肝脏放射影像诊断与鉴别诊断（下）

三、肝转移瘤的螺旋CT表现 肝转移瘤临床多数有原发瘤病史，以多发病灶多见，病理组织学改变多数为转移癌，少数为转移性肉瘤。原发性肿瘤常来自结肠、直肠、胃、胰腺、肺、乳腺及鼻咽等部位。     

胃转移性恶性黑色素瘤1例

目的:探讨胃转移性恶性黑色素瘤的临床病理特征、鉴别诊断及治疗与预后.方法:报道1例胃转移性恶性黑色素瘤, 取胃活检经HE染色及免疫组织化学染色诊断. 并复习国内外相关文献.结果:活检组织切片光镜下见胃黏膜固有层弥漫浸润的小细胞, 部分呈巢状排列, 细胞胞质较丰富, 核偏位, 核仁大而明显, 仅少部分细胞的胞质内可见黑色素颗粒. 免疫组织化学染色显示vimentin(+), S-100(+), HMB45(+),AE1/AE3(-). 病理诊断为胃(底、体交界)恶性黑色素瘤, 结合病史考虑为转移性.结论:恶性黑色素瘤转移到胃时没有典型临床表现, 若出现与原发肿瘤不相关的症状, 要高度怀疑转移. 主要与胃原发性肿瘤鉴别. 预后差. 对远处转移的最初部位为胃的患者, 进行根治性手术能有效缓解症状, 并可能对延长生存期有帮助.     

胃粘膜“一点癌”的X线胃镜诊断与病理组织学对比观察

收治经胃钡气双重造影、胃镜检查、胃粘膜活检病理论断为胃癌，而手术切除标本节段连续切片组织学检查未再发现癌组织的胃粘膜“一点癌”８例。对其诊断标准、胃钡气双重造影、胃镜诊断价值及其肠上皮化生的关系及预后进行了讨论。     

胃癌患者术后端粒长度变化与预后观察

目的分析原发性胃癌组织中的端粒长度变化与患者术后预后的关系.方法以琼脂糖DNA杂交检测58例手术切除的原发性胃癌与邻近胃组织中端粒限制性内切酶片段(TRF)的长度,并观察术后患者的临床状况及生存期.结果发现原发性胃癌组织中的平均TRF长度均比相应邻近胃组织缩短.其中原发性胃癌有14例TRF缩短,5例TRF延长;且在胃癌中TRF的这种异常状态与肿瘤的大小、转移、临床病理分期及患者的生存率相一致.结论 TRF长度不仅参与了胃癌的发生与发展,而且也为胃癌的诊断及预后判断提供了一种新的手段.     

胃肠道多原发恶性肿瘤35例分析

目的 探讨胃肠道多原发恶性肿瘤的临床病理特点。方法 通过计算机病案管理系统检索我院近５年手术治疗的胃肠道恶性肿瘤８２０例,其中３５例经病理确诊为胃肠道多原发癌,发生率为４．３％。男女之比为２．５：１。结果 多原发大肠癌２５例,胃及胃肠多原发癌１０例;同时癌２３例,异时癌１２例;胃多原发癌的眼病年龄、病程、组织分化不良程度均高于大肠多原发癌及胃肠多原发癌。胃肠道多原发癌发病年龄轻,癌灶分布以右半结肠     

库肯勃瘤12例临床分析

目的探讨Krukenberg瘤的临床特点及诊断治疗方法。方法回顾性分析我院2001—2007年收治并行手术治疗、经病理检查确诊的12例Krukenberg瘤临床资料。结果Krukenberg瘤多发于中年女性，双侧卵巢受累多见（10／12）。原发病灶多为低分化腺癌及黏液腺癌。肿瘤分期多为中晚期（Ⅲ、Ⅳ期胃癌6例，DukesC、D期大肠癌6例）。恶性程度高，预后差。平均生存期短，不超过2年。结论Krukenberg瘤多发生于低分化的中晚期胃肠癌转移，其临床症状往往比胃肠原发灶更为突出，呙而易于误诊或漏诊，因此，发现卵巢肿瘤应注意排除转移癌可能，确诊卵巢转移癌应常规行胃肠道检查排除Krukenberg瘤，治疗首选手术，常规切除原发胃肠病灶及子宫双附件并术后化疗。但疗效不甚满意，生存期不到2年。     

