摘要：
Objective To explore the role of CT scan for the diagnosis of lung metastasis in stage Ⅲ gestational trophoblastic neoplasia (GTN).Methods To figure out the role of CT scan for lung metastasis in GTN initial diagnosis,treatment and follow-up,93 GTN patients with lung metastasis from January,2015 to December,2016 were retrospectively analyzed in Obstetrics and Gynecology Hospital of Fudan University.Results (1) Among 93 GTN patients with lung metastasis,70 patients with the International Federation of Gynecology and Obstetrics (FIGO) score ≤6 were defined as low risk GTN and 23 patients score score ≥7 were defined as high risk GTN.Forty nine patients had negative chest X-ray findings and 39 cases with pulmonary lesions were identified both by chest X-ray compared to CT scan.Five cases were excluded due to no consensus could make for the results of chest X-ray.The true positive rate of chest X-ray for lung metastasis were 41％ (29/70) in low risk GTN and 43％ (10/23) in high risk GTN patients without statistical difference (x2=0.090,P=0.925).For those patients with positive chest CT scan and negative chest X-ray finding,pulmonary lesions in 32 (65％,32/49) cases were blocked by heart,chest wall or diaphragm in chest X-ray.Seventeen (35％,17/49) patients with lung lesions less than 5 mm had negative chest X-ray results due to the lower sensitivity compared to CT scan.(2) In 88 patients with stage Ⅲ,78 patients had successful initial treatment,but 4 of them were recurrence in twelve months follow-up.Ten patients were chemotherapy resistance for the initial treatment.The initial chemotherapy remission rate in low risk GTN patients was higher than that in high risk ones (x2=4.911,P=0.027).In 49 cases with negative chest X-ray,there was no correlation with the rate of remission,chemotherapy resistance and recurrence in stage Ⅲ patients (P＞0.05).(3) For those patients who had poorly response to initial chemotherapy,the diameters of lesions in lung were unchanged or increased during the treatment,form (5.1±4.1) mm to (7.4±2.8) mm.The pulmonary lesions were continuously shrunk from (7.8 ± 5.3) mm to (4.7 ± 4.4) mm for those patients with complete and partial remission including the recurrent GTN patients (Z=-2.713,P=0.007).Conclusions Patients with GTN in stage Ⅲ have down staging if only use chest X-ray for imaging at the initial diagnosis.Chest CT scan is recommended for primary imaging evaluation of FIGO staging in qualified medical organization.For those patients with persistent abnormal serum hCG level and negative chest X-ray,chest CT scan is strongly recommended to identify the persist or resistant lung lesions and follow up.%目的 探讨胸部CT平扫在妊娠滋养细胞肿瘤(GTN)肺转移的诊断和随访中的应用.方法 收集2015年1月至2016年12月复旦大学附属妇产科医院收治的93例肺转移GTN[即国际妇产科联盟(FIGO)分期Ⅲ期GTN]患者的胸部CT平扫、胸片及临床资料进行回顾性分析,探讨胸部CT平扫在初诊时对GTN肺部转移病灶的诊断价值、与初次治疗结局的关系及在随访中的作用.结果 (1)93例Ⅲ期GTN患者中,低危GTN (FIGO预后评分≤6分)患者70例、高危GTN (FIGO预后评分≥7分)患者23例;胸片和CT平扫同时诊断的肺转移患者39例,CT平扫诊断为肺转移而胸片检查阴性的患者49例,5例低危GTN患者治疗前的胸片初次阅读与本次复核无法得出一致性结论(未纳入分析).39例胸片和CT平扫同时诊断的患者中,29例为低危GTN患者,胸片检查诊断低危GTN患者肺转移的真阳性率为41％(29/70),10例为高危GTN患者,胸片检查诊断高危GTN患者肺转移的真阳性率为43％(10/23),两者比较,差异无统计学意义(x2=0.090,P=0.925).49例CT平扫诊断而胸片检查阴性的患者中,17例(35％,17/49)患者是因为CT平扫显示肺转移结节直径＜5 mm,而胸片检查未显示明显结节影;32例(65％,32/49)患者肺转移灶被正常解剖结构所阻挡.(2)88例Ⅲ期GTN患者中,初次治疗后缓解74例,复发4例,耐药10例.低危患者、高危患者初始治疗后的缓解率分别为89％(58/65)、70％(16/23),两者比较,差异有统计学意义(x=4.911,P=0.027).胸片和CT平扫同时诊断的患者(39例)与CT平扫诊断而胸片检查阴性的患者(49例)比较,其低危患者和高危患者的缓解率、耐药率、复发率分别比较,差异均无统计学意义(P＞0.05).(3)复发或耐药患者在治疗过程中肺转移灶最大直径无明显变化甚至增大[治疗前、复发或耐药时分别为(5.1±4.1)、(7.4±2.8) mm,增大(2.3±3.7)mm],与初次治疗缓解患者[治疗前、后分别为(7.8±5.3)、(4.7±4.4) mm,缩小(3.1±2.9) mm]比较,差异有统计学意义(Z=-2.713,P=0.007).结论 GTN初诊患者仅使用胸片检查会降低治疗前分期,且无法发现被正常解剖结构所阻挡的肺转移灶.因此,有条件者推荐在治疗前常规行胸部CT平扫.对于常规胸片无法显示肺转移灶的患者、化疗耐药或复发患者,建议用胸部CT平扫进行评估和随访.
