女性生殖系统体细胞肿瘤起源的卵黄囊瘤 2 例

2018-12-19 钞晓培 谭先杰 马水清 现代妇产科进展

上皮性肿瘤伴卵黄囊瘤(yolk sac tumor, YST)成 分多见于呼吸消化道及泌尿道,女性生殖系统罕见, 2016 年该类肿瘤被建议统一命名为体细胞肿瘤起源 的 YST(SDYST)。目前国内外文献共报道了 36 例卵 巢 SDYST(绝经前女性卵巢 YST 起源不明,未纳入该 分析), 13 例子宫内膜 SDYST,尚无宫颈、阴道及外阴 SDYST 的报道。2010 年 11 月至 20

上皮性肿瘤伴卵黄囊瘤(yolk sac tumor, YST)成 分多见于呼吸消化道及泌尿道,女性生殖系统罕见, 2016 年该类肿瘤被建议统一命名为体细胞肿瘤起源 的 YST(SDYST)。目前国内外文献共报道了 36 例卵 巢 SDYST(绝经前女性卵巢 YST 起源不明,未纳入该 分析), 13 例子宫内膜 SDYST,尚无宫颈、阴道及外阴 SDYST 的报道。2010 年 11 月至 2017 年 12 月北京协 和医院共诊治女性生殖系统恶性肿瘤 13059 例,其中 2 例女性生殖系统 SDYST, 占0.015%。SDYST 临床表 现主要为腹部包块、阴道不规则出血及子宫增大。该 类肿瘤侵袭性强,预后差, CA125 及甲胎蛋白(AFP) 等肿瘤标记物术前常升高,疾病得以控制时恢复正 常,疾病进展时再次升高。诊断主要依据组织学及免 疫组化。目前治疗多采取根治性手术及术后辅助治 疗。现结合我院诊治病例及文献报道对 SDYST 进行 描述,以增加临床认识。

1 临床资料

例 1, 28 岁,已婚,因“经期延长、经量增多 1+年,腹胀 1 个月”于 2010 年 11 月 9 日就诊于我院。外院超声提示大量 腹水,除外消化系统疾病后行诊断性刮宫,术后病理:(子宫 内膜、宫颈内膜)子宫内膜腺癌,伴腺体鳞化。2010 年 10 月 20 日曾于当地医院行“剖腹探查术+病灶活检术”,术中见大 网膜有一约 20cm×10cm×6cm 瘤结节,与横结肠粘连致密,盆腔腹膜弥漫粟粒样瘤结节。术后病理示:(腹膜、大网膜) 子宫内膜样腺癌伴卵黄囊样分化。术后第 7 天予 TAP 静脉 腹腔联合化疗 1 程(紫素 120mg+阿霉素 60mg 静脉化疗、顺 铂150mg 腹腔化疗)。入院查体:宫体如孕 8 周大,质软。经 阴道超声提示:子宫增大(6.5cm×6.9cm×4.6cm),内膜明显 增厚 1.4cm,回声不均,内膜周边血流信号较丰富;双侧附件 区未见明显异常。肿瘤标记物 CA125 129U/ml(正常值≤ 35U/ml), CA199 23U/ml(正常值≤34U/ml), AFP 1522ng/ml (正常值≤20ng/ml), β-HCG 518.9mIU/ml(正常值≤5mIU/ ml)。2010 年 12 月 8 日我院行“肿瘤细胞减灭术,完全切 净。子宫大小为 10cm×8cm×5cm,剖视子宫,宫腔内可见菜 花样肿物伴坏死,中等质地,大小 6cm×3cm×2.5cm,肿瘤切 面灰白色。术后病理:(子宫内膜)高-中分化子宫内膜样癌 伴卵黄囊瘤样分化, FIGO Ⅳ期,两种成分间可见明显转化 区,转移瘤的成分和原发病灶相同,而子宫肌层、宫颈、阑尾、 双附件及髂淋巴结均未见肿瘤转移。免疫组化:卵黄囊肿瘤 细胞过碘酸希夫反应(PAS)染色阳性;卵黄囊瘤成分 AFP 染色强阳性,而子宫内膜样腺癌成分为阴性;AE1/AE3 在子 宫内膜样腺癌和卵黄囊瘤两种成分均染色阳性;子宫内膜样 腺癌染色阳性:EMA、 CA125 和 CK7,证实其为上皮性肿瘤, 并且 p53(灶性+);ER、 PR 和 HCG 在两种肿瘤成分染色均 阴性。术后 2 天,血清 AFP 和 β-HCG 分别降至 166.4ng/ml、 13.7mIU/ml,而 CA125 降至正常。术后辅以 6 程 TC(紫杉 醇、卡铂), AFP 在 TC 化疗 4 程后恢复正常,但 β-HCG 降而 复升,给予 EMA/EP(依托泊苷、甲氨蝶呤和放线菌素/依托 泊苷和顺铂)2 程、 PEB(顺铂、依托泊苷和博来霉素)2 程, β-HCG 仍波动于 5~ 20mIU/ml。考虑此现象为异常的垂体反 馈,停止化疗严密观察随访。3 个月后患者的血清 AFP 及 β-HCG 再次升高,予 2 疗程 FAVE 方案(氟脲苷、更生霉素、 依托泊苷和长春新碱)行姑息性化疗,血清 AFP 升至 311. 1ng/ml, β-HCG 升至 2716.5mIU/ml。给予奥沙利铂 200mg、 环磷酰胺 800mg 静脉化疗 1 程,患者放弃进一步治疗,失访。

