优秀病例:黏膜下肿瘤样胃癌一例

2018-12-28 刘华 中国医学论坛报

患者,男,50岁。因“查体发现胃占位半月”于2017年6月1日入院。

患者,男,50岁。因“查体发现占位半月”于2017年6月1日入院。

病史资料

现病史:

因“查体发现占位半月”入院。无腹胀、腹痛,无消瘦。外院胃镜显示:慢性萎缩性胃炎;胃角病变性质待定,HP(+)

既往史:高血压病史。

个人史:无特殊

合并用药史:无

检查

查体:生命体征稳定,腹软,无压痛及反跳痛    

实验室检查:无特殊,肿瘤标志物无异常

腹部CT:无异常

胃镜检查:中度慢性萎缩性胃炎,少数腺体肠上皮化生。Hp(+)




治疗方案

诊断性ESD。



ESD术后病理

黏膜呈中度慢性炎,黏膜下见挤压变形的核深染细胞,结合免疫组化,考虑中-低分化腺癌,病变累及基底切缘,未累及四周切缘。

CK(+),Syn(-),CgA(-),CD56(-),Villin部分(+),CDX-2弱  (+),CD3(-),CD20(-),Ki67(+)。



胃腺癌局部切除后:剩余胃组织见部分黏膜缺失,周围有溃疡形成,未见癌残瘤,大弯淋巴结未见转移癌(0/9),小弯侧淋巴结可见转移癌(5/25),手术断端和网膜组织未见癌。

目前诊断

? 胃癌(Bormann I型)T1bN2M0
? 慢性萎缩性胃炎
? 高血压病(3级,极高危)

下一步诊治及随访

? SOX方案化疗,共8周期
? 根除HP
? 随诊

讨论

黏膜下肿瘤样(SMT)胃癌

? 胃癌是上皮组织肿瘤,多起源于黏膜固有层
? SMT样癌临床少见,占手术切除标本的0.2%~0.62%
? 大部分表现为中央凹陷性改变,部分累及固有肌层,大部分为未分化或低分化腺癌

发生机制

? 癌细胞的黏膜下浸润
? 弥漫浸润癌的早期表现

淋巴结转移率 
 
? 有无淋巴结转移是影响早期胃癌预后最重要的独立危险因素
? 低分化EGC淋巴结转移率为12.9%

诊治方案

诊断方法:胃镜、超声内镜、全腹增强CT或MRI、组织病理学

治疗:



EUS在胃癌分期中的应用

● 对于T1b型胃癌,EUS于病理一致率仅为40%
● 凹陷型病变,溃疡性疾病及未分化癌是影响EUS诊断的因素


诊治流程 

胃镜+活检?EUS?ESD?手术

小结

① SMT样癌表现不典型,临床诊断困难;
② 抓住病变的细微改变,多种诊断方法结合;
③ SMT样的诊治,采取最恰当最优化的方案。


青岛大学附属医院消化内科主治医师,博士。青岛市青年消化委员会委员,主攻是消化内镜的各种诊治疗技术,发表学术论文20余篇,参与国家、省、市级课题4项。“例精求治”2018消化道优秀病例演讲比赛总决赛省级医院组优秀病例。

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  1. [GetPortalCommentsPageByObjectIdResponse(id=1520015, encodeId=3c6c1520015fb, content=<a href='/topic/show?id=6ab11032506f' target=_blank style='color:#2F92EE;'>#黏膜#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=103250, encryptionId=6ab11032506f, topicName=黏膜)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=057f11309297, createdName=snowpeakxu, createdTime=Sun Dec 30 11:06:00 CST 2018, time=2018-12-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=356643, encodeId=16dd356643d7, content=学习了,谢谢分享。, beContent=null, objectType=article, channel=null, level=null, likeNumber=54, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/xkvRjYnJzzRJ2R0y7VhicibvkjPWHjIMmu4ZpKnE9cWAu4lVicS3uDUCfF4M4JWvrkrYfpb2KehPV0Ee29tPqyPEebBUibiaKhnvD/0, createdBy=f8412001184, createdName=惠映实验室, createdTime=Sat Dec 29 00:20:13 CST 2018, time=2018-12-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=356627, encodeId=e6c335662ec7, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=82311653708, createdName=医者仁心5538, createdTime=Fri Dec 28 20:56:18 CST 2018, time=2018-12-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=356623, encodeId=5e1435662309, content=感谢小编为我们准备了如此丰盛的精神大餐,同时也向作者致谢!认真学习了,点赞!, beContent=null, objectType=article, channel=null, level=null, likeNumber=44, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfNLvzZhgPxRuUXgacXpPeW0x8Z3Qr9c3I2kTic4ZIpR29iaftYgkjRcbv982icYMtqANBPYBgPnOia6mVtX76qMXuc/0, createdBy=d85d1636106, createdName=lietome2, createdTime=Fri Dec 28 20:43:50 CST 2018, time=2018-12-28, status=1, ipAttribution=)]
    2018-12-30 snowpeakxu
  2. [GetPortalCommentsPageByObjectIdResponse(id=1520015, encodeId=3c6c1520015fb, content=<a href='/topic/show?id=6ab11032506f' target=_blank style='color:#2F92EE;'>#黏膜#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=103250, encryptionId=6ab11032506f, topicName=黏膜)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=057f11309297, createdName=snowpeakxu, createdTime=Sun Dec 30 11:06:00 CST 2018, time=2018-12-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=356643, encodeId=16dd356643d7, content=学习了,谢谢分享。, beContent=null, objectType=article, channel=null, level=null, likeNumber=54, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/xkvRjYnJzzRJ2R0y7VhicibvkjPWHjIMmu4ZpKnE9cWAu4lVicS3uDUCfF4M4JWvrkrYfpb2KehPV0Ee29tPqyPEebBUibiaKhnvD/0, createdBy=f8412001184, createdName=惠映实验室, createdTime=Sat Dec 29 00:20:13 CST 2018, time=2018-12-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=356627, encodeId=e6c335662ec7, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=82311653708, createdName=医者仁心5538, createdTime=Fri Dec 28 20:56:18 CST 2018, time=2018-12-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=356623, encodeId=5e1435662309, content=感谢小编为我们准备了如此丰盛的精神大餐,同时也向作者致谢!认真学习了,点赞!, beContent=null, objectType=article, channel=null, level=null, likeNumber=44, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfNLvzZhgPxRuUXgacXpPeW0x8Z3Qr9c3I2kTic4ZIpR29iaftYgkjRcbv982icYMtqANBPYBgPnOia6mVtX76qMXuc/0, createdBy=d85d1636106, createdName=lietome2, createdTime=Fri Dec 28 20:43:50 CST 2018, time=2018-12-28, status=1, ipAttribution=)]
    2018-12-29 惠映实验室

