娠剧吐,(,vomiting of pregnancy,),出现时间较正常妊娠早、症状重、持续时间长,(,the,onset is earlier,the symptom is more serious,the,period of symptom is longer than normal pregnancy,),妊娠期高血压疾病征象,(,signs and symptoms of pregnancy,induced hypertension,),可在妊娠,20,周前出现高血压,(,hypertension,),、,蛋白尿,(,proteinuria,),、水肿,(,edema,),，,容易发展至子痫前期,(,preeclampsi,a),三、临床表现,(,clinical manifestations,),完全性葡萄胎,7.,卵巢黄素化囊肿,(,theca lutein ovarian cyst,),系大量,HCG,刺激卵泡内膜细胞,(,theca interna cells,),发生,黄素化而形成的囊肿,多在葡萄胎清除后,2-4,个月自然消退,(,spontaneously,disappeared,),甲状腺功能亢进征象,(,signs and symptons of hyperthyroidism,),HCG,水平的升高常伴有,T3,、,T4,水平的增高,三、临床表现,(,clinical manifestations,),完全性葡萄胎,可有完全性葡萄胎的大多数症状，但程度较轻,(,there are great majority of symptoms of complete,hydatidiform mole,but the degree of symptoms are,slighter than the complete one,),最终的确诊通常需要组织学检查,(,the confirmed,diagnosis is usually needed by means of histologic,or pathologic examination,),三、临床表现,(,clinical manifestations,),部分性葡萄胎,四、自然转归,(,spontaneous end-result,),1.,完全性葡萄胎具有局部侵犯和,/,或远处转移的潜,在危险,(,complete hydatidiform mole has the,potential risks of local invasion and/or,distant metastasis,),葡萄胎排出后，子宫局部侵犯的发生率约为,15%,，远处转移的发生率约为,4%,(,the incidence,of local invasion of uterus is about 15%,the,Incidence of distant metastasis is about 4%,）,HCG,100000U/L,子宫体积明显大于相应孕周,(,corresponding pregnancy weeks,),卵巢黄素囊肿直径,6cm,（,the diameter of,theca lutein ovarian cyst is more than 6 cm,),患者年龄,40,岁,重复性葡萄胎,(,repeated hydatidiform mole,),局部侵犯和远处转移的高危因素,(,the high risk factors of local invasion and,distant metastasis are as follows,）,四、自然转归,(,spontaneous end-result,),首次降至正常的时间约为,9,周，最长不超过,14,周,葡萄胎排空后，,HCG,持续阳性者应考虑妊娠滋养细胞,肿瘤,(,persistent gestational trophoblastic tumor,）,部分性葡萄胎发生子宫局部侵犯的几率为,2-4%,，一般不发生转移。,4.,葡萄胎排空后,HCG,下降的的规律,(,descending regular rule of HCG),四、自然转归,(,spontaneous end-result,),五、诊断,（,diagnosis,）,临床表现,（,clinical manifestations,）,停经后不规则阴道流血,（,abnormal vaginal bleeding after menolipsis,）,子宫异常增大,（,abnormal enlargement of uterus,）,阵发性下腹疼痛,（,paroxysmal pain in the lower abdomen,）,严重的妊娠剧吐,（,serious vomiting of pregnancy,）,孕,5,个月时尚不能触及胎位，听不到胎心,较早出现妊娠期高血压疾病征象,（,the signs of pregnancy induced hypertension,）,辅助检查,(,accessory examinations,),血清,-HCG,测定（,-HCG assay of serum,）,HCG,滴度高于正常妊娠，且孕,12,周后继续升高,B,超检查：,重要检查方法,(,B type ultrasound examination or ultrasonography,),多普勒胎心测定,(,Doppler fetal heart detection,),五、诊断,（,diagnosis,）,六、鉴别诊断,(,differential