经自然腔道腹腔内镜检查在腹膜转移癌诊断中的应用

目的 评价经自然腔道内镜手术(NOTES)在腹膜转移癌诊断中的价值.方法 回顾性分析2007年4月至2010年10月收治的32例经病理活检确诊的腹膜转移癌患者的临床资料,胃肠镜、影像学、腹水细胞学和经胃腹腔内镜检查结果.结果 32例患者经消化内镜检查发现消化道肿瘤9例(28.1%),经影像学检查疑诊卵巢占位性病变8例(25.O%)、胰腺癌2例(6.3%)、原发性肝癌2例(6.3%)、胆管细胞癌1例(3.1%),但均未确诊有腹膜转移癌.腹水细胞学检阳性6例(18.8%).经胃腹腔内镜检查及病理活检后均确诊腹膜转移癌.32例腹膜转移癌患者的经胃腹腔内镜下腹膜病变表现为5型:(1)肿块型3例(9.4%):局部腹膜壁层单个或多个直径≥2 cm的肿物;(2)结节型5例(15.6%):腹膜壁层多个大小不等的结节性病变;(3)溃疡型1例(3.1%):腹膜壁层溃疡性病变;(4)网膜包裹型1例(3.1%):网膜挛缩,与肠管粘连,包裹肠管使之成为饼状;(5)混合型22例(68.8%):同时存在2种或2种以上类型.结论 经胃腹腔内镜检查及组织活检对确诊腹膜转移癌及其内镜表现类型具有重要价值.

Abstract：

Objective To evaluate the value of peritoneoscopy via natural orifice transluminal endoscopic surgery(NOTES)in the diagnosis of patients with peritoneal carcinomatosis.Methods A total of 32 patients with peritoneal carcinomatosis were diagnosed by histological examination of biopsies at our hospital from April 2007 to October 2010.Their data of clinical manifestations,gastroscopy,colonoscopy,abdominal ultrasonography,abdominal computed tomography,magnetic resonance imaging,ascitic cytology and transgastric peritoneoscopy via NOTES were analyzed retrospectively.Results Among them,gastrointestinal cancers were diagnosed by digestive endoscopy in 9 cases(28.1%).And ovarian lesions in 8 cases(25.0%),pancreatic cancer in 2 cases(6.3%),primary liver cancer in 2 cases(6.3%)and bile duct carcinoma in 1 case(3.1%)were suspected according to imaging examinations.No peritoneal carcinomatosis was found by digestive endoscopy or imaging examinations.Ascitic cytology was positive in 6 cases(18.8%).Peritoneal carcinomatosis was diagnosed by transgastric peritoneoscopy via NOTES with histological examination of biopsies in all patients.Their findings of transgastric peritoneoscopy via NOTES were divided into 5 types,i.e.,mass type(n=3,9.4%),nodular type(n=5,15.6%),ulcerative type (n=1,3.1%),omentum-embracing type(n=1,3.1%)and mixture type(n=22,68.8%).Conclusion Transgastric peritoneoscopy via NOTES with histological examination of biopsies has important value in the pathologic diagnosis and the endoscopic typing of peritoneal carcinomatosis.     

结直肠癌腹膜转移癌的诊治进展

结直肠癌腹膜转移癌（ CRC PC）的诊断和治疗已经取得很大进展。过去CRC PC被认为是肿瘤晚期并全身转移的表现,一般只行姑息治疗,预后差;如今适当的CRC PC患者经过积极的治疗可显著改善预后。肿瘤细胞减灭术（ CRS）＋腹腔热灌注化疗（ HIPEC）已成为治疗CRC PC的有效手段。该文综述近年来CRC PC的诊治进展。     

A man with thyrotoxicosis, lymphoma and thymic hyperplasia.

We report a case of non-Hodgkin's lymphoma of Burkitt's type with thyrotoxicosis and thymic hyperplasia in a 27-year old man. As far as we are aware this is the first reported case of Burkitt's lymphoma, thymic hyperplasia and thyrotoxicosis occurring in the same patient.     

Hodgkin's disease after treatment for Burkitt's lymphoma: case report

Hodgkin's disease and non-Hodgkin's lymphomas are interrelated disorders which have been reported to occur either simultaneously or sequentially in the same patient. We report here the development of nodular sclerosing type Hodgkin's disease in a patient two decades after successful treatment for Burkitt's lymphoma with cyclophosphomide and abdominal resection (AR). While the onset of symptoms after treatment for Burkitt's lymphoma was seven years definitive diagnosis of Hodgkin's disease was only made 22 years after the initial diagnosis of Burkitt's lymphoma. The recurrent and solitary nature ofthe lymphadenopathy and the fact that it was initially reported as reactive hyperplasia is typical of nodular lymphocyte predominant Hodgkin's disease. We believe that there was a transitory period of the malignancy as nodular lymphocyte predominant Hodgkin's disease.     

