2021年 · 第36卷第02期

The patient, a 72-year-old male, saw a doctor for "a mass on the right neck for more than 30 years, which increased rapidly for 2 months". Physical examination: A mass about 9 cm ×7 cm in size can be palpable on the right side of the anterior trachea of the neck. It is hard in texture, with clear boundaries. The surface of the mass is smooth, without tenderness, and it can move up and down with swallowing. Laboratory tests: Thyroid function tests were normal. CT examination showed that the right lobe of the thyroid gland was enlarged, and a mass about 7.8 cm ×5.4 cm ×8.1 cm in size was seen (Figure 1), the plain scan density is uneven, multiple calcifications, cystic degeneration and necrosis are seen in the lesion, and the enhanced scan lesion is uneven and enhanced, lower than the surrounding thyroid tissue, and the surrounding space is clear. The left lobe of the thyroid gland and the trachea were compressed and shifted left. Multiple enlarged lymph nodes were seen in bilateral necks, the larger one was about 1.6 cm short in diameter. Bilateral total thyroidectomy was performed. Postoperative pathological diagnosis: (right) thyroid epithelioid angiosarcoma (Figure 2)。 Immunohistochemical examination showed: Vim (+), CK (+), F8 (+), CD34 (focal +), Ki-67 (1% +), CD31 (-), TTF-1 (-), CT (-), TG (-).

A 59-year-old female was admitted to the hospital for "physical examination found a mass in the left upper abdomen for 10 days". Physical examination: soft abdomen, mild tenderness in the left abdomen, no rebound pain, unpalpable subcostal liver and spleen, ascites sign (-). Color ultrasound examination showed that the left upper abdomen occupied a medium echogenous solid space, with a diameter of about 4.2 cm. CT plain scan showed that an oval mass with slightly lower density was found in the spleen-stomach space, with a maximum cross section of about 3.6 cm ×4.8 cm, with clear boundary and uniform internal density. The CT value was about 35.27HU, and the marginal spots were calcified (Figure 1)； The mass was mildly enhanced in the enhanced arterial phase and uniform moderate sustained enhancement in the portal phase, with a CT value of approximately 68.54 HU. Intraoperative exploration showed that the tumor was located under the serosa of the gastric fundus, with a smooth surface and no invasion of adjacent structures. There were no enlarged lymph nodes around the stomach and the large blood vessels in the abdominal cavity. Radical resection of the tumor and a small part of gastric tissue was performed. Postoperative pathological examination revealed that the tumor was round-like solid, about 3.4 cm ×4.7 cm ×5.1 cm in size, without envelope, and the gray-white matter on the sectional surface was tough. Under the light microscope, the tumor cells were densely distributed, arranged in a fusiform palisade shape, the cytoplasm was lightly stained, the nuclear abnormality was not obvious, and the lymphocyte cuffs were seen around the tumor (Figure 2)。 Immunohistochemical staining showed that S-100 (+ + +) (Figure 3), SOX-10 (+), CD117 (-), CD34 (-), Desmin (-), Ki-67 (5% +). Pathological diagnosis: (fundus) schwannoma. The patient recovered well after surgery and was followed up until 18 months. No recurrence or metastasis was found on CT reexamination.

A 51-year-old male patient. The main reason was "more than 2 months after biliary tract surgery, and the melena was relieved for 1 day". The patient underwent laparoscopic choledocholithotomy + cholecystectomy + intraoperative choledochoscopy + T-tube drainage in an external hospital 2 months ago due to "acute pancreatitis, choledocholithiasis, gallbladder stones, and left renal cancer after resection". No obvious abnormalities were found in postoperative choledochography (Figure 1)。 On the evening of April 17, 2017, the patient had tarmaceous melena released multiple times. Gastroscopy showed retention of the tubular structure of the duodenal bulb and ulcer formation (Figure 2)。 T-tube angiography showed leakage of contrast medium at the tip of the T-tube, leakage of contrast medium in the duodenum, and patency of the lower end of the common bile duct. Consider that the T-tube enters the duodenal bulb (Figure 3)。 He was given symptomatic treatment such as hemostasis and acid suppression in the local hospital, but the effect was not good, so he was admitted to our hospital with "upper gastrointestinal bleeding, duodenal bulb ulcer bleeding, T-tube duodenal fistula formation, and biliary tract surgery". Cholangiography on admission revealed patency of the lower common bile duct (Figure 4)。 After admission, hemostasis, acid production, nutritional support and other conservative treatments were given to relieve the symptoms of hematochezia. The T-tube was removed, and the abdominal symptoms were closely observed without discomfort. Reexamination of gastroscopy showed that the original fistula had healed (Figure 5)。 The patient had no obvious abdominal pain and diarrhea, and was cured and discharged.

