2019年 · 第34卷第02期

The patient was a 51-year-old female. He was admitted to hospital for "pain and discomfort in the right upper abdomen for 1 month". No previous history of hepatitis B. Physical examination: swelling of the right upper abdomen, mild tenderness in the right upper abdomen, no rebound pain, the lower edge of the liver is located about 10 cm below the xiphoid process, about 8 cm under the costs, the surface of touch is uneven and hard, and the percussion pain in the liver area is positive. Laboratory tests: AFP was normal, CA 125 51.74 U/ml, other blood routine, liver and kidney function and coagulation function were roughly normal. Ultrasound of liver, gallbladder, pancreas and spleen showed that a huge hypoechoic mass was seen in the right liver, about 15.5 cm ×13.8 cm in size, with irregular shape and unclear boundary. Upper abdominal enhanced CT showed: huge abnormally enhanced mass shadow in the right lobe of the liver, uneven internal density, multiple tumor vascular shadows, irregular annular enhancement around the mass in the arterial phase, no obvious enhancement in the center, and decreased peripheral density in the portal vein phase and delayed phase (Figure 1)。 Consider the possibility of liver cancer. Surgical exploration: A mass of about 18 cm ×14 cm ×10 cm in size was seen in the right liver, which was hard in texture, densely adhered to the surrounding tissues, and there was no obvious satellite focus around it. Right hemihepatectomy and hepatoduodenal ligament lymph node dissection were performed (Figure 2)。 Postoperative pathology showed: sarcomatoid hepatocellular carcinoma; Immunohistochemistry showed: HBsAg (−), GPC3 (−), HepPar1 (−), CEA (−), Ki-67 (80% +), CD34 (vascular +), CK19 (partial +), p53 (mutant), CK20 (−), CK (+), EMA (+), Vimentin (+).

A 27-year-old male was admitted for "recurrent right upper abdominal colic for 2 years, recurrent exacerbation with fever for 1 d". Recently, there was no obvious abnormality in upper gastrointestinal tract angiography. Electronic gastroscopy: chronic non-atrophic gastritis with bile reflux. Physical examination: mild yellowing of skin and sclera, flat and soft abdomen, tenderness in the right upper abdomen, no rebound pain and muscle tension, and no palpable mass. Laboratory test: white blood cells 11.55×10⁹/L, percent neutrophils 0.884, alanine aminotransferase (ALT) 88 U/L, aspartate aminotransferase (AST) 56 U/L, total bilirubin (TBiL) 100 μ mol/L, direct bilirubin (DBiL) 77 μ mol/L, gamma glutamyltransferase (gamma GGT) 374 U/L, alkaline phosphatase (ALP) 150 U/L, tumor markers normal. Abdominal color ultrasound: gallbladder stones, intrahepatic bile duct dilation. Abdominal CT: gallbladder inflammation, multiple stones in the common bile duct and left and right hepatic ducts with biliary dilatation and pneumatosis. Then open cholecystectomy + common bile duct incision exploration lithotomy + T tube drainage were performed under general anesthesia. During the operation, the gallbladder was enlarged with several rice-grain-sized stones. The common bile duct was 1.2 cm thick and contained more black stones. The hilar bile duct was obviously dilated and there were more cinder-like stones. Electronic choledochoscopic exploration showed that the terminal opening of the common bile duct was unobstructed, the sphincter muscle contracted, and the left hepatic duct protruded like a blind bag, with a fissure-like opening in the center (Figure 1), physiological saline is injected into the gastric cavity from then on. There was no palpable mass in the stomach, and local cord-like thickening of the hepatogastric ligament was detected. Careful intraoperative analysis of CT (Figure 2): Hepatic hilar double bile duct shadow, the left bile duct is full of stones, congenital bile duct dysplasia is considered in combination with intraoperative findings. Postoperative T-tube angiography (Figure 3) shows: double common bile duct malformation, the common bile duct originates from the right hepatic duct, the lower end of the common bile duct opens to the descending duodenum, the sphincter functions well, the accessory common bile duct originates from the left hepatic duct, the distal end is linear and narrow, the end opens to the small curve of the gastric antrum, the contrast medium passes smoothly, and the common bile duct and the accessory common bile duct have communicating bile ducts at the hepatic hilum. The patient recovered well after surgery, and the T-tube removal was smooth without complications.

