2019年 · 第34卷第01期

A 76-year-old female was hospitalized for "abdominal distension and pain with fatigue for more than 1 year". Physical examination: No enlarged superficial lymph nodes were palpable throughout the body. The abdomen was swollen, showing a frog-shaped abdomen, without varicose veins on the abdominal wall, and no gastrointestinal pattern and peristaltic waves were seen. A mass of about 50 cm ×20 cm can be palpable in the upper abdomen, which is hard in texture, with unclear boundaries, no obvious tenderness, no rebound pain, and no abdominal muscle tension. Abdominal color ultrasound examination showed a huge mass in the abdominal cavity, considering teratoma, and incomplete organs in the abdominal cavity due to compression. Abdominal enhanced CT showed: huge cystic-solid mass in the abdominal cavity, intact capsule of the lesion, separation in the cyst cavity, watery fat-like density shadows in the cyst cavity, and multiple massive calcification or ossification shadows in some cyst cavities and cyst walls (Figure 1)。 On enhanced CT scan, the solid components of the cyst wall of the lesion showed gradual and obvious enhancement, but the intracyst components were not enhanced in all stages. The pancreas and upper abdominal intestinal canal were compressed and moved around, and the left kidney became flattened and shifted to the right anterior. The renal parenchyma density was uniform and the enhancement was uniform. Exploratory laparotomy was performed. During the operation, the tumor was located behind the peritoneum, extending from the bilateral ribs to the pelvic cavity, with a size of about 70 cm ×25 cm ×15 cm, and was lobulated. It was severely adhered to the small intestine, transverse colon and sigmoid colon, with unclear boundary and unclear anatomical relationship. Part of the small intestine was squeezed to the right lower abdomen, the left side was cystic, the adhesion site between the right side and the small intestine was ossified, the left kidney was wrapped by a tumor, and the left kidney was invaded, compressed and atrophied by the tumor. The adhesion between the tumor and the surrounding tissues was dissected along the tumor envelope, and left nephrectomy was performed to remove the tumor completely. The abdominal cavity was explored and no obvious signs of infiltration were found. The abdominal cavity was washed, and the abdominal wall incision was sutured in one stage. After operation, the tumor was dissected, and it was found that the tumor was lobulated, yellow-white, with a size of 75 cm ×25 cm ×15 cm and a net weight of 10 kg. The pathological report was a well-differentiated liposarcoma with central necrosis with renal capsule invasion. The left kidney tubular epithelium was turbid, swollen and degenerated, a few glomeruli were hyaline degenerated, and medullary fibrosis (Figure 2)。 The postoperative patients were not treated with radiotherapy and chemotherapy, and were followed up for 3 months. No recurrence and metastasis were observed.

A 78-year-old male was admitted for "2 years of discovery of abdominal mass". Physical examination: The abdomen was flat, without tenderness and rebound pain in the whole abdomen, and a mass of about 11 cm ×7 cm ×6 cm could be palpable in the right lower abdomen, which was round, without tenderness, tough in texture and average in mobility. Serum CEA 7.76 ng/ml (reference 0-3.4 ng/ml). Whole abdominal CT examination revealed a round-like low-density lesion in the ileocecal region of the right abdominal cavity, ring-shaped and nodular calcification at the edge, and the boundary with the intestinal tube was poor. The maximum cross-sectional area was 6.8 cm ×4.8 cm, and the CT value was about 13 HU. Considering cystic space-occupying lesions in the ileocecal region, mucinous cyst or mucinous cystadenoma was suspected (Figure 1)。 Colonoscopy showed that the ileocecal valve was lip-shaped, and hemispherical submucosal bulge of about 3 cm ×3 cm was seen at the opening of the appendix, and submucosal interstitial lesions or external pressure in the ileocecal region were observed.Figure 2)。 Exploratory laparotomy was performed. During the operation, the appendix showed tumor-like enlargement, about 12 cm ×7 cm ×5 cm in size, with smooth surface and intact mucosa, no enlargement of lymph nodes around and mesenteric root, and adhesion in the lateral peritoneum. After appendicectomy, frozen pathological examination showed that appendiceal mucinous tumor, so right hemicolectomy was performed (Figure 3)。 Postoperative pathological report: Low-grade mucinous tumor of the appendix, mucus components were seen in the muscular layer and serous surface of the appendix, no epithelium was seen, the tumor did not involve the surgical margins on both sides, and no tumor involvement was seen in the periintestinal lymph nodes (Figure 4)。

