2024年 · 第104卷第35期

The patient, a 73-year-old man, went to Hubei Provincial Corps Hospital of the Armed Police for "dull pain in the upper abdomen for more than 10 days". More than 10 days before admission, there was no obvious trigger for paroxysmal epigastric dull pain, which was obvious at night, without nausea, vomiting, diarrhea and melena. Previous history of cholecystectomy and coronary heart disease; No special family history. The whole body examination is nothing special. Perfect gastroscopy showed multiple bulges of different sizes and punctate black changes in the mucosa of the stomach fundus, gastric body, gastric antrum and duodenum. The center of the bulge was black, the surrounding mucosa was swollen and the surface was smooth, the largest of which was near the duodenal papilla (about 1.2 cm ×1.5 cm) (Figures 1 and 2); colonoscopy showed multiple polyps in the colon, but no black lesions were found. Gastroscopy pathology: (gastric body) mucosa lamina propria showed small focal pigmentation (Figure 3). Immunohistochemistry: HMB45 (+), Ki-67 (+, 40%), Melan-A (+), S-100 (+), SOX10 (+). Whole body PET/CT showed: multiple lymph nodes or nodules in the thoracic, abdominal and pelvic cavities with increased metabolism; Localized thickening and increased metabolism of the stomach body and wall; Multiple metabolic increases throughout the body. The final diagnosis was primary gastroduodenal malignant melanoma stage IV (TxN₂M₁）。 After 8 months of systemic chemotherapy and immunotherapy, the patient died due to deterioration of his condition. Primary upper gastrointestinal malignant melanoma is extremely rare and has no specific clinical manifestations, so it is difficult to diagnose, and because of its strong aggressiveness, lack of effective treatment, and poor prognosis.

A 56-year-old male went to Shiyan People's Hospital for "pain in the right lower abdomen for more than 10 days". The pain is paroxysmal swelling and pain, which does not radiate to other parts. Physical examination showed flat abdomen, no palpable intestinal type, tension of abdominal muscles in the right lower abdomen, tenderness and rebound pain at McMaher's point, and no abnormal mass palpable. Blood routine showed white blood cells 8.44×10⁹g/L, neutrophil ratio 63.2%; Ultrasound examination showed a cystic mass with a range of 7.8 cm ×3.3 cm between the right lower abdomen and intestine, with clear boundaries and poor intracapsular sound transmission, showing "onion skin"-like changes; Ultrasound cross-sectional scanning showed thickening of the intestinal wall, no obvious blood flow signal, and no obvious fluid accumulation around it (Figures 1 and 2). The patient underwent laparoscopic cecectomy, during which an appendix with a length of 8 cm and a diameter of 0.8 to 3.5 cm was removed. The partial lumen of the appendix is dilated, the wall thickness is 0.2~0.5 cm, the serous surface is gray-red and congested, the incision surface contains a large amount of mucoid matter, and the appendix is slightly adhered to the mesenteric root of the small intestine. Pelvic and abdominal exploration did not reveal significant nodules or enlarged lymph nodes. The pathological findings showed a low-grade mucinous tumor of the appendix with stage pT3. One year later, there was no obvious abnormality in ultrasound reexamination in the outside hospital. When a mass in the right lower abdomen is found clinically, the possibility of mucinous tumor of the appendix should be considered and puncture should be avoided to reduce the risk of metastasis of abdominal implants. The treatment principle is to remove the appendix tumor tissue as much as possible. During the operation, attention should be paid to avoid appendix perforation and tumor implantation. If necessary, laparoscopic surgery should be converted to open surgery.