2023年 · 第38卷第06期

The patient, a 48-year-old male, came to our hospital for examination on May 12, 2022 due to "periumbilical discomfort for 1 year", and the breath test showed Helicobacter pylori positive. Serum creatinine 119 μ mol/L. Gastroscopy revealed: chronic atrophic gastritis (Kimura Takemoto classification C2), and the first consideration after sterilization was: fundus gland polyps (removed); Multiple telangiectasias in the stomach; Duodenal papilla swelling (Figure 1). Pathological examination showed chronic non-atrophic gastritis (gastric antrum). Inflammation (+ +), activity (+ +), intestinal metaplasia (+), atrophy (-), atypia (-), HP (+). (gastric body) fundus gland polyp; Ectopic gastric gland of duodenal papilla (Figure 2).

A 45-year-old male was admitted to the hospital for "finding progressive enlarged mass in the right abdomen for more than 3 years". Had an "appendectomy" 6 years ago. Physical examination: Abdominal swelling, surgical scar can be seen in the right lower abdomen, and a huge mass can be palpable in the right abdomen, about 20 cm ×30 cm in size, tough in texture, clear in boundary, and poor mobility. Intensive abdominal MRI revealed a large mass of FS-T in the abdominopelvic cavity₂WI high and low mixed signal mass, DWI showed high and low mixed signal, clear boundary, uneven signal, uneven delayed enhancement in enhancement scan, and the surrounding soft tissue was compressed and displaced (Figure 1). The abdominal cavity was explored: the peripheral boundary of the tumor was relatively clear, the texture was tough, and the adhesion to the right abdominal wall was dense. It could be seen that the tumor originated from the ileocecal region, so the abdominal cavity tumor and the ileocecal region were completely resected.

The patient, a 58-year-old male, saw the doctor because he "found blood during defecation for 2 weeks". Digital rectal examination: An ulcerous mass can be palpable on the right anterior wall of the rectum at 7 cm from the anal margin, which is tough in texture and has average mobility, and cannot reach the upper margin of the tumor. Colonoscopy revealed a circumferential bulging hyperplastic lesion with local ulcer 10 cm from the anal orifice. Laboratory tests: Serum CEA 2.29 ng/ml, AFP 2.05 ng/ml, CA19-9 5.8 U/ml. MRI showed diffuse thickening and abnormal signals of the intestinal wall in the pelvic part of sigmoid colon and rectosacral area. CT of the chest revealed liver metastases. Laparoscopic resection of rectal tumor was performed. Multiple tumor nodules were observed in the pelvic peritoneum during the operation. Anterior rectectomy, lymph node dissection and abdominal nodulectomy were performed according to the results of exploration. Postoperative pathological examination showed that the gross specimen after anterior rectectomy was ulcerative, 5.0 cm ×3.5 cm in size, gray-red and soft in texture, and invaded the serosa layer by naked eye, see Figure 1. Under the light microscope, the cancer tissue was in the shape of a seal ring, arranged in pieces, and a mucus lake was formed (Figure 2). Immunohistochemical examination revealed: CD56 (+) (FIG. 3A), CDX-2 (+) (FIG. 3B), Syn (+) (FIG. 3C), C-crbB-2 (0), TP53 (+), MLH1 (+), MSH2 (+), MSH6 (+), PMS2 (+), CgA (−), Ki-67 ≈70%. Pathological diagnosis: Rectal goblet cell carcinoid (GCC), genetic test suggested KARS wild type. FOLFOX chemotherapy regimen and cetuximab targeted therapy were decided according to CSCO guidelines, and the patient was followed up for 6 months. Currently, the patient is in stable condition.

