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发帖数: 110 | 1 下面这个患者希望能得到版上医生专家的指导意见，危险多大，如何治疗，预后如何？
患者44岁，男，6年前因为肝癌做了肝移植 （符合米兰标准），之后无灾无病好几年。
去年2016年初发现轻微贫血，血色素12，因为当时在服小剂量阿司匹林，于是停服，看
看有没好转。托托拉拉到了年底，还是贫血，血色素10.5。医生说做个内镜。于是在胃
内发现一个肿瘤，内镜医生直觉是GIST。随后CT，但CT却没有异常。4月初第二次胃镜
，GIST依然还在，取样活检表明可能肝癌转移或者是非常罕见的HAC。第二次CT 报告大
小46x35mm，说比较第一次32mm变大了。可能第一次看片医生那天喝多了？肿瘤位置在
Fundus，非常接近GOJ。
AFP好久没有查了，因为肝上的情况一直很好，肝移植前AFP 100多，移植后AFP一直小
于2。上一次至少是2，3年前。也是疏忽了。现在AFP 254. 显然胃上这个要么是转移，
要么是HAC。
下周二医生还要安排一次PETCT，周三见外科医生，估计排除转移外就安排切除了。 求
这里的专家教授指点，这个情况如何是好？下面我贴上最近几个报告。
个人感觉肝移植后5，6年转移到胃实在极其罕见，文献几乎没有报道。虽然病理报告倾
向HCC转移。
内镜：
Oesophagus: There was a plypoidal lesion just below the GOJ which was coming
back into the oesophagus.
Stomach: Evidence of old blood.
Pylorus: The pylorus was normal.
Duodenum: The duodenal cap and second part were normal.
内镜活检病理：
Histology shows multiple fragments including both squamous lined mucosa and
gastric body type mucosa consistent with biopsy from the gastro-oesophageal
junction.
There are tumour fragments with extensive areas of necrosis. The large
polygonal tumour cells with ample eosinophilic cytoplasm are arranged in
trabeculae. Mitoses are frequent.
Immunohistochemical stains of the tumour cells show:
Immunoreactivity: Cam5.2, inhibin, hepatocyte (focal, strong)
Negativity: CK7, calretinin, synaptophysin, chromogranin, S100, CD117, DOG1
The Ki67 proliferative index is high (>50%)
The overall features are those of a hepatoid tumour. The differential
diagnosis includes a metastatic hepatocellular carcinoma. and very unlikely
a hepatoid variant of gastric adenocarcinoma. In view of the patient's
history
of hepatocellular carcinoma, metastatic hepatocellular carcinoma is the
favoured diagnosis. Please correlate with clinical and radiological findings.
第一次CT，2017年1月
Comparison is made to previous study of 17/02/2014. The lungs and pleural
spaces are clear.
Note is made of liver transplant. Low density lesions within the liver are
in keeping with simple cysts and are stable. The biliary tree is
unremarkable.
The kidneys, adrenals, spleen and pancreas are unremarkable. No
lymphadenopathy.
No abnormality is identified within the wall of the stomach on this CT. No
free fluid. The rest of the imaged small and large bowel is unremarkable. No
bony abnormality.
Impression:
No significant change in the appearance of the stomach since the previous
imaging of February 2014. No local nodal disease or distant metastatic
disease identified。
第二次CT, 2017年6月
Examination of chest, abdomen and pelvis with intravenous contrast.
Comparison is made with previous staging study from January 2017.
No enlarged supraclavicular, axillary or mediastinal lymph nodes.
The lungs remain clear.
Appearances of the transplanted liver remain stable with some simple cysts
evident.
The low density mass within the fundus of the stomach has increased in size
and now measures approximately 46 x 35 mm, previously around 32 mm. No
evidence of any local nodal disease.
Elsewhere, appearances within abdomen and pelvis remain within normal limits.
No destructive bone lesion.
Conclusion: Disease has progressed since January 2017 with increasing size
of the solitary metastasis within the fundus of the stomach. |
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