    学习了,谢谢分享。

    0

  3. [GetPortalCommentsPageByObjectIdResponse(id=1520015, encodeId=3c6c1520015fb, content=<a href='/topic/show?id=6ab11032506f' target=_blank style='color:#2F92EE;'>#黏膜#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=103250, encryptionId=6ab11032506f, topicName=黏膜)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=057f11309297, createdName=snowpeakxu, createdTime=Sun Dec 30 11:06:00 CST 2018, time=2018-12-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=356643, encodeId=16dd356643d7, content=学习了,谢谢分享。, beContent=null, objectType=article, channel=null, level=null, likeNumber=54, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/xkvRjYnJzzRJ2R0y7VhicibvkjPWHjIMmu4ZpKnE9cWAu4lVicS3uDUCfF4M4JWvrkrYfpb2KehPV0Ee29tPqyPEebBUibiaKhnvD/0, createdBy=f8412001184, createdName=惠映实验室, createdTime=Sat Dec 29 00:20:13 CST 2018, time=2018-12-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=356627, encodeId=e6c335662ec7, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=82311653708, createdName=医者仁心5538, createdTime=Fri Dec 28 20:56:18 CST 2018, time=2018-12-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=356623, encodeId=5e1435662309, content=感谢小编为我们准备了如此丰盛的精神大餐,同时也向作者致谢!认真学习了,点赞!, beContent=null, objectType=article, channel=null, level=null, likeNumber=44, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfNLvzZhgPxRuUXgacXpPeW0x8Z3Qr9c3I2kTic4ZIpR29iaftYgkjRcbv982icYMtqANBPYBgPnOia6mVtX76qMXuc/0, createdBy=d85d1636106, createdName=lietome2, createdTime=Fri Dec 28 20:43:50 CST 2018, time=2018-12-28, status=1, ipAttribution=)]
    2018-12-28 医者仁心5538

    学习了

    0

  4. [GetPortalCommentsPageByObjectIdResponse(id=1520015, encodeId=3c6c1520015fb, content=<a href='/topic/show?id=6ab11032506f' target=_blank style='color:#2F92EE;'>#黏膜#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=103250, encryptionId=6ab11032506f, topicName=黏膜)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=057f11309297, createdName=snowpeakxu, createdTime=Sun Dec 30 11:06:00 CST 2018, time=2018-12-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=356643, encodeId=16dd356643d7, content=学习了,谢谢分享。, beContent=null, objectType=article, channel=null, level=null, likeNumber=54, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/xkvRjYnJzzRJ2R0y7VhicibvkjPWHjIMmu4ZpKnE9cWAu4lVicS3uDUCfF4M4JWvrkrYfpb2KehPV0Ee29tPqyPEebBUibiaKhnvD/0, createdBy=f8412001184, createdName=惠映实验室, createdTime=Sat Dec 29 00:20:13 CST 2018, time=2018-12-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=356627, encodeId=e6c335662ec7, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=82311653708, createdName=医者仁心5538, createdTime=Fri Dec 28 20:56:18 CST 2018, time=2018-12-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=356623, encodeId=5e1435662309, content=感谢小编为我们准备了如此丰盛的精神大餐,同时也向作者致谢!认真学习了,点赞!, beContent=null, objectType=article, channel=null, level=null, likeNumber=44, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfNLvzZhgPxRuUXgacXpPeW0x8Z3Qr9c3I2kTic4ZIpR29iaftYgkjRcbv982icYMtqANBPYBgPnOia6mVtX76qMXuc/0, createdBy=d85d1636106, createdName=lietome2, createdTime=Fri Dec 28 20:43:50 CST 2018, time=2018-12-28, status=1, ipAttribution=)]
    2018-12-28 lietome2

    感谢小编为我们准备了如此丰盛的精神大餐,同时也向作者致谢!认真学习了,点赞!

    0