偶有鲜血粪便,体检发现肝内占位1周

对1例主诉为"体检发现肝内占位1周"的病例进行讨论.该患者入院诊断为乙状结肠癌合并肝脏多发转移.MDT讨论建议予患者术前介入局部灌注化疗后切除结肠癌原发病灶,术后化疗(奥沙利铂、亚叶酸钙、5-FU)结合靶向治疗(爱必妥).按该方案实施4个月后,患者肝转移灶缩小,行肝转移灶切除,术后予化疗.第2次术后8个月,肝脏再次出现转移灶,经讨论予射频治疗,更换化疗方案为FOLFIRI.2010年10月后,更改化疗方案为FOLFOX联合安维汀.随访至今,未发现复发.     

结肠癌术后5年，直肠癌术后2年，咳嗽咳痰、痰中带血半个月

对1例主诉为“结肠癌术后5年,直肠癌术后2年,咳嗽咳痰、痰中带血半个月”的患者进行病例讨论、该患者5年前曾行结肠癌根治术．2年前行直肠癌根治术．目前发现肺多发转移灶。通过多学科讨论．意见1认为该病例虽为肺部多发转移,但仍可完全切除．建议手术治疗：意见2认为该患者除了肺部．其他部位可能存在潜在转移灶．建议保守治疗．采用FORFIRI方案化疗该患者最终采取手术切除肺转移灶．术后采用FORFIRI方案辅助化疗。     

腹痛腹胀9d，肛门停止排气排粪3d

本文对1例主诉“腹痛腹胀9d,肛门停止排气排粪3d”的病例进行讨论。该例患者入院诊断结肠癌．伴急性肠梗阻。剖腹探查术中发现横结肠近肝曲癌．结肠完全梗阻．肝左叶转移瘤,行右半结肠切除．肝转移灶同期切除．回肠造瘘术。术后病理分期：T4aN1aM1a.术后辅助化疗12个周期．方案为FOLFOX6（奥沙利铂、亚叶酸钙加氟尿嘧啶）。辅助化疗结束后4个月．患者发现盆腔肿物。经MDT讨论．再次剖腹探查,发现左侧卵巢肿物,行肿物切除,术中病理示腺癌,行双侧附件联合全子宫切除术。术后3个月,肺CT复查时,发现有肺单发转移瘤,新辅助治疗4个周期．方案为Xelox（卡培他滨联合奥沙利铂）,再次经胸腔镜下右肺下叶肿物楔形切除术．术后病理示：转移性腺癌．术后Xelox方案辅助化疗6个周期．目前．该患者距第1次手术后30个月．化疗后12个月无肿瘤复发迹象。     

2例肝癌综合降期治疗的MDT讨论

目的探讨多学科协作团队(MDT)讨论在肝癌综合降期治疗中的价值。方法回顾性分析西南医科大学附属医院收治的2例经MDT讨论后采取综合治疗成功降期的肝癌患者的临床资料。结果病例1入院时诊断为肝癌伴双肺广泛转移,临床分期为Ⅲb期,经MDT讨论予以经肝动脉及支气管动脉灌注化疗栓塞,同时联合阿帕替尼进行降期治疗,目前患者双肺转移瘤完全消失,临床分期降为Ⅱb期,拟行根治性手术切除。病例2入院时诊断为肝癌,临床分期为Ⅰb期,术前检查提示肝储备功能较差,无法耐受半肝切除,经MDT讨论予以经动脉化疗栓塞联合阿帕替尼进行降期,同时予以保肝治疗,临床分期降为Ⅰa期,肝储备功能改善,并行腹腔镜右半肝切除,出院后随访3个月未见复发及转移。结论以MDT模式为基础的肝癌综合降期治疗可为无法行一期根治性手术的肝癌患者带来更好的临床结局。     

