2019年 · 第34卷第11期

hepatocellular carcinoma (HCC) is one of the most common and most malignant tumors in the world, ranking sixth in incidence and fourth in mortality^[1]。 In the past four decades, significant progress has been made in the diagnosis and treatment of liver cancer, mainly including: (1) The discovery and application of alpha-fetoprotein (AFP) in the early 1970s made it possible to find asymptomatic early stage liver cancer (subclinical stage), and the early diagnosis and treatment of liver cancer significantly prolonged the survival time of patients. (2) After the 1980s, the rapid progress of imaging enabled us to detect and diagnose smaller liver cancer lesions more accurately; Local ablation is performed for some patients with small liver cancer who cannot tolerate surgery; transcatheter arterial chemoembolization (TACE) is used before surgery to give patients who have no chance of surgical treatment a chance of treatment or even cure (including surgical treatment after comprehensive treatment and reduction). The survival of patients with liver cancer is further prolonged. (3) The rapid development of systemic treatment of liver cancer in the past decade, targeted drugs and immunotherapy have brought new hope to liver cancer patients, allowing more advanced patients to obtain treatment opportunities, and further prolonging the overall survival time^[2]。 The main developments in the past decade are as follows:

A 87-year-old female was admitted to the hospital with the main complaint of "abdominal pain with fever for 20 days". Twenty days ago, the patient had sudden total abdominal pain after breakfast, which was persistent distension and pain, accompanied by nausea and vomiting. The vomit was stomach content, accompanied by diarrhea and fever, and the maximum body temperature was 40 ℃. He was diagnosed as acute cholecystitis in another hospital, and was relieved after anti-diet, intravenous fluid rehydration, anti-infection and analgesic treatment. Two days before admission, the patient developed upper abdominal pain on fasting stomach in the morning, accompanied by nausea and vomiting. The vomit was bile-like yellow fluid, not much, no chills, fever, diarrhea, and skin and sclera yellowing. Visited another hospital, and performed abdominal CT showed: irregular density shadow in the right lobe of the liver, with a long diameter of about 13 cm, unclear boundary and uncertain nature; See also high-density shadows in the gallbladder, which are considered gallbladder stones. After analgesic and anti-infective treatment, the above symptoms were relieved compared with before, and then transferred to our hospital. The patient had a history of acute pancreatitis and no trauma 1 month before admission. There were no comparable patients in the family. Physical examination: abdominal swelling, no abdominal wall varicose veins, no intestinal type, obvious tenderness in the right upper abdomen, no rebound pain, and a palpable mass, about 5 cm in diameter, tough in texture, clear in boundary, average mobility, Murphy's sign (-), enlarged liver voice boundary, percussion pain in the liver area (+), mobile voice (-), and intestinal sound 2 times/min. Auxiliary examination showed: white blood cells 14.48×10⁹/L, neutral ratio 79.7%, CRP 165 mg/L, AFP and CA-199 normal. Ultrasound of liver, gallbladder, pancreas and spleen (2018.6.20): A mixed echo light group was seen along the circular ligament of the liver, from the lower edge to the upper umbilicus, with a range of about 14.0×5.8 cm, with clear boundary and uneven echo; Hyperechoic light clusters in the gallbladder. Diagnosis: gallbladder stones with chronic cholecystitis; Abdominal cavity mixed echo light mass, consider abscess possible. Based on the patient's medical history, physical examination and auxiliary examination, the diagnosis was considered as: (1) Gallbladder stones and chronic cholecystitis. (2) Hepatic round ligament abscess. On the third day after admission, peritoneal encapsulated effusion puncture and catheter drainage was performed under ultrasound guidance. The drainage fluid was purulent and the volume was approximately 50 ml. Upper abdominal enhanced CT was performed after puncture (Figure 1，Figure 2，Figure 3) shows: irregular mass shadows are seen in the hilar-left lobe of the liver, running along the circular ligament of the liver to the anterior and inferior abdominal wall, the wall thickness is uneven and strengthened, the internal density is uneven and multiple gas density shadows are seen; High density shadows in the gallbladder. Further diagnosis was as follows: (1) Hepatic round ligament abscess. (2) Gallbladder stones were discharged with drainage tube after 1 week of anti-infective treatment. At discharge, the symptoms were in complete relief and the daily drainage volume was 20 ml. 2.5 months after the abscess puncture and drainage, the reexamination of CT showed that the circular ligament abscess of the liver was significantly improved compared with the previous one (Figure 4，Figure 5，Figure 6)。 Re-examination 5 months after drainage showed that the abscess was completely absorbed (Figure 7，Figure 8)。 After 5 months of discharge, the abdominal CT examination showed that the abscess significantly subsided, abdominal pain, fever and other symptoms disappeared, and there was no discomfort after the drainage tube was removed.

