患者女性,48岁。

主诉：乙状结肠癌术后1年半,CT发现肝占位1周。

现病史：1年半前因“腹部隐痛1月,肠镜发现乙状结肠肿物3天”入院,入院后行“乙状结肠癌根治术”,术后病理：乙状结肠腺癌,中分化,浸润肌层,淋巴结5/10枚有转移。术后予XELOX方案化疗（Oxaliplatin 130mg/m² d1；Xeloda 100mg/m² bid d1-d14,每3周为1个周期,共8个周期）。术前CEA 50.26ng/ml,术后CEA水平恢复正常,化疗期间CEA正常。1周前在CT检查发现“肝占位”,以“乙状结肠癌术后肝转移”收入院。

既往史：有子宫肌瘤病史。

家族史：无异常。

体格检查：一般情况良好,浅表淋巴结无肿大,心肺未发现异常。腹软,正中见手术瘢痕；腹软,无压痛,无反跳痛,未扪及包块；移动性浊音（-）；肠鸣音正常。直肠指检：未见异常。

辅助检查：胸腹部盆腔CT（图32-1）：肝右叶前段、左叶内侧段见一团块状低密度影,边缘欠清,密度欠均匀,直径约7.5cm,增强扫描显示病灶边缘强化较明显,中心部强化扫描未见强化。子宫外形增大,宫壁间及宫壁外见数个大小不等结节影,增强扫描见不均匀环形强化,边缘与子宫壁分界欠清,最大直径约为2.9cm,相邻肠壁受压。诊断意见：①肝内占位性病变,结合病史,考虑为肝转移瘤；②子宫占位性病变,考虑转移瘤或子宫肌瘤可能,请结合临床；③胸部CT平扫及增强扫描未见异常。电子肠镜：乙状结肠癌术后大肠黏膜未见异常。肿瘤标志物：CEA 391.61ng/ml,AFP 5.17ng/ml。

初步分析：患者术后病理分期为T₂N₂M₀,术后辅助化疗半年,现CT发现肝占位,血CEA明显升高,AFP正常,患者诊断考虑为“乙状结肠癌术后肝转移”。患者肝占位单发,有手术直接切除可能,但需要明确肝外有无其他转移灶。

：拟行PET/CT检查,但因医院机器已坏,未能检查。请肝胆外科会诊后转肝胆外科,于2009-02-01行手术切除肝转移瘤,术中探查发现子宫可触及肿物,因盆腔粘连严重,未能触摸其整体情况,估计是子宫肌瘤。术后在肝胆外科行经皮肝动脉灌注化疗1次,建议患者行全身化疗,但患者因第1次手术后化疗反应严重,不同意化疗,在外院用中医中药治疗。半年后复查肝脏CT再次发现肝占位,且下腹出现包块,CT提示卵巢肿物,考虑为卵巢转移。患者在肿瘤内科予XELOX方案化疗及靶向药物西妥昔单抗治疗,肝脏占位明显缩小,但卵巢肿物无明显缩小。

图32-1　胸腹部盆腔CT

最后诊断：①乙状结肠癌术后肝转移；②卵巢转移癌；③子宫肌瘤。

：后继续XELOX方案化疗及靶向药物西妥昔单抗治疗,目前仍存活。

1.Yoo PS,Lopez-Soler RI,Longo WE,Cha CH.Liver resection for metastatic colorectal cancer in the age of neoadjuvant chemotherapy and bevacizumab \[J\].Clin Colorectal Cancer,2006,6：202-207.

2.Altendorf-Hofmann A,Scheele J.A critical review of the major indicators of prognosis after resection of hepatic metastases from colorectal carcinoma\ [J\].Surg Oncol Clin N Am,2003,12：165-192.

3.Staniunas RJ,Schoetz DJ.Extended resection for carcinoma of colon and rectum\[J\].Surg Clin North Am,1993,3：117-129.

4.Delbeke D,Martin WH.PET and PET/CT for evaluation of colorectal carcinoma\[J\].Semin Nucl Med,2004,34：209-223.

5.Park YJ,Park KJ,Park JG,et al.Prognosis factor in 2230Korean colorectal cancer patients：analysis of consecutively operated cases\[J\].World J Surg,1999,23：721-726.

6.Sargent DJ,Wieand HS,Haller DG,et al.Disease-free survival versus overall survival as a primary end point for adjuvant colon cancer studies：individual patient data from 20,898patients on 18randomized trials\[J\].J Clin Oncol,2005,23：8664-8670.

7.Rodriguez-Moranta F,Salo J,Arcusa A,et al.Postoperative surveillance in patients with colorectal cancer who have undergone curative resection：a prospective,multicenter,randomized,controlled trial\[J\].J Clin Oncol, 2006,24：386-393.

8.Desch CE,Benson AB,3rd,Somerfield MR,et al.Colorectal cancer surveillance：2005update of an American Society of Clinical Oncology practice guideline\[J\].J Clin Oncol,2005,23：8512-8519.

9.Guyot F,Faivre J,Manfredi S,et al.Time trends in the treatment and survival of recurrences from colorectal cancer\[J\].Ann Oncol,2005,16：756-761.

10.Priolli DG,Cardinalli IA,Pereira JA,et al.Metastatic lymph node ratio as an independent prognostic variable in colorectal cancer：study of 113patients\[J\].Tech Coloproctol,2009,13（2）：113-121.

11.Wang J,Hassett JM,Dayton MT,et al.Lymph node ratio：role in the staging of node-positive colon cancer\[J\].Ann Surg Oncol,2008,15（6）：1600-1608.

12.Jemal A,Murray T,Ward E,et al.Cancer statistics,2005\[J\].CA Cancer J C lin,2005,55（1）：10-30.

13.Van Cutsem E,Nordlinger B,Adam R,et al.Towards a pan-European consensus on the treatment of patients with colorectal liver metastases\[J\]. Eur J Cancer,2006,42：2212-2221.

14.Venook AP.The Kemeny article reviewed.Oncology,2006,20：477-484.

15.Choti MA,Sitzmann JV,Tiburi MF,et al.Trends in long-term survival following liver resection for hepatic colorectal metastases\[J\].Ann Surg,2002,235：759-766.

16.Pawlik TM,Scoggins CR,Zorzi D,et al.Effect of surgical margin status on survival and site of recurrence after hepatic resection for colorectal metastases\[J\].Ann Surg,2005,241：715-722.