例 2, 58 岁,绝经后女性,因“自触及下腹部包块 20+天, 伴大便困难、尿频”于 2017 年 3 月就诊于我院。超声提示: 子宫后方混合回声 13.5cm×9.0cm×10.7cm,壁及分隔上可探 及短条状血流信号,局部囊腔内可见不规则团块状中等回 声,范围约 6.1cm×5.1cm×5.0cm,未探及明显血流信号。肿 瘤标记物 AFP 219.7ng/ml, CA125、 CA199 及 CEA 均正常。 合并高血压糖尿病心肌梗死史。妇科查体:右附件区可扪 及直径约 15cm 囊实性包块,界清,活动度欠佳。2017 年 3 月于我院行“开腹探查+全面分期术”。术中见子宫及左附件萎缩,右卵巢肿瘤直径约 10cm,且与周围肠管、腹膜粘连 固定,余处探查未见转移灶。术后石蜡病理:(右附件)卵巢 透明细胞癌,伴卵黄囊瘤成分,可见两种成分的过渡区。免 疫组化:(蜡块 1)AFP(部分+), SALL-4(+), EMA(部分+), CK7(部分+), p53(-), ER(-), PR(-), PAX-8(部分+), P16 (部分+), Vimentin(-), WT-1(-), CK20(局灶+), Ki-67(index 约 55%), OCT3/4(-), Napsin A(-);(蜡块 2) SALL-4 (局部+), CK7(+), EMA(+), Napsin A(-);(蜡块 3)AE1/ AE3(-), Napsin A(-)。诊断:卵巢透明细胞癌伴卵黄囊瘤 Ic 期。术后经我院妇科肿瘤专业组讨论,给予 PEB(按周) 化疗 3 程,血清 AFP 在第 1 程化疗后恢复正常, CA125 及 CA199 在术前、术后化疗过程及随访中均正常。第 3 疗程 PEB 化疗后,患者发生急性心肌梗死、急性脑梗死而暂停化 疗,目前仍在继续随访中。无瘤生存期 9 个月。2 例患者的 临床特点及免疫组化特点见表 1、表 2。



2 讨 论 

YST 多发生于女性和男性生殖道,尤其是性腺, 也可发生于性腺外区,最常见的是骶尾区、大脑、纵 膈和腹膜后[1-3]。在女性生殖道, YST 很少发生于卵 巢以外的组织,如子宫体、宫颈、阴道或外阴[4-6],其 中阴道是性腺外 YTS 最常见的区域[7],但阴道原发 YST 非常少见。上皮性肿瘤伴 YST 成分最常发生于 呼吸消化道及泌尿道。女性生殖道的苗勒氏管上皮 性肿瘤可发展为滋养细胞肿瘤或 YST,但较罕见,大 部分为腺癌伴 YST 成分同时伴/不伴绒癌、胚胎癌。 Mcnamee 等提议将这些上皮性肿瘤伴 YST 成分的叫 做“体细胞来源的 YST”,并且建议对不同部位发生 的此种肿瘤进行统一命名[8]。