腹腔热灌注化疗联合静脉化疗与单纯静脉化疗治疗腹腔转移癌的自身对照研究

目的:对比腹腔热灌注化疗联合静脉化疗与单纯静脉化疗治疗腹腔转移癌的不良反应以及疗效。方法:采用自身对照方法,选取56例序贯进行腹腔热灌注化疗联合静脉化疗和单纯静脉化疗患者,分别观察腹腔热灌注化疗联合静脉化疗和单纯静脉化疗的毒副反应并对比,同时随访生存情况。结果:腹腔热灌注化疗联合静脉化疗与单纯静脉化疗相比,腹痛发生率较高(25%与8.9%),Ⅲ+Ⅳ白细胞减少较低(16.%与21%),而胃肠道反应比较,差异无统计学意义(P>0.05),中位总生存期为22个月。结论:对比单纯静脉化疗,腹腔热灌注化疗联合静脉化疗治疗腹腔转移癌安全有效,但腹痛发生率较高。     

腹腔和腹膜后不同性质淋巴结病变的CT诊

目的：研究不同性质腹腔、腹膜后淋巴结病变的CT表现特点以提高CT诊断的准确性,方法：对9例腹腔和腹膜后淋巴结结核、8例非Hodgkin淋巴瘤（NHL）、7例Hodgkin病（HD）及6例淋巴结转移的治疗前CT图像资料进行对照研究。结果：（1）病灶周边出现 薄且厚薄均匀的高密度环状强化带,强化环内结构无强化且近似水样密度而致病灶呈“囊肿样”表现,为结核的CT特征;（2）病灶融合呈大块状且均匀强化,包绕高密度的大血管呈“夹心饼样”表现,为恶性淋巴瘤的CT特征;（3）转移瘤病灶多孤立、散在分布。结论：（1）病灶的不同增强CT特点对鉴别诊断具有重要意义,病灶的平扫密度特点对鉴别诊断具有参考价值,（2）病灶的大小及分布范围等鉴别诊断意义不大。     

持续性非卧床腹膜透析患者的临床特征及影响腹膜转运功能的相关因素

目的：观察不同腹膜转运类型的持续性非卧床腹膜透析(continuous ambulatory peritoneal dialysis,CAPD)患 者的临床特征,探讨影响腹膜转运功能的相关因素。方法：回顾性总结158例CAPD患者的临床资料,根据腹膜平衡 试验评价患者的腹膜转运功能并将其分为高平均转运+高转运组(A组,n=84)和低平均转运+低转运组(B组,n=74), 并对两组患者的人口学资料、临床生物化学指标以及心血管并发症情况进行比较;应用logistic回归分析寻找影响患 者腹膜转运功能的相关因素。结果：B组患者血清白蛋白(albumin,ALB)水平显著高于A组(P<0.05)。A组患者的4 h透 析液肌酐与血肌酐浓度的比值(dialysate/plasma creatinine,D/Pcr)、超敏C反应蛋白(high-sensitivity C-reactive protein,hs- CRP)、体重指数(body mass index,BMI)及心血管并发症的发生率均显著高于B组(均P<0.05)。相关分析显示：D/Pcr与 BMI,hs-CRP和心血管并发症呈正相关(分别r=0.179,0.373和0.426,均P<0.05);与ALB呈负相关(r=–0.393,P<0.01)。 Logistic回归分析显示：高BMI(OR=1.178,P<0.05)、心血管并发症(OR=5.035,P<0.01)以及低血清ALB(OR=0.852, P<0.01)为患者腹膜高转运的危险因素。结论：腹膜透析患者血清ALB水平、BMI和心血管并发症与腹膜高转运相关, 可作为预估患者腹膜转运功能的参考指标。     

