Choriocarcinoma is a highly deteriorated tumor of trophoblast cells, in which the trophoblast cells lose their original villi and become a staphyloma structure. According to some data, most of the choriocarcinomas occur at a certain period after pregnancy, and very few occur after menopause. About 44% of choriocarcinomas occur within 3 months of pregnancy, 67.2% within 1 year, and 32% over 1 year, some of them may occur at the same time as pregnancy, and may be transmitted to newborns through umbilical cord blood, resulting in neonatal choriocarcinoma. Choriocarcinoma occurs after first pregnancy or first delivery, accounting for about 20% of the total number of cases. Choriocarcinoma is 50% from gravida, 25% from miscarriage, and 25% from full-term delivery.
I. Abnormal manifestations
1.Vaginal bleeding: It is a common symptom, which is irregular vaginal bleeding after gravida, miscarriage or full-term delivery, with variable amount.
2.Sauce-colored foul-smelling vaginal discharge.
3.Pseudopregnancy symptoms: caused by tumor secretion of HCG and estrogen and progesterone, such as areola vulva pigmentation, breast enlargement, a few may have lactation and amenorrhea, etc.
4.Cryptoid cysts: persistence of cryptoid cysts after miscarriage and delivery should be highly alerted.
5, pelvic mass: often palpable lower abdominal masses, soft and irregular in shape. For uterine perforation should be immediately surgically removed, or if the lesion is confined to the uterus and chemotherapy is ineffective.
6, abdominal pain: abdominal pain can occur when invading the uterine wall, penetrating the uterus or when blood accumulation in the uterine cavity occurs.
7. Metastatic symptoms: the most common ones are lung, brain, vaginal, pelvic and liver metastases. 60%~80% of the patients have lung metastases at the time of consultation, often showing symptoms such as cough, hemoptysis dyspnea and chest pain; vaginal metastases may show vaginal bleeding, which may lead to hemorrhagic shock; brain metastases may initially show sudden and transient falls, aphasia, blindness and confusion, and in the late stage, headache, vomiting, aphasia, blindness, convulsions, hemiparesis and coma. In the late stage, headache, vomiting, aphasia, blindness, convulsions, hemiparesis, coma and even brain herniation may occur. The early symptoms of liver, spleen, kidney and gastrointestinal metastases are not obvious, but when the liver and spleen metastases rupture and hemorrhage, the symptoms of peritonitis may appear; the gastrointestinal tract may show vomiting blood and black stool; the urinary system may show hematuria.
Treatment
The principle of treatment for this disease is chemotherapy, together with surgery, radiotherapy, traditional Chinese medicine and immunotherapy. Chemotherapy is preferred for this disease, with a cure rate of nearly 70%, and chemotherapy is the main treatment for patients with late stage.
1.Malignant staphyloma or early stage choriocarcinoma can generally be cured by chemotherapy alone.
2.For advanced stage and drug-resistant choriocarcinoma, systemic chemotherapy is the main treatment, supplemented by local treatment.
3.For large lesions that are difficult to be cured by chemotherapy, single lesions should be treated with surgery or radiotherapy, while multiple lesions should be treated with chemotherapy.
4.For advanced stage and drug-resistant choriocarcinoma, the treatment course should be extended appropriately to reduce recurrence.
Surgical treatment
(1) Surgery: ①Uterine lesions: total hysterectomy or subextensive hysterectomy, used for cases without fertility or drug resistance, can preserve ovaries to maintain normal endocrine function. For young people who require fertility, hysterectomy may be considered for residual uterine lesions even after chemotherapy. (2) Multi-organ metastasectomy.
(2) Surgery time: Generally, 2~4 courses of chemotherapy are recommended to control the disease basically before surgery is performed.
Chemotherapy
Chemotherapy principles.
(1) High dose of drugs to ensure efficacy.
(2) Combination of drugs: generally use a drug alone for two or three courses of chemotherapy before switching to another drug. If the condition is urgent or the patient has multiple metastases, two or more drugs can be used in combination.
3）Course of treatment: a course of treatment should be 8~10 days, and in general, obvious efficacy can appear 10~14 days after stopping a course of treatment.
(4) Indications for drug change: In some cases, the efficacy is not obvious after one course of treatment, and it is necessary to continue the second course of treatment to see obvious efficacy; if the effect is still not obvious after two consecutive courses of treatment, the drug should be changed or combined with two drugs in time. If the effect is still not obvious after two consecutive courses, the drug should be changed or combined.
(5) Discontinuation indications: disappearance of clinical symptoms and lesions in the body; normal blood and urine HCG measurement once a week or more than 3 consecutive weeks in the normal range. After all the above indicators are achieved, then consolidate one or two courses of treatment before discontinuing the drug for observation, and only after the condition is not repeated can be discharged.
(6) Observation of efficacy; HCG measurement in blood and urine will show obvious changes only after stopping the drug; lung metastasis will show obvious effect only after 2 weeks of chemotherapy, therefore, several indexes should not be tested too early.
Post-chemotherapy follow-up
Follow-up time: monthly for 1 year after stopping chemotherapy, every 3 months for 1~2 years, and once a year for 2~5 years; no recurrence for 5 years can be regarded as a cure.
