2019年 · 第57卷第02期

Hepatoid adenocarcinoma is a very rare and special type of adenocarcinoma. It originates extrahepatically, but its morphological and immunohistochemical characteristics are similar to hepatocellular carcinoma. Initially Ishikura et al.^[1]The concept of hepatoid adenocarcinoma was proposed due to the observation of high expression of alpha-fetoprotein in some patients with gastric adenocarcinoma. Hepatoid adenocarcinoma may be primary to different organs, with the stomach being a relatively large source^[2,3]。 Gastric hepatoid adenocarcinoma is more common in elderly patients, with strong aggression and low survival rate. It often metastasizes to the liver and lymph nodes early, and its prognosis is far worse than that of common gastric adenocarcinoma^[4]。 Early detection and complete surgical resection are currently considered to be an important way to cure hepatoid adenocarcinoma; It is very important to identify hepatocellular carcinoma and hepatoid adenocarcinoma metastases and to find the primary site of hepatoid adenocarcinoma. Due to the low incidence of hepatoid adenocarcinoma, few reports in China, and the low specificity of clinical and imaging features of patients, it is easy to be misdiagnosed or missed. We report the clinicopathological characteristics, immunophenotypes and related treatments of 13 patients with hepatoid adenocarcinoma, in order to improve the understanding and diagnosis of this tumor.

angiosarcoma (AS) is a malignant tumor derived from vascular endothelial cells^[1,2,3,4]。 The incidence was low, accounting for 2% of all soft tissue sarcomas. Angiosarcomas originating from bone are less than 1% of primary sarcomas of bone^[5,6]The most common sites of onset are the femur and pelvis, and spinal angiosarcoma accounts for only about 10% of bone angiosarcoma^[7,8]Pulmonary metastases were common^[5]。 Because of the low incidence of the disease, only a few cases have been reported^{[1,6,9,10,11,12,13,14,15,16]}The clinical characteristics and treatment modalities are still unclear. We performed a retrospective analysis of 8 cases of spinal AS admitted to our hospital, and the summary report is presented below.

PatientMale, 27 years old. He was admitted to the Department of Pancreatobiliary Surgery, the First Affiliated Hospital of Harbin Medical University on May 27, 2017 due to "epigastric pain with nausea and vomiting for 1 d". The patient developed upper abdominal pain without obvious trigger 1 d ago, which continued without relief, and later spread to total abdominal pain, radiating to the low back, accompanied by nausea and vomiting. The patient had previous history of hyperlipidemia and gallstones. Admission physical examination: general condition is poor, heart rate is 150 beats/min, abdominal distension, total abdominal tenderness, rebound pain, accompanied by muscle tension, and intestinal sounds are not heard. Blood amylase 1 306 U/L, procalcitonin (PCT) was 4.62 μ g/L, C-reactive protein (CRP) was 266.00 mg/L, and white blood cell count was 16.11×10 using ELECSYS B·R·A·H·M·S procalcitonin antibody kit of Roche, Switzerland⁹/L, the percentage of neutrophils was 81.80%, urea nitrogen was 6.62 mmol/L, serum creatinine was 101.4 μ mol/L, serum calcium was 1.79 mmol/L, and albumin was 20.3 g/L; CT examination showed increased pancreatic volume, rough edges, massive peripancreatic exudation, peritoneal effusion, bilateral pleural effusion with bilateral lung insufficiency (FIG. 1A）。 One hour after admission, the patient was transferred to ICU for treatment due to dyspnea and rapid heart rate. He was given vital signs monitoring, tracheal intubation, continuous renal replacement therapy (CRRT), gastrointestinal decompression, maintaining internal environment stability, and antibacterial drugs (piperacillin sodium tazobactam, 2.5 g/d), proton pump inhibitors, somatostatin and nutritional support.

PatientFemale, 45 years old. He was admitted to hospital on March 23, 2018 due to "dull pain in the right upper abdomen for two years and aggravated for half a month". Two years ago, the patient developed dull pain in the right upper abdomen without obvious trigger, no fear of cold and fever, and no yellowing skin. He went to a local hospital and was given antispasmodic and anti-infective treatment (details unknown), and improved after treatment. Half a month ago, the patient's right upper abdominal pain was worse than before, accompanied by nausea and vomiting, the vomit was stomach content, accompanied by chills and fever, the body temperature was as high as 38.5℃, accompanied by yellow skin staining and yellow urine, and went to a local hospital. Magnetic resonance cholangiopancreatography showed that the local wall of the descending duodenum was thickened, and the intrahepatic bile duct, left and right hepatic ducts and the upper section of the common bile duct were dilated. Electronic gastroscopy showed a flat bulge beside the duodenal papilla with irregular surface; The pathological examination results showed high-grade intraepithelial neoplasia of the glandular epithelium, which was improved after symptomatic treatment with cefoperazone sodium, sulbactam sodium and adenosylmethionine butanedisulfonate in the local hospital. The outpatient clinic was admitted to the hospital with "ampullary space occupation". The patient has clear consciousness, good spirit, poor diet and sleep, normal stool, yellow urine, and no obvious change in recent weight. The patient underwent surgical treatment for "choledochal cyst" more than 40 years ago (the specific surgical procedure is unknown), and underwent "laparoscopic cholecystectomy" for "cholecystitis with gallbladder stones" 2 years ago. The rest of the personal history and family history are not special. Physical examination at admission: No yellowing staining of the skin and sclera, old surgical scar in the right upper abdomen, soft abdomen, no tenderness, rebound pain and muscle tension, no palpable mass, no subcostal reach of the liver and spleen, percussion pain in the liver area (-), negative mobile voiced sound, and normal intestinal sound. Laboratory test: white blood cell count 4.1×10⁹/L, the percentage of neutrophils was 57.7%, hemoglobin 122 g/L, C-reactive protein (CRP) 1.8 mg/L, ALT 32.2 U/L, AST 23.4 U/L, glutamyltransferase 210.1 U/L, total bilirubin 11.2 μ mol/L, direct bilirubin 5.7 μ mol/L. Tumor marker: CA19-9 36.93 U/ml. Results of CT pancreatic thin slice + superior mesenteric revascularization: The wall of the ampullary duodenum was thickened, and the enhancement was followed by non-uniform enhancement. The intrahepatic and extrahepatic bile ducts were dilated, and the lower segment of the common bile duct was unclear. Magnetic resonance cholangiopancreatography: intrahepatic bile duct and upper common bile duct were dilated, the lower common bile duct was not clearly displayed, the gallbladder was not clearly displayed, the pancreatic duct was not obviously dilated, and there were multiple small lymph nodes in the hilar, considering the descending duodenum occupying space, involving the lower common bile duct. The preoperative diagnosis was ampullary mass occupation (ampullary cancer, duodenal cancer suspected).

