2023年 · 第38卷第02期

The patient was a 55-year-old female. See a doctor because "physical examination found mild elevation of serum tumor markers". Gastroscopy showed type 0~ Ⅱb lesions on the anterior wall of the junction of the gastric antrum (Figure 1), and tissue biopsy showed moderately differentiated adenocarcinoma, HER2 (0). Endoscopic ultrasound showed that the lesions invaded the 1st to 2nd layers, and the maximum diameter of the cross section was 1.77 cm, uT1aN0 (Figure 2). Enhanced CT examination showed that the suspected stomach wall was slightly thickened, about 5mm, and the boundary was not clear (Figure 3). Diagnosis: gastric antrum cancer cT1aN0, endoscopic mucosal dissection (ESD) was performed. Pathological examination showed: Ⅱb, histological type was mucinous adenocarcinoma with moderately differentiated tubular adenocarcinoma and signet ring cell carcinoma (muc>tub2>sig), Lauren's mixed type, the carcinoma invaded the submucosa, the deepest part of invasion was 1500 μ m away from the mucosal muscle (SM2), the deepest part of invasion was mucinous adenocarcinoma, no vascular tumor thrombus and nerve invasion were observed, and the basal and horizontal margins were positive. Radical distal gastrectomy + D₂Lymph node dissection showed no abnormalities in the abdominal cavity. Pathological examination showed that mucinous adenocarcinoma was seen in the whole thickness of the stomach wall, duodenum and omentum tissues (Figure 4), and no nerve invasion was seen. A large number of lymph nodes metastasized in 15/16, and vascular tumor thrombus was seen in the proximal and distal ends. Immunohistochemistry: AFP (-), CD34 (indicating vascular tumor thrombus), Cmet (1+), EGFR (2+), HER2 (1+), KI67 (70% +), PMMR, SALL4 (-), D2~40 (indicating vascular tumor thrombus), in situ hybridization EBER (-). Two cycles of TS regimen (albumin paclitaxel + tegio) chemotherapy were started at the 3rd week after operation. Two months after operation, the serum tumor markers were increased compared with the previous. Bone scan showed multiple bone metastases throughout the body, and the patient was not treated again.

A 52-year-old female was admitted mainly for "intermittent abdominal pain for 1 year and aggravated for 1 week". Abdominal enhanced CT examination showed that the small intestinal wall was thickened at the level of the flat umbilicus in the lower abdomen, the intestinal lumen was narrowed, and the enhancement showed uneven enhancement, and the shadows of small lymph nodes were seen around it (Figure 1). Abdominal color ultrasound, inguinal lymph node, cervical lymph node color ultrasound and colonoscopy showed no abnormalities. Laparoscopy-assisted partial small intestine resection was performed. Exploration showed a small intestinal mass 3.5 m away from the flexural ligament, about 5 cm ×4 cm in size, hard in texture, congested with local external serosa, proximal small intestine dilatation, and edema wall thickness. Partial small intestine resection and intestinal anastomosis were performed. Postoperative pathological examination showed: (small intestine) clear cell sarcomatoid tumor, penetrating the muscle layer to the subserous fat, no vascular tumor thrombus and nerve invasion, both cut margins were clear, and no metastasis was seen in the periintestinal lymph nodes (0/4) (Figure 2). Immunohistochemistry showed: Vimentin (+), Melanoma/HMB45 (-), S100 (+), CD56 (partial +), Syn (weak +), Melan-A (-), SOX10 (+).

A 43-year-old female was admitted for "pelvic mass found at physical examination for 6 d". Total abdominal CT examination showed soft tissue density in the left iliac vascular area and cystic low density shadow in the right adnexal area. Pelvic enhanced MRI examination showed an oval cystic-solid abnormal signal in the left iliac vascular area, with a size of approximately 4.7 cm ×3.9 cm, considering a neurogenic tumor (Figure 1). Retroperitoneal mass resection was performed. During the operation, the tumor was located on the outside of the fascia of the inferior ventral nerve of the left ureter, the upper edge entered the obturator, and the lower edge was located at the bifurcation of the left iliac vein. The tumor was cystic and solid, tough in texture, about 5 cm ×4 cm ×4 cm in size, and the surface envelope was intact. Nerve fibers were visible on the surface and both ends of the tumor, and the tumor was fully free and completely resected (Figure 2). Postoperative pathological examination revealed: (retroperitoneal) schwannoma with ossification (Figure 3A). Immunohistochemical examination revealed: Vimentin (+), S-100 (+), SOX10 (+) (Figure 3B), SMA (-), Desmin (-), CD17 (-), CD34 (-), Ki67 proliferation index<1%。

A 34-year-old female was admitted for "abdominal mass found on physical examination". Five years ago, he underwent "myomectomy" in the local maternal and child health hospital, and the pathological examination was leiomyoma. Enhanced CT examination revealed solid mass occupation in the left lower abdomen (Figure 1). Laparoscopic exploration showed a mass of about 8 cm ×6 cm ×4 cm in the middle segment of the descending colon, and a mass of about 3.5 cm ×2 cm ×2 cm in the peritoneum of the left posterior side of the uterus. Postoperative pathological examination showed: spindle cell tumor with mild cell morphology, red cytoplasm, rich in dilated blood vessels, and tending to leiomyoma (Figure 2). Immunohistochemical examination showed that the positive rates of Dog-1 (-), CD117 (-), CD34 (-), Actin (+), Desmin (+), SMA (+) and Ki-67<1%, estrogen receptor (+), progesterone receptor (+) (Figures 3, 4), and the results support smooth muscle tumors. Combined with the clinical history, the patient was diagnosed as benign metastasizing leiomyoma (BML). The patient's condition was stable after 3 years follow-up.

