2020年 · 第35卷第12期

A 53-year-old male was admitted to the hospital for "bloody stool with anal falling sensation for 1 year, aggravated for 1 week". The patient's mother died of colon cancer. Colonoscopy showed that the sigmoid colon was 15~20 cm away from the anal margin, and there were irregular new organisms in the annular cavity, and the rest of the large intestine showed numerous polypoid bulges diffusely distributed (Figure 1)。 Pathological examination showed that the intestinal epithelium (sigmoid colon) had severe atypical hyperplasia and cancer. Pelvic CT examination showed thickening of the intestinal wall in the sigmoid-rectal junction. Laparoscopic total colectomy and terminal ileostomy were performed (Figure 2)。 Postoperative pathological examination showed: (sigmoid colon) high to moderately differentiated adenocarcinoma, the size of the tumor was about 6 cm ×5 cm ×1.4 cm, penetrated the whole thickness of the intestinal wall, involved the periintestinal adipose tissue, no tumor thrombus in the vessel, nerve involvement, tubular adenoma was seen 14 and 58cm from the upper residue, respectively, and glandular epithelial dysplasia was grade 1. Multiple adenomas were seen in the rest of the colon. There was no cancer metastasis in peri-intestinal lymph nodes (0/48). Immunohistochemistry showed: CEA (+), Her (1+), CDX-2 (+), CK (+), CD56 (-), Ki-67 (70%), Vimentin (-).

The patient was a female, 20+ weeks pregnant, who went to the doctor for "upper abdominal pain with nausea and vomiting for 1 d". This patient had previous pregnancy and delivery. Liver nodules were found on examination 3 years ago, possibly benign tumors, and the specific size was unknown. On admission, there was anemia, no abdominal muscle tension, and tenderness in the upper abdomen. Hemoglobin: 83 g/L. Ultrasound and fetal heart detection showed that intrauterine pregnancy was a single live fetus and the fetus was healthy. Abdominal B-ultrasound showed a clear liver contour, and a heterogeneous echo area with slightly hyperechoic predominance was seen in the right lobe of the liver, about 75 mm ×83 mm, and the echoes of the remaining liver parenchyma were evenly distributed. MRI considered bleeding and rupture of the space-occupying lesion of the right liver. After multi-disciplinary discussion in hepatobiliary surgery, obstetrics, anesthesiology, etc., it is concluded that: (1) At present, the patient's liver tumor ruptures and bleeds, and there is more hemorrhage under the liver capsule, which may break into the abdominal cavity at any time due to recurrent bleeding, which can be seriously life-threatening and needs emergency surgical treatment; (2) At present, the pregnant woman is in the second trimester, and the fetus is in good health and can tolerate surgery. After full communication and preparation, surgical treatment was performed. During the operation, the surface of the right liver was surrounded by a huge hematoma, occupying about 1/2 of the surface area of the right liver. Multiple masses were seen in the other right liver, but all of them were limited to the right hemihepatic area. Anterior approach anatomical right hemihepatectomy was performed, which lasted about 3 h and bled about 100 ml (Figure 1)。 Pathology: Multiple focal nodular hyperplasia of the liver with mild dysplasia in the region, mass size 1.5 cm ×1 cm ×1 cm, 4 cm ×2 cm ×1 cm, with rupture, hemorrhage, necrosis, hematoma formation, and negative liver margin. Immunohistochemistry: Glypican-3 (−), Hepatocyte (+), CD34 (vascular +), CK7 (bile duct +), CK19 (bile duct +), GS-6 (+), CD10 (bile duct +), Ki-67 (scattered +), CgA (−), Syn (−). Special staining: VG (+) (Figure 2,Figure 3)。 During the perioperative period, magnesium sulfate, progesterone and other drugs were used to protect fetus and inhibit uterine contractions, and routine fetal heart rate was detected before and after operation. The patient recovered smoothly after operation, the fetus was in good health, and the B-ultrasound showed that the fetus developed normally (Figure 4)。 The hospital was discharged on the 10th postoperative day.

