一例隐匿的直肠神经内分泌肿瘤

2018-11-20 杨喜洋 胃肠病

患者男性,30岁,主因“肛周脓肿”入住普外科,肛周脓肿切开引流一周后,于我内镜中心行电子结肠镜检查了解肠道及肛周情况。


作者:杨喜洋 许昌市立医院内镜中心主任

患者男性,30岁,主因“肛周脓肿”入住普外科,肛周脓肿切开引流一周后,于我内镜中心行电子结肠镜检查了解肠道及肛周情况。

结肠镜顺利至回肠末段约10cm,缓缓退镜,至脾曲见一半球形隆起,直径约0.8cm,表面充血。

这个病灶内镜诊断很明确:结肠腺瘤。

直接做了内镜下黏膜切除术(EMR)。







继续退镜,降结肠、乙状结肠,慢一点,再慢一点,地毯式搜索,缓慢退镜至距肛门缘15cm直肠,一扁平隆起随蠕动波由远至近,不经意间撞入眼帘,直径约0.5cm,表面光滑,色泽与周边黏膜一致,没有明确的分界线。





心中警铃大作,镜子仔细再看隆起的轮廓,多年的经验告诉我:“此非善类,谨慎,谨慎,再谨慎。”

“请再给我10分钟时间”,微笑着对麻醉团队的邢大大,刘麻麻提了个不情之请。



反复评估了5分钟左右,果断嘱咐助手拿Dual刀直接剥离,心中已有答案,犯罪分子,再狡猾,伪装的再好,也逃不出猎人的眼睛。

5分钟后,病灶剥离完整,创面干干净净。





钛夹闭合创面完整



回收标本送病理。答案已了然于心。

三天后,病理科主任联系我:“某某病人病理结果出来了,发给你看下”。







和我们的镜下诊断一致:“神经内分泌肿瘤(类癌)”。

与病理科主任交流,“做个免疫组化,看看分期”,不谋而合,王主任笑曰:“已着手做了。”



一周后免疫组化结果回示:



直肠神经内分泌肿瘤(直肠类癌)是发生于直肠黏膜上皮内嗜银细胞的肿瘤。直肠类癌发展缓慢,病情隐匿,早期常无明显症状,临床诊断较困难。

起初在黏膜下有一个或数个结节,质硬、活动,表面光滑,长到一定程度可穿破黏膜并发生转移。

瘤体直径小于1厘米、无淋巴结转移者行局部切除比较安全。

按照肿瘤的增殖活性将直肠神经内分泌肿瘤分级为:

G1(低级别,核分裂象数1/10高倍视野或Ki~67指数≤2%)、
G2(中级别,核分裂象数2~20/10高倍视野或Ki-67指数3%~20%)、
G3(高级别,核分裂象数>20/10高倍视野或Ki-67指数>20%)。

在上述基础上,直肠神经内分泌肿瘤病理分类如下: 

神经内分泌瘤(NET) 是高分化神经内分泌肿瘤,分级为G1和G2。
神经内分泌癌(NEC) 是低分化高度恶性肿瘤,分级为G3。 
混合性腺神经内分泌癌(mixedadenoendocrinecarcinoma,MANEC) 是一种特殊类型的神经内分泌癌,形态学上包括腺癌和神经内分泌癌两种成分,两种成分的任何一种至少占30%。

直肠类癌在早期是可治的,术后五年生存率多可达99%以上。

可见,早期发现、早期治疗,显得尤为重要。

此病多发生于30~40岁,男性多于女性。其生长缓慢,病程长,而且早期常无临床症状,无面色潮红、水肿、喘息或痉挛腹痛等类癌综合征。

一半以上的患者确诊时无症状,少部分患者可以有肛门和直肠部不适、便秘、排便习惯改变、便血等症状。晚期患者可表现出乏力、体重降低、腹痛等。

直肠神经内分泌肿瘤(直肠类癌)临床表现缺乏特异性,直肠指诊及内镜检查有助于早期发现,组织病理学和免疫组化分析可确诊,对于极早期的直肠类癌内镜下切除是一种效果确实的方法,预后主要取决于早期发现、早期确诊及早期治疗。

“早癌诊断,常抱审慎之心”,自己的耐心、细心、细致、专注、高度的责任心和使命感,发现了这例极隐匿,极易漏诊的极早期的神经内分泌肿瘤(类癌),并及时采用正确的手术方式切除了它,达到了治愈性切除的效果,挽救了一条年轻的生命,拯救了一个家庭,面对患者年迈的父亲和漂亮的妻子,我一身轻松,因为完成了自己的使命;同时也替他们开心,父子可以相伴,夫妻可以相守……

内镜之路,如履薄冰,对自己苛刻,对学生严格,我们手里握的是一根镜子,也是一条生命,可能一个不留神就会漏诊,等早期癌变成晚期癌时,病人的生存质量截然不同。对医生自己,对病人家属来说都会抱憾终生。

所以,在物欲横流、人心浮躁的今天,守得住初心,脑子里时刻绷紧一根弦,狠抓内镜质量,让所有人的人生不留遗憾。

选择医学可能是偶然,但你一旦选择了,就必须用一生的忠诚和热情去对待它。干一行,爱一行,精一行,专一行,热爱生活,敬畏生命,善待生命,终将收获精彩人生……

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    2019-06-04 gwc392
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    2018-11-20 天地飞扬

    了解一下,谢谢分享!

    0

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