A 20-year-old female was admitted to the hospital due to "intermittent vomiting and anorexia for half a month". The vomiting symptoms worsened 1 day ago, and she developed strabismus with tremor, blurred vision, tinnitus, weakness of both lower limbs, and unsteady standing. The patient was obese for 6 years and was diagnosed with morbid obesity and underwent laparoscopic sleeve gastrectomy (LSG). Physical examination: weight 125 kg, height 153 cm. Poor mental response, BMI 53.8 kg/m²。 Strabismus with tremor, bilateral pupils of equal size, about 3 mm, less sensitive to light reflection. Kerning sign and Brudzinski sign were negative, Babinski sign was bilaterally negative, bilateral pain sensation was normal, bilateral finger-nose test and heel-knee-tibia test were positive, muscle tone was normal, and muscle strength was grade 5. Audiological test: 2~5 Hz hypofunction of the horizontal semicircular canal in both ears; Vestibular function tests: horizontal vestibular ocular hyporeflex, vertical hyperactivity, horizontal and vertical VOR incubation period prolongation, suggesting mixed hypofunction of the vestibular center and periphery, and reduced sensitivity of high-frequency responses of horizontal and vertical semicircular canals. Cranial CT: No abnormalities in cranial morphology were found. Cranial MRI: Abnormal flaky slightly high signal was seen on the dorsal side of bilateral thalamus at DWI (Figure 1), there was no abnormal expansion or narrowing of the ventricular morphology and sulcus fissure cistern, and no displacement of the midline structure, so Wernicke encephalopathy was considered. After intramuscular injection of thiamine 100 mg 3 times/d, the mental state was improved and the dizziness symptoms were relieved after 2 days. The diagnosis of Wernicke encephalopathy was defined by combining the MRI findings of the head, the history of LGS and clinical symptoms. After continued intramuscular injection of thiamine 300 mg/d for 2 days, the patient's symptoms such as vomiting, tinnitus, strabismus and drowsiness were significantly relieved, but he still had standing instability and nystagmus. After continued intramuscular injection of thiamine 200 mg 3 times/d for 1 week, the clinical symptoms were basically relieved, and after continued oral injection of thiamine 100 mg/d for 1 month, he could basically take care of himself. Re-examination of skull MRI showed no abnormalities in the skull and brain.

An 85-year-old female was admitted to the hospital for "2 weeks of effort to defecate". Digital rectal examination showed a 5 cm ×5 cm hemispherical mass on the right posterior wall of the rectum 4 cm away from the anal margin. The surface was smooth, the texture was medium hard, the movement was capable, and the finger cuff was not stained with blood. Colonoscopy showed that an irregular bulging mass of mucosa was seen 2 cm above the dentate line, with ulcerated surface, brittle texture and easy bleeding. A 0.5 cm ×0.5 cm polyp was seen 30 cm from the anal margin. Diagnosis of rectal cancer with colonic polyps. Biopsy pathology showed chronic inflammation of rectal mucosa and adenomatous polyps of colon with low grade neoplasia. Abdominal CT examination showed rectal mass shadow, considering the possibility of stromal tumor (Figure 1)。 Transanorectal tumor resection was performed. During the operation, a 4.0 cm ×4.0 cm mass was found 2 cm above the dentate line, which was located under the rectal mucosa with a smooth surface. After incision of the rectal mucosa, the mass was completely removed. Postoperative pathological examination revealed: morphological changes of typical stromal tumor, spindle cell type, pathological mitotic image<5/50HPF. Immunohistochemical staining showed that CD117 (+), CD34 (+) and Ki-67 were 3% ~5%, and Desmin, DOG, S-100 and SMA were all negative. On March 23, 2018, due to "difficulty in fecal discharge", CT examination in the local hospital showed recurrence of rectal tumor, and I was admitted to our hospital again. The digital rectal examination revealed a 6 cm ×8 cm hemispherical mass in the right posterior wall of the rectum, 4 cm from the anal margin, with a smooth surface, moderately hard texture and poor mobility. Abdominal CT examination showed that a tumor growing outward of the cavity could be seen in the low rectum. Transanorectal lesion resection was performed. During the operation, the tumor was located 3 cm from the anus, 5 to 10 points from the lithotomy position on the right anterior lateral wall of the rectum, and a spherical mass with a size of 8 cm ×6 cm was located under the rectal mucosa with clear boundaries. The tumor was removed completely after incision of the rectal mucosa. Postoperative pathological examination showed rectal stromal tumor with pathological mitotic image<5/50HPF. Immunohistochemical staining showed that CD117, CD34, DOG-1 and VIM were all positive, Her-2 (0) and Ki-67 (about 3% +).

