2023年 · 第38卷第12期

Three years ago, I published the article "New Opportunities for Surgical Treatment of Retroperitoneal Tumors in China" in this journal. On the basis of reviewing the development history of retroperitoneal tumor surgery in European and American countries and China, I discussed the global challenges of retroperitoneal tumors and the opportunities in China. In recent years, great progress has been made in the research of retroperitoneal tumors in China, especially in basic research, but we should also see that the challenges faced by China in this field are still outstanding, and our colleagues still have a long way to go.

A 43-year-old woman was admitted for "inadvertent discovery of a left breast mass for 15 d". Breast color ultrasound examination showed that a 1.7 cm ×0.9 cm ×0.7 cm nodule was seen in the left breast at 4 o'clock direction, which was irregular in shape, with a long axis parallel to the skin, a matte edge, distorted surrounding structure, hypoechoic and uneven inside, attenuated posterior echo, and no blood flow signal, which was in line with BI-RADS category 4B (Figure 1). Pathological examination: (left breast mass) A pile of gray-white fragmented tissue, with a total volume of 1.8 cm ×1.0 cm ×0.8 cm. The cut surface was gray-white and tough in texture, and a local cystic cavity seemed to be seen. What was seen under light microscope: the boundary of the tumor tissue was unclear, and the proliferating spindle-shaped or fat spindle-shaped cells were arranged in short bundles or vortexes. The tumor cells proliferated actively, the nucleus was obese and lightly stained, and obvious small nucleolus was visible. The mitotic image was easy to see, but there was no pathological mitotic image. The interstitium was loose and mucous, with erythrocyte extravasation and lymphocyte infiltration (Figure 2), and no lobulated structure and epithelioid fissure were seen. Immunohistochemical results: SMA (+), Vimentin (+), Desmin (partial +), Beta-catenin (cytoplasmic +), CD34 (vascular +), CK-guang (-), ER (-), PR (-), P63 (-), Ki-67 index (5%). FISH test result: It indicates that USP6 is broken. Diagnosis: (left breast mass) nodular fasciitis.

A 54-year-old female was admitted to the hospital for "3 months of finding anterior neck mass". Physical examination: A hard mass can be palpable in the left lobe and isthmus of the thyroid gland, about 4 cm in size, with clear boundary, no tenderness, and moving up and down with swallowing. Multiple swollen lymph nodes can be palpable in the left neck, the larger one is about 2 cm, the boundary is clear, and the movement can be achieved. Neck ultrasound showed a hypoechoic solid mass in the left lobe of thyroid gland with unclear boundary, uneven internal echo, patchy and punctate strong echo reflex, and punctate blood flow signal in color Doppler flow imaging, TI-RADS category 5; The lymph nodes of the left cervical regions Ⅱ, Ⅲ, Ⅳ and Ⅵ were swollen. CT examination of the neck showed an irregular mass in the left lobe and isthmus of the thyroid gland, with unclear boundary and uneven density. The CT value of plain scan was about 51 HU, and the enhanced scan showed mild enhancement. The three-stage CT values were about 53, 73, and 66 HU respectively. The lesion invaded the left anterior wall of the trachea and partially protruded into the tracheal lumen, which was considered malignant (Figure 1A); There were multiple enlarged lymph nodes in areas II, III, IV and VI of the left cervix, and the enhanced scan showed annular enhancement, considering metastasis (Figure 1B). During the operation, the tumor was located in the left lobe and isthmus of the thyroid gland, invaded the first ring of the common trachea, and protruded into the lumen of the trachea. The tumor adhered to the band muscle and the cricothyroid muscle; There are several swollen lymph nodes in the Ⅱ ~ Ⅵ area of the left neck, which are cystic-solid, medium in quality and clear in boundary. Total thyroidectomy + central lymph node dissection, left cervical lymph node dissection + partial tracheectomy and tracheostomy were performed. Postoperative pathological examination showed: malignant thyroid tumor. Immunohistochemical results: Vimentin (few +), Ki67 (about 80% +), Desmin (+), ERG (+ / -), S-100 (-), SMA (+), TNI-1 (+), Myogenin (+), CD34 (partial +), MyoD1 (+), special staining results: reticular fiber staining (showing fiber discontinuity), consistent with rhabdomyosarcoma (Figures 2 and 3). Lymph node metastatic tumors submitted for examination: 4/4 of the thyroid periphery, 1/1 of the left cervical zone II, 1/6 of the left cervical zone III, and 1/1 of the recurrent laryngeal nerve entering the larynx. Postoperative staging: T4bN1bM0 IVb stage. Local 6mV-X-ray radiotherapy was given postoperatively, and the total radiotherapy dose was 600 Gy/30 times/42 days. FP regimen (cisplatin + fluorouracil) concurrent chemotherapy for 2 cycles, total: cisplatin 90 mg ×2, fluorouracil 2.5 g ×2. Due to frequent ventricular premature contractions, the MID regimen (mesna + ifosfamide + dacarbazine) was changed to 4 cycles of chemotherapy, with a total of ifosfamide 10 g ×4, dacarbazine 900 mg ×4, and mesna 0.4 g ×3 times/d ×5×4. After 52 months follow-up, no recurrence and metastasis were observed.