diagnosis,),可借助,HCG,测定及,B,超检查,(,with the help of HCG assay and B type ultrasonography,),可借助,B,超检查,(,with the help of B type ultrasonography,),羊水过多,(,hydramnious or polyhydramnious,),流产,(,abortion,),双胎妊娠,（,twin pregnancy,）,七、处理,(,management,),1.,清除宫腔内容物，注意事项如下：,选用吸宫术，术中选用大号吸管,手术应在输血输液的条件下进行,注意预防子宫穿孔,(,pay attention to prevention of uterine perforation,),小于,12,周妊娠的子宫可一次刮净，大于,12,周,妊娠的子宫可于一周后刮宫,。,刮出物送病理学检查,（,pathologic examination,）,3.,预防性化疗,(preventive chemotherapy),适用于有高危因素或随访困难者,可用于甲氨喋呤,(methotrexate,MTX),或氟脲,嘧啶,(5-fluorouracil,5-FU),或放线菌素,D,(actinomycin D,Act-D),单一化疗一个疗程,七、处理,(,management,),2.,卵巢黄素化囊肿的处理,(management of theca lutein ovarian cyst),七、处理,(,management,),4.,子宫切除术,(,hysterectomy,),年龄大于,40,岁，有恶变的高危因素，无生,育要求者可考虑行子宫切除术，保留双侧附件,子宫小于,14,周妊娠者可直接切除子宫,八、随访,(follow-up survey),葡萄胎日后可恶变为侵蚀性葡萄胎,(,invasive mole,),或绒癌,(,choriocarcinoma,),，,所以随访极为重要,(,the follow-up survey is extremely important,),八、随访,(,follow-up survey,),1.,HCG,定量测定,(,quantitative determination of HCG,),葡萄胎排空后每周一次,(,once a week,),直至正常,3,次,正常后每月一次持续,6,个月,(,to last 6 months,),每半年一次,(,once every 6 months,),持续,2,年,随访期必须严格避孕,(,contraception,),1,年,2.,注意月经是否规则,(,pay attention to that the,menstruation is regular or not,),有无转移灶,(,there are manifestations of metastasis or not,),八、随访,(follow-up survey),第二节 妊娠滋养细胞肿瘤,(gestational trophoblastic neoplasia,GTN),第二节 妊娠滋养细胞肿瘤,患者，,53,岁，,G,5,P,5,，葡萄胎吸宫术后,2,个月，血,HCG,持,续高值，无不规则阴道出血，无咳痰咳血。妇科检查,未发现异常。超声仅示子宫下段小肌瘤，胸片无异常。,血,HCG,高值，,10,万,u/L,。诊断为侵蚀性葡萄胎而手术。,术后血,HCG,下降明显，,18000U/L,。患者继续接受化疗。,第二节 妊娠滋养细胞肿瘤,患者女，,24,岁，侵蚀性葡萄胎吸宫及化疗,侵蚀性葡萄胎吸宫后,1,月,侵蚀性葡萄胎吸宫后,2,月，化疗后,2,周,侵蚀性葡萄胎吸宫后,2,月，化疗后,4,周,侵蚀性葡萄胎吸宫后,2,月，化疗后,6,周,侵蚀性葡萄胎吸宫后,2,月，化疗后,12,周,第二节 妊娠滋养细胞肿瘤,葡萄胎排空后半年以内的妊娠滋养细胞肿瘤，,组织学诊断多称为,侵蚀性葡萄胎,(the tissue of hydatidiform mole invaded,myometrium and caused tissue destruction,or complicated by metastasis out of uterus,itis called,invasive mole,),第二节 妊娠滋养细胞肿瘤,葡萄胎排空后,1,年以上或继发于流产、足月妊娠,及异位妊娠后者，组织学诊断为,絨癌,(it is called,choriocarnoma,),第二节 妊娠滋养细胞肿瘤,侵蚀性葡萄胎仅继发于葡萄胎之后,(,invasive mole is a kind of secondary,disease,the onset is only after,hydatidiform mole),，,具有恶性行为，,但恶性程度不高。,绒癌是一种高度恶性肿瘤，预后较差,(the prognosis of choriocarnoma is worse),第二节 妊娠滋养细胞肿瘤,妊娠滋养细胞肿瘤,60%,继发于葡萄胎，,30%,继发于流产,10%,继发于足月妊娠或异位妊娠,第二节 妊娠滋养细胞肿瘤,绒毛膜癌是一种继发于正常或异常妊娠之后的,滋养细胞肿瘤,(choriocarcinoma is a kind,of malignant trophoblastic tumor,it is a secondary,disease after normal or abnormal pregnancy,),。