A 56-year-old male was admitted to hospital for 2 months due to the discovery of a mass in his right upper abdomen. He had a history of hepatitis B virus for 20 years. In the past 2 months, he felt that the mass in his right upper abdomen gradually increased, without abdominal pain, discomfort and jaundice. He was diagnosed with right liver cancer by abdominal enhanced CT in another hospital. Physical examination at admission: no yellowing staining of the skin and sclera, no abnormalities in the heart and lungs, flat and soft abdomen, the lower edge of the liver can be palpable 10 cm below the xiphoid process and 5 cm below the right costal arch, no tenderness, positive percussion pain in the liver area, and normal intestinal sounds. Enhanced CT of the liver showed a mass shadow in the right lobe of the liver, with uneven enhancement in the arterial phase, and blood supply to the hepatic artery was visible, which was considered as massive hepatocarcinoma of the right liver (Figure 1), examination of liver MRI enhancement showed that the arterial phase of the right lobe of the liver showed obvious uneven enhancement changes, considering liver massive liver cancer. CT and MRI examination did not find the left liver occupied space. CA199 110.4 U/ml, AFP 162.3 ng/ml, CA15-3, CA72-4, CEA were all normal, blood routine: WBC 7.2×10⁹/L, Hb127 g/L, PLT329×10⁹/L, liver function: ALT 90 U/L, AST 67 U/L, total bilirubin 18.9 μ mol/L, direct bilirubin 7.6 μ mol/L, HBsAg (+), HBeAb (+), HBcAb (+). The preoperative diagnosis was liver cancer in the right lobe of the liver. During the operation, the right liver tumor was found to be about 17 cm ×17 cm in size, and the left liver segment III visceral surface tumor was about 2.0 cm ×2.5 cm in size. The resection of the right liver segment V and VI and the left liver segment III tumor were performed. Postoperative pathology: hepatocellular adenoma in the right lobe of the liver (Figure 2), primary liver cancer of the left lobe of the liver (Figure 3), Immunohistochemistry: A4: GPC-3 (+), Ki-67 (~5% +), CK18 (+), KD19 (-), EGFR (weak +), TOPOII (-), Hepatocyle (+), S-100 (-), CK (+), CD₅₆(-), CD₃₄(Vascular +), CEA (-), CD₁₀(＋)，P₅₃(－)； A6: Ki-67 (about 30% +), CD₃₄(Vascular +), CEA (-), CD₁₀(－)，P₅₃(focal +); A1: Ki-67 (about 10% +). The patient recovered well and was discharged after surgery.