2.1 女性生殖系统体细胞肿瘤起源的 YST 的发生机制

卵巢 YST 是原始生殖细胞沿卵黄囊方向分化 的结果,是儿童和青春期女性常见的卵巢恶性肿瘤 之一,多发生于 30 岁之前,少见于 40 岁以上女性, 发生于绝经后妇女罕见,且多伴发卵巢上皮性肿瘤[9],或更罕见的没有可辨认的卵巢上皮性肿瘤前 体。对于绝经后女性卵巢 YST 的起源存在多种学 说,目前认为肿瘤化生是最佳理论,即体细胞癌获得 生殖细胞分化能力从而出现卵巢上皮性肿瘤伴 YST 成分[10]。性腺外原发生殖细胞肿瘤的发生机制存 有争议,文献报道中起源于子宫内膜样腺癌的卵巢 YST 支持性腺外 YST 可能起源于体细胞肿瘤,通过 异常分化而来。本文报道的 2 例患者组织学均可见 上皮性肿瘤及 YST 两种成分的过渡区,再次证实了 这类肿瘤中的 YST 成分来源于体细胞肿瘤的异常分化。

2.2 女性生殖系统体细胞肿瘤起源的 YST 的临床特点

卵巢 SDYST 的临床表现无特异性,多为阴道 不规则出血、腹部包块、腹痛、腹胀或子宫增大,但其 侵袭性较卵巢单纯 YST 更强,即使早期,预后也很 差。子宫内膜原发 YST 转移发生早,且易侵袭到周 围组织,转移途径为血液和淋巴系统。子宫内膜 SDYST 的临床表现尚不明确。本文报道的第 1 例患者为子宫内膜 SDYST,其血清学 AFP 及 CA125 术后 迅速下降,疾病进展时升高,表明两者可作为该肿瘤 对治疗反应性及监测肿瘤复发和进展的标记物。 HCG 虽升高,但未得到组织病理学证实。通过文献 复习,已报道多例 HCG 升高但无组织学证据的病 例,表明其确实存在滋养细胞分化。第 2 例患者术 前仅血清 AFP 升高,术后辅助化疗 1 程后即恢复正 常,且在化疗过程中及化疗后随访中未见升高,影像 学检查也未证实肿瘤复发迹象。一般情况下, SDYST 患者血清学检查多可发现 AFP 升高,可轻度 增高或高达上万,并且与组织学中 YST 成分含量相 关[11]。但值得注意的是,极少数患者的血清学 AFP 处于正常范围内,可能与肿瘤期别较早相关。血清 学 CA125 常升高,并且在术后或肿瘤得到控制时显 著下降,而在疾病进展或复发时显著升高,此点同 AFP。大量 AFP 抑制了 T 淋巴细胞和免疫球蛋白 IgA 与 IgG 的产生,机体免疫功能严重受损,可能促 使癌细胞生长加快、肿瘤复发和(或)转移,患者预后 不良。

