Objective To investigate the effect of sumical resection in the management of gestafional trophoblastic neoplasia(GTN)patients with pulmonary metastases.Methods A retrospective review of the medical records of 62 GTN patients who underwent pulmonary resection was carried out.The cases were divided into recurrent group(group A,,l=10),drug-resistant group(group B,n=28),and the group with satisfactory response to chemotherapy but residual pulmonary lesion(s)(group C,n=25).One patient underwent lobectomy twice,and she was allocated simultaneously to groups A and B.The patients'median age,antecedent pregnancy,International Federation of Gynecology and Obstetrics(NGO)risk score,number of preoperative chemotherapy courses,preoperative β-human chorionic gonadotrophin (β-hCG)titer,lesion size,number of lobes affected,positive rate of histology,follow-ups and prognosis were compared between the three groups.Results The proportion of hish-risk patients in the three groups wag 90%,82%and 44%,respectively.The complete remission rates of the three groups were 90%,79%and 100%,with relapse mtes of 2/8,15%and zero,respectively.Positive histology of the resected specimen wasmore frequently recognized in recurrent and drug-resistant groups(A 60%,B 36%,C 12%).In the drug-resistant group there were more preoperative chemotherapy 8essiorls(A 3,B 7,C 5)and more patients with abnormal preoperative B-hCG titer(A 50%,B 61%,C 12%).Conclusions Surgical resection is effective in the treatment of pulmonary metastases of GTN.Surgery is indicated when clinical evidence suggests that pulmonary metastatic disease causes relapse or drug—resistance and the lesions are relatively localized.Surgical resection is not recommended for patients with satisfactory response to chemotherapy but residual pulmonary lesions.

Objective To analyze prophylactic chemotherapy outcome and clinical characteristics in patients of high-risk hydatidiform mole. Methods Twenty-three patients who were diagnosed as high-risk hydatidiform mole and undergone prophylactic chemotherapy in our hospital were retrospectively analyzed.After prophylactic chemotherapy, 11 patients didn't develop to gestational trophoblastic neoplasia (GTN),while the other 12 patients developed to GTN and needed a regimen change to combination chemotherapy.The clinical characteristics of these patients and outcome of prophylactic chemotherapy were compared between two groups. Results There was no significant difference between the two groups on patients' age,weeks of delayed menses, enlarged uterine size excessive for gestational age, and incidence of theca-lutein cysts of ovaries. However,the median levels of pre-evacuation serum β-hCG in two groups were 469 144 U/L and 768 044 U/L respectively, and median days needed for β-hCG declining to normal(≤2U/L) at the first time were 71 and 120 days respectively, which were both significantly different between two groups.Analyzed with receiver operating charactristic(ROC), the level of serum β-hCG could be a predictor for prognosis. Choosing 750 000 U/L as the cut-off value, we could expect the serum β-hCG to have a specificity of 91% and a sensitivity of 58% to predict whether prophylactic chemotherapy will be successful.Conclusions For those patients who have to receive prophylactic chemotherapy because of risk factors and unavailable hCG assessments for follow-up, it's better to use double-agent or combination chemotherapy if the level of serum β-hCG reached 750 000 U/L so as to reduce therapy duration and prevent relevant chemoresistance.

Objective To analyze and compare the clinical characteristics and the treatment outcome of the patients with chemo-resistant and relapsed gestational trophoblastic neoplasia (GTN).Methods The clinical records of the patients with refractory GTN treated at the Peking Union Medical College Hospital (PUMCH) from Jan 2005 to Dec 2007 were retrospectively reviewed.According to the reasons for referral, all cases were classified as chemo-resistant GTN group who had never a normal serum human chorionic gonadotropin-beta subunit (β-hCG) level during their previous treatment, relapsed GTN group who had elevated serum β-hCG levels in the absence of the pregnancy after finished treatment 3 months or more, and undetermined GTN group who had elevated serum β-hCG levels in the absence of the pregnancy less than 3 months after completed treatment.The clinical features and treatment outcomes were compared between undetermined GTN group and chemo-resistant GTN group and also between undetermined GTN group and relapsed GTN group, respectively.Results Of 81 patients with refractory GTN, 32 cases were defined as undetermined GTN, 38 cases as chemo-resistant GTN and 11 cases as relapsed GTN.The median number of previous chemotherapy regimens, the rate of serologic complete remission ( SCR), the patients who needed to change regimens due to resistance, and the patients who needed to change regimens in the undetermined GTN group and the chemo-resistant GTN group were 2.3 versus 3.1 ( P = 0.010),100% (32/32) versus 66% (25/38, P ＜ 0.01 ), 22% (7/32) versus 58% (22/38, P = 0.002) and 28% (9/32) versus 63% (24/38, P = 0.003 ), respectively.No significant difference were observed between undetermined GTN group and relapsed GTN group in clinical features, previous and current treatment or treatment outcome ( all P ＞0.05 ).Conclusions In order to evaluate accurately the treatment outcome of refractory GTN, it seems more appropriate for the patients who had reached the normal value of serum β-hCG when completed treatment to be defined as patients with relapsed GTN, while whose serum β-hCG levels elevated in the absence of the pregnancy after the completion of treatment, irrespectively of duration of stopping treatment.Comparing with the patients with chemo-resistant GTN, the outcome of patients with relapsed GTN is better.

