2019年 · 第34卷第09期

The patient was a 53-year-old male. He was admitted to hospital for more than 1 month because his pancreas occupied space during physical examination. Previous denial of history of diseases such as hypertension. Tumor markers were all normal. Upper abdominal CT (Figure 1): A round-like cystic-solid occupation was seen on the head of the pancreas, and mucinous cystadenoma was considered. Endoscopic ultrasound guided fine needle puncture biopsy: A mixed cystic-solid mass about 7.5 cm ×7.0 cm in size was found on the head of the pancreas, with clear boundaries and uniform hypoechoic inside, and no tumor cells were found by puncture. Pancreaticoduodenectomy was performed. Patients' blood pressure increased significantly during intraoperative tumor compression, up to 180/110 mmHg. Postoperative pathology: The pancreatic head mass was cystic and solid, with dark red and soft parenchyma; The tumor tissue showed a typical organ-like structure arrangement under the microscope (Figure 2), with abundant blood sinusoids, nest-like and cord-like distribution of tumor cells, abundant cytoplasm, slightly eosinophilic, round nucleus, and no mitotic image. Pathological diagnosis: pancreatic paraganglioma, tumor margins and lymph nodes were negative. Immunohistochemical staining: NSE (+), Syn (+) (Figure 3), CgA (2+), S100 (+)Figure 4), CD56 (+), Ki-67 (+ less than 1%), insulin (individual cells, +), CK (keratin), EMA, Vimentin, CK18, CK8, CD34 and Glucagon were all negative. The blood pressure was normal after surgery, and no radiotherapy or chemotherapy was performed. There was no recurrence or metastasis after 15 months follow-up.

The patient, a 73-year-old male, was admitted to the hospital because the pancreas occupied space for half a year. Abdominal ultrasound: multiple cystic masses in the head, body and tail of the pancreas. Fasting blood glucose 12.26 mmol/L, CA199: 1 093.1 U/ml, CA125: 38.8 U/ml. Abdominal CT: The pancreatic duct was significantly dilated with multiple nodules, considering intraductal papillary mucinous tumor of the pancreas (Figure 1)。 Intraoperative exploration: The pancreas is enlarged, with multiple nodules of varying sizes on the surface, the larger one is located at the head of the pancreas, approx. 3.0 cm ×3.0 cm ×2.3 cm. Total pancreatectomy was performed and the mass was completely removed (Figure 2), postoperative pathology: intraductal mucinous adenocarcinoma of the pancreas (Figure 3)。 The patient was followed up for half a year after discharge, and no tumor recurrence was found on reexamination.

The patient, a 56-year-old female, was admitted to the hospital for 2 years due to the discovery of a right breast mass. Breast ultrasound: A 2.0 cm ×1.7 cm hypoechoic light cluster was detected at the edge of the gland at 10 points of the right breast, with unclear boundary and irregular shape (Figure 1)。 A 2.5 cm ×1.2 cm lymph node echo was detected under the right axilla, and the cutaneous-medullary boundary was still clear. Pathological report of puncture of right breast mass: fibrous tissue hyperplasia, scattered abnormal cell nests, not excluding cancer. Excision and biopsy of right breast mass under general anesthesia. The section surface of the tumor is gray-white, hard, delicate and infiltrative. Rapid pathology: invasive carcinoma (right breast) (metaplastic carcinoma is likely). Modified radical mastectomy was performed. Under the microscope: The tumor cells were spindle-shaped, and the nested arrangement was unclear from the surrounding boundary. Star-shaped epithelioid cells can be seen between spindle cells (Figure 2), scattered lymphocytes were seen in the lesion, duct-like structures were seen locally, epithelial cells were mildly abnormal, and ossification and calcification areas were seen (Figure 3)。 Postoperative pathology: (right breast) metaplastic carcinoma (fibromatosis-like metaplastic carcinoma). Immunohistochemical staining: CK (AE1/AE3) (+), ER (-), PR (-), Ki-67 (positive rate 40%), HER2 (-). No cancer metastasis was seen in axillary lymph nodes (0/20). After the operation, 4 cycles of chemotherapy were given, and the follow-up was 4 years. No recurrence was observed.

A 79-year-old female was admitted with "abdominal pain for 3 months". The patient had a history of "primary liver cancer". Three months ago, he was diagnosed as "liver cancer with para-aortic lymph node metastasis". The enlarged lymph nodes compressed the celiac plexus, resulting in intractable abdominal pain, which was difficult to control with conventional analgesics. The visual analog score was 7 points. neurolytic celiac plexus block (NCPB) was performed to control abdominal pain. The therapeutic routes of NCPB include: needle insertion through left or right dorsal and abdominal routes. The needle insertion route through abdominal puncture needs to pass through the liver, and because the liver moves up and down with respiratory movement, the difficulty of puncture is increased, the accuracy of puncture is reduced, and the risk of liver bleeding is increased. The needle insertion through the right back needs to pass through the right kidney, and it is difficult for the puncture needle to reach the abdominal aorta; The needle insertion through the left back needs to pass through the abdominal aorta. Although the complications of the abdominal aorta are increased, the puncture needle can accurately reach the abdominal aorta, thus ensuring the efficacy of NCPB. Therefore, the needle insertion route through the left abdominal aorta was decided. The detailed procedure of NCPB through the abdominal aortic approach in this patient is shown inFigure 1。 After the operation, the puncture needle was removed, and abdominal CT examination was performed 5 minutes later. No complications such as local hemorrhage, hematoma, abdominal aortic dissection and abdominal aortic pseudoaneurysm were found. The patient's abdominal pain improved immediately after surgery, and the visual analogue scale was 3 points. The abdominal pain could be controlled with conventional analgesics at one month of follow-up.