2024年 · 第39卷第08期

The patient was a 78-year-old male. Admitted for "intermittent abdominal pain for 2 months, aggravated with fever for 5 days". Physical examination: Flat abdomen, tight abdominal muscles, tenderness and rebound pain in the left abdomen, and no intestinal sounds were heard. Routine blood test: white blood cell count 16.12×10⁹/L, red blood cell count 3.77×10¹²/L, hemoglobin 111 g/L, neutrophil percentage 84.5%. CT examination showed that the wall of the left middle and upper abdomen and pelvic small intestine was thick and enhanced, the intestinal tube was slightly dilated, fluid accumulated, and pelvic fluid accumulated (Figure 1). Laparoscopic exploration was performed, and perforation of the small intestine about 20 cm away from Trigger's ligament was found during the operation. This segment of the small intestine was severe edema with severe adhesion and obstruction, resulting in dark red color of the intestinal segment about 10 cm, and the diseased intestinal segment was completely removed. Pathological findings: malignant tumor, size 2.5 cm ×1.0 cm ×1.2 cm. The cells are abundant, with obvious abnormalities. Some cells are spindle-shaped, some are epithelioid, and the nuclear division is easy to see, supporting sarcomatoid carcinoma (Figure 2). Cancer tissue invading subserous fibroadipose tissue; Intravascular tumor thrombus was observed, but no typical nerve invasion was observed; No cancer was found in both end margin and mesenteric margin; There was no cancer in the annular mucosal tissue, and the other tissue was inflammatory necrosis; There was no metastatic carcinoma in peri-intestinal lymph nodes (0/2). Immunohistochemical results: CD31 (vascular +), D2-40 (vascular +), intravascular tumor thrombus was visible. CK (+) (Figure 3), Vimentin (+) (Figure 4), S-100 (-), SOX10 (-), CD117 (-), AFP (-), SMARCA4/Brg1 (+), Ki-67 (40% +), MLH1 (+), PMS2 (+), MSH2 (+), MSH6 (+), showing that the tumor mismatch repair protein was intact. Sarcomatoid carcinoma was diagnosed. Chemotherapy with "paclitaxel + cisplatin" regimen was given 1 month after discharge. After 1 and 3 months of follow-up, the general state of the patient was good.

The 42-year-old female was admitted to hospital mainly for "upper abdominal discomfort for more than half a year". Enhanced CT examination of the whole abdomen revealed a small curvature mass of the stomach, considering a stromal tumor (Figure 1). Gastroscopy showed that ulcer-like new organisms could be seen in small curves of the stomach body, with central ulcer and unclear boundary. The upper boundary was about 3cm away from the tooth line, and the lower boundary was about below the stomach body. Pathological examination showed abnormal cell mass, considering malignant tumor. Immunohistochemical examination showed AE1/AE3 (-), CD3 (scattered +), CD20 (scattered +), CD34 (-), CEA (-), Ki67 (number of positive cells 30%), S100 (+), SOX-10 (+), CD117 (-), DOG-1 (-), HMB45 (-), MART-1 (-), MPO (-), CD30 (-), CD21 (-), spindle cell tumor in mucosa, tending to neurogenic malignant tumor. Routine blood tests after admission showed: Hb 82.0 g/L. Laparoscopic exploration showed that the tumor was located in the small curve of the stomach body and invaded the serosa. It was of mass type, about 10 cm ×8 cm ×6 cm in size, and was closely related to the pancreatic envelope (Figures 2 and 3). Radical total gastrectomy and esophagojejunal Roux-en-Y anastomosis were performed. Postoperative pathological examination showed that there was 2 cm residual from the upper side and 6 cm residual from the lower side. A 10 cm ×7 cm ×6 cm ulcer-type mass was seen on the posterior wall of the small curve of the stomach, with gray-yellow section and brittle texture. Immunohistochemical examination showed: AE1/AE3 (-), Vimentin (-), Syn ((focal +), Desmin (-), S100 (+), SOX-10 (+), CD3 (-), CD20 (-), CD34 (vascular +), CD117 (-), CD31 (vascular +), Ki67 (positive cell count 50%), HMB45 (-), TFE3 (-), and malignant peripheral nerve sheath tumor (MPNST) was diagnosed (Figures 4, 5, 6). The patients were reviewed regularly after operation, and no recurrence or metastasis was observed until 23 May 2023.

A 47-year-old male was admitted with "persistent abdominal pain for 14 h". Blood pressure 84/54 mmHg, heart rate 104 beats/min. Physical examination: abdominal muscle tension, mobile voiced sound (+), periumbilical tenderness (+). Routine blood test showed: WBC 10.87×10⁹/L, Hb 81 g/L. Serum D-dimer 19.01 mg/L. Abdominal puncture evacuation does not coagulate. Whole abdominal CT examination showed that the wall thickness of the small intestine in the left middle abdomen showed concentric circles; The left adrenal gland was thickened and the density was not uniform, showing a slightly higher density shadow and a localized low density area (Figure 1). Preoperative diagnosis: intussusception, abdominal hemorrhage, acute diffuse peritonitis, hemorrhagic shock. An exploratory laparotomy was performed in the emergency department and about 2 000 ml of free bloody fluid was seen in the abdominal cavity. Hematoma of the mesenteric root of the small intestine, ascending colon, transverse colon and descending mesenteric root. A mass of about 3 cm in diameter was seen in the small intestine 15 cm away from the Trigger's ligament, which invaded the serous layer of the small intestine, and the distal intestinal tube was inserted into the tumor. Intussusception reduction of small intestine was performed, and 10 cm of small intestine and its mesangium at the distal and proximal ends of the tumor were removed. Active bleeding was still observed after flushing the abdominal cavity. When the gastrocolic ligament was opened, the capsule of the lower margin of the pancreas was ruptured, and a large number of blood clots were found in the retroperitoneum. After the hematoma was removed, a gel sponge was packed in the retroperitoneum to compress and stop bleeding. Pathological diagnosis: Clear cell sarcoma (CCS) of the small intestine. Postoperative adrenal enhanced CT examination showed that irregular mass shadow was seen in the left adrenal area, and the boundary with the left renal artery and left renal vein was unclear, which was suspected of metastasis (Figure 2). PET-CT examination showed that the metabolism of the left adrenal gland was increased, and metastasis was considered. Everolimus was given orally regularly after surgery. Upper gastrointestinal bleeding caused by tumor invasion of the posterior wall of the stomach 3 months after surgery was improved by conservative treatment. He died from rebleeding of upper gastrointestinal tract 5 months after surgery.