Objective To measure the quality of life (QoL) of gestational trophoblastic neoplasia ( GTN ) survivors after chemotherapy by using a self-invented scale, and to explore the factors associated with QoL Methods The design of questionnaire was based on a series of internationally valid QoL scales,which was tested by epidemiology and showed good reliability and validity. A total of 100 survivors of GTN patients from Peking Union Medical College Hospital participated in this survey from December 2008 to May 2009. Results Patients with disease-free more than three months after chemotherapy enjoys a good QoL,while only 16% (16/100) of survivors feel general overall QoL, but no one feels bad Qol. As refer to sexual function, more than half of these patients (70%, 70/100) satisfied with their sexual life, while there were still 47% (47/100) and 45% (45/100) of the patients complaining of decreased sexual desire and dryness of vagina. 66% (66/100) of the GTN survivors expressed depression, and 50% (50/100) of patients complained anxiety, which were potential factors influencing QoL of GTN survivors. Relevant analysis explored the possible predictors of QoL for GTN patients, including physical function ( r = 0. 609,P ＜0. 01 ), sexual function ( r = 0. 473, P ＜ 0. 01 ), and social psychology ( r = 0. 294, P ＜ 0. 01 ).Conclusions GTN survivors have an overall good QoL after chemotherapy, the possible predictors of QoL for GTN patients include physical function, sexual function and social psychology. The sexual dysfunctions mostly present with short of sexual desire and dryness of vagina. Fear of recurrence may be a potential factor influencing QoL a long term after remission.

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.

Objective To investigate the clinical characteristics, management and prognosis of gestational trophoblastic disease in women aged 50 years or more. Methods Thirty-eight cases of gestational trophoblastic disease in women aged 50 years or more, who were treated in Peking Union Medical College Hospital between 1992 and 2002, were reviewed retrospectively. Results The median age was 52 years (range from 50 to 58 years ). The lesions included 5 hydatidiform moles (13%), 19 invasive moles (50%), 12 choriocarcinomas (32%) and 2 placenta site trophoblastic tumors (5%). All of 38 cases presented with abnormal vaginal bleeding. Twenty-three cases of hydatidiform moles were diagnosed at their first visit to the hospital, and 15 of them received prophylactic chemotherapy, of whom 10 progressed to invasive mole, 3 developed lung metastasis. All of the other 8 cases without prophylactic chemotherapy progressed to malignant changes with metastasis of lung. The use of prophylactic chemotherapy reduced the incidence of subsequent metastasis. All of 38 cases received chemotherapy. Thirty-two cases underwent hysterectomy, complete remission was achieved in 91% of patients; complete remission was achieved in 2 of 6 patients without hysterectomy. Conclusions The diagnosis of pregnancy and pregnancy-related disease should be considered in the elderly women presenting with abnormal vaginal bleeding. Once gestational trophoblastic disease in women aged 50 years or more is diagnosed, chemotherapy should be given as soon as possible. Hysterectomy is frequently required to improve the prognosis of gestational trophoblastic disease in the elderly women.

OBJECTIVETo study the alkaloids of Macleaya cordata.

METHODThe alkaloids were isolated and purified by various column chromatography as well as recrystallization. Their structures were identified by physico-chemical properties and spectral analysis.

RESULTThirteen alkaloids were isolated and identified as 6-methoxy-dihydrosanguinarine (1), norsanguinarine (2), 6-acetonyl-dihyrochelerythrine (3), 6-acetonyl-dihyrosanguinnarine (4), sanguidimerine (5), chelidimerine (6), (+/-) -bocconarborine A (7), (+/-)-bocconarborine B (8), cryptopine (9), dihydrosanguinarine (10), dihydrochelerythrine (11), protopine (12), alpha-allocryptopine (13).

CONCLUSIONCompounds 2, 3, 5 - 9 were firstly isolated from the genus Macleaya and compound 1 was obtained from M. cordata for the first time.

