Clinical Analysis And Literature Review Of Placental Site Trophoblastic Tumor

Part 1 Clinical analysis of placental site trophoblastic tumorObjective: The clinical data of Placental Site Trophoblastic Tumor(PSTT)in our hospital were retrospectively analyzed,and its clinicopathological features,treatment and prognosis were summarized.Methods: Collect the second hospital,hebei medical university from January 2013 to December 2018 PSTT patients clinical data,including: age,maternal history,always presence of Hydatidiform Mole(Hydatidiform Mole,HM)history,menstrual history,at the end of the last type of pregnancy,pregnancy is apart from the onset time,clinical manifestations,imaging features,laboratory data,pathological characteristics,treatment,prognosis,and special cases,etc.Results: From January 2013 to December 2018,5 patients with PSTT were admitted to our hospital,and PSTT accounted for 3.16% of Gestational Trophoblastic Neoplasia(GTN).The age of onset ranged from 21 to 47 years old,with an average age of 32.4 years.The previous pregnancy types of the 5 PSTT patients were Partial Hydatidiform Mole(PHM),full term delivery for 3 cases and abortion for 1 case.The interval between the first and second trimesters ranged from 1 to 25 months,with an average interval of 13.4 months.Among the 5 patients with PSTT,there were 2 patients with irregular vaginal bleeding,1 patient with prolonged menstrual period,and 1 patient with intrauterine lesions found after abortion.One case of lower limbs with eyelid edema;All the 5 PSTT patients had no hypertension,edema or ascites,except for case 3,which developed hypertension,edema and ascites due to Thrombotic Microangiopathy(TMA).Transvaginal gynecological ultrasonography in 5 patients with PSTT indicated that all 5 patients had uterine enlargement to varying degrees,and localized lesions could be detected.Among the 5 patients,4 patients had rich blood flow,and 1 patient had extremely rich blood flow.All lesions were indistinct from the muscularis.The average blood-hcg value was 1041.62mIU/ML.After treatment,it took between 22 and 60 days for blood-hcg to be reduced to normal,with an average time of 35.8 days.Alkaline phosphatase detection fluctuated in 58 ~ 96U/L in 5 patients,and the average alkaline phosphatase value was 76.6U/L,all within the normal range.Among the 5 patients with PSTT,2 cases were confirmed by hysterectomy specimens,and 3 cases were confirmed by hysteroscopy or curettage specimens,and all underwent secondary surgery with laparoscopic hysterectomy and bilateral salpingectomy.Gross specimen: All specimens for hysterectomy specimens,the uterus increases in varying degrees and irregular,4 cases were visible in the myometrium shape irregular nodular lesions,and the surrounding is no clear boundary between myometrium,necrosis and hemorrhage as well part area,type in the middle of the visible light microscope check sizes sertoli cell(Intermediate Trophoblastic,IT),visible fission like,4 cases were visible CKpan positive(100%),focal HCG positive positive in 3 patients(75%),1 case(25%),4 cases were performed ki-67 index detection,Ki-67 index in 3 cases ranged from 10 % to 30%,and ki-67 index in 1 case was greater than 75%.Case 3 in 1 case with TMA for starting the clinical symptoms of patients with rare PSTT,its starting performance is double lower limbs with eyelid edema,at the same time with thrombocytopenia,anemia,proteinuria,urine occult blood,ascites,abnormal renal function,such as the symptoms of kidney damage,first option in renal medicine,pathological diagnosis of renal biopsy: 1,2,TMA pih sex renal damage,routine renal medicine treatment before symptoms get better,transferred to our department muck GongQieChu postoperative,the symptoms ease gradually,so the case identified as first-episode patients with clinical manifestations of PSTT for TMA.Except 1 case turned the superior hospital is not clear in installment,the rest 4 cases were FIGO ? period.The follow-up time of the 4 patients with PSTT ranged from 14 to 37 months,and the average follow-up time was 27.5 months,without recurrence.Summary: PSTT is a rare form of GTN,accounting for 3.16% of patients with PSTT in our hospital.PSTT usually occurs in women of childbearing age,with the median age of onset being 32 years old.PSTT has no characteristic clinical manifestations,the most common clinical manifestations are irregular vaginal bleeding and amenorrhea,a small number of patients show symptoms of non-primary diseases such as TMA,and gynecological diseases should be excluded for women of childbearing age with symptoms of kidney damage.Blood-hcg is generally mildly elevated or negative.It is easy to misdiagnose and misdiagnose.Histopathology is the "gold standard" for diagnosis.PSTT is not sensitive to chemotherapy,and the preferred treatment is hysterectomy.Patients with high risk factors should be supplemented with chemotherapy after surgery.Most of PSTT patients have a good prognosis,while a few patients have extrauterine metastasis.Part 2 Literature review of renal disease in patients with placental site trophoblastic tumorObjective: Because the cases in our hospital included a PSTT patient with renal disease,which was clinically rare,this part of the study summarized the cases of PSTT with renal disease in various databases and analyzed their clinicopathological characteristics.Methods: Literature materials of PSTT with renal disease were retrieved from CNKI,wanfang database,pubmed,China biomedical literature database and wip database,and relevant data were extracted.The retrieval time was from the self-established database to December 2018,and the extracted data included: Merger by the type of kidney disease,age,history,at the end of the last type of pregnancy,maternal pregnancy is apart