Objective To study the clinical features,differential diagnosis and treatment of caesarean scar pregnancy (CSP) with sonographic mass.Methods A retrospective analysis was performed on 39 patients of CSP with sonographic mass undergoing treatment in Peking Union Medical College Hospital from 2005 to 2012.14 cases with misdiagnosis of gestational trophoblastic neoplasm,among 4 cases were administered by chemotherapy with methotrexate (MTX),cisplatin,fluorouracil (5-FU) and dactinomycin.According to treatment methods,39 cases were divided into five groups: 3 cases in methotrexate,16 cases in dilation and curettage,15 cases in excision of CSP lesion via laparoscopy,6 cases in excision of CSP lesion via laparotomy,and 4 cases in transabdominal hysterectomy (TAH).Results (1)Clinical characteristics: the mean age was (33 ± 5) years old.Five patients had undergone two prior caesarean sections.The median interval from the last caesarean delivery to CSP was 4 years.Thirty-five cases presented vaginal bleeding or abnormal serum β-hCG level from 5 cases with medical abortion,9 cases with artificial abortion and 21 cases with dilation and curettage.The sonography showed cystic-solid or solid mass with mixed echoes in the lower segment of anterior uterine wall,surrounded by peritrophoblastic vasculature.(2) Treatment outcome: diagnosis of gestational trophoblastic neoplasm was suspected or made in 20 patients,four of whom were even treated by chemotherapy.MTX therapy was given to 3 patients,2 of whom were cured.Dilation and curettages were given to 16 patients,11 of whom were cured.8 patients underwent curettage with sonographic guidance after uterine artery embolism,and 8 patients with laparoscopic or hysteroscopic guidance.All of 15 patients underwent excision of CSP lesion via laparoscopy were cured.4 patients were treated by TAH.(3) Time of in hospital and operation:in laparoscopy group,the average hospitalization days were (3.5 ± 1.6) days,the average operation duration was (54 ± 16)minutes.In laparotomy group,the average hospitalization days were (9.7 ± 5.8) days,and the average surgical duration was (87 ± 15) minutes.It reached significant difference (P ＜ 0.05).Conclusions CSP with sonographic mass was the consequence of continued growth of residual pregnancy mass after incomplete abortion or curettage of CSP with gestation sac.The similar sonographic image might lead to misdiagnosis.Individual therapy was recommended.Excision of CSP lesion via laparoscopy might be the primary option for its advantages in differential diagnosis,caesarean scar defect repair and successful ratio.%目的 探讨包块型剖宫产术后子宫瘢痕妊娠(CSP)的临床特点、鉴别诊断及治疗方式.方法 回顾性分析2005年至2012年北京协和医院妇产科收治的39例包块型CSP患者的临床资料,其中14例在外院误诊为滋养细胞肿瘤,并有4例接受了不同药物[甲氨蝶呤(MTX)、顺铂、氟尿嘧啶、放线菌素D]的化疗；6例外院未明确诊断,但可疑为滋养细胞肿瘤.按不同治疗方式将39例患者分为MTX治疗组(3例),行MTX 50 mg/m2单次肌内注射或50 mg病灶局部注射；清宫组(16例),行清宫术；腹腔镜组(15例),行腹腔镜CSP病灶切除术(包括2例清宫术治疗失败患者)；开腹组(6例),开腹行CSP病灶切除术(包括1例MTX治疗失败患者)；子宫切除组(4例),开腹行子宫全切除术(包括2例清宫术治疗失败患者).分析其临床特征和治疗结局.结果 (1)临床特征:患者平均年龄(33±5)岁,其中两次剖宫产史者5例；CSP距末次剖宫产中位时间为4年.39例患者中,35例患者表现为药物流产(5例)、人工流产手术(9例)或清宫术(21例)后持续阴道出血或β-hCG持续异常.B超表现为子宫前壁下段可见囊实性或实性混合回声包块,周边可探及丰富的高速低阻血流频谱.(2)治疗结局:39例患者中,20例患者曾被疑诊或误诊为滋养细胞肿瘤.MTX治疗组3例患者中2例成功；清宫组16例患者中,8例在子宫动脉栓塞后B超监视下清宫,6例成功,8例在腹腔镜或宫腔镜下清宫,5例成功；腹腔镜组15例患者均行腹腔镜CSP病灶切除术,均治疗成功；开腹组6例患者均行开腹CSP病灶切除术,均治疗成功；子宫切除组4例患者均行开腹子宫全切除术,均治疗成功.(3)住院时间及手术时间:腹腔镜组平均住院时间为(3.5±1.6)d,平均手术时间为(54±16) min;开腹组平均住院时间为(9.7±5.8)d,平均手术时间为(87 ±15) min;两组住院时间及手术时间比较,差异均有统计学意义(P＜0.05).结论 包块型CSP多为孕囊型CSP清宫不全或不全流产后残留妊娠组织继续生长而成,超声图像容易与滋养细胞肿瘤混淆导致误诊.应当根据患者具体情况采用个体化治疗方案,腹腔镜CSP病灶切除术在保留患者生育功能的同时,具有成功率高、安全性高及住院时间短的优点,可作为包块型CSP治疗的首选.
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