兔VX2腹膜转移癌模型的建立及CT表现

目的:建立稳定的动物腹膜转移癌模型,分析移植性腹膜转移癌的CT影像学特征,鉴定其生物学行为。方法:将新西兰大白兔36只分为开腹包埋、开腹穿刺及直接经皮穿刺种植3组(每组12只),每组又分为6只瘤块接种,6只悬液接种,接种VX2肿瘤。观察种植肿瘤生长状况,通过影像学及病理学检查分析局部区域及远处转移情况。结果:3种方法构建模型的成功率分别是100%(12/12)、91.7%(11/12)和58.3%(7/12),开腹包埋、开腹穿刺接种种植率差异无统计学意义(P>0.05),开腹与经皮穿刺比较,差异有统计学意义(P<0.05)。接种2周后,3组都能形成典型溃疡型胃癌并腹膜转移癌表现,CT上表现为占位性病变,呈稍高软组织密度结节,增强后肿瘤表现为明显或轻度强化,宿主衰竭,4周出现肺部转移。病理学检查符合典型VX2组织学特点。结论:开腹包埋与开腹穿刺接种制作VX2兔腹膜转移癌模型简单,实验周期短,接种率高,CT平扫和增强是检测肿瘤生长及血供的可靠方法,其病理表现类似人类腹膜转移癌,为腹膜癌治疗的实验研究提供可靠的大型动物模型。     

持续循环腹腔热灌注化疗治疗恶性腹水的临床应用初探

目的探讨腹腔热灌注化疗治疗恶性腹水的可行性、临床初步疗效及不良反应。方法对我院2007年12月-2012年6月收治的23例恶性腹水患者应用腹腔热灌注化疗,18例患者在腹腔镜辅助下完成,5例患者剖腹探查完成。每例患者进行腹腔热灌注化疗5次,首次治疗在手术室内全麻下监护下完成,随后两次在病房或ICU内进行,持续循环灌注生理盐水400-600mL/min,治疗温度(43±0.2)℃,灌注90min,灌注药物根据原发病的不同选择5-氟尿嘧啶加丝裂霉素或卡铂,对其治疗效果进行长期随访。结果腹腔热灌注化疗后23例恶性腹水患者21例腹水全部消失,2例部分缓解,有效率为100%;患者KPS评分上升(P<0.01),肿瘤标志物下降(P<0.05),一般状况、精神状态好转,食欲改善,体重增加,贫血症状明显缓解;热灌注化疗期间患者均感不同程度的腹胀,但尚可忍受,4例患者I°、Ⅱ°骨髓抑制和消化道反应,自行缓解,近期临床疗效满意。随访时间6个月至1年3个月,患者生存期1个半月-13个月,中位生存期7个月,存活最长一例为胃肠道恶性间质瘤患者,存活13个月仍健在。结论腹腔热灌注化疗可保证腹腔内灌注液体速度一致,维持腹腔内温度稳定,维持化疗药物与肿瘤的充分接触,不良反应少,患者可以耐受,是一种安全有效的恶性腹水治疗方法,有着很好的临床应用前景。     

Association between growth factor heregulin1α and receptors in growth of ovarian cancer cell line with high potentiality of peritoneal dissemination

Ovarian cancer, one of the poor-prognosis gynecological malignancies, is often associated with extensive peritoneal carcinomatosis when initially treated. The mechanism of the formation of peritoneal carcinomatosis from ovarian cancer is still unknown. It has been reported that overexpression of cancer-related growth factors and/or receptors may worsen the prognosis of diseases. In the previous paper, we had established the human ovarian serous adenocarcinoma cell lines from those with no potentiality of peritoneal dissemination (FOC-3) to high potentiality (MFOC-3), however, the mechanism of its phenotypical change remains unknown. In this paper, we compared these two cell lines for growth potential and the expression of growth factor heregulin (HRG)-1α and HER-2, HER-3, and HER-4 receptors. In addition, the effect of anti-receptor antibodies on cell growth was investigated. RT-PCR and Western blot analysis found the promotion of the expression of HRG precursor and HRG-1α in MFOC-3. Examination of the number of growing cells over time revealed a statistically significant increase in the number of cells in MFOC-3 compared with FOC-3. In a study using the addition of exogenous HRG-1α, no changes were observed in FOC-3 while statistically significant cell growth was noted in MFOC-3. In a growth inhibition study, statistically significant cell growth inhibition was achieved with the addition of anti-HER2 receptor antibody. Taken together, the results of this study suggested that HRG may play an important role in the increased growth potential of peritoneal dissemination of ovarian cancer. In particular, HER-2 receptors that can act as a starting point to trigger intracellular signaling pathways are strongly involved in the progression of cancer. Therefore, molecular target drug therapies blocking the HER-2 receptor are promising candidates for ovarian cancer treatment in the future.     