2.3 女性生殖系统体细胞肿瘤起源的 YST 的诊断 及鉴别诊断

女性生殖系统 SDYST 罕见且诊断困 难,发生率较难确定。自 1987 年 Rutgers 等[12]报道 了第 1 例起源于卵巢子宫内膜样腺癌的 YST,此后 有多例报道。目前国内外共36 例卵巢 SDYST 报道, 其中 1 例上皮性肿瘤成分为良性上皮性肿瘤-黏液 性囊腺瘤[13], 1 例为透明交界性肿瘤[8]。恶性上皮 性肿瘤成分中,卵巢子宫内膜样腺癌较常见,共 12 例,卵巢透明细胞癌 11 例。值得注意的是,文献报 道中有 17 例为绝经后女性卵巢单纯 YST,考虑其所 起源的上皮性肿瘤成分被 YST 的过度生长所完全取 代[11]。此外,共报道了 13 例子宫内膜 SDYST,其中 1 例为绝经前子宫内膜原发 YST 伴透明细胞癌[14], 12 例为绝经后女性子宫内膜原发 YST 伴恶性上皮 性肿瘤(恶性苗勒氏管混合瘤 2 例[15-16],子宫内膜 腺癌 1 例[17],浆液性腺癌 2 例[18-19],混合性上皮性 肿瘤 7 例[19-20])。目前尚无宫颈、阴道及外阴 SDYST 的报道。我院诊治的 2 例女性生殖道 SDYST 患者中,其原发部位分别为卵巢及子宫内膜。 当 YST 发生于性腺外部位,且发生在少见年龄 段,加之其组织学多样性及倾向于模仿体细胞肿瘤, 而使正确诊断极富有挑战[21]。其诊断主要根据组 织学及免疫组化,镜下可见上皮性肿瘤及 YST(疏松 网状结构、嗜酸性小体即 S-D 小体)两种组织成分的 典型组织学特点,但有时需与透明细胞癌、子宫内膜样腺癌等相鉴别。既往认为,免疫组化中 AFP 染色 阳性在 YST 的组织学诊断中很重要。但研究发现, 多种其它肿瘤也有此表现[22],并且并非所有 YST 均 可表现为 AFP 阳性[23]。诊断 YST 的新标记物,如 GPC-3、 SALL-4 等对其组织学诊断也有帮助。CK7 和 EMA 是鉴别卵巢 YST 和子宫内膜样腺癌的重要 标记物, YST 中两者染色常为阴性,而在子宫内膜样 腺癌成分中常为阳性[8]。

2.4 女性生殖系统体细胞肿瘤起源的 YST 的治疗及预后

女性生殖系统 SDYST 极为罕见,目前尚无 标准治疗方案。由于 YST 的漏诊或误诊,治疗效果 不佳。目前治疗策略为初治时采取根治性手术切 除、术后辅助化疗,若初治时手术较困难,可先行新 辅助化疗。即使肿瘤初治时处于早期,由于 YST 成 分存在,需术后辅助治疗。卵巢原发 SDYST 患者初 始手术范围多采取肿瘤细胞减灭术或全面分期术, 但其化疗方案的选择使我们处于两难的境地。经长 期探索及临床经验积累,建议其初始化疗选择针对 恶性生殖细胞肿瘤的方案,然后添加以铂类为基础 的针对卵巢上皮癌的化疗方案[24],如 PEB/PVB 方 案联合 TC 方案。从其转移及复发组织学角度考虑, 建议辅助治疗选择以铂类为基础的对卵巢上皮癌和 生殖细胞肿瘤均有效的化疗方案[8, 11]。 发生于子宫内膜、宫颈、阴道及外阴的 SDYST 患者,建议采用相应部位的肿瘤手术原则。由于女 性生殖系统卵巢外 SDYST 报道的病例极少甚至尚 无相关报道,其化疗方案尚不明确。需注意的是,对 于外阴 YST 的随访,血清学 AFP 并不是一个敏感的 肿瘤标记物[25],其可能并不能帮助此疾病的诊断以 及在随访过程中监测肿瘤的复发,该点与卵巢 YST 不同[26]。此外,监测肿瘤治疗情况的较敏感的血清 学肿瘤标记物 AFP 在化疗期间常可达到正常,但是 这可能只反应了混合性肿瘤的一种成分的消退[27]。 卵巢 SDYST 侵袭性强,即使临床期别较早,预 后仍较差[11],肿瘤前体子宫内膜腺癌的分化程度与 患者预后无关,而肿瘤分期及诊断时升高的肿瘤标 记物与患者预后有关[27]。YST 成分可在转移灶和 复发病灶中出现,相较于子宫内膜腺癌成分等肿瘤 前体,卵巢肿瘤的 YST 成分似乎是导致该罕见肿瘤 不良预后的主要原因[28],近来,采取激进治疗的卵 巢 SDYST 的 I 期患者的预后有所改善。而生殖系统 其它部位发生的上皮性肿瘤起源的 YST 预后不详。

总之,女性生殖系统 SDYST 罕见,侵袭性强,需 尽早发现、正确诊断[29]。此外,尚需纳入更多病例以诊断、研究及随诊,以寻求最佳治疗方案,改善 其不良预后。

参考文献略。

原始出处:

钞晓培,谭先杰,马水清,向阳. 女性生殖系统体细胞肿瘤起源的卵黄囊瘤2例报道并文献复习[J]. 现代妇产科进展,2018,27(06):452-455.