腹膜后巨大脂肪肉瘤一例报告并文献复习

目的探讨腹膜后巨大脂肪肉瘤术后腹腔复发患者多学科诊疗模式（MDT）。 方法回顾性分析腹膜后巨大脂肪肉瘤术后腹腔复发患者1例,男,45岁,复发肿瘤大小约10 cm×9 cm的临床病例资料及其两次诊治过程及MDT讨论要点分析,复习总结国内外相关文献。 结果患者行开放腹腔多发肿物切除+胆囊切除+大网膜切除术成功切除肿瘤,术后病理为去分化型脂肪内瘤。经治疗后恢复良好出院。一个半月后复发,继续靶向药物（阿帕替尼500 mg qd）治疗。 结论腹膜后脂肪肉瘤早期诊断困难,手术难度大,MDT及结合影像学检查及临床病理学特征可作出正确诊断,充分评估早期手术治疗可获得一定疗效,但去分化型脂肪内瘤总体预后不良。     

Ⅲ期骨肉瘤的治疗

目的探讨Ⅲ期骨肉瘤的诊断、治疗和预后。方法分析1989年12月至2003年12月收治的23例Ⅲ期肢体骨肉瘤患者,男14例,女9例;年龄16～31岁,平均22.4岁。肺转移15例,骨转移7例(跳跃转移5例,骨肉瘤病2例),同时存在肺和骨转移1例。经术前化疗,并行原发肿瘤和转移病灶的切除手术。结果经术前化疗,1例就诊时肺部有1个结节的患者转移瘤消失,1例同时存在肺和骨转移者,切除原发病灶后,出现多处转移,不能行转移灶切除手术;2例骨肉瘤病者仅切除原发病灶;5例跳跃转移者中的2例,切除原发和跳跃转移病灶后,各出现1个肺转移灶。16例行开胸术,其中6例再次出现肺转移灶而行二次开胸术,3例患者二次开胸术后出现肺外转移而放弃治疗。原发病灶与转移病灶的肿瘤坏死率差异无统计学意义。随访5～168个月(平均74.6个月),无瘤生存9例,带瘤生存4例,死亡10例。Cox模型分析提示转移病灶的数目与预后相关(P<0.05)。肺转移与跳跃转移病灶的Kaplan-Meier生存曲线经log-rank检验,差异无统计学意义。结论新辅助化疗及原发病灶和转移灶的手术切除是Ⅲ期骨肉瘤治疗的有效方法,首次肺转移灶切除采用胸骨正中切口,转移瘤的数目与预后相关。     

复杂泡型肝包虫根治性肝切除的MDT讨论

目的通过MDT讨论提高复杂泡型肝包虫病外科治疗的效果。方法对四川大学华西医院2016年3月收治的1例复杂泡型肝包虫患者在术前所进行的MDT讨论进行总结,并随访患者短期预后。结果患者术前CT扫描检查发现肝包虫病灶侵犯第1和第2肝门以及肝后下腔静脉,经MDT讨论后决定行根治性右三肝切除加胆肠吻合术,术后继续给予阿苯达唑治疗,出院后随访12个月未见肝包虫复发,且肝左外叶增生明显。结论复杂泡型肝包虫手术根治性切除率低,通过MDT多科讨论可提高外科治疗的有效性。     

肝移植治疗不可切除性直肠癌肝转移1例

本例不可切除性直肠癌肝转移患者确诊直肠癌时已合并肝内不可切除多发转移, 切除原发病灶后采用FOLFOX方案化疗+贝伐珠单抗靶向治疗。2年后患者肝内转移灶增多增大, 未见肝外转移灶及原位复发, 实施肝移植手术, 术后采用他克莫司+西罗莫司免疫抑制方案, 雷替曲塞化疗。肝移植3年后, 本例患者肿瘤复发, 总生存期为6年。本例提示, 对于不可切除性结直肠癌肝转移患者, 在未发现原位复发及其他远隔转移的情况下实施肝移植手术可以提高患者的生活质量并获得较好的预后。     

