Duodenal smooth muscle sarcoma

　　One, pathological classification:According to the growth pattern of duodenal smooth muscle sarcoma, the pathological types can be divided into 4 types: extraluminal type, intraluminal type, extraluminal and intraluminal type, and interstitial type. Smooth muscle sarcoma is mainly seen in the extraluminal and extraluminal and intraluminal types.

　　Two, pathological morphology:The tumor is mostly solitary, occasionally multiple.肉眼观察瘤体为结节状，周界清楚，无纤维包膜。The tumor appears nodular under肉眼 observation, with clear boundaries and no fibrous capsule.切面呈灰白色，质地细软。The cut surface is grayish white, with a fine and soft texture.肿瘤出血时可形成囊形变，囊腔常有窦道与肠腔相通。When the tumor bleeds, it can form a cystic change, and the cyst cavity is often connected with the intestinal lumen through sinusoids.镜检可见肿瘤由分化不良的平滑肌细胞组成，瘤细胞为中等密度或为高密度，呈菱形或不规则形。Microscopic examination shows that the tumor is composed of poorly differentiated smooth muscle cells, with tumor cells of moderate or high density,呈菱形或不规则形。The nuclei of the tumor cells are large and deeply stained, exhibiting anisotropy and polymorphism, and an increased number of nuclear division figures is a sign of smooth muscle sarcoma.Over half of the cases show peritumoral invasion.

　　3. Pathological diagnostic criteria:There is no unified standard for distinguishing between benign and malignant tumors. Generally, tumors with a diameter greater than 10cm or those with metastasis can be diagnosed as sarcomas; those with a diameter greater than 8cm, friable texture, and rich blood supply are more likely to be sarcomas. Rapid pathological examination of the tissue slices during surgery is sometimes difficult to correctly determine the benign or malignant nature, and the number of mitotic figures observed in paraffin sections should be used as the main basis for diagnosis.

　　1. If the number of mitotic figures per high-power field is more than 2, it is malignant.

　　2. If the number of mitotic figures per high-power field exceeds 5, it is a sarcoma.

　　3. If the number of mitotic figures per high-power field is 1-5, it is low-grade malignant; more than 5 indicate a sarcoma.

　　4. Atypical mitotic figures, nuclear pleomorphism, and deep staining are the basic features of sarcomas.

　　5. If the number of mitotic figures per high-power field is ≥4 and the round nuclei exceed 20%, it is a sarcoma.

　　4. Malignant transformation and metastasis:It is unclear whether fibroids can become malignant. Previously, it was considered that epithelioid fibroids are benign tumors with a tendency towards malignancy. Now, it is believed that this type of tumor exists in both benign and malignant forms, with malignancy being rare, and the latter often metastasizing to the liver or peritoneal implantation. Smooth muscle sarcomas often metastasize to the liver or peritoneal tumor bed, with rare lymphatic metastasis.

　　1. Abdominal pain:This is a relatively common symptom, with most patients only feeling discomfort in the upper abdomen or having upper abdominal pain similar to that of peptic ulcer disease.

　　2. Upper gastrointestinal bleeding:Fecal occult blood positive or black stools are common, and occasionally shock may occur due to massive bleeding, often caused by ischemia, necrosis, and ulceration of the tumor surface, more common in fibroids, which have a rich mucosal vascular network and are prone to erosion, ulceration, and bleeding. It can also be seen in larger adenomas and hemangiomas.

　　3. Duodenal obstruction:The narrowing of the duodenal lumen can cause obstructive symptoms due to the occupation of the tumor itself or due to prolapse or intussusception as the tumor grows. Most patients present with intermittent upper abdominal colic, nausea, and vomiting.

　　4. Jaundice:Benign tumors located around the duodenal papilla can block or compress the bile duct, causing varying degrees of jaundice, with about 60% of cases showing Courvoisier's sign, that is, an obstructive gallbladder enlargement.

　　The symptoms and signs of tumors in the duodenal smooth muscle are similar to those of other benign and malignant duodenal tumors, but bleeding and abdominal masses are more prominent. Statistics show that the incidence of bleeding in sarcomas is about 80%, and in fibroids about 50%, which can be minor, continuous, or intermittent massive bleeding. There is no direct relationship between the size of the tumor and the occurrence or degree of bleeding. The masses are mostly located in the upper right abdomen, with a smooth surface, hard or cystic sensation, and poor mobility. Some masses can be felt in the lower right abdomen.

　　1. Calcium supplementation helps prevent benign intestinal tumors:Some studies have shown that those who take calcium supplements every day have a reduced risk of recurrent intestinal polyps by 19~34%. Foods rich in calcium include milk and other dairy products, as well as broccoli. In addition, vitamin D (which helps the body absorb calcium) also shows the effect of reducing the risk of colorectal cancer.

