2020年 · 第35卷第02期

The patient was a 65-year-old male. Admitted for "6 years after finding a lower abdominal mass". Physical examination: soft abdomen, no tenderness in the whole abdomen, no muscle tension and rebound pain, slightly swollen lower abdomen, and a mass about 20 cm ×15 cm ×15 cm in size can be palpable, with unclear boundaries, soft texture and good mobility. Laboratory tests showed that serum CEA was 16.51 ng/mL, and serum AFP, CA125 and CA199 were normal. Abdominal B-ultrasound showed that a hypoechoic mass was visible on the right side of the lower abdomen, about 18 cm ×16 cm ×15 cm in size, with clear boundary, regular shape and uneven internal echo. Color Doppler showed punctate color blood flow around and inside (Figure 1)。 Enhanced abdominal CT showed: cystic mass occupation in the middle abdomen (Figure 2)。 An exploratory laparotomy was performed. Intraoperative exploration revealed that the appendix was huge, with cystic changes, about 20 cm long, 15 cm in diameter at the widest point, and 8 cm in diameter at the root, connected to the cecum (Figure 3)。 A radical right hemicolectomy was performed. The postoperative pathological specimens showed that the size of the appendix was about 28 cm ×16 cm ×16 cm, the section was cystic, a large number of gray-yellow and gray-red sticky frozen materials were seen in the cyst, the thickness of the cyst wall was about 0.2 cm, and the inside of the cyst wall was smooth. Postoperative pathological examination: (appendix) low-grade mucinous tumor, mucinous tissue did not penetrate the muscle wall; The mucosal edema of the right colon was accompanied by inflammatory cell infiltration of the intestinal wall, and 20 mesenteric lymph nodes were hyperplasia. No recurrence or metastasis has been seen in the follow-up patients so far.

A 53-year-old female was seen for "repeated fever for more than 1 month with distension and discomfort in the left upper abdomen". Blood routine showed: WBC 14.12×10⁹/L, Hb 55 g/L, N 0.817. B-ultrasound showed: splenomegaly, mixed mass mainly liquid in the spleen. Physical examination: body temperature 38 ℃, anemia, pale conjunctiva, soft abdomen, full palpation of left upper abdomen, no tenderness, percussion pain in left kidney area (+). Abdominal enhanced CT showed: the spleen volume increased, large low-density shadows were seen in it, and the surrounding exudation; Thickening of the intestinal wall in the splenic flexure of the colon (FIG. 1A)。 Colonoscopy showed irregular ulcer infiltrative mass of colonic splenic flexure. Diagnosis: splenic flexural carcinoma of the colon, splenic abscess, severe anemia. Considering the general condition of the patient is poor, if immediate surgical treatment is performed, POSSUM predicts the complication rate of 65%, and P-POSSUM predicts the mortality rate of 5%, so splenic abscess puncture is performed first. During the operation, the pus was extracted under CT positioning and then an external drainage tube was placed for continuous drainage (FIG. 1B), blood transfusion and anti-infective therapy for 1 week followed by exploratory laparotomy. Intraoperative findings: colonic splenic flexure ulcer type tumor invaded the splenic capsule, spleen enlargement formed dense adhesion with diaphragm and retroperitoneum, splenic abscess formed, the diameter of the abscess cavity was 12 cm, and there was 200 ml of fishy pus. Radical resection of left colon cancer combined with incision and drainage of splenic abscess was performed. During the operation, the splenic capsule was incised with an ultrasonic knife 3 cm away from the area around the tumor invasion, and it entered the abscess cavity. The abscess was bluntly separated and separated, and the pus was aspirated. A three-lumen irrigation tube was placed in the abscess cavity, and a single-lumen drainage tube was placed next to the spleen. After operation, the abscess cavity was continuously irrigated, antibiotics and intravenous nutrition support were applied. Postoperative pathological report: Differentiated tubular adenocarcinoma of the left colon infiltrated to the outside of the serosa and adhered to the splenic capsule, but did not invade the splenic parenchyma. After 2 weeks, the patient was discharged with a tube and treated with oral antibiotics. One month later, reexamination of abdominal enhanced CT showed that the drainage tube was in place, and the abscess cavity of the spleen basically disappeared (Figure 1C), remove the drainage tube.