Burkitt's lymphoma in Uganda: the role of immunohistochemistry in diagnosis

BACKGROUND: Haematoxylin and eosin staining has remained the standard diagnostic method for Burkitt's lymphoma. Ancillary tests including immunohistochemistry, not widely available in developing countries, are important tools in verifying the diagnosis of lymphomas with equivocal morphological findings. OBJECTIVE: To evaluate the reliability of haematoxylin and eosin staining in the diagnosis of Burkitt's lymphoma using immunohistochemistry as the gold standard. DESIGN: Cross sectional study. SETTING: Department of Pathology laboratory, Makerere University Medical School, Uganda. SUBJECTS: One hundred and thirty eight formalin fixed paraffin embedded biopsies of Burkitt's lymphoma diagnosed from January 2001 to December 2005. RESULTS: Of the 138 tumours, 88.4% were extra-nodal: jaw 36.2%, ovary 21%, gastrointestinal tract 12.3% other abdominal 11.6%. Males (55.8%) predominated. The sensitivity and specificity of haematoxylin and eosin were 93.2% and 50% respectively. The positive and negative predictive values were 91.7% and 55.6%. CONCLUSION: Histology using haematoxylin and eosin staining is sensitive in the diagnosis of Burkitt's lymphoma but not very specific. Immunohistochemical staining with CD20, Ki-67 and bcl-2 is necessary for difficult cases.     

脑膜癌病

目的 探讨脑膜癌病的临床表现、EEG、CT、MRI及脑脊液细胞学检查与诊断之间的关系。进一步提高对脑膜癌病的认识。方法 对4例脑膜癌病的临床资料及EEG、CT、MRI、脑脊液检查进行综合分析。结果 脑膜癌病主要病变累及软脑膜、颅神经及脊神经根。临床表现复杂,主要出现脑症状,颅神经症状和脊神经症状。脑脊液检查,多数患蛋白与细胞数轻－中度增高,葡萄糖及氯化物减少。结论 EEG、CT、MRI检查对诊断脑膜癌病变有重要参考价值。诊断时需注意与结核性脑炎,新型隐球菌性脑膜炎及脑囊虫病相鉴别。脑脊液发现癌细胞是诊断本病的可靠依据。     

The rapid reversal of profound hypothermia using peritoneal dialysis

Severe hypothermia is associated with serious patient morbidity and mortality. The groups most frequently affected are the elderly, the very young and substance abusers. We describe three such cases which were successfully treated using warmed peritoneal dialysis. Two patients recovered completely and were left with no long term deficits. The third patient recovered from the acute event, but succumbed later to an underlying medical condition. Warmed peritoneal lavage is an efficient, cost effective approach which is easily performed without specialist equipment, and involves minimal risk to the patient.     

Malignant peritoneal mesothelioma

Malignant peritoneal mesotheliomas are rare tumors arising from the peritoneal surface. We report a 53 year old, non-asbestos exposed Saudi male who presented with exudative ascites. The diagnosis was obtained from laparoscopic biopsy. To the best of our knowledge this entity has not been described in the Saudi community. The aim is to increase the awareness among the medical community about this rare entity.     

腹膜透析相关性腹膜炎后包裹性腹膜硬化症1例

包裹性腹膜硬化症(encapsulating peritoneal sclerosis,EPS)是腹膜透析患者罕见但严重的并发症,50%患者在确诊后12 个月内死亡,早期无明显临床症状,易漏诊,少有早期诊断的报道。2018 年12 月22 日中南大学湘雅三医院肾脏风湿免疫科收治1 例因腹膜炎后继发EPS的患者,透析时间达17 个月。该患者在腹膜炎后出现腹膜透析管机械障碍,腹膜透析液出入腹腔困难,遂行腹腔镜检查,术中证实腹膜略有增厚,回盲段肠管与壁层腹膜紧密粘连包裹,诊断为EPS并行粘连松解术,术后腹膜透析管恢复正常。继续对患者进行控制感染、营养支持、血液透析过渡等综合治疗,10 d 后患者的腹膜炎得到了控制,因而恢复腹膜透析。出院后继续口服莫西沙星抗感染2 周,随访6 个月,现维持自动腹膜透析,患者透析顺利、病情稳定。临床医师需提高对EPS的认识,早期诊断及腹腔镜下松解粘连有助于继续腹膜透析治疗。     