A 69-year-old male was seen for "dull pain and discomfort in the left lower abdomen with distension and pain in the left chest wall for 2 months". Enhanced CT examination of the whole abdomen showed a mixed density mass in the left retroperitoneum, about 6.5 cm ×7.3 cm in size. The enhanced scan showed obvious continuous wreath-like enhancement, with large patchy necrosis and obvious thick and tortuous vascular shadows at the edges (Figure 1). CT scan of the chest showed: 2 nodules in the upper lobe of the left lung, with smooth edges, and the size was 1.1 cm ×1.0 cm and 0.9 cm ×0.8 cm, respectively (Figure 2); Bone destruction of the left second rib with formation of a surrounding soft tissue mass (Figure 3). Considering retroperitoneal malignant tumor with lung and rib metastasis, a puncture biopsy of the left second rib was performed. Pathological examination showed that the tumor was diffusely arranged, the abnormal cells were round, the nucleus was round, and it was deeply stained. Most of them were consistent in size, with different focal sizes and abundant interstitial blood vessels (Figure 4). Immunohistochemistry showed: STAT6 (+), S-100 (-), EMA (-), ERG (+), CK (-), Ki-67 (~10% +), CD34 (-), PR (-), GFAP (-), GPC-3 (-), Hepa (-), CD99 (+). The diagnosis was malignant solitary fibrous tumor (SFT). Retroperitoneal tumor resection, metastatic radiotherapy (45Gy/15F) and adjuvant chemotherapy (epirubicin + ifosfamide) were performed. Postoperative pathology confirmed that the retroperitoneal mass was SFT.

A 43-year-old male was admitted for "half-month retroperitoneal occupation". Physical examination: blood pressure 134/92 mmHg, heart rate 87 beats/min. Abdominal color ultrasound examination: A cystic-solid mass was seen in the left middle and upper abdomen and below the pancreas, with a size of about 10.2 cm ×8.4 cm ×8.4 cm, clear boundary, irregular shape, uneven internal echo, liquefied area, no calcification, enhanced posterior echo, and 3 to 4 punctate blood vessels or 1 longer blood vessel could be seen in the tumor. The tumor is closely related to the abdominal aorta and left renal artery. Enhanced CT examination of thorax, abdomen and pelvis: A round cystic-solid mass was seen retroperitoneally on the left side with clear borders. The solid part was moderately enhanced on the enhanced scan, but the cystic part was not enhanced. The lesion extent was about 8.8 cm ×7.9 cm ×8.4 cm, and the surrounding fat space was blurred (Figure 1).