结直肠癌同时性肝转移手术时机的选择

目的 探讨可切除性结直肠癌同时性肝转移的手术时机.方法 回顾性分析2009年10月至2011年11月上海交通大学医学院附属仁济医院收治的5例结直肠癌伴同时性肝转移患者的临床资料,根据患者的情况分别行手术治疗+辅助化疗、新辅助化疗或靶向治疗.结果5例患者均行手术+术后辅助治疗.3例原发灶和肝转移灶可切除者,1例先行新辅助化疗,肝转移灶明显缩小后一期手术切除原发灶和肝转移灶,术后6个月MRI检查发现肝内复发;1例未行新辅助化疗,术后9个月CT检查发现肺内多发转移灶;1例因原发灶穿孔腹腔感染,先切除原发灶,术后化疗+靶向治疗,二期切除肝内转移灶,术后12个月CT检查发现肺内单发转移灶.其余2例因肝内多发性转移灶无法手术切除,仅切除原发灶,1例术后13个月死于骨转移;另1例行辅助化疗+靶向治疗,CT检查示肝内转移灶曾一度进行性缩小,但术后11个月开始肝内转移灶渐增多、增大.5例患者术后均行k-ras基因检测,除病例2的Condon 12位点为野生型、Condon 13位点为突变型外,其余患者均为野生型.结论新辅助化疗或新辅助化疗+靶向治疗的效果个体差异大,消灭体内微转移灶作用有限,首选一期手术切除原发灶和同时性肝转移灶有可能使患者获益最大.     

多学科联合治疗原发性巨大肝癌1例

目的探讨建立多学科综合治疗团队(multi-disciplinary team,MDT)在诊治原发性巨大肝癌中的作用和意义。方法对重庆医科大学附属第二医院肝胆外科于2018年7月收治的1例巨大肝癌患者展开MDT讨论,并复习相关文献,对巨块型肝癌的治疗方式进行总结。结果患者系老年男性,3年前初次就诊诊断为:肝右叶原发性肝细胞癌(小肝癌),拒绝行手术治疗,出院后自行口服中药。此次再次就诊时,患者的肝右叶肿瘤直径增大至10 cm左右,经MDT讨论后初步制定治疗方案为经肝动脉化疗栓塞(TACE)联合外科根治性手术。患者在14周内先后行2次TACE后,肝右叶肿瘤明显萎缩,肝左叶显著增生。于入院后5个月经再次MDT讨论后行经腹腔镜右半肝切除术。手术过程顺利,手术历时270 min,术中出血量约500 mL,予以输注悬浮红细胞400 mL。术后发生一过性肝功能衰竭,经保肝、对症支持治疗后于术后12 d康复出院。术后4个月复查腹部CT检查提示肝左叶明显增生,肿瘤无复发征象。继续随访。结论对于暂时无根治性手术指征的巨大肝癌患者,经过TACE治疗后部分患者可获得二期手术根治性切除机会。临床工作中应灵活应用MDT诊疗方式并贯彻巨大肝癌患者治疗的始终,为患者制定最佳的治疗方案。     

Surgical resection for liver metastasis and local recurrence of pheochromocytoma 16 years after primary surgery: A case report

Introduction and importancePheochromocytomas arise from the adrenal medulla and are rare. Pheochromocytomas metastasize to bone, lung and liver, and surgery might be the curative treatment. However, few cases are detected when they are resectable lesions because of difficulty in diagnosis and rapid growth. We herein report a patient who underwent resection of liver metastasis and local recurrence of pheochromocytoma.Case presentationA 74-year-old woman visited our hospital for treatment for liver and retroperitoneal tumors. She had undergone left adrenal gland resection for pheochromocytoma 16 years earlier. Eleven years after primary surgery, breast cancer was diagnosed and resected. During the breast cancer follow-up, a liver tumor was identified with computed tomography. Breast cancer recurrence and metastasis were considered, so chemotherapy was administered first. However, the liver tumor gradually enlarged, and another lesion appeared in the retroperitoneum. The tumors were diagnosed as pheochromocytoma recurrence using ¹²³I-metaiodobenzylguanidine scintigraphy, and she underwent resection of the local recurrence and liver metastasis. She was discharged on postoperative day 25 without complications, and no evidence of recurrence occurred more than 3.5 years postoperatively.Clinical discussionAll pheochromocytomas have metastatic potential; however, there are no reliable markers to predict malignancy. Early detection of recurrence by regular imaging and complete resection are important in the treatment. If the recurrence was oligometastasis and tumor growth is slow, surgical resection may be eligible.ConclusionA favorable outcome resulted from complete resection for liver metastasis and local recurrence of pheochromocytoma.     