,其中,50%,发生于葡萄胎之后，,25%,发生于流产,(,abortion,),后，,22.5%,发生于足月,(,term pregnancy,),妊娠,后，,2.5%,发生于异位妊娠,(,ectopic pregnancy,),后,一、病理,(,pathology,),侵蚀性葡萄胎,(,invasive mole,),1.,大体检查可,见子宫肌壁内,有大小不等、,深浅不一的水,泡状组织。宫,腔内可有原发,病灶，也可以,没有。,一、病理,(pathology),侵蚀性葡萄胎,(invasive mole),镜下可见肌层内水泡状组织的形态和葡萄胎相似，可见,绒毛结构,、滋养细胞增生和分化不良,(it can be seen that include villus structure,hypeplasia of trophocyte and the undifferentiated trophocyte,）,一、病理,(,pathology,),侵蚀性葡萄胎,(,invasive mole,),CT,图像,1.,绒癌绝大多数,原发于子宫，肉,眼可见肿瘤位于,子宫肌层内，单,个或多个，大小,不等（,0.55cm,）,无固定形态，与,周围组织分界,清。暗红色、质,脆，伴出血坏死。,一、病理,(,pathology,),绒癌,(,choriocarcinoma),镜下可见滋养细胞,不形成绒毛,或水泡状结构，细胞成片高度增生，广泛侵入子宫肌层并破坏血管，造成出血坏死。,一、病理,(,pathology,),绒癌,(,choriocarcinoma,),一、病理,(,pathology,),绒癌,(,choriocarcinoma),一、病理,(,pathology,),绒癌,(,choriocarcinoma),一、病理,(,pathology,),绒癌,(,choriocarcinoma),二、临床表现,(clinical menifestations),发病时间,(the period of onset),多数侵蚀性葡萄胎发生于葡萄胎排出后,6,个月内,(the onset of invasive mole is mostly within 6,months after that the hydatidiform mole has been,removed,）,继发于葡萄胎后的绒癌大多数,1,年以上发病,(the onset of choriocacinoma after hydatidiform,is mostly exceeded one year),发病时间,(,the period of onset,),继发于流产和足月产的绒癌,50%,在,1,年内发病,(the onset of choriocarcinoma after abortion and,term pregnancy is about 50%within one year),二、临床表现,(,clinical menifestations,),无转移妊娠滋养细胞肿瘤,不规则阴道流血,（,irregular vaginal bleeding,）,子宫复旧不全或不均匀性增大,(subinvolution,or heterogeneous enlargement of uterus,）,卵巢黄素化囊肿持续存在,(persistent the lutein ovarian cyst),腹痛,(abdominal pain),假孕症状,(the symptoms of false pregnancy),二、临床表现,(clinical menifestations),转移性妊娠滋养细胞肿瘤,1.,转移的一般规律,(general regular of metastisis),主要为绒癌,(choriocarcinoma),，尤其是继发于非葡萄胎,妊娠后绒癌,肿瘤主要经血行播散,(hematogenous),，转移发生早且广泛,最常见的转移部位是肺,(,lung,),，其次是阴道,(,vagina,),，,盆腔,(,pelvic cavity,),，肝,(,liver,),和脑,(,brain,),二、临床表现,(,clinical menifestations,),共同点特点：出血,转移性妊娠滋养细胞肿瘤,2.,肺转移,(lung metastasis),通常表现为胸痛,(chest pain),、咳嗽,(cough),、咯血,(hemoptysis),及呼吸,困难,(expiratory dyspnea),转移灶较小时也可无任何症状,(may have no any symptoms),二、临床表现,(,clinical menifestations,),3.,阴道转移,(vagina metastasis),4.,肝转移,(liver metastasis),可见紫兰色结节，阴道前壁居多,表现为上腹部及肝区疼痛,转移性滋养细胞肿瘤,二、临床表现,(,clinical menifestations,),转移性滋养细胞肿瘤,5.,脑转移,(brain metastasis),二、临床表现,(clinical menifestations),瘤栓期,(stage of tumor cell embolus),，,表现为一过性脑缺血症状，如猝然跌倒,(fall down suddenly),，,暂时性失语或,失明等,(temporary aphasia or blindness,，,etc),转移性滋养细胞肿瘤,5.,脑转移,(brain metastasis),二、临床表现,(clinical menifestations),脑瘤期,(stage of encephaloma),，,患者出现头痛,(headache),、喷射样呕吐,(progectile vomiting),、,偏瘫,(hemiplegia),、抽搐,(tic),甚至昏迷,(coma),脑疝期,(stage of cerebral hernia),脑转移为主要的致死原因,转移性滋养细胞肿瘤,6.,其他转移,(metastasis of other place),包括脾、肾、膀胱、消化道、骨等,(including spleen,kidney,bladder,alimentary canal,bone,etc),，,其症状,随转移部位不同而异。