A 2-year-old male was admitted to the hospital with the main complaint of "vomiting with abdominal distension and fever for 2 days after laparoscopic choledochal cyst resection". The child underwent laparoscopic modified cholangiointestinal loop anastomosis (Warren) for choledochal cyst in our hospital 1 year ago, and recovered well after operation. Vomiting occurred without obvious trigger 2 days ago. The vomit was stomach content at first, and then coffee-like substance, which was more frequent and large, accompanied by abdominal distension and fever. The abdominal distension gradually worsened, and the fever peak was 39℃. After the local hospital gave anti-infective rehydration and enema treatment, vomiting and abdominal distension could not be relieved, and there was no defecation and exhaust, so he was transferred to our hospital for treatment. Physical examination: dehydrated appearance, poor mental response, abdominal distension, total abdominal tenderness, accompanied by abdominal muscle tension, no abnormal mass palpable, weak intestinal sound, poor peripheral circulation of limbs. Laboratory tests showed: ALT 66.2 U/L, AST 77.5 U/L, CRP 132.92 mg/L, procalcitonin>100.000 ng/ml; The abdominal upright radiograph showed that the gastric vesicle was under the left diaphragm, with a slightly larger fluid level in it, and a small amount of gas-containing intestinal shadow was visible in the right middle abdomen, without dilatation, but with a small fluid level, the rest of the abdomen was dense, and the abdominal shape was slightly swollen. After admission to the hospital, while correcting the shock, active preoperative preparation, emergency general anesthesia for exploratory laparotomy, intraoperative exploration showed diffuse intestinal dilatation, small intestine herniated through the mesangial hole of the biliary loop, forming imprisoned obstruction, compressing the mesangial blood vessels of the biliary loop, the biliary loop intestinal tube was dilated, thin, gray in color, without peristalsis, and necrotic (Figure 1)。 From the mesangial hiatus, the hernia was reset into the small intestine, the obstruction was released, the necrotic gallbladder was removed (from the jejunal anastomosis), and the bile from the common hepatic duct was discharged smoothly. The proximal small intestine and the distal small intestine were trimmed, and the proximal small intestine and the distal small intestine were anastomosed end-to-end at 30 cm, and the distal small intestine was lifted to the hilum after passing through the colon as a biliary loop. The common hepatic duct and the biliary loop small intestine were anastomosed end-to-end. After operation, the children recovered well, ate well, and all laboratory indexes gradually returned to normal.

A 51-year-old female was admitted to the hospital due to "distension and pain in the right upper abdomen for more than 6 months, and the liver occupied space for 3 days by B-ultrasound". No previous history of hepatitis B or schistosomiasis. Physical examination: No jaundice, mild tenderness in the right upper abdomen, no rebound pain, and negative "Murphy's" sign. Laboratory tests: blood, urine, stool routine, liver, kidney function and tumor indexes were all normal, and five items of hepatitis B were negative. B-ultrasound showed a huge intrahepatic mass, internal hypoechoic, peripheral equal and higher echoic, accompanied by dotted and striped blood flow signals. CT scan showed a huge lobulated cystic mass in the liver, with a maximum diameter of about 126 mm. The main body in the cyst was water-like with low density, and a few stripes of slightly higher density shadows were seen. The outer wall was smooth, and multiple nodules and papilla-like low density shadows were seen on the inner wall (Figure 1)。 The nodules and papillary structures in the enhanced arterial phase were significantly enhanced, slightly higher than those in the adjacent liver parenchyma (Figure 2)； The portal pulse and the delayed phase continued to strengthen, relatively weakened, and the density was slightly lower than that of the adjacent liver solid mass. Some nodules saw slender blood vessel shadows (Figure 3)。 The bile duct adjacent to the lesion was slightly widened, but no abnormalities were observed in the rest. During the operation, the tumor involved the IV, VII and VIII segments of the liver, with a relatively intact capsule. The tumor was completely removed by liver segment resection where the tumor was located. Pathological examination: The tumor was cystic and solid, 110 mm ×116 mm ×65 mm in size, soft in texture and gray-white in section. Microscopically, the tumor showed multiple papillary shapes, covered with stratified eosinophilic cells, with abundant eosinophilic cytoplasm and large nucleus. It invaded the interstitial wall of the bile duct locally, but did not involve the liver parenchyma (Figure 4，Figure 5)。 Immunohistochemistry Muc-5AC (+), Muc-6 (+) (Figure 6), ARG-1 (−), Muc-2 (−), CK19 (+), CD34 (vascular +), CK20 (+ +). Pathological diagnosis: intrahepatic bile duct intraductal eosinophilic papillary tumor with invasive carcinoma.