Laparoscopic intra-arterial catheter implantation for regional chemotherapy of liver metastasis

In patients with unresectable metastatic disease confined to the liver, intra-arterial regional chemotherapy with implantable systems is an attractive option. Since April 1992, laparoscopic colorectal resections have been performed in our institution. Within this series of patients, three cases with bilateral liver metastasis from colon cancer were observed and underwent laparoscopic intra-arterial catheter implantation in the gastroduodenal artery for regional chemotherapy. In two patients the metastases were synchronous, and in both cases a laparoscopic colon resection was also performed, for tumors located in the cecum and in the sigmoid colon, respectively. The laparoscopic surgical technique for intra-arterial catheter implantation is described in detail. In this limited experience the procedure, from a purely technical point of view, was not considered difficult and was completed in 70 min on average. No complications were observed and the patient with metachronous liver metastasis was discharged on 3rd postoperative day.     

Long-term survival after surgical resection of liver metastasis from lung cancer

Lung cancer metastasis to the liver indicates a poor prognosis, and the majority of patients with metastatic disease to the liver are not indicated for surgery because of the number or distribution of metastases or the presence of extrahepatic disease. We herein describe a case of long-term survival after a surgical resection of liver metastases from lung cancer. Six months after surgery for Stage IB primary lung adenocarcinoma, a 71-year-old male was found to have a metastatic tumor in his liver. A hepatic resection for the metastatic tumor and another small metastatic foci found intraoperatively was carried out, and the tumors were pathologically diagnosed as liver metastases from lung cancer. The patient is presently alive and well without recurrence, as of 5 years and 2 months after the liver resection. This is the first report of the successful surgical treatment of liver metastasis from lung cancer.     

大肠癌同时伴肝转移67例临床治疗分析

目的探讨大肠癌同时伴肝转移的外科治疗效果。方法回顾性分析2003年1月至2007年12月67例大肠癌伴肝转移经外科手术治疗的临床资料。结果13例全肝多个转移灶病人行原发病灶切除加门静脉化疗泵植入术,余54例行原发灶和肝转移灶同期切除。本组术后1、2、3年生存率分别为91．0％（61／67）、71．6％（48／67）和40．3％（27／67）。生存时间最短为8个月,最长为57个月,中位生存期为30．2个月。结论大肠癌肝转移病人行原发灶和肝转移灶同期切除辅以局部及全身化疗,亦可取得满意效果。     

An effective chemotherapy regimen for liver metastasis from retroperitoneal fibrosarcoma: Report of a case

Retroperitoneal fibrosarcoma is a rare disease that has proven difficult to treat due to its high incidence of postoperative local recurrence. We recently experienced a patient in whom retroperitoneal fibrosarcoma was followed by liver metastasis without local recurrence. A 34-year-old woman who initially presented with right upper quadrant pain was found to have a retroperitoneal tumor by diagnostic imaging techniques. Extirpation of the tumor was performed and the histopathological diagnosis was fibrosarcoma. A solitary metastasis was detected in the lateral segment 1 year after this operation and a lateral segmentectomy was carried out; however, a short time later, multiple liver metastases were found. Initially, ethanol injections were given with little effect, following which CYVADIC chemotherapy, consisting of cyclophosphamide, vincristine, farmorubicin, and dacarbazine was administered. An excellent responsiveness without severe toxicity was achieved after five cycles, with a significant reduction in tumor size, being estimated as a complete response. Thus, we consider that this chemotherapy regimen could be a promising mode of treatment for liver metastasis from retroperitoneal fibrosarcoma without local recurrence.     

