Right upper abdomen of huge non hepatic tumors resection in 8 cases

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Originated in the right upper quadrant or retroperitoneal organs such as the right kidney, right adrenal gland and pancreatic organs first l

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Originated in the right upper quadrant or retroperitoneal organs such as the right kidney, right adrenal gland and pancreatic organs first large tumor (diameter > 10cm), and is closely related to clinical liver is easily misdiagnosed and give up surgical treatment for huge hepatic tumor. Because of the non tumor of the liver, the difficulty of operation, the risk is lower than the large liver tumor, so the correct clinical differentiation, the resection rate is high, the prognosis is better. In our hospital from May 2004 to December 2009 there were 8 cases of right upper quadrant in 8 cases of huge non hepatic tumors, are as follows.

1 clinical data

1.1 general data in this group of men in 5 cases, female in 3 cases. Age 21~58 years old, average 38.2 years old. The time from tumor detection to operation was 1 weeks ~3 years, of which, 1 cases were misdiagnosed as advanced hepatocellular carcinoma (HCC) for more than 3 years. 6 cases diagnosed as benign and malignant liver tumor giant transferred to our department, 2 cases from the Department of Urology in our hospital according to the right adrenal gland and right retroperitoneal tumor laparotomy, tumors and liver are closely related, can not exclude the hepatic tumor, surgery in our department.

3 cases of 1.2 clinical manifestations of abdominal pain, abdominal distension, 1 cases with nausea, vomiting, have a fever, 1 cases with anemia; right hypochondrium fullness and discomfort in 2 cases; in 1 cases; 2 cases were mass examination found. 8 of the 3 patients had fatigue, decreased food intake and weight loss. 8 cases of hepatitis markers were negative; tumor markers AFP, CEA, CA19-9 were not significantly increased; liver function after admission were all Child.

Check the 1.3 imaging of 8 patients underwent ultrasound examination, tumor image of 11.1 cm 9.7 cm 7.7 cm '' ~20 cm '18.7 cm' 18.3 cm range, 2 cases were diagnosed correctly for non hepatic tumor, 6 cases were diagnosed as hepatic origin, such as the right lobe of the liver showed uneven echo in no echo mass, intrahepatic cystic solid mass part etc.. CT examination in 8 cases, the largest mass plane image of 11.8 cm 8.5 'cm~ 28 cm' 22 cm range, CT value 5-20 ~33-60HU, 2 cases were diagnosed correctly for non hepatic tumor, 6 cases were misdiagnosed as liver tumor. MRI examination of 5 cases, were not able to distinguish between non - liver tumor. 3 cases with DSA angiography, including 1 cases in hospital and hepatic artery angiography failed to distinguish tumor non hepatic, 2 times successively underwent percutaneous hepatic artery embolization chemotherapy; another 2 cases in our hospital from the celiac artery, hepatic artery angiography, 1 cases of right hepatic artery were normal, the other 1 cases hepatic artery compression, but did not participate in tumor blood supply features, are correctly distinguished as non hepatic tumor.

1.4 cases were treated with surgical resection, of which, 1 cases underwent surgery for the first time in 3 cases. The upper abdominal incision or "people" reverse "L" incision, including 1 cases of thoracoabdominal incision (up to fourth mass on the sudden right pleural and 5 intercostal plane). Operation time: 5.5~11 h, median time: 6.8 h; intraoperative blood loss: 400~6000 mL, the median blood loss: mL; intraoperative blood transfusion: 0~5250 mL, the median blood transfusion: 2750 mL. Tumor size: 11~30 cm, average: 15cm; tumor weight: 960~5100 g, average: 2605 G. 7 cases of patients were treated with naked eyes, in which a total of two cases were combined with subtotal gastrectomy, and a total of 2 patients underwent resection of the inferior vena cava wall in the lower part of the body, and a total of 2 patients underwent complete resection of the right renal adipose capsule, and a total of 1 patients with pancreatic and intestinal anastomosis after resection of the pancreatic body and tail of the pancreas. 1 patients with massive tumor (postoperative pathology report for the diagnosis of inflammatory fatty sarcoma), intraoperative hypotension, right renal adipose capsule and the tumor around the inferior vena cava residual tumor. 5 months after the recurrence, tumor diameter of 11 cm and the invasion of gastric antrum, duodenum, pancreatic, colon, caused by upper gastrointestinal obstruction, bleeding, anemia. 1 months after the second operation, the tumor was excised, pancreatoduodenectomy, transverse colon resection, pancreatic leakage after operation, recovered after conservative treatment in January. 4 months after relapse, 2 ultrasound guided ablation radiofrequency, 1 ¡ radiotherapy, tumor control was 3 months. Self after taking the medicine, the tumor increases rapidly, the third operation, the tumors, invasion of the surrounding tissue and the right diaphragmatic muscle, the liver, right kidney, intestinal adhesion, separation of bleeding more, give up surgery. Third postoperative death in January. 2 patients in January to accept the tumor bed of three-dimensional conformal radiotherapy (3DCRT), Daye 50 Gy; 1 patients after complete resection of the tumor, the surgical field placement of 125I radioactive particles 50.