A 68-year-old male was found to have "nodules in the left lobe of the thyroid for 1 month". Physical examination: One obvious tough mass can be palpable in the left lobe of the thyroid gland. Ultrasound examination showed that the left lobe of the thyroid gland was a heterogeneous mass, about 4.9 cm ×2.6 cm ×2.9 cm in size, with clear boundaries, messy and uneven internal echoes, and TI-RADS classification of 4 categories (Figures 1A and 1B). All five indexes of thyroid function were normal. Subtotal left thyroidectomy was performed, and spindle cell tumor was diagnosed by intraoperative rapid freezing pathology. Postoperative pathological examination: Under light microscope, it was a cellular spindle cell tumor. The tumor cells were arranged in various ways, without obvious nuclear atypia, and abundant adipocytes and normal thyroid follicular components were seen (Figure 2A). The tumor cells contained unequal amounts of diffuse collagen distribution, and branched thin-walled blood vessels were visible, which were "staghorn-like" (Figure 2B). Immunohistochemical staining showed diffuse nuclear expression of STAT6 (FIG. 3A), positive expression of CD34 (FIG. 3B) and CD99, negative expression of S-100, Desmin and CD117, and extremely low Ki-67 index. The pathological diagnosis was adipogenic solitary fibrosis tumor (SFT). The patient took 1 tablet of sodium levothyroxine orally daily for 6 months after discharge. After 1 1/2 years of follow-up, there was no recurrence and distant metastasis by ultrasound and CT examination.

A 47-year-old female went to the urology department of our hospital for "dull pain in right waist and abdomen for 2 days". The patient often feels distension in the lower abdomen. "pelvic arteriovenous malformations (pAVM)" were found during IUD implantation more than 20 years ago, but they were not treated. Abdominal enhanced CT: severe hydronephrosis in the right nephrosis (Figure 1); pAVM and right ureter compression (Figure 2). Because the right kidney has no function, he underwent "laparoscopic right nephrectomy" in the urology department of our hospital, and was transferred to the undergraduate department for continued treatment. Physical examination: Obvious tremor was palpable under the umbilicus, and loud vascular murmur could be heard. DSA showed: giant arteriovenous malformation on the right side, mainly supplied by the internal iliac artery, and a small amount of arteriovenous malformation on the left side (Figure 3); Prolonged angiography time showed that venous blood returned to the common iliac vein through the thick internal iliac vein and then joined into the inferior vena cava. Surgical treatment was performed. During the operation, the patient was taken in supine position and entered the abdomen layer by layer. Exploration showed that there were a large number of tortuous veins in the pelvic cavity, the thickest one was 2 cm in diameter, and obvious tremor could be palpable. The retroperitoneum was opened to reveal the right common iliac, internal iliac, external iliac artery and internal iliac vein. The internal iliac vein was obviously thickened, about 2.5 cm in diameter. The initiation of the right internal iliac artery was double ligated with No. 10 silk thread, and the root of the right internal iliac vein was ligated with No. 7 silk thread. Re-examination showed that the pelvic floor tremor disappeared. After 10 months of follow-up, abdominal enhanced CT showed that the veins in the arterial phase were not developed, the malformed veins were atrophied and completely thrombotized (Figure 4), and the subumbilical vascular murmur disappeared.

A 57-year-old female was admitted for "abdominal mass found on physical examination for 2 months". Abdominal CT examination showed that a mass of abnormal density shadow was seen on the right side of the middle and upper abdomen, showing cystic-solid changes, and the possibility of small intestinal stromal tumor was high (Figure 1). Intraoperative exploration showed that the tumor originated from the initiation of the jejunum, the size of the tumor was 13 cm ×11 cm ×6.5 cm, and most of it was exophytic. The tumor caused mild stenosis of the intestinal lumen and compressed the surrounding intestine, corresponding to multiple enlarged lymph nodes in the mesenteric lining. Complete tumor resection was performed. After 6 months follow-up, no tumor recurrence was observed. Postoperative pathological examination showed that the main body of the tumor was located in the muscle layer, showing invasive growth, destroying the smooth muscle of the intestinal wall, invading the submucosa and subserosa (Figure 2A). It was composed of fibroblasts and myofibroblasts, arranged in parallel bundles and interwoven shapes, and some of them were arranged in a wavy shape. The interstitium was loose, and edema and mucoid changes were visible. The chromatin of the tumor cell nucleus was sparse or vacuolated, and small nucleoli were visible, and the cytoplasm was bichromatic, with slender ends (Figure 2B). The tumor cells in the myxoid area were star-shaped with no clear mitotic image. The tumor contained small to medium large blood vessels with edema around the blood vessels. There was no metastasis in the peri-intestinal lymph nodes (0/4). Immunohistochemical staining results showed: Vimentin (+) (FIG. 3A), β-Catenin (nuclear +) (FIG. 3B), Calponin (partially positive) (FIG. 3C), CD117 (-), Dog-1 (-), CD34 (vascular +), SMA (-), Desmin (-), S-100 (-), Ki67 (positive index about 5%), estrogen receptor (-), progesterone receptor (-), CD99 (+), STAT6 (-). Combined with the clinical manifestations and pathological examination results, the final diagnosis was primary invasive fibromatosis of jejunum.