PatientMale, 50 years old, was admitted to hospital on August 21, 2017 due to "skin sclera yellowing for more than 10 days". Since the onset of the disease, the yellowing stain of the patient's skin sclera has gradually aggravated, and there is no fever, abdominal pain, abdominal distension, etc. Nothing special in the past. Physical examination at admission: vital signs were stable. Severe yellowing of the skin sclera. The whole abdomen is soft, with mild tenderness in the right middle and upper abdomen, without rebound pain and muscle tension. Gallbladder tenderness, positive Murphy sign. Abdominal ultrasound examination: the common hepatic duct area is about 5.5 cm ×1.8 cm in size and hyperechoic, running along the common bile duct, intrahepatic bile duct dilatation, large gallbladder measurement, gallbladder stones, some stones located in the neck, and bile mud deposition. Laboratory test: blood routine: white blood cell count 16.56×10⁹/L, neutrophil percentage 86.1%; Liver function: total bilirubin 303.1 μ mol/L, direct bilirubin 222.9 μ mol/L; CA19-9>700 U/ml. Abdominal enhanced CT examination: massive soft tissue shadow in the hilar area, about 3.4 cm ×2.5 cm in size, mildly enhanced; The gallbladder is large and the intrahepatic bile duct is dilated (FIG. 1A）。 Abdominal plain scan MRI showed slightly lower T1WI and slightly higher T2WI signal shadows in the hilar area, about 3.2 cm ×2.5 cm ×3.7 cm in size, with clear boundary, portal vein compression and intrahepatic bile duct dilation (FIG. 1B）。 After 8 days of anti-infection and liver protection treatment, re-examination: blood routine: white blood cell count 9.12×10⁹/L, neutrophil percentage 67.1%; Liver function: total bilirubin 86.0 μ mol/L, direct bilirubin 73.6 μ mol/L; CA19-9>700 U/ml. Re-examination of abdominal enhanced CT showed massive soft tissue shadows in the hilar area, which did not change significantly compared with the previous one (Figure 1C）。 Preoperative diagnosis: (1) Obstructive jaundice: hilar cholangiocarcinoma? (2) Gallbladder stones with acute cholecystitis. Radical resection of hilar cholangiocarcinoma was proposed.

In 1894, based on the understanding that breast cancer is a local disease, Holsted pioneered the standard radical mastectomy for breast cancer, which laid the basic principle of complete tumor resection (R0 resection) in oncology surgery. In 1977, AJCC developed the first tumor staging system (TNM staging) based on tumor (T), regional lymph node (N) and distant metastasis (M) information with reference to tumor burden; Up to now, 8 editions have been updated and revised, and it has become a macro-reference basis for formulating group therapy strategies based on tumor staging worldwide. In 2010 and 2013, the American Society of Clinical Oncology and the American Pathological Association respectively formulated the evaluation criteria for the status of estrogen receptor, progesterone receptor and human epidermal growth factor receptor 2 in breast cancer by histopathological immunohistochemistry, which provided the possibility of promoting the classified treatment of breast cancer. At present, breast cancer has become the first malignant tumor in Chinese women. Priority of diagnosis and standardized treatment concept are the keys to improve the clinical diagnosis and treatment of breast cancer.

A 40-year-old male was diagnosed with "space-occupying lesion of the right liver" before surgery. Preoperative MRI revealed high blood supply nodules in 8 segments of the liver with a maximum diameter of about 1 cm, and enhanced imaging showed fast forward and fast out, which was considered malignant (Figure 1）。 Hepatic function Child-Pugh grade A, 15 min retention rate of indocyanine green 3 d before surgery<10%, laparoscopic 8-segment ventral resection of the liver was proposed.

Comrade Gao Changqing, member of the Communist Party of China, academician of the Chinese Academy of Engineering, former vice president of the People's Liberation Army General Hospital, chief physician, professor, doctoral supervisor, first-class professional technology, director of the Institute of Cardiac Surgery of the whole army, a famous cardiovascular surgeon in China, and editorial member of the 11th, 12th and 13th editorial committee of Chinese Journal of Surgery, died in Beijing at 15: 59 on January 8, 2019 at the age of 59 due to ineffective treatment.