A 26-year-old woman with a perianal mass found for 6 months, painful with pus outflow when pressed. A hard mass, about 6 cm ×8 cm in size, with unclear boundaries, increased skin temperature and tenderness can be palpable in the perianal direction from 3 to 9 o'clock at the lithotomy position. No new organisms were found within 6 cm of the finger examination from the anus, and the finger cuff was not stained with blood. The outpatient clinic was admitted to the hospital with "complex anal fistula". Incision and drainage were performed. After methylene blue was injected into the external fistula, the gauze in the anus was dyed, the bougie was inserted into the external fistula all the way to the inner mouth of the crypt, the bougie was pulled out, the skin and subcutaneous tissue in the middle of the external fistula were incised in a fusiform shape, the fistula was opened, and the necrotic tissue in the fistula was removed for pathological examination. Postoperative pathological findings: broken gray-red tissue, size 3.0 cm ×1.0 cm ×0.7 cm. Under the light microscope, the surface is covered with squamous epithelium, and the nests of atypical cells in the interstitium are distributed in sheet-like shape. The nucleus is round or oval, some nuclei are dark stained, and some cytoplasm is red stained (Figure 1). Immunohistochemical staining examination: CK (-), SMA (-), Desmin (+), Myogenin (+), MyoD1 (+) (Figure 2), Ki-67 (60% +), CgA (-), Syn (-), CD38 (-), LCA (-), HMB45 (-), S-100 protein (-). Pathological diagnosis: (Perianal) alveolar rhabdomyosarcoma (ARMS). Pelvic MRI plain scan + diffusion imaging (3.0T) showed that an abnormal signal mass was seen on the right side of the perianal region, with irregular shape and less smooth edge, with an extent of about 5.3 cm ×4.8 cm ×3.1 cm, T₁WI low signal, T₂WI/DWI was high signal (Figure 3), significantly enhanced after enhancement, and the local boundary with the rectum was poorly defined. Whole body tomography of the tumor showed: perianal mass flaky mass tissue density shadow, high glucose metabolism, consistent with malignant tumor; Multiple enlarged lymph nodes in the inguinal area and pelvic cavity on both sides, mild glucose metabolism, considering the possibility of metastasis. The patient was given chemotherapy first and then surgically removed the tumor. Three years after operation, bilateral breast masses were found, and the pathological diagnosis of puncture biopsy was: (bilateral breast) ARMS metastasis. At present, they survived with tumors.

A 77-year-old male was admitted with "dull pain in the upper abdomen for 4 d" and had a history of hypertension. Physical examination after admission showed no obvious positive signs. Tumor markers: CA 19-9 68.7 U/ml, alpha-fetoprotein 726.42 ng/ml, carcinoembryonic antigen 31.08 ng/ml. Both total abdominal enhanced CT (Figure 1) and upper abdominal enhanced magnetic resonance showed that the left lobe of the liver occupied a rounded space, with a size of about 6.9 cm ×7.7 cm, with uneven enhancement in the arterial phase and continuous enhancement in the venous phase, considering liver cancer, and local thickening of the gastric wall on the side of the small curvature of the stomach, with mild enhancement in the enhancement phase, considering gastric cancer. Gastroscopy showed a huge deep concave ulcer on the small curved side of the stomach body, stiff stomach wall, covered with filthy coating, and biopsy was performed. Pathology showed gastric cancer. After multi-disciplinary treatment (MDT) discussion, the diagnosis considered primary liver cancer combined with gastric cancer, and performed laparoscopic left lateral lobectomy combined with total gastrectomy. Postoperative liver pathology showed hepatocellular carcinoma, and gastric pathology showed moderately poorly differentiated adenocarcinoma (PT4aN3aM0), see Figures 2 and 3. Adjuvant chemotherapy was started about 1 month after operation. After 6 cycles of SOX chemotherapy, the tumor markers CA19-9, alpha-fetoprotein and carcinoembryonic antigen all returned to normal. After 1 year follow-up, the patient recovered well, and no obvious tumor recurrence and metastasis were found on reexamination of enhanced CT.

An 86-year-old male was admitted with "incision pain for 4 d and hematuria for 1 d after laparoscopic inguinal hernia repair". In the past, he had "transurethral resection of the prostate and cystostomy". Physical examination: tenderness in the lower abdomen, localized bulge in the right inguinal area. Color ultrasound showed encapsulated effusion in the right inguinal area and a small amount of peritoneal effusion. Immediately perform puncture and liquid extraction under the guidance of color ultrasound, extract about 400 ml of soy sauce-like liquid, and place it for catheterization. The urine characteristics are the same as the puncture liquid, and treat infection prevention, nutritional support, oral treatment of prostatic hyperplasia drugs and other treatments. On the 3rd and 5th days of admission, two puncture and fluid extraction under the guidance of color ultrasound were performed, each time about 50 ml of fluid was extracted, and the characteristics were basically the same as before. Dynamic enhancement of urinary tract CT on day 7 showed a rupture of the anterior bladder wall of about 6 mm ×4 mm (Figure 1). On the 17th day, CT reexamination showed that the effusion volume did not change obviously, and the effusion puncture and catheterization under the guidance of color Doppler ultrasound were performed. After multiple reexaminations of color Doppler ultrasound, the preperitoneal effusion gradually decreased to disappeared. On the 35th day, the puncture drainage tube prolapsed, and indwelling catheterization was continued. On the 44th day, retrograde cystography CT showed that the anterior wall of the bladder was broken about 2 mm, and the effusion was significantly reduced. On the 59th day, retrograde cystography CT showed no leakage of contrast medium, and the effusion was basically absorbed (Figure 2). The urinary catheter was intermittently clamped to exercise bladder function for 3 days. After re-examination of color ultrasound without effusion, the urinary catheter was removed, and the urination was smooth and the serum creatinine was normal. He was discharged on the 65th day. After 1 month follow-up, he recovered well without hernia recurrence, patch infection and abnormal urination.