Objective To discuss the effects of prophylactic chemotherapy on the outcomes and prognosis of invasive mole patients.Methods One hundred and fifteen invasive mole (IM) patients older than 40 years were registered in Peking Union Medical Collage Hospital.Eleven of them were treated with prophylactic chemotherapy before diagnosed as IM prophylactic chemotherapy group,while the other 104 cases received therapeutic chemotherapy after diagnosed as IM (non-prophylactic chemotherapy group).The general clinical data (including age,clinical stage,risk factor score),treatment,outcomes and relapse of patients were retrospectively compared between two groups.Results (1) The age of prophylactic chemotherapy group and non-prophylactic chemotherapy group were (47±5) versus (46±4) years old.Ratio of clinical stage Ⅰ-Ⅱ were 3/11 versus 29.8％ (31/104),clinical stage Ⅲ-Ⅳ were 8/11 versus 70.2％ (73/104).Ratio of risk factor score 0-6 were 11/11 versus 84.6％ (88/104),risk factor score ＞6 were 0 versus 15.4％(16/104).There were no significant statistical differences between two groups in age,clinical stage or risk factor score (all P＞0.05).(2) Treatment:the total chemotherapy courses between prophylactic chemotherapy group and non-prophylactic chemotherapy group (median 7 versus 5) were significantly different (Z=3.071,P=0.002).There were no significant statistical differences between two groups in the chemotherapy courses until negative conversion of β-hCG,consolidation chemotherapy courses,total therapeutic chemotherapy courses or ratio of hysterectomy (all P＞0.05).(3) Outcomes and relapse:between the prophylactic chemotherapy group and the non-prophylactic chemotherapy group,the complete remission rate were 11/11 versus 98.1％(102/104),the relapse rate were 0 versus 1.0％(1/102).There were no significant difference between the two groups in outcomes or relapse rate (P＞0.05).Conclusions Prophylactic chemotherapy does not substantially benefit the IM patients older than 40 years.Prophylactic chemotherapy may not significantly improve patients' prognosis,in which increased sample size is required in further study.

Objective To evaluate the efficacy of surgical management combined with chemotherapy in the treatment of drug-resistant gestational trophoblastic neoplasm(GTN)patients,and investigate factors influencing the outcome of the surgery combined with chemotherapy.Methods Medical records of 42 patents with drug-resistant GTN who were treated by chemotherapy combined with surgical management at Peking Union Medical College Hospital from Jan 1996 to Jan 2006 were reviewed.Results Among 42 patients,32 achieved serologically complete rendssion(SCR)with an SCR rate of 76%,and 10 patients had a treatment failure.Treatment failure was more frequently geen in patients who also had metastasis of other sites except for lungs and vagina and patients with antecedent non-molar pregnancy (P=0.023 and 0.017,respectively).Preoperative human chorionie gonadotropin-beta subunit(β-hCG)titer>10 U/L (P=0.020),failure to reach normal serum titers of β-hCG during treatment(P=0.003),age ≥35 years (OR:12.6,95%CI:2.4-66.0,P=0.002)and preoperative chemotherapy regimens≥4(OR:4.5,95% CI:1.0-20.1.P=0.059)were also correlated with treatment failure.All the 10 patients with treatment failure had at least 3 of 6 above mentioned predictors of treatment failure.Conclusions Surgical management combined with chemotherapy is effective in the treatment of drug-resistant GTN.Age≥35 years,antecedent non-molar pregnancy,metastasis of other sites except for lungs and vagina,preoperative β-hCG titer>10 U/L,failure to reach normal serum titers of β-hCG during treatment,and preoperative chemotherapy regimens≥4 are significant predictors of treatment failure.Patients with 3 or more predictors of treatment failure usually have poor prognosis.Therefore,surgical management should not be performed for these patients.

Objective To distinguish choriocarcinoma from gestational or non-gestational choriocarcinoma and also identify the causative pregnancy of gestational choriocarcinoma by the genetic origin through molecular genetic analysis. Methods Twelve patients with choriocarcinoma, who had experienced surgery prior to chemotherapy were enrolled in this study. All 12 cases were diagnosed pathologically as choriocarcinoma. Peripheral venous blood samples and formalin-fixed paraffin-embedded blocks of choriocarcinoma tissue microdissected from haematoxylin and eosin-stained sections of tissue by microdissection method were available from the patient and (or) her husband. DNA was then prepared from the couples' blood samples and choriocarcinoma tissue by using standard techniques. PCR amplification and fluorescent microsatellite genotyping were performed by using DNA from the couples and captured choriocarcinoma tissues. The genetic contributions to the choriocarcinoma tissue were determined by comparing the fragments of genes from the choriocarcinoma tissue to those from blood samples of the couples. Results The primary lesion was ovary in 7 cases, but only 4 of them had the maternal contribution, indicating a non-gestational origin; the other three were gestational choriocarcinoma. The primary lesion was uterus in 5 cases, which were all gestational choriocarcinoma confirmed by genetic analyses. The causative pregnancies of the 8 cases with gestational choriocarcinoma were identified as androgenetic complete hydatidiform mole (AnCHM) in six cases and normal pregnancies in two cases, respectively. Conclusion Microsatellite polymorphism analysis is a molecular approach for distinguishing the non-gestational choriocarcinoma from the gestational one, and also be used to identify the causative pregnancy of gestational choriocarcinoma.