张德春 赖景奎 强文胜 熊昌久 曾鹏 张鹏 Shah Ram Babu 王维国 田伯乐
·病例报告·
胰腺部位的胃肠道外间质肿瘤一例
张德春 赖景奎 强文胜 熊昌久 曾鹏 张鹏 Shah Ram Babu 王维国 田伯乐
患者女,55岁,因“上腹痛4 d”入院,不伴黄疸,无消化道出血史,否认胰腺炎病史。入院时体检:上腹部深压痛,无明显反跳痛及肌紧张。彩超和上腹部增强CT提示胰头占位,胆囊结石, 慢性胆囊炎。CA19-9等肿瘤标志物、肝功能、血淀粉酶等检查均正常。初步诊断为:胰头占位,肿瘤?;胆囊结石,慢性胆囊炎。行胰十二指肠切除术,术中见胰头部5 cm×4 cm×3 cm大小包块,边界清楚,包膜完整,与十二指肠有间隙,周围未见肿大淋巴结,胆囊内扪及结石,腹盆腔其余器官未见异常。先切取部分组织送术中快速冷冻活检,报告“胰头梭形细胞肿瘤,提示胃肠外间质瘤可能”。遂行包含肿瘤的胰头切除、胰肠Roux-en-Y吻合术,胆囊切除术。术后病检证实胰头部的胃肠道外间质肿瘤(extra-gastrointestinal stromal tumor, E-GIST),免疫组化显示CD117(+)、CD34(+)、DOG1(+)。术后恢复顺利,第7天康复出院。由于经济原因未能服用格列卫,至今已随访半年无复发。
讨论胃肠道间质肿瘤临床上并不罕见,绝大多数发生于胃、小肠等消化道部位,发生于胃肠道外的不到10%。临床上常表现为腹痛、消化道出血或腹部包块。E-GIST可发生于大网膜、横结肠系膜、膈肌、子宫,甚至阴囊和胸膜等罕见部位。从2004年至今,全世界共报道了13例胰腺的E-GIST[1-12]。胰腺的E-GIST非常罕见,绝大多数患者没有任何症状或无特征性的临床表现,多在体检时发现。本例患者因腹痛就诊,检查中发现胰腺占位,但根本没有考虑到E-GIST。文献中有4名经皮细针穿刺活检得到确诊[6,8,9,11],但我们认为术前穿刺活检不宜提倡,因有造成肿瘤破裂、种植的可能。胰腺部位出现边界清楚的包块、无明显的临床症状、虽然在胰头也不伴黄疸、或包块较大无恶变质、CA19-9等肿瘤标志物不高等,我们认为有提示E-GIST的可能。
手术切除是治疗胰腺E-GIST的最有效手段,局部切除应为首选术式,多数不需要行区域淋巴结清扫。文献报道的术式有胰十二指肠切除术(含保留幽门的胰十二指肠切除术)、胰体尾切除+脾切除术(含腹腔镜操作)、胰腺部分切除术等,术后预后较好,有术后5年半无复发的报道。本例患者病变在胰头,故只行胰头切除术,术后无并发症发生,随访半年无复发,是文献报道中第1例行胰头切除术胰头部E-GIST的病例。
[1] Neto MR, Machuca TN, Pinho RV, et al. Gastrointestinal stromal tumor: report of two unusual cases.Virchows Arch, 2004, 444:594-596.
[2] Yamaura K, Kato K, Miyazawa M, et al. Stromal tumor of the pancreas with expression of c-kit protein: report of a case. J Gastroenterol Hepatol, 2004,19:467-470.
[3] Krska Z, Pesková M, Povysil C, et al. GIST of pancreas. Prague Med Rep, 2005, 106:201-208.
[4] Daum O, Klecka J, Ferda J, et al. Gastrointestinal stromal tumor of the pancreas: case report with documentation of KIT gene mutation. Virchows Arch, 2005,446:470-472.
[5] Showalter SL, Lloyd JM, Glassman DT, et al. Extragastrointestinal stromal tumor of the pancreas: case report and a review of the literature. Arch Surg, 2008, 143:305-308.
[6] Yan BM,Pai RK,Van Dam J.Diagnosis of pancreatic gastrointestinal stromal tumor by EUS guided FNA.JOP,2008,9:192-196.
[7] Trabelsi A, Yacoub-Abid LB, Mtimet A, et al. Gastrointestinal stromal tumor of the pancreas:A case report and review of the literature. N Am J Med Sci,2009,1:324-326.
[8] Harindhanavudhil T, Tanawuttiwat1 T, Pyle J, et al. Extragastrointestinal stromal tumor presenting as hemorrhagic pancreatic cyst diagnosed by EUS-FNA. JOP,2009,10:189-191.
[9] Saif MW, Hotchkiss S, Kaley K. Gastrointestinal stromal tumor of the pancreas. JOP, 2010,11:405-406.
[10] Padhi S, Kongara R, Uppin SG, et al. Extragastrointestinal stromal tumor arising in the pancreas: a case report with review of the literature. JOP, 2010,11:244-248.
[11] Rao NR, Vij M, Singla N, et al. Malignant pancreatic extra-gastrointestinal stromal tumor diagnosed by ultrasound guided fine needle aspiration cytology. a case report with a review of the literature. JOP,2011,12:283-286.
[12] Vij M, Agrawal V, Pandey R. Malignant estra-gastrointestinal stromal tumor of the pancreas. A case report and review of literature. JOP,2011,12:200-204.
10.3760/cma.j.issn.1674-1935.2012.03.025
610000 成都,彭州市人民医院肝胆外科(张德春、赖景奎、强文胜、熊昌久、曾鹏、张鹏);四川大学华西医院肝胆胰外科(Shah Ram Babu、王维国、田伯乐)
田伯乐, Email: bo-le@medmail.com.cn
2011-11-30)
(本文编辑:吕芳萍)