The patient was a 55-year-old female. He came to hospital for "lower abdominal mass for more than 3 years". Intensive CT examination showed that the retroperitoneum occupied a rounded space, with a size of 11.5 cm ×8.3 cm ×9.8 cm, with a rounded cystic low-density focus inside, and iliac vessels accompanying the lesion (Figure 1). MRI examination showed: irregular massive cystic-solid mass occupying the right side of the retroperitoneum, with a size of about 9.5 cm ×11.5 cm ×7.7 cm; The solid part presents a slightly equal T1 and slightly equal T2 abnormal signal, and the enhanced scan is uneven and enhanced; The cystic part showed long T1 and long T2 abnormal signals, and the cyst wall was thicker. The cyst wall was enhanced by enhancement scan. The lesion was closely related to the right intervertebral foramen of the corresponding horizontal lumbar vertebra, and the adjacent structures of the lesion were compressed and displaced (Figure 2). A retroperitoneal tumor was diagnosed, considering a neurogenic tumor. Multidisciplinary discussions were conducted in gastrointestinal surgery, spinal surgery, urology, vascular surgery, interventions, anesthesiology. Bilateral ureteral stent tube was placed before surgery to facilitate the identification of ureter during surgery and prevent injury. The operation was first performed by spinal surgery department for intraspinal tumor dissection and nerve root dissection, followed by intestinal adhesion release and retroperitoneal tumor resection by gastrointestinal surgery department, and the operation was smooth (Figure 3). Postoperative pathological examination: spindle cell tumor, volume 14 cm ×8 cm ×7 cm, local hemorrhagic cystic degeneration, uneven cell density, mild cell morphology, rare nuclear fissure, and interstitial scattered lymphocyte infiltration (Figure 4); Immunohistochemistry: SOX10 (+), NF (-), EMA (-), S-100 (+), Ki-67 (5% + in hotspots), CD34 (-), STAT6 (-), Actin (-), consistent with schwannoma.

A 42-year-old male was admitted with "sudden back and abdominal pain and discomfort for 9 h". CTA showed type B aortic dissection (Figure 1). Endovascular isolation of the thoracic aorta with stent under general anesthesia was performed after 1 week. The pigtail catheter was introduced along the left femoral artery approach, and the segment-by-segment angiography was clearly located in the true lumen along the way. The pigtail catheter was sent to the ascending aorta (Figure 2A), and the 8F long sheath was exchanged to the aortic arch. The trap is fed along the long sheath to capture the left brachial artery. The guidewire is drawn out through the sheath of the left femoral artery to establish a guidewire track, and the superhard guidewire is fed along the long sheath to the ascending aorta. A single inline branch covered stent (34-28-200 mm) was introduced along the left femoral artery approach and released close to the distal end of the left common carotid artery. After complete release, the delivery system was withdrawn to the lower end of the stent. At this time, under DSA fluoroscopy, the stent gradually moved distally (Figure 2B), and the lower end of the stent was displaced to the level of the first lumbar vertebra before the stent was fixed. Catheterography introduced by the left brachial artery approach showed that the blood flow in the stent was stagnant, and the distal end of the stent was not developed. It was considered that the aortic intima was stripped and accumulated at the lower end of the stent during the operation, blocking the abdominal aorta and visceral artery (Figure 2C). After communicating with family members, it was decided to switch to laparotomy, and the median abdominal incision was used. The intestine and liver were dull in color when explored in the abdominal cavity. The small intestine was pushed to the right, the retroperitoneum was opened, the abdominal aorta was exposed, the left renal vein was disconnected, the superior mesenteric artery and both renal arteries were freed, and they were controlled by trapping respectively. The abdominal aorta above and below the renal artery was cuffed to control, and the abdominal aorta and bilateral renal arteries were blocked. After a longitudinal incision of about 5 cm was made on the anterior wall of the abdominal aorta, intima accumulation was seen, and the proximal intima turned back to the distal end. The intima was carefully stripped, the distal intima was fixed with a 6-0 slip line, and the anterior wall incision of the abdominal aorta was sutured with a 4-0 slip line. The abdominal aorta and bilateral renal arteries were opened, and the pulsation of the abdominal aorta and bilateral renal arteries was good. The length of the exfoliated intima was about 20 cm, and the openings of the celiac trunk, superior mesenteric artery and both renal arteries were visible on it (Figure 2D). Introducing the catheter along the left brachial artery approach to the stent for angiography, it was seen that the blood flow in the stent and abdominal aorta was smooth, the celiac trunk was not developed, and the superior mesenteric artery was developed, but the lower end of the stent covered the opening of the superior mesenteric artery, and the bilateral renal arteries were well developed. The superior mesenteric artery was exposed in the small mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric Re-angiography showed that the celiac trunk, superior mesenteric artery and both renal arteries were well developed. Reconstruction of the left renal vein. After operation, the patient was treated with anti-diet, anti-infection, anticoagulation and fluid rehydration, and the patient recovered and was discharged. Six months after operation, CTA showed that the blood flow in the aorta and stent was unobstructed, a small amount of intimal tissue remained at the distal end of the subclavian artery, and the celiac trunk, superior mesenteric artery and both renal arteries were well visualized.