A 64-year-old male was admitted to the hospital because "physical examination found liver space-occupying lesions for more than 20 days"; No prior history of hepatitis cirrhosis; Physical examination: The skin sclera is not yellow, and the superficial swollen lymph nodes are not reached, and the abdomen is swollen. A hard round mass can be palpable in the right upper abdomen and under the xiphoid process, with tenderness (±). Percussion pain in the liver area (±), no tenderness in the remaining abdomen, no rebound pain, and ascites sign (-). Auxiliary examination: Biochemistry, urine routine, coagulation function normal, blood routine: white blood cells: 13.74×10⁹/L Percentage neutrophils: 79.1% Neutrophils: 10.87×10⁹/L; Tumor markers: CA50: 83.30 U/ml, CA-199: 693.90 U/ml, alpha-fetoprotein (AFP) and carcinoembryonic antigen (CEA) were in the normal range; Infectious markers: hepatitis B surface antibody (HBsAb): 165.10 IU/L hepatitis B core antibody (HBcAb), hepatitis B surface antigen (HBsAg), hepatitis B e antigen (HBeAg), hepatitis B e antibody (HBeAb) were all negative, and hepatitis C antibody was all negative; CT examination: A patchy slightly lower density shadow, about 69 mm ×52 mm in size, was seen in the liver. The intrahepatic bile duct was not dilated, and the enhancement showed uneven enhancement. The gallbladder wall was blurred and slightly thicker, and enhancement was seen (Figure 1，Figure 2)。 Combined with the medical history and related examinations, the possibility of liver cancer is considered clinically. Treatment process: Relevant examinations were completed, contraindications for surgery were excluded, and radical liver tumor resection + cholecystectomy was performed under general anesthesia on April 24, 2018. The operation was smooth, the resection was complete, and the mass did not rupture or bleed. Postoperative pathological diagnosis: (liver) squamous cell carcinoma, partially showing adenoid squamous cell carcinoma (Figure 3，Figure 4)。 (Gallbladder) Chronic cholecystitis. Neither the liver margin nor the gallbladder neck margin showed cancer tissue. No cancer metastasis was observed in the hepatoduodenal ligament lymph nodes (0/8). Immunohistochemistry: CKpan (+), CK7 (+), CK20 (-), Villin (+), CK5/6 (+), P40 (+), P63 (+), CK19 (+), CD31 (-), CD34 (-), Ki-67 (~30% +), AFP (-) (Figure 5)。 Postoperative diagnosis: primary squamous cell carcinoma of liver (PSCCL) Treatment results: The patient recovered well after operation and was discharged 10 days after operation. The patient is still alive until now, and no tumor recurrence or metastasis has been seen.