A 45-year-old male was admitted to the hospital with "cord-like masses in both lower limbs for 20 years and skin ulcers for 4 years". The patient underwent varicose vein surgery in an external hospital more than 10 years ago, and the varicose veins recurred in the second year after surgery. Physical examination: There was no tortuous dilatation of the superficial veins of the abdominal wall, no palpation of the liver and spleen under the costs, tortuous dilatation of the superficial veins of both lower limbs, extensive pigmentation of both calves, formation of multiple scattered small ulcers, and moderate depressed edema of the calves. Venous enhanced CT showed local diaphragm-like changes in the posterior hepatic segment of the inferior vena cava (IVC), and local dilatation of the left renal vein showed tumor-like changes (Figure 1)。 Modified Seldinger method puncture right femoral venography: inferior vena cava T_9～10Contrast agent retention at vertebral level, and there are small flow column-like ejection signs in the blocked blood flow; A 5F pigtail tube was placed at the distal end of the diaphragm, pressure measurement: 18 cmH₂O (1 cm H₂O =0.098 kPa). The 5F vertebral artery catheter was guided by a 0.035-inch loach guidewire through the diaphragm hole into the superior vena cava and exchanged for a pigtail catheter placed in the right atrium, manometry: 2 cmH₂O (normal 0~10.88 cmH₂O); Balloons with diameters of 5, 8, 12, 20, and 25 mm were selected to dilate the inferior vena cava in the septal segment in turn, and the balloon notch was obvious (Figure 2)； Angiography after balloon withdrawal: the original septum-like lesion of inferior vena cava disappeared, the contrast agent was not retained, and the blood flow was smooth; The pressure was measured as described above and the pressure difference was reduced to 4 cmH₂O. 5F single-curved catheter was superselected to left renal vein angiography: the diameter of the main trunk of the left renal vein was about 11 mm, the middle section was obviously tumor-like dilated, and the tumor size was about 3 cm ×2 cm ×2 cm. A covered stent was selected, and the stent was introduced into the predetermined position of the renal vein through a 12F long sheath. The stent was released, and the balloon (14 mm ×40 mm) stent was expanded backward. The position of the contrast stent was satisfactory. The branch, main trunk and inferior vena cava of the left renal vein were well developed, and no contrast agent entered the tumor cavity, and the isolation was satisfactory. After operation, low molecular weight heparin bridged warfarin was administered to anticoagulation for half a year, and the international standardized ratio was maintained at 2.0~3.0. There were no obvious abnormalities in inferior vena cava and renal vein at 3, 6 months and 1 and 2 years after operation. Angiography at the third year after operation showed that the blood flow of inferior vena cava and left renal vein was unobstructed (Figure 3), the pressure difference between the inferior vena cava and the right atrium was zero. The patient's varicose veins of both lower limbs collapsed, the skin pigment became pale, and the ulcer healed.

A 51-year-old female was admitted to the hospital for "discovering a neck mass for more than 4 months". Physical examination: A mass about 3 cm ×2.5 cm in size can be found in the neck, with tough texture, clear border, no tenderness, movable, and no skin ulcer sinus tract. A month ago, B-ultrasound examination of the neck showed: 20 mm ×13 mm mixed echo nodules in the subcutaneous fat layer on the right side of the posterior neck, with clear boundaries, mainly solid, enhanced posterior echoes, even echoes in the parenchyma, multiple dotted and striped blood flow signals, and the arterial spectrum can be detected internally, showing a bidirectional spectrum. MRI examination showed that there was a circular abnormal signal focus in the subcutaneous fat layer of the neck (flat C6 level), with a diameter of about 2.1 cm. The T1WI showed low signal, and the T2WI and lipid suppression showed high signal. The lesions were significantly enhanced on enhanced scan, and there was a strip-shaped area without enhancement in the lesions with clear boundary (Figure 1)。 Surgical exploration: A mass about 2.5 cm ×2.5 cm in size was seen in the subcutaneous layer of the right neck, with hard texture, clear border and visible capsule. Pathological examination showed: (neck mass) low-grade malignant myxofibrosarcoma of subcutaneous soft tissue with negative surgical margin. Immunohistochemical examination showed that Vim (+) (Figure 2), SMA (+), CD34 (−), Desmin (−), S-100 (−).