A 68-year-old female was admitted to hospital mainly because of "pelvic space-occupying lesions found by physical examination for more than 1 month" and had a history of hypertension for more than 1 year. Physical examination: soft abdomen, no tenderness, palpable mass in the lower abdomen, clear boundary, poor mobility. Abdominal CT examination revealed a solid pelvic tumor with regular shape and clear boundaries, about 11 cm in size (Figure 1)。 Pelvic MRI examination showed: pelvic cystic-solid mass shadow, about 11 cm in size, uneven signal, T1 showed isosensitive and low signal shadow, T2 showed isosensitive, high and low signal shadow, and the relationship with bilateral adnexes was unclear, and no obvious enlarged lymph node shadow was seen in the pelvic cavity. Urinary 24 h vanillamandelic acid (VMA) was not tested preoperatively. The pelvic cavity was diagnosed as huge occupying space, and laparotomy was performed. During the operation, a solid pelvic mass was found, gray-white in color, about 11 cm in size, approximately spherical, tough in quality, mostly intact capsule, mild adhesion to bilateral adnexes, and poor boundary with retroperitoneum. During tumor exploration and free resection, the patient's blood pressure fluctuated, and the maximum systolic blood pressure was about 240 mmHg, which was considered as "pheochromocytoma-like disease" during operation. The hemodynamics were maintained by the anesthesiologist, and the operation proceeded smoothly, but the intraoperative cryopathological examination failed to confirm the diagnosis. Postoperative pathological report: pelvic nodular mass, 11 cm ×10 cm ×8.5 cm in size, with partial capsule, solid section, gray-white, gray-yellow, gray-brown, cystic change in some areas and slightly transparent in some areas. Under light microscope, the tumor was mainly composed of a mixture of paraganglioma and ganglioneuroma, and the boundary between the two was unclear (Figure 2)。 Immunohistochemical staining showed: CgA (+) (Figure 3), CD56 (+), NSE (+), Syn (+), S100 (+), Vimentin (+), CK (-), SMA (-), CD117 (-), CD34 (-), DOG-1 (-), Ki67 positive cells are sparse and occasional. The pathological diagnosis was compound paraganglioma. After operation, the patient was given routine rehydration support treatment. The patient's blood pressure was stable and he recovered well. He was discharged from hospital 1 week after operation. After 6 months follow-up, the patient's condition was stable without recurrence, and the symptoms of hypertension were significantly improved compared with those before operation.

The patient was a 38-year-old female. He was admitted to the hospital with the main complaint of "pain in the right lower abdomen for 2 days". Ultrasonic examination showed that the intestinal space in the appendix area was found to be about 2.7 cm ×1.9 cm liquid dark area. Appendicitis was diagnosed. After symptomatic treatment, the curative effect is not good, and total lower abdominal pain gradually appears, accompanied by low fever. Previous "history of chronic appendicitis" for 5 years. Physical examination: BMI: 27.34 kg/m²。 Lower abdominal tenderness with muscle tension and rebound pain. Laboratory test: peripheral blood leukocytes 6.64×10⁹/L, neutrophils 4.48×10⁹/L, Hb 153 g/L, Platelets 167×10⁹/L. Pelvic CT examination showed that the ileocecal intestinal canal was unevenly thickened, and more lymph nodes could be seen in the surrounding fat space. The wall of the intestinal tube in the left lower abdomen was obviously thickened, and exudative density shadows were seen in the surrounding fat space, and the surrounding blood vessels and mesentery were aggregated. Because the patient's signs are severe, but the peripheral blood leukocytes are not high, the possibility of sigmoid colon tumor is considered before operation. Exploratory laparotomy was performed in the emergency department. During the operation, about 50 ml of yellow fluid in the pelvic cavity and intestinal space, about 2 cm of appendix tip and mesangial congestion and edema, lengthy sigmoid colon and 1 intestinal fat bleeding to form hematoma, and peripheral mesangial congestion and edema (Figure 1)。 The intraoperative diagnosis was: acute attack of chronic appendicitis and acute enteric lipoptosis. Appendectomy and intestinal fat resection were performed. Thrombosis of the root vessels was found after resection of the intestinal fat sag, and air leakage test was performed to confirm that the colon was not perforated and then the intestinal fat sag wound was embedded. Pathological examination showed: acute attack of chronic appendicitis, vasodilatation, hyperemia and hemorrhage in adipose tissue (Figure 2)。