A 53-year-old male was seen for 20 d after the discovery of a painless gingival mass in the posterior tooth area of the left mandible. The history of "hepatitis B" was found for more than 20 years. He underwent "liver cancer resection" in Shanghai Oriental Hospital before July (the specific situation is unknown). Now his condition is stable, and he is treated with drugs after operation (the specific medication is unknown). Physical examination: The skin and sclera were yellow stained, and a "C"-shaped scar was seen in the right upper abdomen (liver area), but there were no positive signs. Stomatological examination showed that a mass was seen in the buccal gingiva of the left mandibular posterior tooth area (tooth positions 36, 37 and 38), about 5.0 cm ×3.5 cm ×2.3 cm in size, with middle quality, clear boundary and pedicle. The mass protruded towards the buccal side, the surface was filthy, with necrosis and exudation, easy bleeding on local palpation, no tenderness, and no obvious ulceration of the surrounding mucosa. Admission Diagnosis: Left Mandibular Gingivoma? Postoperative liver cancer. A partial resection of the left mandible was performed on 28 Aug 2014. Postoperative pathology: (left mandible) metastatic hepatocellular carcinoma (Figure 1)。 Immunohistochemistry: AFP (focal +), Hepatocyte (+) (Figure 2), CD₁₀(-), CK (-), CK34 β E12 (-),P₆₃(−), GCDFP-15 (−). After 1 month follow-up, the patient died.

A 47-year-old female was admitted to the hospital with "melena, uncontrollable anemia and fatigue for more than half a year". Denial of coagulation dysfunction and substance abuse. Previous history of fibrous histiocytic tumors predominantly small round cells, surgically resected for primary and secondary local metastases in back, right axillary, neck and left axillary in 2010, 2012, 2013 and 2014, respectively (metastases were confirmed in 2012 and metastases were not excluded in 2013 and 2014). Endoscopic choledocholithotomy was performed in May 2018. The symptoms of this onset appeared for unknown reasons 3 months after stone removal. At the onset of the disease, the patient was pale and weak, but the physical examination showed no tenderness and fever. Blood routine showed that the lowest Hb was only 5.5 g/dl (normal range: 11.5~15.0 g/dl), and the inflammation and tumor markers were all normal. None of the imaging tests confirmed the diagnosis. The patient went to many hospitals for this reason, and finally was admitted to the Department of Gastroenterology of our hospital. Dark red bloody fluid was observed intermittently flowing out of the cystic duct opening through SpyGlass scope (Figure 1), but no stones or other lesions were found. After resuscitation with fluid rehydration and blood transfusion, he was transferred to the hepatobiliary surgery department and immediately underwent laparoscopic cholecystectomy. Immediately after the operation, the gallbladder was dissected and a polyp with a diameter of about 6 mm at the bottom of the gallbladder cavity was found, and a black-purple lymph node with a diameter of 4 mm was also found in the ampulla (Figure 2)。 Postoperative pathology showed that the polypoid protrusion at the bottom of the gallbladder was a mesenchymal tumor, low-grade malignancy, involving the muscular layer. There was no metastasis in the lymph nodes, but there was vascular hyperplasia, congestion and a little hemosiderin deposition in the lymph nodes. The results of immunohistochemical analysis were similar to those of the primary tumor, with metastasis being considered first. The nasobiliary duct was removed 1 d after surgery and was cured and discharged 3 d after surgery. At 1 month postoperative follow-up, the patient had no melena and the anemia was corrected.

A 59-year-old male underwent "laparoscopic cholecystectomy" 10 years ago due to "gallstones with acute cholecystitis". The postoperative pathology showed "papillary adenocarcinoma of the gallbladder neck". He underwent "open radical cholecystectomy" again 10 days after the operation. This time, he was admitted to hospital because of "10 years after gallbladder cancer operation, a mass in the upper abdominal wall was found for 1 d". Physical examination: The abdomen is soft, with an old surgical scar about 20 cm long, and a hard mass can be palpable near the scar under the xiphoid process, without tenderness. Upper abdominal enhanced MRI showed that a circular abnormal signal was observed in the anterior part of the abdominal cavity of the upper abdomen near the midline, with a size of about 33×33 mm. T1WI and T2WI showed high signal and mixed signal, and DWI showed obvious high signal. After enhancement, T1WI showed high signal due to the lesion, and whether or not enhancement and enhancement could not be accurately judged (FIG. 1A)。 Then, on January 17, 2018, laparoscopic exploration was performed under general anesthesia. No ascites and obvious metastatic nodules were found. After separation and adhesion, the abdominal wall mass under the xiphoid process was located outside the peritoneum, with a volume of about 5×3×3 cm (FIG. 1B)。 Take the incision above the mass and see that the mass is located in the muscular layer of the abdominal wall, and make a side mass about 1 cm to completely remove the tumor (Figure 1C、Figure 1D)。 Postoperative pathology showed: "Atypical epithelial ethmoid hyperplasia was seen in some areas of the tumor submitted for examination (FIG. 2A) protruding towards the cystic cavity, accompanied by large necrosis and hemorrhage and interstitial ossification around multifocal cancer (Figure 2B), and infiltrated into the fibrous interstitium, no neurovascular invasion was observed, and several cancer cells produced bone-like matrix (Figure 2C)； Partial cyst wall thickening and fibrosis with old hemorrhage hemosiderin deposition, interstitial massive fibrotic bone (Figure 2D)。 Immunohistochemical staining: CK7 (+ + +), CK20 (+ +), CEA (+), Villin (+ + +), P53 (-), Ki-67 (+) 40%, CK19 (+ + +), MC (HBME1) (-), Wilms Tumor (-). Combined with immunohistochemistry and medical history, it was diagnosed as port-site metastasis (PSM) after gallbladder cancer operation.

