【摘 要】
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目的 一例同时性乳腺癌和胃癌双原发伴有肝转移患者,根据临床、体检、实验室检查、影像学检查和病理检查结果 ,对该患者肝转移病灶的来源进行鉴别诊断.方法 患者女性,49 岁.主诉：发现右腋下肿块2 月余,发现肝占位1 月.患者2017.8 触及右腋下肿块,质硬,活动性差,右手活动不便.2017.9 触及右锁骨上肿块,约2cm 大小,质硬,无压痛.2017.10.6 外院B 超：右侧乳腺内结节(BI-R
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目的 一例同时性乳腺癌和胃癌双原发伴有肝转移患者,根据临床、体检、实验室检查、影像学检查和病理检查结果 ,对该患者肝转移病灶的来源进行鉴别诊断.方法 患者女性,49 岁.主诉：发现右腋下肿块2 月余,发现肝占位1 月.患者2017.8 触及右腋下肿块,质硬,活动性差,右手活动不便.2017.9 触及右锁骨上肿块,约2cm 大小,质硬,无压痛.2017.10.6 外院B 超：右侧乳腺内结节(BI-RADS：4A),右侧腋下及锁骨上低回声,肿大淋巴可能.肝内多发实性占位,考虑转移性CA 可能.2017.10.10 外院CT：1.右乳占位,右侧腋窝淋巴结明显肿大2.两肺下叶粟粒小结节3.肝内多发异常强化,考虑转移可能,肝左内叶病灶,腺瘤？转移瘤？4.右肾小囊肿.2017.10.18 外院行右乳肿块穿刺活检：(右乳肿块)IDC,Ⅱ级,免疫组化：ER(2+)PR-HER2(++)E-CAD+KI67(约20％)P63-SMA-.FISH：HER2/CEP17＜2.0 无扩增.初步诊断：右乳浸润性导管癌肝、右腋下、右锁骨上淋巴结转移(luminal 型).2017.10.7患者稍有腹部不适,外院查胃镜：浅表性胃炎伴糜烂,胃窦溃疡.胃窦活检病理示：(胃窦)低分化腺癌(印戒细胞癌).IHC：肿瘤细胞：CK+CK7 部分+CK20+CDX-2+HER2-P53 弱+KI67(50％+).这例患者同时性双原发癌,肝转移灶来源是来自乳腺癌还是胃癌？结果 2017.10.17 外院行肝内占位穿刺活检,病理：倾向转移性低分化腺癌,倾向胃肠来源.IHC：CEA+CK+CK20-CK7+GCDFP-HER2-ER-PR-KI67(50％).2017.11 我院就诊,经多学科讨论后认为该患者肝脏转移病灶CT 表现存在乏血供和富血供两种类型,不排除还存在乳腺转移可能,建议行肝脏富血供病灶穿刺活检.2017.11.13 我院病理会诊咨询意见：(右乳)浸润性癌,Ⅱ级,伴神经内分泌分化. ER+(10％,中等),PR-,HER2(1+),Ki-67(+,约20％),Syn+,E-cadherin+.(胃窦,活检)腺癌,部分为印戒细胞癌.(肝穿刺)低分化腺癌,结合酶标结果 及临床,符合胃癌转移. CK7(+),CK20(-),Arg-1(+/-),Hep-1(-),PAX8(-),CEA(多抗)+,CD10(-),HER2(-),Ki-67(+,约30％).2017.11.21 我院肝脏富血供病灶穿刺：(肝占位,活检)浸润性癌,结合免疫组化结果 及病史,符合乳腺癌转移. AE1/AE3(+),Arg-1(-),CD10-OPT(-),CD34(脉管+),CDX2(-),CK19(+),CK20(-),CK7(+),GATA3(+),GCDFP15(少量+),Hep-1(-),Mammaglobin(-),MUC1(+),MUC5AC(-),P40(-),ER(+(弱,10％)),PR(+(强,20％)),HER2(1+),Ki-67(40％).该患者最终诊断为：胃低分化腺癌,肝转移；右乳浸润性癌,肝、右腋下、右锁骨上淋巴结转移.结论 这例患者提示,对于多原发肿瘤患者,肝脏转移灶可由多个原发病灶同时转移而来,临床上需注意诊断和鉴别诊断.
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