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  1. [GetPortalCommentsPageByObjectIdResponse(id=1945904, encodeId=deba19459044b, content=<a href='/topic/show?id=8560691054a' target=_blank style='color:#2F92EE;'>#生殖系统#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=69105, encryptionId=8560691054a, topicName=生殖系统)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e572480, createdName=旅苦化文_208, createdTime=Thu Oct 10 14:29:00 CST 2019, time=2019-10-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1945753, encodeId=06f41945e5399, content=<a href='/topic/show?id=febb691021d' target=_blank style='color:#2F92EE;'>#生殖系#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=45, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=69102, encryptionId=febb691021d, topicName=生殖系)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c9d3459, createdName=周虎, createdTime=Thu Oct 31 15:29:00 CST 2019, time=2019-10-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1438329, encodeId=14e014383296e, content=<a href='/topic/show?id=c8a526638f6' target=_blank style='color:#2F92EE;'>#体细胞#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=37, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=26638, encryptionId=c8a526638f6, topicName=体细胞)], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/aLGWoFXAyMbIu3qymFOyheQLjPSX3OUs5GmkyBlcCOwTPIeq3why9NGibxxUqYo6hcx8qZLHZFgNPnBK1yzWeOFpyg2OnWOt0/0, createdBy=fa4716, createdName=zhouqu_8, createdTime=Fri Dec 21 10:29:00 CST 2018, time=2018-12-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1531904, encodeId=aed215319043c, content=<a href='/topic/show?id=0579446550d' target=_blank style='color:#2F92EE;'>#女性生殖#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=44655, encryptionId=0579446550d, topicName=女性生殖)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=39cc12287476, createdName=slcumt, createdTime=Fri Dec 21 10:29:00 CST 2018, time=2018-12-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1591737, encodeId=4b441591e37f1, content=<a href='/topic/show?id=35b73690607' target=_blank style='color:#2F92EE;'>#卵黄囊瘤#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=36906, encryptionId=35b73690607, topicName=卵黄囊瘤)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=498517999342, createdName=lancelotzzl, createdTime=Fri Dec 21 10:29:00 CST 2018, time=2018-12-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1629032, encodeId=66d01629032b0, content=<a href='/topic/show?id=71713690570' target=_blank style='color:#2F92EE;'>#卵黄囊#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=28, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=36905, encryptionId=71713690570, topicName=卵黄囊)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=8b8a21265760, createdName=shalley73, createdTime=Fri Dec 21 10:29:00 CST 2018, time=2018-12-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=355876, encodeId=6b6a3558e69c, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=68, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=82311653708, createdName=医者仁心5538, createdTime=Wed Dec 19 21:37:44 CST 2018, time=2018-12-19, status=1, ipAttribution=)]
  2. [GetPortalCommentsPageByObjectIdResponse(id=1945904, encodeId=deba19459044b, content=<a href='/topic/show?id=8560691054a' target=_blank style='color:#2F92EE;'>#生殖系统#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=69105, encryptionId=8560691054a, topicName=生殖系统)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e572480, createdName=旅苦化文_208, createdTime=Thu Oct 10 14:29:00 CST 2019, time=2019-10-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1945753, encodeId=06f41945e5399, content=<a href='/topic/show?id=febb691021d' target=_blank style='color:#2F92EE;'>#生殖系#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=45, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=69102, encryptionId=febb691021d, topicName=生殖系)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c9d3459, createdName=周虎, createdTime=Thu Oct 31 15:29:00 CST 2019, time=2019-10-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1438329, encodeId=14e014383296e, content=<a href='/topic/show?id=c8a526638f6' target=_blank style='color:#2F92EE;'>#体细胞#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=37, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=26638, encryptionId=c8a526638f6, topicName=体细胞)], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/aLGWoFXAyMbIu3qymFOyheQLjPSX3OUs5GmkyBlcCOwTPIeq3why9NGibxxUqYo6hcx8qZLHZFgNPnBK1yzWeOFpyg2OnWOt0/0, createdBy=fa4716, createdName=zhouqu_8, createdTime=Fri Dec 21 10:29:00 CST 2018, time=2018-12-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1531904, encodeId=aed215319043c, content=<a href='/topic/show?id=0579446550d' target=_blank