　　2. Fruits, vegetables, and whole grains can help prevent benign intestinal tumors:These foods are rich in fiber and can reduce the risk of intestinal polyps. In addition, fruits and vegetables are also rich in antioxidants, which can prevent colorectal cancer.

　　3. Not smoking and drinking can prevent benign intestinal tumors:Smoking and excessive drinking can increase the risk of intestinal polyps and colorectal cancer. Women should not drink more than 150ml of wine, or 360ml of beer, or 40ml of Baijiu per day, while men should not exceed twice the amount of women. If you have a family history of colorectal cancer, you should especially reduce smoking and drinking to reduce the risk of onset.

　　4. Insist on physical exercise, maintain a healthy weight:Controlling weight can independently reduce the risk of intestinal diseases. It is recommended to exercise at least five times a week, with each session lasting at least 30 minutes. If you can do moderate-intensity exercise for 45 minutes every day, it will be more effective in reducing the risk of colorectal cancer.

　　5. Maintain a good attitude towards stress, combine work and rest, and do not overwork.It can be seen that stress is an important cause of cancer. Traditional Chinese medicine believes that stress leads to overwork and physical weakness, thus causing a decrease in immune function, endocrine disorders, internal metabolism disorders, and the deposition of acidic substances in the body; stress can also lead to mental tension, qi stagnation and blood stasis, internal fire intrusion, etc.

　　6. Do not eat contaminated food:If contaminated water, crops, poultry and eggs, moldy food, etc., should eat some green organic food, to prevent disease from the mouth.

　　1. Barium meal X-ray imaging

　　The X-ray imaging manifestations vary with the growth pattern and size of the tumor. Intraluminal tumors can appear smooth with clear boundaries as a filling defect, and if ulcers form, there will be a shadow of depression in the filling defect; extraluminal tumors show compression of the duodenum, disordered mucosal folds; if the tumor ulcerates and communicates with the intestinal lumen, there will be a large diverticulum sign.

　　2. Duodenal endoscopy

　　It can be seen that there are extrinsic changes of the intestinal wall or submucosal elevated lesions, mucosal erosion, and the lesions below the descending part of the duodenum are easily missed. Biopsy is also difficult to take due to material constraints, making it difficult to make an accurate diagnosis.

　　3. CT examination

　　There is a clear, solid mass shadow in the duodenal area, and if there is contrast agent and gas within the tumor, it is more helpful for diagnosis. Enhanced scanning shows a tumor with moderate blood supply or more abundant blood supply, which should be differentiated from pancreatic head tumors.

　　1. Patients with muscle sarcoma should choose high-protein, high-vitamin, and easily digestible foods, and through reasonable nutrition matching and appropriate cooking, try to improve the appetite of patients, so that the nutrition and energy in their diet can meet the needs of the body.

　　2. Patients with muscle sarcoma should avoid foods and刺激性 foods that are harmful to their condition, such as chili, especially for patients in the acute stage and those with yin deficiency and fire hyperactivity.

　　3. Generally, it is not advisable to use frying, roasting, and爆 methods for food used in therapy to avoid the destruction of its effective components or the change of its nature, losing its therapeutic effect. It is recommended to use steaming, boiling, stewing, and soup-making methods.

　　1. Treatment

　　Once the disease is diagnosed, even if there is local recurrence of the tumor or metastatic foci, active exploration should be performed, and the opportunity for surgery should not be easily abandoned. Strive for radical resection. For advanced or recurrent cases, as long as the overall condition and local anatomical conditions permit, palliative resection or other surgery should be actively performed. This can extend the survival period, and sometimes even achieve unexpected effects. The surgical plan should be determined according to the size, growth site, and growth pattern of the tumor. Local resection is only applicable to extraperitoneal type myomas of the lateral wall of the duodenum. Since the recurrence of sarcoma after surgery is mainly due to tumor bed and tumor implantation in the abdominal cavity, avoiding the rupture of the tumor capsule during surgery is one of the key factors for preventing recurrence. Distilled water can be used to soak and flush the tumor bed at the end of the operation. Pancreaticoduodenectomy is applicable to larger tumors or those located around the duodenal papilla.

　　The boundary of the liver metastasis of smooth muscle sarcoma is clear and can be excised along the edge of the mass. If there are multiple metastatic foci localized in one lobe, it is advisable to perform lobectomy of the liver. For liver metastases that cannot be resected, hepatic artery catheterization and portal vein catheterization chemotherapy can be performed. The author encountered a 46-year-old male patient with duodenal smooth muscle sarcoma (about 4cm in diameter) and a 5cm metastatic focus in the right posterior lobe of the liver, who underwent resection of the duodenal segment where the sarcoma was located and irregular resection of the right posterior lobe of the liver. After 3 years of surgery, due to tumor recurrence, he underwent resection of liver tumors again and was discharged in good condition.

　　2. Prognosis

　　Local recurrence after surgery is easy, involving adjacent intestines and other abdominal organs.