Invasive mole all come from hydatidifoem mole, and most of them occur within half a year after the removal of mole. Patients may present with irregular vaginal bleeding, and HCG levels increase after hydatidifoem mole treatment. May also be combined with extra-uterine metastatic lesions. The principle of treatment is comprehensive treatment with chemotherapy as the mainstay, surgery and radiotherapy as supplementary. Surgery is mainly used for adjuvant chemotherapy to control major bleeding, remove drug-resistant lesions, reduce tumor burden, and shorten the course of chemotherapy[5]. But for the treatment of lung metastases, systemic chemotherapy is the typical choice rather than surgery[6–7].
In this case, the patient age 31-year-old,who still had irregular bleeding in vagina after applying drug or induced abortion for fivty-three days. Serum HCG was determined to be greater than 10,6189mIU/ml, the characteristics of this case were clear GTN and the lesion is limited to the uterus, no distant metastasis. Most of GTN chemotherapy can be cured, chemotherapy is the first choice. Surgical treatment is no longer the main treatment for GTN. For special cases, drug-resistant and relapsed patients, locallesion resection is performed simultaneously with chemotherapy. However, forolder people without fertility requirements, hysterectomy can be the first choice. Generally, surgical treatment is mainly used as adjuvant treatment. It plays a certain role in controlling various complications such as massive hemorrhage, eliminating drug-resistant lesions, reducing tumor load and shortening chemotherapy course, and is applied in some specific cases. For young women with fertility requirements, if the blood hCG level is not high, the drug-resistant focus is single and the extrauterine metastasis has been controlled, focus resection may be considered.
This patient has a fertility requirement, but HCG exceeding10,000 mIU/ml, if her required excision of lesion, when was the best time? Though the B-ultrasound and pelvic MRI showed a 12 × 8 cm mass, invasion of the myometrium, no masses in the uterine cavity. Invades the huge mass of the myometrium, prone to complications of uterine rupture. According FIGO 2018,GTN guidelines, combined with patient requirements, if we early chemotherapy, and then surgery, keeping the chemotherapy after surgery or Surgical local excision of the lesion or intervention to prevent rupture bleeding, the patient maybe cannot occur uterine rupture. It is also possible that during chemotherapy, there will be uterine rupture and bleeding, and the uterus will still be lost. Can we also perform interventional therapy or radiotherapy combined with chemotherapy to reduce the activity of lesions before performing surgery? Because of we didn't try any of this, a bad ending happened.
Through this case, we summarize as follows: 1. After the abortion, the specimen should be sent for pathological examination, and HCG should be checked regularly until it is normal; 2.Abnormal vaginal bleeding needs to be checked in the hospital; 3. US and MRI indicate that the mass is larger than 5 cm, that invasion of the muscle layer, hysterectomy should be performed. If there is a fertility requirement, remove the mass in the uterine cavity and invade the myometrium, and perform local mass resection. Chemotherapy can be performed for 2–3 courses or interventional or radiotherapy to control lesion activitybefore surgery; 4. If the mass invades the myometrium and reaches plasma When applying the membrane, be wary of uterine rupture and consider surgery before chemotherapy.