2016年 · 第54卷第07期

Prostate cancer is the malignant tumor with the highest incidence in men in Europe and America^[1]。 In China, its incidence is also increasing year by year. It is estimated that there were 60,300 new cases of prostate cancer and about 26,600 deaths in China in 2015^[2]。 Most prostate cancer patients in China have metastasis at the initial diagnosis. At present, the first-line treatment for patients with advanced metastatic prostate cancer is still endocrine therapy, but after a median of 18 to 24 months of endocrine therapy, almost all patients will progress to castration-resistant prostate cancer (CRPC). Once patients enter the CRPC stage, the prognosis is generally poor. Since docetaxel was approved by the U.S. Food and Drug Administration for the treatment of CRPC in 2004, a variety of drugs have been shown in clinical trials to be effective in prolonging the overall survival of patients with CRPC^[3]。 Therefore, how to correctly apply the current treatment methods and formulate the best diagnosis and treatment plan for CRPC patients is an important issue before our clinicians. We organized experts to write this consensus, hoping to help clinicians make sound clinical decisions, prolong patient survival time and improve quality of life.

Female, 63 years old, admitted to hospital on 3 December 2015 due to "physical examination found spleen occupying space for 1 year". The patient's abdominal ultrasound examination at the local hospital on 27 November 2014 showed gallbladder stones, cholecystitis, and a 2.1 cm ×2.3 cm moderately strong echo in the spleen, considering the possibility of splenic hemangioma. Because the patient had no other discomfort, he was not treated, and he was reviewed regularly, about once every six months. During the re-examination, it was found that the space occupied in the spleen gradually increased. On October 22, 2015, the abdominal ultrasound examination in an external hospital showed gallbladder stones, splenomegaly, and a 7.2 cm ×5.0 cm moderately strong echo in the spleen, considering the possibility of tumor. The patient had no abdominal pain, abdominal distension, nausea, vomiting, hematemesis, melena and other discomfort. Previous history of hypertension and hepatitis B, 4 years ago, the patient underwent meningioma resection due to "meningioma". After admission, the patient actively improved the relevant examinations, and the results of blood routine, blood biochemistry and coagulation function were no abnormalities, and the HBV-DNA was 3.14×10⁴Tumor markers: carcinoembryonic antigen (179.2 μ g/L) and CA19-9 (330.1 U/ml) were both elevated, and alpha-fetoprotein (5.54 μ g/L) and CA125 (6.04 U/ml) levels were normal. Abdominal enhanced CT examination: A mass shadow with a maximum diameter of about 6 cm was seen in the spleen, and the CT value was about 23 Hu. No obvious enhancement was seen during the enhanced scan. Considering the possibility of tumor, gallbladder stones (FIG. 1A)。 Later, abdominal MRI examination was performed in our hospital: a round-like abnormal signal shadow of about 73.0 cm ×51.0 cm ×6.8 cm was seen in the parenchyma of the spleen, with T1WI low signal and T2WI high signal, and multiple T2WI low signal separation shadows were seen in the spleen (FIG. 1B), the diffusion-weighted image showed low signal, the abnormal signal shadow intensity of the reverse phase image did not decrease, there was no obvious abnormal enhancement in the arterial phase, mild halo-like enhancement at the edge of the parenchymal phase and delayed phase, mild progressive enhancement in its internal septum, unclear boundary between the lesion and the pancreatic tail, and patchy irregular progressive mild to moderate enhancement in the pancreatic tail near the splenic hilum. Considering the possibility of splenic malignancy, the possibility of lymphangioma co-infection involving the adjacent pancreatic tail is not excluded. Preoperative diagnosis: spleen tumor, gallstones.

Female, 63 years old, was admitted to hospital on May 4, 2015 due to "chest tightness for 6 months, aggravated with weakness of both lower limbs for more than 4 months". Radical surgery for endometrial cancer was performed 10 years ago, and radical surgery for colon cancer was performed 8 years ago. No regular radiotherapy or chemotherapy was performed after surgery, and there was no distant metastasis after long-term follow-up. He had a history of hypertension for more than 6 months and did not receive regular antihypertensive therapy. Physical examination: blood pressure of the right upper limb was 177/88 mmHg (1 mmHg =0.133 kPa), the right lower limb was 132/67 mmHg, the limbs were movable, and the dorsal pedis arteries on both sides were palpable. CT angiography of thoracic and abdominal aorta (outside hospital) showed that chronic aortic dissection may be (Figure 1，Figure 2)。 Echocardiography showed that the aorta occupied space in the lumen, and the ascending aorta did not see significant dilatation. CT of head and chest showed no embolism and distant metastatic lesions. After admission, the patient completed all preoperative preparations and underwent intra-aortic tumor resection + ascending aorta replacement + total aortic arch replacement + stent trunk implantation + ascending aorta-right femoral artery bypass under general anesthesia on May 6, 2015. The difference of systolic blood pressure between upper and lower limbs under general anesthesia during operation was 50 mmHg; The basal width of the intra-aortic tumor was approximately 1 cm, located in the posterior wall of the ascending aorta, and was confined to the intima, with the aortic adventitia intact and uninvolved (Figure 3，Figure 4)。 The operation was successful, and the postoperative pathology suggested: poorly differentiated malignant mesenchymal tissue tumor, and the immunohistochemical consideration was endometrial sarcoma. The patients were recommended to undergo chemoradiotherapy according to the follow-up results. There was no local recurrence and no distant metastasis in follow-up CT at 1 and 3 months after operation.

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A 64-year-old female was admitted for "painless full-course macroscopic hematuria for 5 d". Ultrasonography revealed a tumor in the right side wall of the bladder, approximately 1.8 cm ×1.5 cm in size; CT examination of urinary system showed that the right posterior wall of bladder occupied a solid space, about 1.5 cm ×1.0 cm in size, and no obvious abnormalities were found in bilateral upper urinary tract; Cystoscopy showed a cauliflower-like mass in the right posterior wall of the bladder, about 1.5 cm ×1.5 cm in size, about 1.0 cm away from the right ureteral orifice, located in the right ureteral running area, and no abnormalities were found in the remaining bladder wall. Biopsy showed low-grade papillary urothelial carcinoma.

Comrade Shi Yingkang, a member of the Communist Party of China, professor, doctoral supervisor and former dean of West China Clinical Medical College (West China Hospital) of Sichuan University, member of the Expert Advisory Committee of the State Council's Leading Group for Deepening the Reform of Medical and Health System, vice president of Chinese Medical Association, recipient of special government allowance from the State Council, academic and technical leader of Sichuan Province, and deputy editor-in-chief of Chinese Journal of Surgery, unfortunately died on the afternoon of May 11, 2016 at the age of 65.