Follow up: irregular vaginal bleeding, hemoptysis, headache, blood and urine HCG measurement, menstruation, marital status, gynecological examination, routine blood test, chest X-ray, pelvic examination, etc. For those who retain their fertility and have children, screening for the birth of children is required.
Prognosis: At present, the cure rate of early stage or low risk patients is almost 100%, and the cure rate of late stage patients can reach 70% through comprehensive treatment mainly with chemotherapy. Young patients with preserved fertility can have healthy children, but some patients, especially those with advanced multi-organ metastases, eventually die of drug resistance. However, some patients, especially those with advanced multi-organ metastases, may eventually die of drug resistance. If a second treatment is given early, there is still a chance of cure.
Toxic side effects of antineoplastic drugs
Local reaction: local redness, swelling and pain in veins, pigmentation and venous embolism along the veins, and severe pain if the drugs are highly irritating.
Bone marrow suppression: Most antitumor drugs have bone marrow suppression effect. This is manifested by a decrease in peripheral blood leukocytes, platelets and hemoglobin, the first two being the most pronounced, which can lead to infection and subsequent bleeding.
Gastrointestinal reactions: manifested as nausea, vomiting, abdominal pain, abdominal distension, etc.
Nephrotoxicity: manifested as hematuria, proteinuria, elevated urea nitrogen, etc.
Hepatotoxicity: Many antitumor drugs are metabolized in the liver, which has different degrees of damage to the liver, manifested as elevated transaminases.
Cardiotoxicity: manifested as weakness, active dyspnea, episodic dyspnea, heart enlargement, edema, etc.
Pulmonary toxicity: mainly manifested as interstitial inflammation and pulmonary fibrosis of the lung. Symptoms include cough, chest tightness, and shortness of breath.
Neurotoxicity: including peripheral neuropathy and acute encephalopathy or spinal cord injury. Manifestations include numbness of fingers and toes, sensory abnormalities, constipation, paralytic intestinal obstruction, headache, drowsiness, apathy, and convulsions.
Radiotherapy has been reported to be used for brain metastases, and up to 50% of patients with initial diagnosis can be cured.
Indications for radiotherapy: ①Acute bleeding from extensive metastases such as vulva, vagina and cervix can be stopped by radiotherapy. ②Brain, liver and other important organs metastasis and urgent exclusion of symptoms or pelvic lesions cannot be removed. ③ Chemotherapy drug residual lesions or drug-resistant lesions.
Radiotherapy method: according to the site, size, field and choice of irradiation method, vaginal and cervical metastases can be used for intracavitary radiotherapy, other parts can be used for external irradiation, try to protect normal tissue.
Chinese medicine treatment: ①Adjust the immune function of the body. ② Direct anti-cancer effect. ③ Reduce the side effects of radiotherapy and chemotherapy.
III. Rehabilitation after treatment
1. After benign hyperemesis gravidarum, you should insist on checking urine HCG once a month, once every 3 months after negative, and once every 6 months afterwards, and insist on 2 years. Lung X-ray should be performed at the same time of each examination.
2.Patients who have gravida, malignant gravida and choriocarcinoma should take contraceptive measures other than avoiding intrauterine device within 3 years and should not conceive.
3.For vaginal examination, pay attention to using finger diagnosis first and avoid using vaginal speculum first to avoid cutting vaginal metastatic lesions causing hemorrhage.
4. Pay attention to keep the vulva clean, and rinse the vulva with warm water 1~2 times a day.
5. Pay attention to the presence of lung metastasis and brain metastasis: cough, hemoptysis and dyspnea are symptoms of lung metastasis; headache, vomiting, visual impairment, convulsion, coma and impaired movement of limbs are symptoms of brain metastasis. Once the above symptoms appear, you should go to a specialist hospital immediately.
6.Patients who are clinically cured should also follow the doctor’s prescription for regular review and pay high attention to the recurrence symptoms within 1 year, especially those who have persistently positive blood HCG and urine pregnancy test, or those who have once turned negative and then appear positive again have a higher recurrence rate, and there are also recurrences after 4~5 years.
7. The follow-up period should generally be reviewed once a month in the first year, once every 3 months in 2~3 years, and then once a year until the 5th year, and once every 2 years after 5 years.
Fourth, preventive health care
1, pay attention to pregnancy health care, before and during pregnancy to avoid exposure to harmful substances, avoid viral infectious diseases, nutrition should be rich, mood to be comfortable.
2, eugenics, avoid inbred marriage, avoid multiple pregnancies.
3, pay attention to whether the early pregnancy reaction is particularly serious phenomenon.
4, pay attention to the enlargement of the uterus, such as too large or too small need to pay attention to.
5, pay attention to the fetal movement. If the fetus is still not moving after 4 to 5 months, you should seek medical attention.
6.Pay attention to the duration of pregnancy, whether there is vaginal bleeding, bleeding or vaginal bleeding after miscarriage or delivery, etc. If there is irregular vaginal bleeding, the amount is more or less, intermittent and recurrent, dark brown in color, you should be alert.
7. Pay attention to check the vaginal discharge, put the discharge into water whether floating villi are visible and whether there are blister-like objects.
8.After delivery of pregnancy or miscarriage of gravida, pay attention to the monitoring of blood and urine HCG.
9.After delivery or miscarriage, especially after miscarriage of gravida, sudden onset of unexplained cough and hemoptysis should be promptly followed by pulmonary examination and blood and urine HCG measurement.