Abstract
SUMMARY In recent years, there have been more and more reports about cystadenoma. Cystadenoma can occur in many parts of the body, and cystadenoma in different parts may show different clinical symptoms, however, some patients with cystadenoma have no symptoms. The vast majority of cystadenomas are benign lesions, but a small number of cystadenomas can be malignant. For example, a small number of ovarian cystadenomas and pancreatic cystadenomas may be malignant. This study reported a patient with small intestinal cystadenoma diagnosed by pathology. The patient's physical examination revealed a lesion in the left upper abdomen. He had only abdominal distension and no other discomfort. His laboratory examination results were basically normal, i.e. blood routine, urine routine, stool routine, liver function, kidney function, myocardial enzyme, tumor marker, etc. The patient underwent sectional small intestine resection and the pathological sample was analyzed. The histological findings of the resected intestinal sample were consistent with cystadenoma. Computed tomography scan of the abdomen was performed 4 months after the surgery. No recurrence of the tumor was found. The patient recovered in good condition. By consulting the literature, I found very few reports of small intestinal cystadenoma before, it was very rare. This article described the clinical manifestation, diagnosis and differential diagnosis, treatment and prognosis of a case of small intestinal cystadenoma, it suggested that cystadenoma can occur in the small intestine, other than the ovary, pancreas, liver, lung, thyroid, prostate, seminal vesicle, skin, etc. The cystadenoma in small intestine is easy to be mistaken with other tumors, such as small intestine stromal tumor, small intestine adenocarcinoma, small intestine lipoma, small intestine hemangiomas, etc., and it is difficult to fully confirm through imaging examinations, such as computed tomography and magnetic resonance imaging. Laparotomy and histopathological examination are necessary before definitive diagnosis. This disease can be treated by small bowel resection at the affected region and good prognosis can be achieved.
Keywords: Intestine, small, Cystadenoma, Diagnosis, Treatment, Prognosis
囊腺瘤可见于卵巢,胰腺,肝,肺,甲状腺等部位,但发生于小肠的囊腺瘤很少见,其临床表现及疾病预后尚不清楚,极易误诊或漏诊.本文即报道1例发生于小肠(空肠段)的囊腺瘤,并结合相关文献复习,以进一步提升对囊腺瘤及小肠肿瘤的认识.
1. 病例资料
患者,男,49岁,主因体检发现左上腹占位性病变,被河北省肿瘤医院收入院行进一步检查.入院时患者轻度上腹胀满,餐后加重,无其他不适,既往体健,无特殊病史,否认家族类似病史.入院查体:腹部平坦,未见胃肠型及蠕动波,腹壁静脉无曲张,无瘢痕,腹软,左上腹稍压之不适,无反跳痛及肌紧张,无液波震颤,肝颈静脉回流征阴性,Murphy(-),腹部叩鼓音,移动性浊音阴性,肠鸣音正常,未闻及振水音及血管杂音,余未见异常.辅助检查:血,尿,便常规,肝,肾功能,电解质,心肌酶,凝血功能及肠癌五项(B2-微球蛋白,癌胚抗原,铁蛋白,糖类抗原19-9,糖类抗原72-4)均正常.术前4 d腹部CT示左上腹类圆形软组织肿块影,病变大小约6.5 cm×4.8 cm×4.5 cm(图1), 病变与临近小肠肠管关系密切,CT值:平扫期34 HU,动脉期34 HU,静脉期37 HU,密度均匀.腹腔及腹膜后未见肿大淋巴结,考虑为左上腹软组织肿物,肠源性病变,不除外间质瘤.术前2 d腹部磁共振示左上腹胰尾前下方椭圆形异常信号影,大小约6.5 cm×4.8 cm×4.5 cm(图2),病变与临近小肠肠管关系密切,呈长T1,稍长T2信号,增强扫描未见异常强化,腹腔及腹膜后未见肿大淋巴结,考虑为左上腹囊性病变影.
1.
术前4 d腹部CT所示病变
The lesion shown by abdominal CT 4 days before surgery
2.