A 56-year-old male was admitted for "cough for 4 months". 4 months ago, the patient developed severe cough and expectoration after aspiration of Voltaren tablets, accompanied by chest tightness and shortness of breath, accompanied by fever, and the highest body temperature was 39℃. He went to a local hospital and examined the chest CT as "aspiration pneumonia". After the anti-infective treatment effect was not good, the patient was given cefoperazone sodium and sulbactam sodium 1.0 g Q12H intravenous drip, and then changed to imipenem and cilastatin sodium 0.5 g Q8H intravenous drip. After discharge, the patient's symptoms of cough and expectoration gradually worsened, coughing up yellow purulent sputum, rising violently in the morning, with a daily sputum volume of about 200 ml, accompanied by fever, and the highest body temperature was unknown, so he went to the Department of Respiratory Medicine of our hospital for treatment, and the outpatient clinic planned to be admitted to the hospital with "aspiration pneumonia". After admission, the symptoms were not relieved after intravenous infusion of imipenem and cilastatin sodium 0.5g Q8H for anti-infection, cough relief and nebulization. After detailed medical history, the patient said that he had undergone radical resection of liver metastasis from colon cancer at the same time 1 year ago, and a new liver lesion was found 6 months ago, which was treated with radiofrequency ablation. Enhanced CT of the upper abdomen was performed, suggesting "bile duct bronchial fistula consideration" (Figure 1)。 endoscopic retrograde cholangiopancreatography (ERCP) + endoscopic nasobiliary drainage (ENBD) were performed after the consultation in gastroenterology department (Figure 2), 150~200 ml of bile-like liquid was drawn out from the nasobiliary duct every day, and the symptoms of cough and sputum were improved after anti-infective treatment with levofloxacin, the amount of sputum was significantly reduced, and there was no fever again.

The patient was a 48-year-old female. Admitted for "paroxysmal epigastric pain for 3 d". The patient developed abdominal pain without obvious trigger 3 days ago, which was paroxysmal and not severe. It was mainly in the upper abdomen at first, and then left abdominal pain, without radiation pain, no obvious aggravating and relieving factors for pain, no nausea and vomiting, no diarrhea, no fear of cold and fever, and no yellowing of skin and eye whites. In the past, I underwent "sacral and pelvic schwannoma resection" in Shanghai Hospital, and recovered well after operation. Physical examination: A 12 cm ×10 cm mass can be seen in the left abdomen, with clear borders, tough texture and mild tenderness. Total abdominal CT plain scan and enhanced scan: No spleen shadow was seen under the left diaphragm, the spleen was displaced forward and downward to the middle abdomen, the splenic artery was rotated and thickened, the surrounding fat space was blurred, the shape of the spleen was obviously enlarged, the size of the larger layer was about 15 cm ×10 cm, the density was uneven, the spleen was unevenly enhanced in the enhanced scan, the degree of enhancement of most parenchyma was reduced, and the fat space around the spleen was blurred. Diagnosis results: (1) migratory spleen possible; (2) The rotation of splenic artery and the strengthening degree of spleen were reduced with blurred peripheral fat space. Please combine with clinical. Surgical exploration: During the operation, the spleen was located in the left lower abdomen, about 12 cm ×8 cm ×6 cm in size, dark in color and brittle in texture, with a small amount of exudate around the spleen and adhesion to the small intestine, omentum and abdominal wall, and the splenic pedicle blood vessels and short gastric blood vessels were spiral twisted. During the operation, the spleen was bluntly separated from the surrounding adhesive tissues, and the spleen was free. Postoperative pathological examination: Spleen tissue with extensive hemorrhagic necrosis, splenic cord fibrous tissue hyperplasia, consistent with pedicle torsion changes.