腹腔内注射羟基喜树碱治疗腹膜转移癌的实验研究

目的:研究腹腔内注射羟基喜树碱(HCPT)对腹膜腔转移癌模型的疗效和安全性。方法:将高转移性人肝癌细胞株HCCLM3接种于30只裸鼠腹腔内,制成腹膜转移癌模型,随机分为治疗组和对照组各15只;前者组按2 mg/kg剂量腹腔内注射HCPT,后者注射等体积的0.85%氯化钠溶液;于第2,4,6周连续注射7 d,观察8周。监测荷瘤裸鼠的体重和腹膜癌的变化,测量血液学和血清学指标。结果:至研究终点时,治疗组14只裸鼠存活,对照组存活5只;治疗组的平均生存期是(55±1)d(95%CI:54-57 d),对照组的平均生存期是(43±4)d(95%CI:34-51 d)(P=0.002)。治疗组的肿瘤重量明显小于对照组。治疗组未观察到血性腹水和腹腔内弥漫性种植灶,对照组有4只裸鼠出现血性腹水,6只出现腹膜腔内弥漫性种植灶(P<0.001)。外周血白细胞计数在治疗组低于对照组(P<0.05),血清甲胎蛋白浓度在治疗组低于对照组(P<0.05),γ-谷氨酰转肽酶活性在治疗组低于对照组(P<0.05)。两组裸鼠的体重、血常规和血生化其他指标均无统计学差异。未观察到明显的药物相关毒副作用。结论:腹腔内注射HCPT治疗腹膜癌模型,能抑制肿瘤生长,减轻腹膜癌病情,延长荷瘤宿主生存期。     

MRI appearances of peritoneal mesothelioma--a case report

A rare case of diffuse malignant peritoneal mesothelioma in a 71 year-old Malay man with no previous history of asbestos or radiation exposure is described. The clinical manifestation was a large abdominal mass. At laparotomy he was found to be in the advanced stage of the disease. The tumour was not resectable and patient was sent home. He gradually deteriorated and died three months after diagnosis was made. The magnetic resonance imaging (MRI) features of peritoneal mesothelioma which has not been previously reported are described.     

Tuberculosis presenting with pelvic mass, peritoneal lesions, and elevation of serum CA125 mimicking malignant tumor: a case report

Tuberculosis is a curable infective disease which can mimic a malignant tumor. We report on a young woman who presented with abdominal fullness, body weight loss, and microcytic anemia. A pelvic mass and peritoneal lesions were found. The serum CA125 level was high. The initial gynecologic echo and abdominal CT scan revealed bilateral ovarian mass with peritoneal lesions, and malignancy was highly suspected. Diagnostic laparoscopy was performed, and peritoneal tuberculosis was pathologically proven. Combination anti-tuberculosis therapy was prescribed for one year. She was followed up in the outpatient clinic regularly with symptom improvement, body weigh gain, and improvement of anemia. We suggest that in cases of a pelvic mass and peritoneal lesions, with elevation of the serum CA125 level, tuberculosis should always be kept on the list of differential diagnoses. A tissue diagnosis should always be obtained before treatment, regardless of initial image study and laboratory findings.     

Severe intrahepatic cholestasis in an elderly patient with primary amyloidosis and colon adenocarcinoma

Hepatic involvement in primary amyloidosis (AL type) is not rare but is often clinically silent. However, presentation with jaundice in AL-type amyloidosis is rare, with an incidence of less than 5% reported in the literature. It is considered to be a preterminal sign. We herein report on a case of primary hepatic amyloidosis presenting with severe intrahepatic cholestasis. Viral, drug, alcohol, and autoimmune etiologies were all excluded. A liver biopsy was performed because of unexplained cholestatic jaundice for 3 months. The pathology showed hepatic amyloidosis with extensive amyloid deposition in the expanded portal tracts and sinusoidal space. The patient received supportive treatment only, because of persistent jaundice, coexistent colon cancer with para-aortic lymph node metastasis, and possibly peritoneal carcinomatosis. Unfortunately, the patient died of sepsis 10 months after the onset of jaundice. We suggest that hepatic amyloidosis must be considered in the differential diagnosis of unexplained cholestatic jaundice.     

腹膜表面层和腹膜通透性的关系

近年来,终末期肾脏病(ESRD)的病人数以每年 10%以上的速度增长.由于受肾源的限制,透析疗法是目前治疗ESRD的主要方法,这包括血液透析(血透)和腹膜透析(腹透)二种.腹透, 特别是持续性不卧床腹膜透析(CAPD),是一种有效治疗ESRD患者的方法.CAPD治疗价廉、操作简便、病人可在家自行透析,适合几乎所有的ESRD病人.在我国香港,80%以上的透析患者选择腹透治疗.