The patient was a 40-year-old female. Four months before admission, sudden distension and pain in the right upper abdomen, accompanied by radiating pain in the right back and right shoulder, occurred after dinner. Enhanced CT of the abdomen: Consider subcapsular hematoma in the right lobe of the liver with a small amount of blood and fluid accumulation in the abdominopelvic cavity. He has gone to many hospitals to give symptomatic, anti-inflammatory, analgesic and other conservative treatments. Four days before admission, he appeared again with distension and pain in the right upper abdomen, accompanied by radiating pain in the right shoulder and back, so he went to the emergency department of Tianjin First Central Hospital. Re-examination of abdominal enhanced CT showed that the tumor in the right lobe of the liver was significantly enlarged, accompanied by intraperitoneal hemorrhage, and tumor rupture and hemorrhage were not excluded (Figure 1)。 He was admitted to the Department of Hepatobiliary Surgery of our hospital with "liver space-occupying lesions with hemorrhage". Physical examination: mild tenderness in the right upper abdomen, no rebound pain, positive liver percussion pain, and negative mobile voicing. All tumor markers were negative. Upper abdominal distension and pain gradually worsened after admission, and re-examination of abdominal ultrasound showed an increase in peritoneal effusion, considering blood accumulation. Diagnostic abdominal puncture extraction without coagulation. Exploratory laparotomy + liver mass resection was performed considering rupture and hemorrhage of liver mass. The abdominal cavity was opened by an inverted L-shaped incision in the right upper abdomen. After opening the abdominal cavity, a large amount of blood accumulated in the abdominal cavity was seen, and about 4,000 ml of dark red blood was aspirated. During the operation, red blood cells and plasma were transfused to maintain blood pressure. A huge cystic mass was seen between the right lobe of the liver and the diaphragm, with ulceration and bleeding on the surface, a large amount of blood clots in the sac, and the liver parenchyma was obviously compressed to the left. The cystic mass was completely removed, and no other mass was found in the exploration of other organs and tissues in the abdominal cavity. Postoperative pathology: (Hepatic) extrarenal malignant rhabdoid tumor (MRT) with hemorrhage, necrosis, cystic degeneration, immunohistochemical staining: Vimentin and CK8/18 (diffuse +), CD56 and SMA (focal +), Fli-1 and CK (weak +), hepatocyte markers Heppar-1, GPC3 and AFP negative, bile duct epithelial marker CK19 (-), vascular endothelial markers CD31, CD34 and F8 negative, rhabdoid muscle markers myogenin and MyoD1 negative, plasma cell markers CD138 and CD38 negative, remaining CD30, D2-40, EMA and CD163 negative, histochemical staining PAS (-), reticular fiber perivascular (+), Ki-67 index about 15%. The patient recovered well after surgery. No other anti-tumor therapy was received after discharge. After 9 months of operation, abdominal enhanced CT examination showed that there were multiple nodules in the peritoneum of the lower abdomen, which were considered to have a high possibility of metastasis. No recurrence and metastasis in the liver and other organs of the abdominal cavity were found (Figure 2)。 Current tumor-bearing survival.

The patient was a 68-year-old male. Emergency admission due to "upper abdominal distension and pain for 2 days, aggravated with vomiting for 6 hours". Physical examination: heart rate 106 beats/min, breathing 23 beats/min. Acute pain appearance. The breathing sound of the right lower lung was weakened, the upper abdomen was accessible to tenderness, mild rebound pain, and the intestinal sound was about 6 times/min. Laboratory test: white blood cells 12.9×10⁹/L, the percentage of neutrophils was 87.1%. Treatments such as fasting, gastrointestinal decompression, fluid rehydration and anti-infection were given. Emergency total abdominal enhanced CT: the right side of the liver is irregular in shape, part of the small intestine herniates into the right diaphragm, and the intestinal tube of the small intestine accumulates gas and fluid with gas-liquid level, suggesting small intestinal obstruction (Figure 1,Figure 2)。 Laparoscopic exploration under emergency general anesthesia after perfect preoperative preparation: during the operation, part of the right liver and about 80cm small intestine were herniated into the right thoracic cavity through the right diaphragmatic hiatus, and the surrounding congestion and edema and moderate amount of dark blood fluid exudated. The hernia ring was enlarged to absorb the contents, and the part of the small intestine herniated into the thoracic cavity was found to be necrotic. The diaphragm is severe dysplasia, with multiple large defects and communicating with the chest cavity, and only part of it is membranous or band-like connected to the surface of the right liver (Figure 3)。 Necrotic small intestine segment resection end-to-end anastomosis (Figure 4), a large amount of physiological saline was repeatedly washed in the thoracic and abdominal cavity, and a closed thoracic drainage root was placed on the right thoracic cavity. Considering partial necrosis of the small intestine and the possibility of contamination in the abdominal cavity, the lateral and anterior diaphragm defects were repaired with one 8 cm ×15 cm biological patch each, and the patches were sutured to the edge of the diaphragm and the liver attachment or the liver capsule appropriately by intermittent suture with Prolene thread. After 2 days of ICU treatment, he was transferred back to the general ward and continued fasting, gastrointestinal decompression, anti-infection, fluid rehydration and appropriate nutritional support treatment. On the 4th day after operation, the anus was exhausted, the gastric tube was removed on the 5th day, the abdominal drainage tube was removed on the 8th day after gradual restoration of diet, and the chest + upper abdomen plain CT scan was re-examined on the 10th day: a small amount of fluid effusion in the right pleural cavity, the right lung basically recruited, and most of the right liver returned to the normal position (Figure 5), the chest tube was removed on the 12th day, and he was cured and discharged on the 16th day. Postoperative pathology showed hemorrhagic infarction of small intestine segment. Follow-up until more than 2 years postoperatively, no recurrence.