style='color:#2F92EE;'>#女性生殖#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=44655, encryptionId=0579446550d, topicName=女性生殖)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=39cc12287476, createdName=slcumt, createdTime=Fri Dec 21 10:29:00 CST 2018, time=2018-12-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1591737, encodeId=4b441591e37f1, content=<a href='/topic/show?id=35b73690607' target=_blank style='color:#2F92EE;'>#卵黄囊瘤#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=36906, encryptionId=35b73690607, topicName=卵黄囊瘤)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=498517999342, createdName=lancelotzzl, createdTime=Fri Dec 21 10:29:00 CST 2018, time=2018-12-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1629032, encodeId=66d01629032b0, content=<a href='/topic/show?id=71713690570' target=_blank style='color:#2F92EE;'>#卵黄囊#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=28, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=36905, encryptionId=71713690570, topicName=卵黄囊)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=8b8a21265760, createdName=shalley73, createdTime=Fri Dec 21 10:29:00 CST 2018, time=2018-12-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=355876, encodeId=6b6a3558e69c, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=68, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=82311653708, createdName=医者仁心5538, createdTime=Wed Dec 19 21:37:44 CST 2018, time=2018-12-19, status=1, ipAttribution=)]
    2019-10-31 周虎
  3. [GetPortalCommentsPageByObjectIdResponse(id=1945904, encodeId=deba19459044b, content=<a href='/topic/show?id=8560691054a' target=_blank style='color:#2F92EE;'>#生殖系统#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=69105, encryptionId=8560691054a, topicName=生殖系统)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e572480, createdName=旅苦化文_208, createdTime=Thu Oct 10 14:29:00 CST 2019, time=2019-10-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1945753, encodeId=06f41945e5399, content=<a href='/topic/show?id=febb691021d' target=_blank style='color:#2F92EE;'>#生殖系#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=45, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=69102, encryptionId=febb691021d, topicName=生殖系)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c9d3459, createdName=周虎, createdTime=Thu Oct 31 15:29:00 CST 2019, time=2019-10-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1438329, encodeId=14e014383296e, content=<a href='/topic/show?id=c8a526638f6' target=_blank style='color:#2F92EE;'>#体细胞#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=37, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=26638, encryptionId=c8a526638f6, topicName=体细胞)], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/aLGWoFXAyMbIu3qymFOyheQLjPSX3OUs5GmkyBlcCOwTPIeq3why9NGibxxUqYo6hcx8qZLHZFgNPnBK1yzWeOFpyg2OnWOt0/0, createdBy=fa4716, createdName=zhouqu_8, createdTime=Fri Dec 21 10:29:00 CST 2018, time=2018-12-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1531904, encodeId=aed215319043c, content=<a href='/topic/show?id=0579446550d' target=_blank style='color:#2F92EE;'>#女性生殖#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=44655, encryptionId=0579446550d, topicName=女性生殖)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=39cc12287476, createdName=slcumt, createdTime=Fri Dec 21 10:29:00 CST 2018, time=2018-12-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1591737, encodeId=4b441591e37f1, content=<a href='/topic/show?id=35b73690607' target=_blank style='color:#2F92EE;'>#卵黄囊瘤#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=36906, encryptionId=35b73690607, topicName=卵黄囊瘤)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=498517999342, createdName=lancelotzzl, createdTime=Fri Dec 21 10:29:00 CST 2018, time=2018-12-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1629032, encodeId=66d01629032b0, content=<a href='/topic/show?id=71713690570' target=_blank style='color:#2F92EE;'>#卵黄囊#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=28, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=36905, encryptionId=71713690570, topicName=卵黄囊)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=8b8a21265760, createdName=shalley73, createdTime=Fri Dec 21 10:29:00 CST 2018, time=2018-12-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=355876, encodeId=6b6a3558e69c, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=68, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=82311653708, createdName=医者仁心5538, createdTime=Wed Dec 19 21:37:44 CST 2018, time=2018-12-19, status=1, ipAttribution=)]
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    2018-12-19 医者仁心5538

    学习了

    0

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