,二、临床表现,(,clinical menifestations,),三、诊断,(,diagnosis,),葡萄胎清宫后,6398,天,;,人流术后,30,天,;,自然流产后,19,天,;,足月妊娠分娩后,12,天,;,宫外孕术后,89,天,.,血,-HCG,下降规律：,三、诊断,(,diagnosis,),1.,可根据病史,（,case history,）,、临床表现,（,clinical,menifestations,）,、发病时间,（,the period of onset,）、,前次妊娠的性质等作出初步判断,血,-HCG,测定,（,-HCG assay of serum,）：,葡萄胎后的主要诊断依据,血,-HCG,测定,4,次呈平台状态并持续,3,周或更长（,1,、,7,、,14,、,21,日），,血,-HCG,测定,3,次升高，并至少持续,2,周或更长（,1,、,7,、,14,日）,血,-HCG,水平持续异常达,6,个月或更长,三、诊断,(,diagnosis,),2.,血,-HCG,测定,（,-HCG assay of serum,）：,非葡萄胎后,足月产、流产及异位妊娠后,4,周以上，血,-HCG,仍,持续高水平或一度下降又上升,排除妊娠物残留或再次妊娠,B,型超声检查,(,B type ultrasonography,),可见子宫增大,(,enlargement of uterus,),和肌层内的,高回声团块,4.X,线胸片检查,(,X-ray chest-radiography,),可见肺纹理增粗或斑片状、结节状、棉球状、团块状阴影,5.CT,和磁共振检查,(computerized tomography,CT,and magnatic,resonance images,MRI examinations),三、诊断,(,diagnosis,),组织学诊断,(histological diagnosis),镜下见到绒毛结构者应诊断为侵蚀性葡萄胎,(if the villus structure can be seen microscopically that the diagnosis of invasive mole should be made),若仅见滋养细胞浸润及坏死出血，未见绒毛结构者应诊断为绒癌,(if the villus structure can not be seen microscopically that the diagnosis of choriocarcinoma should be made),三、诊断,(,diagnosis,),四、临床分期和预后评分,(clinical staging and prognostic scoring),临床分期目前采用国际妇产科联盟,(,international federation of gynecology and,obstetrics,FIGO),2000,年制订的分期标准,（表,34,2,）,解剖学分期,（,FIGO 2000,）,(,表,34-,2,，,P297,）,预后评分,(prognostic scoring),目前采用国际妇产科联盟（,FIGO,）,2000,年制订的新方法,（表,34,3，P297,）,6,分者为低危，,7,分者为高危,评分内容包括患者年龄、前次妊娠的性质、发病,距前次妊娠的时间、治疗前血,HCG,定量、最大肿,瘤直径、转移部位、转移病灶数目，先前有无化,疗失败等。,五、临床分期和预后评分,(,clinical staging and prognostic scoring,),改良,FIGO,预后评分系统,六、治疗,(,treatment,),总的治疗原则,(general principles of treatment),是以,化疗,(chemotherapy),为主,，辅以手术,(operation),和放疗,(radiotherapy),的综合治疗,(combining therapy),原则,化疗,(chemotherapy),1.,目前国内常用的一线化疗药物,药物用法详见表,34,5,六、治疗,(,treatment,),化疗,(,chemotherapy),2.,化疗原则,（,principle of chemotherapy,）,期患者采用单一化疗,（,single chemotherapy,）,期选取用联合化疗,（,combining chemotherapy,）,期或耐药患者选取用强联合化疗方案,（如,EMA-CO,方案）,六、治疗,(,treatment,),3.,疗效评价,(evaluation of therapeutic efficiency),化疗结束后应每周测定一次,-HCG,化疗结束后,18,日内（或,3,周内）血,-,HCG,至少下降,1,个对数方为有效。