2020年 · 第35卷第05期

A 31-year-old female was admitted to the hospital because "physical examination found that the thyroid and pancreas occupied space for 8 d". MRI: Space-occupying lesions in the body and tail of the pancreas and abnormal signals in the right lobe of the liver, excluding solid pseudopapillary tumor of the pancreas and liver metastasis. Thyroid ultrasound: A nodule in size of 3.3 mm ×5.3 mm was observed next to the trachea in the middle and lower right lobe of the thyroid gland. Ultrasound-guided liver puncture and thyroid fine needle biopsy considering metastasis of solid pseudopapilloma. Prior right lobectomy of the thyroid with rapid intraoperative pathological return of solid pseudopapillary tumor of the pancreas. Posterior laparotomy showed space-occupying lesions in the body and tail of the pancreas, surrounding the splenic artery and vein; There were two space-occupying lesions in the right anterior lobe of the liver and cystic space-occupying in the right posterior lobe of the liver. Excision of body and tail of pancreas was performed (Figure 1), splenectomy, enucleation of liver tumor. Postoperative pathology: Solid pseudopapillary tumor of pancreas, with tumor volume of 7 cm ×6 cm ×4.5 cm, local capsule incomplete, invading the surrounding pancreas and fibroadipose tissue, and tumor infiltration in vessels and nerves; Solid pseudopapillary tumor was found in the liver tissue submitted for examination (FIG. 2A、Figure 2B)； Intrathyroid pancreatic solid pseudopapillary tumor metastasis (Figure 2C)。 No recurrence was observed at 3 months postoperatively.

The patient was a 42-year-old female. Admitted for 3 d with upper abdominal pain. CA199 218.7 U/ml. CT: A round low-density shadow was seen in the tail of the pancreas, with clear borders, about 3.0 cm ×2.6 cm. After enhancement, the round low-density shadow in the tail of the pancreas was unevenly enhanced, and there were spotty enhancement foci with clear boundaries, and line-like obvious enhancement capsule shadows were seen (FIG. 1A)。 MRI: cystic long T1 and long T2 signals in the tail of pancreas, with uneven signals, low signal in T1WI and high signal in T2WI, with clear boundaries (FIG. 1B)。 Preoperative diagnosis: neoplastic lesion of the tail of the pancreas. Body-tail pancreatectomy was performed under general anesthesia. During the operation, the tumor was located in the tail of the pancreas, with a diameter of about 3.0 cm, and the boundary with the surrounding tissues was clear. Body and tail pancreatectomy was performed, and he was discharged 7 days after operation. Postoperative pathology: The tumor was soft, with clear borders, translucent shape, and microcapsule changes on the section. Microscopically, the tumor showed spongiform microcapsule changes, reddish lymphatic fluid was seen in the cavity, and a single layer of flat lymphatic endothelial cells was seen in the cyst wall (Figure 1C，Figure 1D)。 Pathological diagnosis: lymphangioma of the pancreas. No recurrence was observed after 1 year follow-up.

A 50-year-old male was treated by hemodialysis for chronic kidney disease 4 years ago and developed secondary hyperparathyroidism 2 years ago. The patient was admitted to the hospital for examination of parathyroid hormone 1 832 pg/ml and serum calcium 2.80 mmol/L. ECT: Multiple round-like metabolic hypertrophy in the thyroid gland. There are multiple symptoms of bone pain throughout the body, and nodular protrusions of different sizes can be seen in the scrotum and penis area, which are tough to touch and have no tenderness (FIG. 1A)。 Scrotal ultrasound: The bilateral scrotal wall was thickened up to 10 mm, and multiple bright light clusters were seen in the interior with a larger size of 19 mm ×8 mm, accompanied by acoustic shadows at the back (FIG. 1B), consider scrotal calcium salt deposition caused by uremic hyperparathyroidism. Under general anesthesia, bilateral parathyroidectomy (4) and autotransplantation of right forearm parathyroid gland were performed. Postoperatively, parathyroid hormone decreased to 83 pg/ml, the symptoms of systemic bone pain disappeared, the blood calcium decreased to the normal range, and the calcium salt deposition in scrotum and penis area did not change significantly.