1.5 pathological examination of 7 cases of malignant tumors, including liposarcoma (including 1 cases of inflammatory liposarcoma and 1 cases of pleomorphic liposarcoma) in 3 cases, 2 cases of malignant adrenal pheochromocytoma, 1 cases with massive bleeding, degeneration and necrosis, part of the region with rich cell pleomorphism and atypia, mitotic, focal visible capsule infiltration; 1 cases of right adrenal cortical carcinoma, with massive bleeding, degeneration, necrosis, infiltration of liver resection of the inferior vena cava and vascular wall coated visible tumor tissue; omentum malignant gastrointestinal stromal tumor with intratumoral hemorrhage, degeneration and necrosis in 1 cases. There were 1 cases of malignant potential tumors, which were solid pseudopapillary tumors of the pancreas. There was no clear invasion of the vessels and nerves.

1.6 follow-up and prognosis of all the 8 cases were followed up, 7 cases survived, no regular outpatient, surgical field and distant metastasis and recurrence of signs, including adrenocortical carcinoma in 1 patients with preoperative CT showed right middle lobe circular slightly high density, the edge is clear, a diameter of about 1.8 cm, except for the distant metastasis preoperative and postoperative time (3 months) by abdominal and pulmonary CT has been 1 years and 6 months, no recurrence of right lung resection, especially with no obvious increase. Third patients died of tumor recurrence after surgery in January, with a total of 1 patients who died from surgery for a period of first years to a period of 1 years. Postoperative survival in 8 cases (3 patients with 1 years from February 2009 to December 2009), the 1 year survival rate of 100%; 4 cases survived after surgery for 2 years, 2 years survival rate was 50%; postoperative 3 cases survived more than 3 years, 3 years survival rate was 37.5%; 1 patients survived for more than 5 years, since the body jian.

2 discussion

2.1 right upper abdominal giant tumor localization diagnosis of the reasons for the difficulties of this group of 6 cases, ultrasound and CT MRI were not distinguished for the huge mass of right upper quadrant non hepatic, were diagnosed as massive hepatic benign and malignant tumors; 2 patients in admissions, although preoperative ultrasonography, CT and DSA in the diagnosis of right adrenal gland and back of the head of pancreas tumor, but intraoperative see below, liver tumor and the first hepatic portal is closely related to the Department of urology patients who failed to determine whether tumor originated in the liver, that diagnosis of right upper abdominal giant tumors before and during operation is difficult. The reason is the anterior and posterior renal fascia and peritoneum, lumbar fascia, diaphragmatic fascia fusion, the fusion site in the upper pole of kidney and kidney in the level of each half, resulting in renal clearance and the right upper opening communicated with the bare area of liver, left abdomen and left diaphragm connected space. Therefore, originated in the right upper quadrant or retroperitoneal organs such as giant tumor of right kidney, right adrenal gland easily pressed into the liver, and the liver is soft, the external pressure of tumor and liver tumor is difficult to identify.

Our department transferred to the 2.2 cases of this group of images for the identification of non hepatic tumor characteristics of this group of 6 patients outside the hospital, after careful analysis of the image data is CT scan results, find some obviously different from liver cancer or benign liver tumor imaging features, preoperative diagnosis of non hepatic the masses and actively implement the surgical treatment. After the summary, we obtained some available for identification of right upper abdominal tumor for huge non hepatic imaging features: (1) the CT value is low, slightly higher than the liquid density in the right upper quadrant of the huge liposarcoma. (2) there was fat clearance between the tumor and the liver tissue. Most of the right upper abdominal non hepatic lesion has this feature. (3) "sandwich biscuit" sign. In this group, 1 cases of giant gastrointestinal stromal tumors (CT) showed that the gallbladder was compressed and shifted to the right, and the gallbladder was located between the liver and the tumor, and it was like a sandwich biscuit. (4) "fish bone" enhancement syndrome. This group of 2 cases of right adrenal malignant pheochromocytoma CT enhanced scan, a fish bone like enhancement, CT for the diagnosis of hepatic hemangioma, but this is totally different from the enhanced features of hemangioma of the early lesions edge nodular enhancement features, gradually to promote, the central strength gradually reduced. (5) enhanced CT scan showed that the blood vessels in the tumor were abundant and the vascular network was complete, which was different from that of hepatocellular carcinoma (HCC) with patchy or nodular enhancement and no complete vascular shadow. 2.3 treatment experience