术前2 d腹部磁共振所示病变
The lesion shown by abdominal MR 2 days before surgery
入院诊断:左上腹肿物.于入院第5天在全身麻醉下行剖腹探查,小肠肿物及部分小肠切除术.术中探查无腹水,无腹腔,腹膜种植结节,肿物位于屈氏韧带小肠处,与小肠关系密切,大小约8 cm×7 cm×6 cm,质软,与周围组织粘连.术后病理:切除肠管长11 cm,距一残端0.8 cm可见一个4 cm×3 cm×3 cm的囊性肿物,壁厚约0.2~0.3 cm,发生于肠壁肌层,向腔外突出,内可见囊性扩张的腺体,腺体被覆假复层纤毛粒状上皮.术后病理诊断:囊腺瘤(考虑为胚源性)(图3).
3.
左上腹肿物组织病理表现(A,HE ×25;B,HE ×100)
Histopathological features of left upper abdominal mass (A, HE ×25; B, HE ×100)
术后给予抗感染,腹腔引流,营养支持,止痛等对症治疗,术后6 d患者恢复尚可,遂出院.术后4个月随访,患者腹部无不适,上腹部平扫CT显示左侧腹壁可见切口影,左上腹部小肠肠管内可见高密度影,腹腔及腹膜后未见肿大淋巴结(图4).
4.
术后4个月原病变处腹部CT扫描
Abdominal CT of primary lesions at 4 months after surgery
2. 讨论
文献报道的囊腺瘤多见于卵巢,胰腺,肝,肺,甲状腺,少见于肾[1],前列腺[2],精囊腺[3],阑尾[4]等,截至目前国内外关于小肠囊腺瘤的相关报道极少,且尚未见空肠囊腺瘤的报道,故可见小肠囊腺瘤发病率极低,非常罕见.
囊腺瘤是一种具有潜在恶性的肿瘤,大多囊腺瘤患者肿瘤切除后恢复良好,无需放疗和化疗,远期观察少有复发,但也有少数文献报道了部分卵巢,胰腺部位的囊腺瘤出现癌变[5,6].不同部位的囊腺瘤一般具有与之部位相关的症状表现,但亦有一部分囊腺瘤患者无任何症状.本文所报道的小肠囊腺瘤患者仅有轻度上腹胀满,一般情况良好.
本例患者临床症状表现无特异性,常规CT检查发现左上腹占位,而血液相关检查均无明显异常,可见相比临床症状和血液检查,影像学检查对该病的发现更有意义,而真正确诊则需要病理诊断做支持.小肠囊腺瘤需与小肠间质瘤,小肠腺癌,小肠脂肪瘤,小肠血管瘤等肿瘤相鉴别.(1)小肠间质瘤:小肠间质瘤是消化道常见的间叶源性肿瘤,特征性地表达CD117是其最主要的免疫组织化学特征,细胞核相关抗原 Ki-67,凋亡抑制蛋白Survivin,增殖细胞核抗原(proliferating cell nuclear antigen,PCNA)的检测有助于判断间质瘤的恶性程度和患者预后[7].小肠间质瘤最常发生于空肠,常见症状为消化道出血,其次表现有腹胀,腹痛,恶心,呕吐等.CT,磁共振对小肠间质瘤的诊断有一定指导意义[8].(2)小肠腺癌:腺癌是小肠最常见的恶性肿瘤,易发于小肠近侧,约50%位于十二指肠,40%位于空肠,只有10%位于回肠[9],临床表现主要有腹痛,腹部肿块,黑便等,病理可分为乳头状腺癌,黏液腺癌及未分化癌.小肠腺癌与癌胚抗原,糖类抗原19-9有一定关系[10].CT,磁共振可用于诊断原发肿瘤以及所属肠壁淋巴结,肝等部位是否有转移.(3)小肠脂肪瘤:该病罕见,临床表现隐匿,大于2 cm的小肠脂肪瘤可引起黑便,随着瘤体进一步增大,可引起肠道梗阻或肠套叠.肠道脂肪瘤多为黏膜下型,即瘤体在黏膜下生长,突入腔内,此外还有肌间型及浆膜下型,浆膜下型瘤体向腔外突出,多无临床症状,较大者可触及腹部光滑,可移动性的包块.CT对于小肠脂肪瘤的确诊有重要意义,可见小肠部密度均匀,边界清楚,无明显强化且CT值呈明显负值(脂肪密度)的肿物[11].(4)小肠血管瘤:该病发病率低,大约占小肠良性肿瘤的7%~10%[12],病变多位于空肠,多数起自小肠黏膜下的血管丛,本质属血管畸形,可分为海绵状血管瘤,毛细血管瘤及混合型血管瘤3种[13],临床常见症状有黑便,便血,腹痛,此外还可见肠套叠,肠梗阻等表现.