例如,由化疗前的,100000U/L,降至,10000 U/L,方为有效,还应结合妇科检查,(gynecological examination),、,B,超、,CT,等检查综合判断,化疗,(chemotherapy),六、治疗,(,treatment,),4.,毒副反应防治,(prophylaxis and treatment of,toxic reaction and side reaction),骨髓抑制,(arrest of bone marrow),消化道反应,(reaction of alimeneary canal),肝功能损害,(damage of liver function),肾功能损害,(damage of renal function),脱发,(alopecia),化疗,(chemotherapy),六、治疗,(,treatment),5.,停药指征,(indication of stoping remedy),症状和体征消失,(disappearing of symptoms and signs),原发和转移病灶消失,(disappearing of primary,focus and metastatic focus),血,-HCG,每周测定一次，连续,3,次正常,以上三者称为临床痊愈,(clinical cure),化疗,(chemotherapy),六、治疗,(treatment),5.,停药指征,(indication of stoping remedy),低危患者临床痊愈后巩固化疗至少,1,个疗程,若,-HCG,下降缓慢和病变广泛的给予,23,个疗程,高危患者临床痊愈后巩固化疗,23,个疗程,随访,5,年无复发者称为治愈,（,radical cure,）,化疗,(chemotherapy),六、治疗,(treatment),子宫切除术,(hysterectomy),：,低危无生育要求无转移的患者初次手术即行之,大病灶、耐药病灶或子宫穿孔者化疗基础上手术,2.,肺叶切除,(pneumonectomy),手术,(operation),六、治疗,(,treatment),年轻患者可保留一侧或双侧卵巢,有生育要求者可考虑行病灶剜出术,选择二线化疗药物联合化疗,PVB,方案,顺铂,（,cisplatin,DDP,）,长春新碱,（,vincristin,VCR,）,博来霉素,（,bleomycin,BLM,）,BEP,方案,博来霉素,（,bleomycin,BLM,）,依托泊苷,（,etoposide,VP-16,）,顺铂,（,cisplatin,DDP,）,耐药复发病例的治疗,(the treatment of drug-resistant and recurrence cases),六、治疗,(,treatment,),选择二线化疗药物联合化疗,依托泊苷,（,etoposide,VP-16,）,异环磷酰胺,（,ifosfamide,IFO,）,顺铂或卡铂,（,carboplatic,CBP,）,VIP,方案,合理使用手术,(operation),和放疗,(radiotherapy),耐药复发病例的治疗,(the treatment of drug-resistant and recurrence cases),六、治疗,(,treatment,),七、随访,(follow-up survey),出院后,3,个月,1,次,以后每,6,个月,1,次直至,3,年,以后每年,1,次共,5,年,随访内容同葡萄胎,以后每,2,年,1,次,化疗停止,12,个月方可妊娠,七、随访,(follow-up survey),国外推荐：,期随访,1,年,期随访,2,年,妊娠滋养细胞疾病包括：葡萄胎、侵蚀性葡萄胎、,絨癌及胎盘部位滋养细胞肿瘤,葡萄胎有八大临床表现,葡萄胎可以发生局部侵犯及远处转移,B,超为重要诊断方法,治疗清宫：吸宫术,随访非常重要,葡萄胎小结,妊娠滋养细胞肿瘤包括：侵蚀性葡萄胎、絨癌,及胎盘部位滋养细胞肿瘤,多继发于葡萄胎后,继发于流产、足月产及异位妊娠后为绒癌,侵蚀性葡萄胎可见到绒毛，絨癌的绒毛不可见,主要临床表现为不规则流血,血,HCG,的监测为重要诊断方法,治疗化疗为主,滋养细胞肿瘤小结,患者,28,岁，足月产后,6,个月，阴道不规则出血两个月余，咳嗽咯血,20,天，在当地医院按气管炎治疗无效，并以不全流产先后清宫两次，术后因 出血不止，抗休克治疗好转后于,2002,年,8,月,2,日急诊入院。,病例分析,入院检查：,T38.8,，,P120,次,/,分，,R22,次,/,分，,BP10.96/8.22kPa,。,重度贫血貌，双肺呼吸音粗糙，未闻及干湿性罗音，心界不大，各瓣膜未闻及病理性杂音。腹软，肝脾未触及。,妇科检查：于尿道外口上方见两个直径约,1cm,圆形紫蓝色结节，表面光滑。阴道内有一凝血块，去除后见阴道前壁中上段有一直径约,5cm,转移灶，紫蓝色，表面光滑。左侧阴道壁有一直径约,6cm,病灶，表面破溃面积约,53cm,，有活动出血。宫颈前后唇各有一直径,1cm,紫蓝色结节，表面光滑。宫体如孕,80,天大小，表面高低不平，质中硬，稍活动，压痛不明显。宫旁增厚，未触及 包块。,病例分析,实验室检查：,Hb65g/L,，,WBC8.9109/L,PC84/109/L,；肝肾功能正常。,胸片：两肺见多发、散在大小不等粟粒状阴影，右下肺为重。,B,超：子宫,6.76.35.8cm3,，形态失常，前壁肌层内可见多个无回声小暗区，宫内膜尚清晰，宫颈与膀胱及直肠浸润。,血,-hcG 10,万,u/L,。,病例分析,病例分析,入院诊断：,绒癌（,：,8,）。,阴道转移灶出血。,失血性贫血。,病例分析,治疗经过：入院后第二天开始化疗，,5-FU26mg/k