胃肠道腺癌腹壁种植性转移患者的临床病理特征及预后分析

目的 分析胃肠道腺癌腹壁种植性转移患者的临床病理特征及预后。方法 回顾性分析青岛大学附属威海市中心医院2017年7月至2020年12月收治的11例胃肠道腺癌腹壁种植性转移患者的临床资料,总结其病理检查结果及临床预后情况。结果 11例患者中,原发病为胃癌4例,肠癌7例。4例胃癌病变部位均为远端胃。7例肠癌中病灶位于右半结肠5例,左半结肠1例,乙状结肠1例。11例患者中10例原发肿瘤组织病理学检查结果均显示为中-低分化腺癌,9例患者病理学分期为T3期及以上。11例患者发现腹壁转移癌复发距首次手术时间为2～49个月,中位时间为17.9个月,与患者术后是否行放疗、化疗无明显关联。转移性肿瘤与原发肿瘤病理组织学形态几乎一致。腹壁转移术后患者生存时间为2～20个月,中位生存时间为8.7个月。1例失访,1例至今存活,其余患者均因肿瘤广泛转移而死亡。结论 腹壁种植性转移肿瘤的组织学形态与原发肿瘤几乎一致。原发肿瘤分化差、病理学分期较晚,提示肿瘤发展进入晚期阶段,建议患者术后定期复诊体检,及早发现种植性转移病灶。临床医师应根据患者的组织病理学检查结果和全身情况等制定适宜的治疗方案。     

不同类型胃肠类癌的临床分析与比较

目的　分析不同病理类型胃肠类癌的临床特点 ,以提高对该类疾病的认识与诊治水平。方法　回顾性分析北京协和医院 1982～ 2 0 0 3年的病理分类胃肠类癌 36例 ,并根据世界卫生组织肿瘤国际组织学新分类标准 (2 0 0 0 )分为恶性类癌、类癌 2组 ;比较 2组类癌的发病年龄特点、临床表现差异、转移情况、在消化系统内分泌肿瘤和肿瘤中的发病比例以及确诊的主要手段等。结果 (1)患病比 :胃肠类癌占同期消化系统肿瘤的 0 .35 % ,占同期消化系统内分泌肿瘤的 10 .2 0 %。 (2 )年龄 :恶性类癌发病年龄为 (5 5 .8± 12 .8)岁 ,类癌发病年龄为 (45 .1± 12 .0 )岁 ,前者明显高于后者。 (3)部位 :类癌多发于直肠 (6 3% ) ,而发生于胃 (35 % )与结肠 (2 5 % )应考虑恶性类癌。(4)转移 :淋巴结与肝脏是恶性类癌常见的转移部位 (6 0 % ) ;胃与结肠部位的恶性类癌转移率明显高于直肠与其他部位。(5 )检查手段 :胃肠类癌的发现多依赖内镜检查 ,但直肠指检不应偏废。 (6 )类癌综合征的发生率低 ,恶性类癌多见。结论　胃肠类癌在消化系统肿瘤中的发病率较低 ,但并非罕见 ;直肠是类癌的好发部位 ,胃与结肠是恶性类癌的好发部位 ;恶性类癌发病年龄较大且易伴肝与淋巴结转移 ,类癌综合征多见于恶性类癌。     

前列腺癌睾丸摘除术后原发性肺癌1例报道并文献复习

目的加深对多原发癌的认识，避免误诊、误治。方法对1例经前列腺活检和经皮肺活检证实的前列腺癌术后原发性肺癌患者的病史、临床表现、胸部CT和病理资料，结合有关文献进行分析。结果病理学检查是诊断多原发癌的重要方法，免疫组化能提高诊断的特异性。对于确诊为恶性肿瘤的患者出现其他部位占位，应排除多原发癌的可能。结论明确诊断为多原发癌对于患者的治疗及预后有很大帮助。     

消化系神经内分泌癌及文献分析209例

目的:探讨消化系统神经内分泌癌(NEC)发生部位、临床表现、内镜及影像学特点、病理特征、诊断和鉴别诊断、治疗及预后.方法:将我院2000-2005年收治的7例NEC病例和文献检索的202例病例分为A、B两组,分别探讨消化系统NEC临床特点,治疗和预后.结果:消化系统NEC临床表现多为无功能NEC,以局部占位及消耗症状为主,壶腹周围NEC可以急性胰腺炎发作为首发表现;有功能的NEC例数约占2.4%.大小在0.5-13.0 cm,分为典型类癌、不典型类癌和小细胞癌,确诊需要进行突触素(Syn)、细胞角蛋白(CK)、神经特异性烯醇化酶(NSE)、嗜铬素A(CgA)、上皮膜抗原(EMA)等的免疫组化检查和(或)电镜检查发现神经内分泌颗粒(NSG).以手术治疗为主,辅以化疗、放疗,必要时栓塞化疗,也可以辅以生物治疗.对于有功能的NEC,首先需要控制因激素分泌过多所致的相关类癌综合征.小细胞癌预后最差,不典型类癌次之,类癌预后较好,5 a生存率可达70%.肿瘤的大小、转移与否、手术切除是否彻底等等亦是影响预后的重要因素.结论:消化系统NEC发生部位以胃、胰腺、直肠等部位多见,临床表现多样,少数可有类癌综合征表现,治疗方法以手术为主,辅以放化疗及生物治疗或介入治疗,根据病理类型判断其恶性程度和预后.     