A 75-year-old male was admitted to the hospital due to "skin itching all over the body for more than half a month, and the liver was found to occupy space for 10 days". Physical examination: Scattered erythema, papules, scales and scab can be seen on the skin of the whole body (Figure 1)。 Laboratory test: white blood cell count 29.50×10⁹/L, eosinophil count 10.91×10⁹/L, the percentage of eosinophils was 37.0%, serum IgE was normal, and serum tumor markers were negative. Abdominal enhanced CT showed an irregular slightly lower density focus in the S6 and 7 segments of the right liver, with a size of about 48 mm ×45 mm ×36 mm. The focus was obviously uneven and annular enhancement in the arterial phase of enhanced scan, but still enhancement in the portal vein phase. The lymph nodes around the common hepatic artery were swollen and showed uneven enhancement (Figure 2)。 Hepatic sarcomatoid carcinoma revealed by puncture biopsy of a liver mass. The results of skin biopsy showed slight thickening of the epidermis, hyperplasia of the acanthus layer, and perivascular infiltration of eosinophils in the superficial dermis. Bone marrow biopsy: Bone marrow hyperplasia was obviously active, the proportion of granulocytes increased, and the proportion of eosinophils increased significantly. Clinical diagnosis: eosinophilic dermatitis secondary to sarcomatoid carcinoma of the liver. Open right posterior lobectomy and abdominal lymph node dissection were performed. The mass was cut open and removed, and the cut surface was gray-white, medium in texture and clear in border (Figure 3)。 Postoperative pathology: sarcomatoid carcinoma of the right posterior lobe of the liver, with metastasis in the lymph nodes of group 8p. Immunohistochemical staining: CK-PAN (+), Ki-67 (+50%), SMA (+), Vimentin (+) (Figure 4)。 Hepatic sarcomatoid carcinoma was diagnosed. The symptoms of skin pruritus and rash disappeared after operation, the white blood cells and eosinophils returned to normal, and the white blood cell count was 7.31×10⁹/L, eosinophil count 0.33×10⁹/L.

The patient was a 53-year-old male. He was admitted to the hospital with "repeated right upper abdominal distension and pain for more than 2 months, aggravated for 3 days". Two months ago, there was no clear trigger for distension and pain in the right upper abdomen. Recently, the aggravation was persistent, the scleral skin was yellow, there was no chills and fever, the urine was yellow, and the stool color was normal. History of liver cancer surgery 1 year ago. At the time of review, no signs of gallbladder stones and biliary obstruction were found on abdominal CT. Admission physical examination: generally acceptable; Yellow staining of skin, mucosa and sclera throughout the body; Percussion pain in the liver area (±). Laboratory tests: Blood routine: WBC 6.02×10⁹/L, neutrophil ratio 79.2%, C-reactive protein 43 mg/L; Urinary routine: urobiliogen +, urinary bilirubin +; Liver function: total bilirubin 147.3 μ mol/L, direct bilirubin 80.1 μ mol/L, indirect bilirubin 67.2 μ mol/L, alanine aminotransferase 101 U/L, aspartate aminotransferase 134 U/L, alkaline phosphatase 224 U/L, glutaminyl transferase 38 6 U/L; Tumor marker : CEA 3.1 ng/ml, AFP 4.65 ng/ml.

A 58-year-old male was admitted to the hospital due to "yellowing of the skin and sclera of the whole body for more than 20 days". 13 years of previous history of hepatitis B. Weight loss of 5 kg after onset. Physical examination: The skin sclera was yellow, the abdomen was soft, no tenderness, no moving void, the spleen could be palpable at the lower edge of the right abdominal costal arch, moderately enlarged, the inferior pole of the spleen exceeded the subcostal 4 cm, and the texture was hard. Liver function report: total bilirubin (TB) 178.84 μ mmol/L, conjugated bilirubin (CB) 144.80 μ mmol/L, tumor marker CA19-9 33.30 U/ml, carcinoembryonic antigen (CEA): 1.35 ng/ml, the rest normal. Imaging examination: Chest X-ray and electrocardiogram showed dextrocardiac (Figure 1)。 B-ultrasound and MRI report: congenital transposition malformation of the viscera, normal size and morphology of the liver, slight dilatation of the intrahepatic bile duct, the inner diameter of the upper section of the common bile duct is 1.4 cm, the wall of the upper section of the common bile duct pancreas is thickened, the lumen is narrowed and occluded, and irregular soft tissue shadows are seen, the size is about 14 mm ×12 mm, suggesting a high possibility of cholangiocarcinoma (Figure 2、Figure 3)。