A 55-year-old male was admitted to the hospital due to "distension and pain in the upper abdomen for 1 month, and an abdominal mass was found for 5 days". Physical examination: The upper abdomen is tough in texture, and a hard mass can be palpable, with poor mobility, mild tenderness when touched, and reduced drum area of gastric vesicles. Abdominal enhanced CT showed multiple soft tissue density shadows between the left lateral lobe of the liver and the small curvature of the stomach, and the boundary with the stomach body was not clear, partially pressing the left lateral lobe of the liver upward, and the lower level was approximately to the level of the renal hilum. The larger one is about 95 mm ×86 mm ×81 mm, and its internal density is not uniform, and separation and envelope can be seen. On enhanced CT scan, there was no enhancement of low-density lesions, slight enhancement of parenchymal components, and obvious enhancement of margins (Figure 1)。 Gastroscopy showed: chronic superficial gastritis, external pressure bulge of the stomach body. Serum tumor markers CA125 40 U/ml, CA19-9 58 U/ml. Clinical diagnosis: space-occupying lesions in the abdominal cavity (gastric stromal tumor is likely). Surgical treatment was performed. During the operation, an irregular tumor was found on the surface of the small curve of the stomach and the serosa of the anterior wall, with a size of about 12 cm ×10 cm ×9 cm. The surface was still smooth, and the adjacent liver was compressed. No obvious tumor invasion was observed. Abdominal mass resection, subtotal gastrectomy + gastrojejunal Roux-en-Y anastomosis were performed. The large curvature of the stomach was 19 cm long, the small curvature was 14 cm long, and the lateral margins of cardia and pylorus were about 1.5 cm each from the mass. Massive necrosis and hemorrhage were observed after dissection of the tumor, and the incision surface was light brown and brown (Figure 2)。 Postoperative pathological report: No tumor was found at the two margins of stomach, but the tumor involved vessels, and no tumor involved nerves and lymph nodes (Figure 3)。 Immunohistochemical staining: CK-pan (+), Calretinin (+), Wilms tumor gene product 1 (WT-1, +), Vimentin (+) (Figure 4), Ki-67 (+80%), CD199 (partial +), CD34 (-), Desmin (-), SMA (-), Bcl-2 (-), CD117 (-), Dog-1 (-), S-100 (-), Keratin 5/6 (CK5/6, -). malignant mesothelioma (MM) was diagnosed.

A 58-year-old male underwent radical distal gastrectomy and Roux-en-Y reconstruction of the digestive tract due to "gastric cancer" (jejunum was transected 20 cm below the ligament of Tracy, the distal end was anastomosed with the posterior wall of the residual stomach, and the proximal end was anastomosed laterally at about 45 cm below the gastrointestinal anastomosis). The preoperative stage was T3-4aNxM0, and the postoperative stage was confirmed by pathological examination as T4aN0M0 (stage ⅡB). Eight days after surgery, the patient developed pain in the upper abdomen, radiating to the back, without nausea and vomiting. CT examination showed dilatation of the duodenal input loop (Figure 1), considered as postoperative acute input loop obstruction.

A 49-year-old female was admitted to the hospital due to "change in stool habits for more than 1 month". Colonoscopy revealed multiple polyps in the colon, and familial adenomatous polyposis was considered. A total of 6 family members of two generations of the same lineage were diagnosed as familial adenomatous polyposis. Total colectomy + ileorectal anastomosis was performed. Recurrent abdominal pain and discomfort began 4 months after the operation, and a mass the size of a ping-pong ball was palpable in the abdomen 8 months after the operation. Abdominal B-ultrasound examination revealed huge solid occupation in the abdominal cavity of the middle and lower abdomen. Exploratory laparotomy + partial resection of small intestine + palliative resection of mesenteric mass were performed. Postoperative pathological report: stromal tumor, low invasiveness. Abdominal CT reexamination 1 month after operation showed no tumor in the abdominal cavity (FIG. 1A)。 Oral imatinib 400 mg/d was given postoperatively. After 4 months, the tumor progressed and was switched to oral imatinib 600 mg/d. CT reexamination after 8 months showed that the tumor continued to progress (FIG. 1B), the patient's abdomen has obviously swollen, so the drug was stopped. Oral sunitinib 400 mg/d was started on June 1, 2008, and the condition was immediately relieved. One week later, the mass was clearly reduced, the tumor reached partial remission, and the disease has remained stable until now. In September 2010, the patient underwent pathological gene testing in Zhongshan Hospital affiliated to Fudan University, and was diagnosed with familial adenomatous polyposis complicated with desmoid tumor and gadener syndrome. A reexamination of the abdominal CT on 12 January 2016 revealed a space-occupying lesion in the abdominal cavity, which was similar in size to the mass examined by previous CT (Figure 1C)。 This patient is the second patient with oral sunitinib in my country, and it is also the patient with the longest tumor-bearing survival time with oral sunitinib in my country.