Metastatic tumors to the stomach： Clinical and endoscopic features

INTRODUCTION The stomach is an unusual site for metastasis. There have been several published reports on metastatic lesions in the stomach. However, information on gastric duodenal metastases is generally limited to single case reports. The present study …     

Widespread Metastasis to the Stomach 10 Years After Primary Breast Cancer: A case report and review of the literature

Rationale:Breast cancer is a common malignant tumor. The most common metastatic sites of breast cancer are the bone, brain, liver and lung, and gastrointestinal metastases are rare. Considering that the median time interval from the initial breast cancer diagnosis to stomach metastasis is 77.5 months, gastrointestinal metastases are rarely observed 10 years after primary breast cancer.Patient concerns:Here, we present a 63-year-old female with unusual endoscopy results that revealed scattered polyps and mucosal infiltration throughout the stomach, which were later confirmed to be metastatic lobular carcinoma of the breast that had been surgically removed 10 years earlier.Diagnosis:The patient was diagnosed with gastric metastases of breast cancer by immunohistochemistry.Interventions:The patient underwent endocrine therapy with palbociclib and tamoxifen.Outcomes:After 1 year of endocrine therapy, the symptoms of upper abdominal discomfort and fatigue were relieved and a new gastroscopy revealed there had been no significant progression of the gastric metastasis. According to the Response Evaluation Criteria in Solid Tumors (RECIST), the patient reached a state of stable disease.Lessons:Gastric metastases of breast cancer are rare in the clinical setting. However, considering the possibility of gastric metastases from breast cancer and performing an upper endoscopy are crucial for patients who present with any subtle gastric symptoms and have a past medical history of breast cancer, even if the breast cancer occurred more than 10 years ago.     

Primary Gastric Actinomycosis: A Case Report and Review of the Literature

A case of primary gastric actinomycosis presenting as a bleeding gastric tumor is reported. The diagnosis of this infection of the stomach is difficult and may often be established only by histological examination. If the disease is recognized, the prognosis is good because antibiotic treatment is very effective. Recent literature findings are reviewed and clinical and endoscopic features are compared.     

肝脏神经内分泌肿瘤报道1例并文献回顾

背景肝脏可疑恶性肿瘤行手术切除后病理诊断肝脏神经内分泌肿瘤(hepatic neuroendocrin neoplasmas,HNENs)病例,此病例易与肝癌混淆,了解转移性和原发性HNENs的特性,对临床治疗手段有很好的指导意义.病例简介一名56岁男性患者体检发现肝脏占位性病变复查腹部增强CT提示肝脏转移性恶性肿瘤可能;胃部包块考虑良性.手术切除胃部包块并行术中冰冻病理检查提示梭形细胞肿瘤;完整切除肝脏包块术后石蜡病理检查结果提示NENs(G2),患者术后恢复佳.结论本文报道了一例HNENs,考虑转移性.术前诊断不能排除肝脏转移性恶性肿瘤可能.通过对患者病情的详细分析,最终行手术切除治疗并行病理检查确诊.同时我们对HNENs相关文献进行了分析,进一步了解原发和转移性HNENs的临床特征、治疗方案以及预后,以期对此类疾病有更深入的了解,对临床治疗方案决策做证据支撑作用.     

Simultaneous resection of pancreas and liver metastases from different metachronous primary cancers

Resection of a pancreatic head tumor and partial resection of the liver for metastatic lesions were carried out simultaneously in a 72‐year‐old woman. The patient had a history of two previous operations, right nephrectomy for renal cell carcinoma (clear cell type), done 14 years previously, and an Autincloss procedure for cancer of the left breast (solid tubular carcinoma); (T1N0M0; stage I) done 7 years previously. At the current presentation, preoperative radiographic examination showed a hypervascular tumor in each of the pancreatic and hepatic lesions, but with different patterns. On the basis of histological findings in the two resected specimens, it was difficult to establish whether the hepatic tumor originated from the renal cell carcinoma or the breast cancer, but postoperative immunohistochemical studies for carcinoembryonic antigen (CEA), estrogen receptors, and gross cystic disease fluid protein (GCDFP)‐15 showed that the pancreatic tumor had metastasized from the renal cell carcinoma, and the liver tumor from the breast cancer. The immunohistochemical investigation of different markers thus proved to be useful in making the final diagnosis of metastatic lesions from different and metachronous cancers.     