from the onset time,clinical manifestation,urine protein,urine occult blood,blood albumin,increased blood pressure,increased blood lipid,edema,ascites,kidney damage,such as renal biopsy,blood beta HCG value and its changes,diagnosis method and operation method,preoperative and postoperative chemotherapy,intraoperative and postoperative pathology,FIGO staging,follow-up time and results etc.Results: A total of 15 articles in Chinese and English were included in this part of the study,and a total of 18 cases were counted.18 cases PSTT merge kidney disease include: 11 cases of Nephrotic Syndrome(Nephrotic Syndrome,NS),5 cases for TMA,1 case as with Lupus Nephritis,Lupus Nephritis,LN),1 cases of Membranous Nephropathy(Membranous Nephropathy,MN).The age of onset of 18 patients ranged from 20 to 42 years old,with an average age of 31.67 years old.Among the 18 patients,15 described the type and duration of the previous pregnancy,among which 12 had full-term pregnancy,2 had miscarriage,1 had HM and 3 had unknown type of previous pregnancy.The interval between the first and second trimesters ranged from 2 weeks to 54 months,with an average interval of 17.5 months.The clinical manifestations of patients can be irregular vaginal bleeding,amenorrhea,vaginal drainage,abdominal distension,edema,elevated blood pressure,hematuria,abdominal mass and one or more of them,most of which are two or more.The quantitative detection of 24 h urine protein was performed in 13 patients with PSTT,including 2 patients with 24 h urine protein quantitative >7g/24 h and 11 patients with 24 h urine protein quantitative detection ranging from 2.07 to 12.3g/24 h.Among the 18 patients with PSTT,27.8% were positive for urine occult blood(5/18)and 13 were negative for urine occult blood(72.2%).The blood albumin value of 16 patients with PSTT ranged from 16 to 28.2g/L,and the average blood albumin value was 21.97g/L.Blood pressure increased to varying degrees in 10 of the 18 patients(55.6%).Among the 18 patients,9(50%)had normal blood lipids and 9(50%)had elevated blood lipids.Renal biopsy was performed in 10 cases(55.6%).In the 18 patients,the blood-hcg value was between 40.85 ~ 6773mIU/ML at onset,and the average blood-hcg value was 1107.87mIU/ML.The average duration of blood-hcg reduction to normal was 48.1 days.Among the 18 patients with PSTT,the diagnosis method was curettage or hysteroscopy in 11 patients(61.1%),total hysterectomy in 6 patients(33.3%),and postmortem diagnosis in 1 patient(5.6%).Only 4 patients received preoperative chemotherapy,among which 2 received ema-co regimen(etoposide/vp-16 + methotrexate /MTX+ actinomycin-D/ act-d-vincristine /VCR+ cyclophosphamide /CTX)once(11.1%),1 received act-d +VCR+CTX once(5.6%),and 1 received MTX intramuscular injection(5.6%).Only 7 cases(38.9%)received chemotherapy after surgery.All the 17 patients underwent hysterectomy,some patients retained bilateral or unilateral attachments,and 1 patient did not receive surgical treatment.During the operation,the uterus showed varying degrees of enlargement,and the lesions could be located in the uterine cavity or in the muscular layer.Most of the lesions were poorly demarcated from the muscularis,with focal hemorrhage and necrotic areas.All cases were pathologically diagnosed as PSTT with localized or diffuse growth and mitotic figures.Immunohistochemical HCG is mostly negative or weakly positive,HPL is mostly positive,ki-67 index can be negative or between 10 and 30%.Mitotic couples were found to be between 2 and 4 /10 HPF,and most of them were less than 5 /10 HPF.According to FIGO staging,2000,18 patients had 1 case of each for FIGO ? period(5.6%)and FIGO ? period(5.6%),the rest of the 16 patients were FIGO ? period(88.8%).Among the 18 PSTT patients,3 cases were lost to follow-up,and 2 cases died and the causes of death were all bone marrow suppression and infection caused by postoperative chemotherapy.A total of 13 cases(72.2%)were followed up,and the follow-up time ranged from 2 to 69 months,with an average follow-up time of 20.62 months.No recurrence or metastasis was found.Summary: Cases of PSTT combined with renal damage are very rare,such as TMA,and patients often present with edema,hypertension,ascites,proteinuria and other nephrological symptoms combined with gynecological symptoms.In some cases,renal damage is the first clinical manifestation,which often leads to clinical misdiagnosis and mistreatment.This kind of renal disease can be gradually relieved after the primary lesion resection.It suggests that we should consider the possibility of other systemic diseases and timely screen for tumors in patients with nephrotic syndrome and other renal diseases in women with reproductive years,if the corresponding department treatment is ineffective.Conclusion: PSTT is a rare type of GTN that occurs frequently in women of reproductive age.PSTT can be secondary to various types of pregnancy,most commonly full-term,no characteristic clinical manifestations,blood-hcg is generally mildly elevated or negative,a small number of patients with TMA and other symptoms of non-primary diseases.Histopathology is the "gold standard" for the diagnosis of PSTT.PSTT is not sensitive to chemotherapy,and the preferred treatment is hysterectomy.Patients with high risk factors should be supplemented with chemotherapy after surgery.Most of the PSTT patients had a good prognosis,and a few had extrauterine metastasis.PSTT associated with renal damage is very rare,and such renal disease often has poor medical treatment effect and can be gradually relieved after primary lesion resection.The possibility of gynecological diseases should be considered in the patients with renal damage in women of reproductive period,if the corresponding department treatment is ineffective.