摘要
目的探讨足月妊娠后妊娠滋养细胞肿瘤(GTN)脑转移患者的临床表现、诊断与鉴别诊断、治疗及预后,并进行相关文献复习。方法选择2018年8月10日,于成都市某市级医院产前检查、分娩的1例临床诊断为足月妊娠后GTN脑转移患者为研究对象。采用回顾性研究方法,收集本例患者的临床病例资料,并对其临床表现、诊断及治疗经过进行分析。同时,以“妊娠滋养细胞肿瘤”“足月妊娠后”“脑转移”“化疗”“gestational trophoblastic neoplasia”“postpartum”“brain metastasis”“chemotherapy”为关键词,在中国生物医学文献数据库(CBM)、中国知网(CNKI)、维普中文科技期刊数据库、万方数据知识服务平台及PubMed与Ovid Medline数据库中,检索足月妊娠后GTN脑转移相关文献。文献检索时间设定为上述数据库建库至2020年5月。总结足月妊娠后GTN脑转移患者的临床特点、诊断、治疗及预后等。本研究遵循的程序符合2013年新修订的《世界医学协会赫尔辛基宣言》要求。结果①本例患者为女性,27岁,首次妊娠时为葡萄胎妊娠(MP),清宫术后复查血清β-人绒毛膜促性腺激素(hCG)水平,术后血清β-hCG复查1次正常后,未再接受血清β-hCG随访。1年后再次妊娠,2018年8月11日自然分娩1例足月活产女婴,产时无异常,产后第10天出现咳嗽、头痛等。产后第15天,因头痛进行头颅CT检查发现多发颅内占位,最大者位于右侧小脑半球,约为4.1 cm×3.9 cm×3.1 cm,患者被转入上级医院接受治疗。产后第16天,因颅内高压,患者于上级医院进行侧脑室钻孔引流术,复查血清β-hCG水平为400588 mIU/mL,考虑GTN脑转移,建议患者采取依托泊苷+甲氨蝶呤+放线菌素D+环磷酰胺+长春新碱(EMA-CO)联合化疗方案治疗。产后第20天,患者放弃治疗,自动出院后于家中死亡。②按照本研究制定的文献检索策略进行文献检索结果显示,近5年内足月妊娠后GTN脑转移病例报告仅为1篇,纳入研究为1例足月妊娠后产妇,因分娩后不规则阴道流血45 d,咳嗽伴咯血7 d,经完善相关检查后,确诊为足月妊娠后GTN脑转移。对该患者采取5-氟尿嘧啶联合放线菌素D化疗,并联合鞘内注射甲氨蝶呤和全脑放疗后,其血清及脑脊液β-hCG水平显著降低。对其出院后随访17个月的结果提示,GTN未复发。结论足月妊娠后GTN脑转移恶性程度高,GTN症状容易被产后症状掩盖,临床诊断困难。对此类患者采取规范治疗,可有效提高患者生存率,改善预后。
Objective To explore clinical manifestations,diagnosis,differential diagnosis,treatment and prognosis of a case of parturient with brain metastasis of gestational trophoblastic neoplasia(GTN)after full-term pregnancy,and review relevant literature.Methods On August 10,2018,a patient with clinical diagnosis of brain metastasis of GTN after full-term pregnancy who had prenatal care and delivered in a city-level hospital in Chengdu was selected as research subject.Retrospective analysis method was used to collect clinical data of this patient and analyze her clinical manifestations,diagnosis and treatment process.In addition,from the establishment of China Biology Medicine(CBM),China National Knowledge Infrastructure(CNKI),VIP,Wanfang,PubMed and Ovid Medline databases to May 2020,literature was retrieved with key words including"gestational trophoblastic neoplasia""postpartum""brain metastasis""chemotherapy"to search reported cases of patients with brain metastasis of GTN after full-term pregnancy.Clinical characteristics,diagnosis and treatment protocols of the parturient with brain metastasis of GTN after full-term pregnancy were analyzed and summarized.This study was in line with the World Medical Association Declaration of Helsinki revised in 2013.Results①This patient was a 27-year-old female who had mole pregnancy(MP)during her first pregnancy.After curettage,she received follow-up of serumβ-human chorionic gonadotropin(hCG).But after her serumβ-hCG turned to normal once after MP curettage,she did not receive follow-up of serumβ-hCG anymore.Then one year later,she was re-pregnant.On August 11,2018,a live-born female full-term infant was delivered naturally,and there was no abnormality during delivery.On the 10th day after delivery,she had symptoms such as cough and headache.On the 15th day after delivery,she had CT detection for headache,and results showed multi intracranial mass,the biggest one was at right cerebellar hemisphere with size of 4.1 cm×3.9 cm×3.1 cm,and she was transferred to a superior hospital for further treatment.On the 16th day after delivery,she underwent lateral ventricle trepanation and drainage for intracranial hypertension in the superior hospital.Her serumβ-hCG level was 400588 mIU/mL.Considering brain metastases of GTN,it was recommended that she should take etoposide^(+)methotrexate^(+)actinomycin D^(+)cyclophosphamide^(+)vincristine(EMA-CO)combined chemotherapy treatment.But she gave up treatment on the 20th day after delivery,and then died at home after being discharged automatically.②According to literature retrieval strategy formulated in this study,literature review results revealed that there was only 1 piece of foreign literature about one case with brain metastasis of GTN after full-term pregnancy within the latest 5 years,and this study reported 1 patient with irregular vaginal bleeding for 45 days,and cough blood for 7 days after full-term pregnancy.After completely examinations,she was diagnosed as brain metastasis of GTN.She was treated by 5-fluorouracil combined with actinomycin D chemotherapy regimen,intrathecal methotrexate injection and whole brain radiotherapy,and then her serum and cerebrospinal fluidβ-hCG levels were significantly reduced.She underwent regular follow-up after discharge from hospital,and no GTN relapsed during 17-month follow-up.Conclusions GTN with brain metastasis after full-term pregnancy are highly malignant.Since GTN symptoms are easily covered by postpartum symptoms,diagnosis of brain metastasis of GTN after full-term pregnancy is difficult.Standardized treatment for these patients can effectively increase survival rates and improve prognosis.
作者
柳吉羱
詹泳池
王晓东
Liu Jiyuan;Zhan Yongchi;Wang Xiaodong(Department of Obstetrics and Gynecology,Key Laboratory of Birth Defects and Related Diseases of Women and Children(Sichuan University),Ministry of Education,West China Second University Hospital,Sichuan University,Chengdu 610041,Sichuan Province,China)
出处
《中华妇幼临床医学杂志（电子版）》
CAS
2021年第3期321-326,共6页
Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition)
基金
四川省科技计划重点研发项目(2018SZ0265)。
关键词
妊娠滋养细胞肿瘤
葡萄胎
绒毛膜癌
足月妊娠
脑转移
预后
产妇
Gestational trophoblastic neoplasms
Hydatidiform mole
Choriocarcinoma
Full-term pregnancy
Brain metastasis
Prognosis
Parturient