小肠囊腺瘤的治疗尚无明确方案,参照其他部位囊腺瘤的治疗方案及本例小肠囊腺瘤的治疗经验,总结如下:小肠囊腺瘤的治疗以手术切除为主,手术需将病变肠管及对应系膜切除,吻合肠管,关闭系膜,术中应保证切缘干净,防止囊壁破溃,以免残留和播散;术后需给予抗感染,营养支持,腹腔引流等对症治疗,一般7 d左右患者即可恢复出院,术后无需化疗及放疗.本例患者术后腹部胀满症状消失,术后回访,患者情况良好,未见肿瘤复发,可以推断小肠囊腺瘤与其他部位囊腺瘤相似,预后大多良好.
References
- 1.刘 京生, 赵 学英, 于 阳阳, et al. 肾黏液性乳头状囊腺瘤诊治分析:一例报道并文献复习. 中国全科医学. 2015;18(18):2191–2193. [Google Scholar]
- 2.蒋 学文, 陈 军, 张 兆存, et al. 前列腺囊腺瘤的临床特征分析. 山东大学学报(医学版) 2015;53(3):81–86. [Google Scholar]
- 3.宋 宴鹏. 超声诊断精囊囊腺瘤1例. 中国介入影像与治疗学. 2017;14(5):282. [Google Scholar]
- 4.李 高峰, 黄 耀华, 杨 贤卫. 阑尾粘液性囊腺瘤1例并文献复习. 罕少疾病杂志. 2017;24(6):71–72. [Google Scholar]
- 5.方 如旗, 曹 代荣, 翁 淑萍, et al. 卵巢交界性浆液性,黏液性囊腺瘤的MRI表现及对比分析. 临床放射学杂志. 2014;33(9):1391–1394. [Google Scholar]
- 6.丁 伟超, 张 蓬波, 张 秀忠, et al. 胰腺浆液性囊腺瘤的临床分析(附19例报道) 中国普外基础与临床杂志. 2014;21(5):630–632. [Google Scholar]
- 7.张 艳霞, 章 培军, 闫 燕艳, et al. Ki-67,PCNA和Survivin在胃肠道间质瘤组织中的表达. 山东大学学报(医学版) 2013;51(1):67–70. [Google Scholar]
- 8.詹晨妮. 67例小肠间质瘤的临床诊治分析[D]. 杭州:浙江大学, 2016.
- 9.汤 钊猷. 现代肿瘤学. 上海: 复旦大学出版社; 2011. pp. 1406–1407. [Google Scholar]
- 10.刘 哲峰, 焦 顺昌, 杨 俊兰, et al. 原发性小肠恶性肿瘤120例临床研究. 南方医科大学学报. 2010;30(3):602–604. [PubMed] [Google Scholar]
- 11.丛 春莉, 苏 秉忠. 肠脂肪瘤31例诊治分析. 现代消化及介入诊疗. 2014;19(2):128–129. [Google Scholar]
- 12.刘 猛, 王 巍, 袁 祖荣, et al. 小肠血管瘤一例并文献复习. 中华临床医师杂志(电子版) 2014;8(9):1797–1799. [Google Scholar]
- 13.狄 军艳, 宋 福林, 杨 原, et al. 小肠血管瘤6例报道及误诊原因分析. 诊断病理学杂志. 2006(3):184–186. [Google Scholar]