2020年 · 第35卷第04期

Example 1A 54-year-old male was seen for "finding a right abdominal wall mass for 2 months". Physical examination: A soft mass, about 10cm in diameter, can be palpable in the right lower abdomen. Abdominal CT examination showed that a round-like cystic low-density shadow could be seen below the right and posterior of the duodenum (FIG. 1A), approximately 101 mm in size. Huge cyst under the duodenum, multiple cysts in the liver, small hemangioma in the left lobe of the liver. Intraoperative exploration revealed that the local small intestine was connected to the mass in a sheet shape, located behind the peritoneum, and completely removed by surgery. Postoperative pathological report: Retroperitoneal cyst, bronchial origin (FIG. 1B)。 Case 2, a 61-year-old female, was seen for "5 years of right abdominal mass found". Physical examination: No positive signs were found. Upper abdominal enhanced CT examination showed: space-occupying lesions on the left side of the aorta posterior to the gastric body (Figure 2), about 7 cm ×4 cm ×3 cm in size, with spotty calcification. The mass was found at the upper edge of the body of the pancreas during the operation, and it was completely removed by surgery. Postoperative pathological report: bronchogenic cyst.

A 53-year-old male was admitted with "dull pain in the left middle and upper abdomen, accompanied by pain in the left lower back and chest for 7 days". Physical examination: Mild tenderness in the left middle and upper abdomen. Tumor marker: CA199 251 U/ml. Enhanced CT: Total inversion of thoracic and abdominal organs, pancreatic head occupying 2.2 cm ×2.1 cm ×2.0cm space, mild dilatation of main pancreatic duct, considering the possibility of pancreatic head cancer (Figure 1)。 Three-dimensional reconstruction clearly showed the patient as a "mirror person" (Figure 2)。 Preoperative EUS-FNA: moderately differentiated adenocarcinoma of the pancreas. Clinical diagnosis: pancreatic head cancer with total organ inversion. 3D laparoscopic pancreaticoduodenectomy was performed (Figure 3，Figure 4)。 Postoperative pathology: Medium differentiated adenocarcinoma of pancreatic head, stage: pT2N1M0, stage ⅡB. The operation time was 310 min, the intraoperative bleeding was 260 ml, and there were no postoperative complications such as biliary fistula, pancreatic fistula and hemorrhage.

The patient was a 71-year-old male. He was admitted to hospital because he found a mass in his right upper arm for 8 years, which increased in the past 2 years and accompanied by skin itching. Physical examination: The skin of the right upper arm was rough and dull, and there was a subcutaneous mass, about 15 cm ×8 cm in size, with clear boundaries, good mobility, no redness, swelling and tenderness, no vascular murmur, good mobility of fingers and joints, and no numbness. Laboratory test: peripheral blood leukocytes 8.5×10⁹/L, N 0.36, % eosinophils 0.48, absolute eosinophils 3.6×10⁹/L. Serum fibrinogen 2.42 g/L, serum uric acid 420 μ mol/L, serum IgE 9 380 IU/L. MRI examination showed that a mass-like abnormal signal shadow was found in the muscle space of the right upper arm, the size was about 12 cm ×6 cm, the boundary was still clear, and the T1W was mainly low signal (Figure 1)。 Clinical diagnosis: hemangioma of the right upper arm. Excision of the mass was performed under epidural anesthesia. The mass was wrapped around the radial nerve and axillary brachial plexus, and the boundary was unclear. The mass was removed through the surface of the radial nerve. Pathological examination: The submitted object was a soft tissue mass with skin, about 12 cm ×11 cm ×3.5 cm in size, with a gray-white gray-yellow section, tough in texture and no envelope. Light microscopy: the mass is located in the deep subcutaneous layer, and small blood vessel proliferation, massive eosinophil infiltration and lymphoid follicle formation are seen. Eosinophil accumulation is seen next to lymphoid follicles and around small blood vessels to form eosinophil microabscess (Figure 2)。 Obvious eosinophil infiltration was also observed around nerve fibers in the lesion (Figure 3)。 Pathological diagnosis: Kimura's disease (eosinophilic lymphogranuloma) of the right arm. The patient was given radiotherapy after surgery and recovered better. Blood eosinophil count and serum IgE were significantly decreased. At present, it has been followed up for 21 months, and there is no progression or recurrence of the disease.

A 31-year-old female was admitted to the hospital for "2 years of recurrent huge mass in her buttocks". Since childhood, the patient's skin was scattered with dark brown nodules and coffee-like plaques, and then the buttock nodules gradually increased, like fists, and felt pain and discomfort. He was surgically removed in the local hospital, and the pathological report was "neurofibromatosis". After that, the plaque enlarged and deepened, and similar nodules appeared in the submandibular, left forearm and left knee, all of which were surgically removed. Two years ago, there was a recurrent nodule in the buttock, which rapidly increased and drooped, and the weight increased, which affected its appearance and restricted its walking and movement. At the same time, it contaminated the tumor. The patient's mother suffers from "neurofibromatosis". Physical examination: anemia appearance, left curvature of spine, milk coffee-like spots or patches of different shapes and sizes all over the skin of the body, many soft tissue lumps all over the body, sesame to citrus-like size, as many as hundreds, light red color and soft texture. A lion-hip-like mass on the buttocks, approximately 50 cm ×40 cm in size, droopy, rough in surface and covered with coffee-like spots, soft in texture, unclear in border, pushable and without tenderness. Enhanced CT examination of the whole abdomen showed: (1) multiple lesions parapsoas of the left psoas major muscle, considering neurogenic tumor; (2) The skin of the lower back and buttocks on both sides was obviously extensively thickened, the subcutaneous fat space was exudative changed, and the left hip joint was subluxated. Resection of gluteal neurofibroma + wound drainage were performed (Figure 1), the tumor was widely distributed in the buttock, waist and left leg subcutaneously, with unclear boundaries and no envelope. Part of the skin and tumor tissue were removed according to the preoperative design incision, with a size of about 50 cm ×30 cm (Figure 2)。 Postoperative pathological examination revealed multiple neurofibroma of the buttock. The patient developed subcutaneous effusion, partial flap necrosis and incision dehiscence 1 week after surgery, and underwent debridement of hip incision + negative pressure sealing and drainage. The wound healed gradually after operation, and the patient returned to normal life and work.