The patient was a 54-year-old female. He was admitted to hospital because of "left upper abdominal mass found for 20 days". Color ultrasound examination of the patient in another hospital 20 days ago showed a mixed cystic-solid mass in the left upper abdominal area, without abdominal pain, abdominal distension, nausea, vomiting, chest tightness, choking and other discomfort. No special treatment was performed. Physical examination: soft abdomen, unpalpable liver, palpable 4 cm under the spleen ribs, tough texture, mild tenderness in the left abdomen. CT in our hospital showed that the volume of the spleen was increased, close to the midline of the abdomen, and the diffuse distribution of round uniform low-density shadows of unequal size in the parenchyma of the spleen, with smooth edges and clear boundaries, and local accompanied by punctate calcifications. The larger one was about 4.3 cm ×4.4 cm in size, and the CT value was about 17 Hu. Enhanced scan: No enhancement was seen in multiple lesions of the spleen (Figure 1)。 CT diagnosis: multiple cysts of the spleen. Laparoscopic splenectomy under general anesthesia.

The patient was a 54-year-old male. Three years ago, we underwent "radical resection of right hemicolon cancer" in our hospital. Postoperative pathological examination confirmed that it was colon infiltration ulcer type low to moderate differentiation adenocarcinoma, infiltration into extraserous adipose tissue, and positive lymph node metastasis (pericolon: 2/20, small mesenteric: 0/4) (Figure 1)。 The postoperative diagnosis was pT4N1M0 stage ⅢB. According to NCCN guidelines, adjuvant chemotherapy was standardized after surgery, and it was evaluated after every 4 cycles of chemotherapy. There was no recurrence or metastasis of the disease. CT examination performed in August 2015 showed liver and adrenal metastases (Figure 2)。 B-ultrasound guided liver puncture biopsy was performed, and pathological examination confirmed that it was (liver) mesodifferentiated adenocarcinoma, consistent with colorectal origin. After palliative chemotherapy, the patient suffered from swelling of the scrotum on 20 Feb 2017. Physical examination: No swollen superficial lymph nodes were palpable in the bilateral inguinal area, the right testis was slightly swollen, hard, without tenderness, and the right spermatic cord was obviously thickened. CT examination showed that the right epididymal testis occupied space (Figure 3)。 Testicular puncture biopsy confirmed adenocarcinoma invasion or metastasis in fibrous tissue, CDX2 positive, consistent with testicular metastasis of colon cancer. Palliative orchiectomy was performed on 24 Mar 2017. Postoperative pathological report: (Right) adenocarcinoma infiltration can be seen in testicular tissue, considering colorectal cancer metastasis (Figure 4)。

The patient, a 63-year-old female, was admitted to the hospital because "the skin was found to be yellow for more than half a month"; No history of hepatitis cirrhosis; Physical examination: Skin and sclera were yellow stained, without superficial swollen lymph nodes, and no obvious abnormalities in heart and lung were found. The abdomen was flat and soft, with tenderness in the right upper abdomen (-), no percussion pain in the liver, not under the costs of the liver and spleen, and no obvious mass was palpable. Relevant laboratory tests after admission: blood routine, tumor markers (serum tumor markers CA-199, CA-125, CEA and AFP were all within the normal range), renal function, infection markers [hepatitis B surface antibody (HBsAb): 4.58 IU/L, hepatitis B core antibody (HBcAb), hepatitis B surface antigen (HBsAg), hepatitis B e antigen HBeAg and hepatitis B e antibody (HBeAb) were all negative], and blood coagulation function was normal; Liver function: direct bilirubin 44.7 μ mol/L, total bilirubin 74.9 μ mol/L, indirect bilirubin 30.2 μ mol/L, aspartate aminotransferase 77 U/L, alanine aminotransferase 116 U/L, alkaline phosphatase 1 080 U/L, gamma glutamyl transpeptidase 769 U/L; MRI showed that the left liver duct was mildly dilated, and the left lobe of the liver was abnormally enhanced with nodules, excluding small hepatocarcinoma (Figure 1，FIG. 2A，Figure 2B，Figure 2C)。 Combined with the medical history and related examinations, the possibility of left liver cancer was considered clinically. Treatment process: Perfect relevant preoperative examinations, exclude surgical contraindications, and perform partial left hepatectomy under general anesthesia with tracheal intubation on September 12, 2017. The operation was smooth, the resection was complete, and the mass did not rupture or bleed. Postoperative pathological diagnosis: epithelioid angiomyolipoma (left lateral lobe of liver) (Figure 3)。 Immunohistochemical examination showed that tumor cells were positive for HMB45 (Figure 4), Melan-A positive, vascular SMA positive, fat S100 positive; CKpan negative, AFP negative. Diagnosis: Epithelioid angiomyolipoma (EAML). Treatment results: The patient recovered well after operation, and his liver function was basically normal after postoperative review. He was discharged from hospital 1 week after operation. Since regular review and follow-up, no tumor recurrence or metastasis has been seen.