Protein induced by vitamin K absence or antagonist II-producing gastric cancer

Protein induced by vitamin K absence or antagonist II (PIVKA-II) is a putative specific marker of hepatocellular carcinoma (HCC), but it may also be produced by a small number of gastric cancers. To date, 16 cases of PIVKA-II-producing gastric cancer have been reported, 2 of which were reported by us and all of which were identified in Japan. There are no symptoms specific to PIVKA-II-producing gastric cancer, and the representative clinical symptoms are general fatigue, appetite loss, and upper abdominal pain. Serum alpha-fetoprotein (AFP) levels are also increased in almost all cases. Liver metastasis is observed in approximately 80% of cases and portal vein tumor thrombus is observed in approximately 20% of cases. Differential diagnosis between metastatic liver tumor and HCC is often difficult. Grossly, almost all cases appear as advanced gastric cancer. Histologically, a hepatoid pattern is observed in many cases, in addition to a moderately to poorly differentiated adenocarcinoma component. The production of PIVKA-II and AFP is usually confirmed using immunohistochemical staining. Treatment and prognosis largely depends on the existence of liver metastasis, and the prognosis of patients with liver metastasis is very poor. PIVKA-II may be produced during the hepatocellularmetaplasia of the tumor cells.     

Simultaneous adenocarcinoma and leiomyoma of the stomach presenting as a collision tumor

A 68-year old Japanese man was referred to the Cancer Institute Hospital for the treatment of a rectal cancer. Preoperative esophagogastroduodenoscopy revealed a submucosal tumor with ulcer formation near the esophagogastric junction of the stomach. The initial treatment strategy was to perform a proximal gastrectomy with limited lymph node dissection as well as a simultaneous anterior resection. However, histopathological examination of a biopsy specimen of the submucosal tumor revealed a moderately differentiated adenocarcinoma, and therefore a total gastrectomy with D2 lymph node dissection was performed. Histopathological examination of the resected specimen revealed both adenocarcinoma and leiomyoma presenting as a collision tumor. Preoperative accurate histopathological diagnosis of a gastric submucosal tumor is generally difficult. Consequently, surgical resection of large gastric submucosal tumors may be indicated in the absence of histopathological confirmation of the diagnosis. However, in this case preoperative histopathological diagnosis enabled surgeons to perform the appropriate surgery. We conclude that to determine the appropriate treatment strategy, preoperative histopathological examination of tumors should be performed even in a case of suspected submucosal tumor, particularly if mucosal ulceration is present.     

Primary small cell carcinoma of the stomach

We report on an 80-year-old man with primary gastric small cell carcinoma (SmCC). He was admitted to hospital with hematemesis. An upper gastrointestinal examination revealed an irregularly ulcerated tumor, 60 mm in diameter, on the lesser curvature of the stomach body extending to the cardia. An endoscopic biopsy revealed a solid proliferation of intermediate-sized tumor cells with hyperchromatic nuclei and scanty cytoplasm. Immunohistochemically, the neoplastic cells were positive for neuron-specific enolase and chromogranin A, but negative for carcinoembryonic antigen. No tumor was detected on examination of the chest. Therefore, primary gastric SmCC was diagnosed preoperatively. To date, only 38 cases of primary gastric SmCC, including our case, have been reported. By using endoscopic biopsy, approximately two-thirds of cases have been diagnosed incorrectly. In the reported cases of gastric SmCC, the endoscopic findings frequently indicated a submucosal tumor. Gastric SmCC is clinically aggressive and has an extremely poor prognosis, even when discovered at an early stage. Most patients with gastric SmCC die within 1 year of diagnosis. Although a standard treatment for gastric SmCC has not been established, intensive chemotherapy should be considered to promote long-term survival. We believe that careful examination, including immunohistochemical investigation, is necessary for determining the therapeutic strategy whenever gastric SmCC is suspected during endoscopy.     

Hepatic reactive lymphoid hyperplasia in a patient with primary biliary cirrhosis

Reactive lymphoid hyperplasia (RLH) of the liver is an extremely rare lesion characterized by the proliferation of non-neoplastic lymphocytes forming follicles. Hepatic RLH is known to be associated with gastrointestinal carcinoma and autoimmune diseases including primary biliary cirrhosis (PBC). We report a case of hepatic RLH in a patient with PBC and gastric cancer. A 68 year old Japanese woman with a 10 year history of liver enzyme abnormality was admitted. Laboratory testing revealed that her anti-mitochondrial antibody was markedly elevated. Five mo after the diagnosis of PBC, she was found to have gastric cancer. Abdominal computed tomography disclosed a liver nodule in S8, suggesting metastatic gastric carcinoma. Histopathologically, the resected liver lesion comprised of a nodular proliferation of small lymphocytes with lymphoid follicles. This is the first reported case of hepatic RLH in a patient with both PBC and gastric cancer. Pre-operative diagnosis of hepatic RLH by clinical imaging is extremely difficult. Therefore, a needle biopsy could be useful to make a diagnosis of hepatic RLH, especially to differentiate from metastatic gastrointestinal carcinoma.