Long-Term Survival Achieved by Resection of Metastases in the Liver and Lung in a Patient with Recurrent Colonic Cancer: Report of a Case

A 58-year-old man who underwent a potentially curative resection of cancer of the sigmoid colon at another hospital was subsequently followed up at our hospital. A lateral segmentectomy was per-formed for a solitary hepatic metastasis, and partial resection of right S1 was later carried out for a pulmonary metastasis. Another pulmonary metastasis was found 6 years after his third operation and to minimize the area to be resected, bronchial arterial infusion chemotherapy was performed twice. A 51% reduction in the size of the tumor was achieved, so a right upper lobectomy and wedge resection of the bronchus were performed. The patient remains alive 14 years after the initial resection of colonic cancer. This case is considered noteworthy because it demonstrates the potential effectiveness of local adjuvant chemotherapy and the possibility of extended survival in a patient who has undergone resection of both hepatic and pulmonary metastases from colonic cancer. Received: June 28, 1999 / Accepted: May 30, 2000     

A case with synchronous multiple liver metastases from gastric carcinoma: postoperative long-term disease-free survival

Purpose  We herein report a case with synchronous multiple liver metastases from gastric carcinoma surviving disease-free for more than 10 years after hepatic resection. Methods  A 64-year-old male admitted to our hospital because of constitutional wariness. Preoperative diagnosis was type 1 gastric cancer at the lower third of the stomach and multiple metastases of both hepatic lobes. After we performed distal gastrectomy with regional lymphadenectomy and wedge hepatic resection for eight metastatic liver tumors, he received 5-fluoropyrimidine and platinum-based adjuvant chemotherapy during the early postoperative period. Results  The pathologic examination revealed moderately differentiated gastric adenocarcinoma with regional lymph node metastasis and multiple liver metastases. The postoperative course was uneventful and the patient is doing well without disease recurrence after more than 10 years following surgery. Conclusion  To the best of our knowledge, this patient is the longest disease-free survivor after liver resection for synchronous multiple liver metastases from advanced gastric cancer. In this modern era of developing liver surgery and adjuvant chemotherapy, combination therapy of aggressive surgery and early postoperative adjuvant chemotherapy for advanced gastric cancer with liver metastasis may allow long-term survival in selected patients.     

新辅助化疗方案在可切除结肠癌中的应用进展

新辅助化疗（NACT）是指针对潜在可根治切除的肿瘤患者,以消除微转移、降低肿瘤分期和手术难度、改善术后局部复发和远处转移等为目的,在肿瘤手术切除或放疗之前,先予以全身化疗,待手术或放疗之后继续完成全程化疗的综合方案。结肠癌是最常见的癌症之一,肿瘤根治性切除联合术后辅助化疗是临床潜在可根治切除结肠癌的主要治疗方式。虽然这种治疗模式较前显著改善了患者的预后,但术后局部复发和远处转移仍是患者最主要的致死因素。近年来NACT方案开始被引入局部进展期结肠癌和原发灶可切除的肝转移患者等潜在可根治切除结肠癌患者的治疗。然而,结肠癌患者是否适合NACT及其方案的选择还存在较大的争议。笔者就局部进展期结肠癌、可切除结肠癌肝转移等在NACT中的进展与争议,以及影像学检查对NACT的作用作一综述。     

Metastatic Bednar tumor (pigmented dermatofibrosarcoma protuberans) with fibrosarcomatous change: a case report

Bednar tumor (pigmented dermatofibrosarcoma protuberans) is a variant of dermatofibrosarcoma protuberans (DFSP) that constitutes 5% of all DFSP and has a very low rate of distant metastases. We encountered a rare case of Bednar tumor with multiple different distant metastases. A 51-year-old man, who had had a history of mass resection in his left shoulder 4 years previously, was referred to our institution, complaining of a recurrence of the shoulder mass. The histological diagnosis of primary tumor was Bednar tumor, and he underwent resectional surgery for the recurrent lesion. A second local relapse, lung metastasis, retroperitoneal metastasis, and metastasis to the sigmoid colon have occurred. The recurrence lesion and all metastatic lesions were resected surgically. The histological features of all specimens showed fibrosarcomatous change. Seven months after the last surgical resection, the tumor recurred and the patient died of multiple abdominal metastases 10 years after the first surgical treatment.