A 68-year-old male was found to have "left palm nodules for more than 20 years, intermittent pain". In February 2017, he was resected due to enlarged nodules. Pathological biopsy showed: epithelial tumor of left palm, consistent with basal cell carcinoma. Immunohistochemical staining: CK5/6 (+), CK (+), CP (-), P40 (-), Ki-67 (nest mass 30% +). In December 2017, a "left axillary mass with painless enlargement" was found. Physical examination: 1 depressed scar with a size of 1 cm ×1 cm on the palm of the left hand, with clear borders and no tenderness. The left axillary mass was about 6 cm ×5 cm in size, tough in texture, with poor boundaries, poor mobility, and slight tenderness. The pathology of puncture biopsy showed basal cell carcinoma, and squamous cell carcinoma was not excluded. Immunohistochemical staining: CK7, P40, P63, E-cadherin, CK34 β E12 were all positive, ER, PR, CerBb-2, GCDFP-15, CK19, CK20, CD56, TTF, NapsinA were all negative, and Ki-67 (15% +). Serum tumor-related substances (111.8 U/ml), CA125 (35.81 U/ml) and squamous cell carcinoma-related antigen (10.2 ng/ml) were all increased. Chest CT examination showed that the size of left axillary was about 57.6 mm ×50.8 mm massive soft tissue density shadow, and the enhancement was uneven after enhancement (Figure 1)。 PET-CT: Multiple lymph nodes in the left axilla were enlarged with increased radioactive uptake, which was considered as multiple lymph node metastasis and fusion. On March 9, 2018, the left axillary mass was excised and the axillary lymph nodes were explored. The lymph nodes in the axillary were enlarged and fused, and the adhesion to the surrounding tissues was severe. The axillary mass was excised and the axillary lymph nodes were dissected. The postoperative pathological report was consistent with lymph node metastasis of basal cell carcinoma (lymph node 3/16) (Figure 2)。 Immunohistochemical staining showed strongly positive expression of MLH1, MSH2, MSH6, PMS2 and PD-L, and Ki-67 (90% +).

According to statistics, more than 300,000 people in China die of hepatocellular carcinoma (hereinafter referred to as liver cancer) every year, accounting for about half of the global liver cancer deaths. Liver transplantation is recognized worldwide as one of the most effective methods for the treatment of end-stage liver disease. Since the second upsurge of liver transplantation in China in 1990s, liver transplantation has developed rapidly, showing a trend of specialization and large-scale development, and the quantity and quality of transplantation have approached or reached the level of western developed countries. According to data from the China Liver Transplant Registry, in the past five years, the number of liver transplantation cases of liver cancer in mainland China accounted for 36.8% of the total number of liver transplantation cases. In order to guide the national liver transplantation work to be carried out more standardized, effective and safely, experts from industry societies such as Organ Transplantation Physicians Branch of Chinese Medical Association and Organ Transplantation Branch of Chinese Medical Association organized to formulate the Clinical Practice Guidelines for Liver Cancer Liver Transplantation in 2014, focusing on five parts: selection criteria for liver transplantation recipients, preoperative reduction treatment, antiviral treatment, immunosuppressant application and postoperative recurrence prevention and treatment. In recent years, some new progress has emerged in the field of liver transplantation for liver cancer. In order to adapt to the new development situation faced by liver transplantation for liver cancer in China, the guidelines are now updated. The evidence grading for evidence-based medicine used in this guideline mainly refers to the 2001 Oxford Evidence Grading (seeTable 1), the strength of recommendation opinions mainly refers to the recommended grading of GRADE system, etc.