The patient, a 60-year-old female, was admitted to hospital because of "abdominal mass found for 4 months and right abdominal pain for more than 10 days". Physical examination: There were multiple tumor-like lesions scattered on the body surface, the largest one was about 1.5 cm in diameter, and obvious milk caffeine spots were seen on the outer side of the bilateral thighs (Figure 1)。 A mass was palpable in the right upper abdomen, with unclear boundaries, poor mobility and mild tenderness. Abdominal CT examination showed that a huge mass shadow of slightly lower density with a size of about 5.4 cm ×5.5 cm ×6.7 cm was seen next to the right lower abdominal aorta, and there was stratification in the lesion, and the enhancement and enhancement were not obvious (FIG. 2A)。 Abdominal MRI: A huge mass shadow next to the right lower abdominal aorta with mixed signals, T1WI showed isosignal, T2WI signal stratified, nodular shadow slightly lower and shorter T1 slightly shorter T2 signal shadow was seen in it, enhancement and enhancement were not obvious, DWI did not see obvious diffusion restriction manifestation, the tumor was closely related to the duodenum (Figure 2B)。 Pathological examination of two masses of chest wall and abdominal wall revealed neurofibromatosis. Laparoscopic exploration showed a new organism with a size of about 8.0 cm ×8.0 cm at the junction of the horizontal part of the descending duodenum, and a new organism with a size of about 0.5 cm ×0.4 cm protruding from the serous surface in the middle section of the jejunum. Then, duodenal tumor resection + small intestine tumor resection were performed under laparoscopy. Postoperative pathological examination showed: duodenal stromal tumor with hemorrhagic cystic degeneration, size about 7 cm ×6 cm ×5 cm, mitotic image>10/50 HPF, modified NIH risk classification: high risk; Stromal tumor of jejunum, approximately 0.5 cm in diameter, mitotic<5/50 HPF, modified NIH risk classification: very low risk (Figure 3)。 Genetic test suggests that c-kit and PDGFRA genes are wild type. Second generation sequencing: neurofibromatosis type I (NF1) gene has somatic and germline variations. Combined with the clinical history, it is consistent with the diagnosis of NF1-related gastrointestinal stromal tumor (GIST). The patient did not receive any targeted therapy after discharge, and no tumor recurrence or metastasis was seen at 7 months of follow-up.

A 72-year-old male was admitted due to severe swelling of the right lower limb for 4 d. CTA showed right common iliac artery aneurysm, right internal iliac artery aneurysm (maximum diameter of tumor was 7.7 cm), right iliac arteriovenous fistula (Figure 1), EVAR was performed, and the right internal iliac artery was embolized with interlock and then a covered stent was placed. The swelling of the patient's right lower extremity improved significantly after operation, but the swelling did not completely decrease. After 2 months of reexamination, it was found that the right common iliac aneurysm was completely thrombotized, but there was still a small amount of endoleak in the right internal iliac aneurysm, but the tumor was significantly smaller than before operation. Two years after surgery, the patient was admitted due to aggravated swelling of the right lower limb. B-ultrasound showed right iliofemoral vein thrombosis. CTA found that the internal iliac artery aneurysm was enlarged compared with the first postoperative review (maximum diameter 8.2 cm), and the thick inferior gluteal artery located at the back and lower side of the tumor was visible (Figure 2), consider type II endoleak, mainly right inferior gluteal artery reflux. The right internal iliac aneurysm was resected by retroperitoneal approach under general anesthesia. It was difficult to completely expose the tumor during the operation. After the tumor was squeezed flat, the tumor tension recovered quickly, but the proximal and distal ends of the tumor could not be freely blocked, so the only option was to quickly suture the intratumoral bleeding point after tumor rupture. Intraoperative bleeding was fierce, and the bleeding area was quickly pressed by hand, the proximal end of the tumor and the incision site of the tumor were sutured, and the branch arteries around the tumor were sutured. The bleeding volume was about 1400 ml, and adequate blood transfusion and fluid rehydration were given. The postoperative recovery was good without any adverse events. Re-examination of CTA showed that the tumor was reduced, and no obvious endoleak was seen in the arterial phase, but type II endoleak was still seen in the venous phase (Figure 3)。