Although the treatment of 2.3.1 liposarcoma cases in this group of 8 patients with small sample size, but in 3 cases showed right upper abdominal liposarcoma, common hepatic non liposarcoma in large tumor. At present, the most important treatment method is surgical resection, but the recurrence rate is high. 1 patients died in this group for the massive inflammatory liposarcoma, originated from the right renal adipose capsule, because of huge tumor, first resected primary tumor giant, more intraoperative bleeding, postoperative hypotension, surrounding right renal adipose capsule and residual tumor resection of inferior vena cava completely failed 5 months postoperative recurrence, and invasion of gastric antrum, duodenum, colon, pancreatic head group organs, cause gastrointestinal obstruction, bleeding, severe anemia. Analysis of the patient's condition, we believe that: (1) liposarcoma for expansive growth, despite the huge, as long as the surgical exposure, can be ideal to remove. (2) postoperative recurrence is closely related to the thoroughness of the operation. In order to avoid recurrence, all the adipose tissue of the tumor origin should be removed. (3) for recurrent liposarcoma, rarely distant metastasis, the recurrence after surgery should still be active. (4) liposarcoma transformation among the evil type problem in the recurrence process, that is the same case in the recurrence process of different histological subtypes, degree of malignancy increased. Such as the inflammatory liposarcoma first surgery patients after recurrence, with surrounding tissue and organ infiltration. (5) after resection of liposarcoma with high recurrence rate, reported postoperative radiotherapy and chemotherapy in local radiotherapy on preventing tumor recurrence have a certain effect. This group of 1 cases of liposarcoma resection surgery field placement of 125I radioactive particles, outpatient review is more than 1 years, no recurrence. So we think the surgical field placement of radioactive particles to prevent or delay tumor recurrence may have a certain role. Liposarcoma recurrence especially ¡ after radiotherapy; radiotherapy, has a certain effect on the progress of control after recurrence of tumor.

2.3.2 operation experience despite the huge mass because of right upper abdominal tumor is more expansive growth, pseudo capsule, often have fat clearance and important organs around the surgical difficulty and risk of massive hepatic tumors is relatively small, but clinically complete resection of giant tumor of right upper quadrant is quite difficult and risky. Through the treatment of the 8 patients, we have the following surgical experience: (1) must expose the surgical site to increase the safety of operation, often using the word "man" on abdominal incision, sometimes seventh or eighth additional via the right rib abdominothoracic incision, incision or partial resection of the diaphragm. (2) a huge mass of right upper quadrant often oppression of the first hepatic portal and the hepatoduodenal ligament, hepatoduodenal ligament and tumor surface often full of varicose veins, not easy to cause hemorrhage or surgery history of excessive bleeding, carefully separated at this time need to be patient, No. 0 ligation of varicose veins was separated from the table, surface treatment the first bleeding, with gauze oppression, and then use the 5-0 noninvasive vascular suture hemostasis. Try to avoid rough needle suture bleeding at the tumor surface, or cause bleeding. (3) in the operation, it is necessary to complete the resection of the tumor, so as to avoid the residual tumor and the tumor tissue. (4) to prepare for the joint organ or tissue resection before operation. This group of 8 patients were combined with resection of the stomach, part of inferior vena cava and right renal adipose capsule, 1 cases of recurrent liposarcoma second surgery patients were pancreaticoduodenectomy, transverse colon resection, showed right upper abdominal huge non hepatic tumors often invade surrounding organs and tissues, the need for combined organ resection therefore, to do preoperative bowel preparation, renal function assessment, preparation of vascular surgical instruments etc.. (5) a huge tumor resection blood loss, tumor removal at right upper abdominal retroperitoneal vascular bed open, serious hypotension, shock can be in operation, so the surgeons and anaesthetists should cooperate closely, preventing and responding to severe hypotension during operation.

 

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