2021年 · 第36卷第06期

thyroid cancer (TC) is one of the common malignant tumors in the world. According to clinical and pathological classification, it can be divided into differentiated thyroid cancer, medullary thyroid cancer and undifferentiated thyroid cancer. Although the mortality rate of TC patients is only 0.40/100,000, its incidence ranks 9th among malignant tumors in the world, which deserves attention^［1］。 Through the cluster analysis of high-frequency keywords in TC clinical research at home and abroad, it is found that in the past two decades, scholars' clinical research on TC has focused on exposure factors, diagnosis and evaluation, surgery and targeted therapy, etc. Now, the main hot issues will be discussed.

A 71-year-old female was admitted to the hospital due to "anal distension and discomfort with difficulty in fecal discharge for 1 month". Thrombocytosis was found 2 years ago, and the etiology and regular treatment were not identified. Ulcer-type mass can be palpable at 3 cm from the anal margin in digital rectal examination, which is hard in texture and has acceptable mobility. Under colonoscopy, ulcer-type lesions from 2 to 6 cm away from the anal margin were found, and the pathological examination was adenocarcinoma. Blood routine: WBC 9.35×10⁹/L, RBC 4.2×10⁹/L, PLT 1 920×10⁹/L. Serum tumor markers and coagulation mechanism examination indexes were all in the normal range. Pathology of bone marrow puncture showed that granulocyte and megakaryocyte were active in proliferation, platelet distribution was abundant, and large clusters of platelets were easily seen (Figure 1）。 The BCR/ABL fusion gene was negative and the JAK2 gene was wild-type. Diagnosis of rectal cancer with thrombocythemia with indication for surgery. Considering the high risk of thrombosis and bleeding during the perioperative period, platelet apheresis therapy was performed first to reduce platelet levels, and low molecular weight heparin calcium anticoagulation therapy was given at the same time. Laparoscopic assisted radical resection of rectal cancer was performed, and anticoagulation and deaccumulation treatment were given after excluding the risk of postoperative bleeding. The platelet count dropped to normal level at 2 months after surgery. After 1 year follow-up, the patient was in good general condition, and the platelet count continued to be in the normal range.

A 62-year-old female was admitted with "paroxysmal dull pain in the right lower abdomen for 2 weeks". Enhanced CT examination of the whole abdomen showed that a massive soft tissue density shadow was seen in the middle and lower abdomen, about 8.0 cm ×7.4 cm ×6 cm in size, with a clear boundary, blurred and turbid surrounding fat space, thickened mesenteric membrane, and the enhanced scan showed uneven annular enhancement (Figure 1）。 Physical examination: A huge mass can be palpable in the lower abdomen, which is fixed, hard and has no tenderness. Tumor markers: serum CA125 73 U/ml, serum AFP, CEA and CAl9-9 were all normal. Exploratory laparotomy showed that the mass was located in the small intestine about 50 cm away from the ileocecal region, invading the serosa, hard in texture, about 8 cm ×8 cm in size, and a yellow-white mass about 4 cm ×3 cm in size, hard in texture, was seen in the mesileal about 110 cm away from the mass. Ileocecal and partial small intestine resection was performed. The postoperative pathological specimens found: the ileum was 35 cm long and 4 cm in diameter, the cecum was 10 cm long and 4~10 cm in diameter, and a huge nodule formed with an ulcer surface of about 3.5 cm ×2 cm and an ulcer face facing the outside of the serosa was found 10 cm from the lower incision end, with a size of about 9 cm ×7.5 cm ×9.5 cm. The incision surface was gray and hard. Multiple nodules were seen in the mesentery, adhering to the mesentery, with a range of 13 cm ×8 cm. The appendix was about 8.5 cm long and the tube diameter was 0.7 cm. The mesenteric mass of small intestine is about 4.5 cm ×4 cm ×2 cm, with gray-white and hard cut surface, and unclear adhesion to the mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesenteric mesentericFigure 2）。 Under light microscope: the mass is composed of spindle-shaped cells, arranged in bundles or braids, with red-stained cytoplasm, long spindle-shaped, oval or irregular nuclei, rough chromatin, easy to see nuclear division (>10/HPF), and infiltrate into extraserous adipose tissue (Figure 3）。 Immunohistochemical staining showed: CK (scattered +), EMA (focal +), Vimentin (3+), Ki-67 (50% +), CD34 (-), CD117 (-), Desmin (-), SMA (partial +), Dog-1 (-), S-100 (-), Alk (-), β-Catenin (cytoplasmic +), CD56 (-), CD68 (+). Pathological diagnosis: (abdomen + ileocecal region + part of ileum, small intestine mesenteric) undifferentiated high-grade pleomorphic sarcoma. The patient was given radiotherapy and chemotherapy after operation, and no recurrence or metastasis was seen after 10 months follow-up.

The patient was a 19-year-old female. Admitted for "right breast mass for 6 months". Physical examination: 11 cm ×8 cm mass below the center of the right breast, with high skin tension, tough texture, unclear boundary and inactivity. A 3.5 cm ×2.5 cm oval bright red patch can be seen on the skin at 7 points and 3cm away from the nipple of the right breast, with clear boundary and fading when pressed. No lymph nodes were enlarged under both axillaries (Figure 1）。 Color ultrasound examination showed: the right breast echo was uneven, and there were flat lymph nodes under both axils. MRI showed: right breast mass combined with hemorrhage and inflammatory changes, edema of surrounding tissue, folioid tumor could not be excluded, and multiple small lymph nodes under both axillaries. Prior to puncture, approximately 400 ml of bloody fluid with old blood clots were withdrawn. Extended resection of right breast mass was performed. Pathological examination showed: (right) breast angiosarcoma, the tumor involved dermal adnexa (Figure 2）。 Immunohistochemical examination showed that the positive rate of Ki-67 was about 60%, ER (-), PR (-), EMA (-), CD31 (+), CD34 (+), P53 (-), Vimentin (+), CK (guang-), AACT (+), AAT (-). Right breast single mastectomy was performed again, and pathological examination showed: (1) (right breast angiosarcoma, after tumor resection) tumor components remained around the breast incision, and the tumor involved the nipple; (2) No tumor tissue was found in the middle and upper, middle and outer, and middle and inner quadrants of the (right) breast. AI regimen chemotherapy was given postoperatively: doxorubicin liposome 60 mg + ifosfamide 6 g on days 1 to 3, 21 days as a cycle, a total of 6 cycles. At present, 8 months after the operation, no signs of recurrence and metastasis have been seen.

The patient, a 53-year-old female, was admitted to the hospital for "finding multiple liver mass occupying for 1 month". Physical examination: A hard mass with clear boundaries, smooth surface and no tenderness, about 7 cm ×6 cm in size, could be found in the right upper abdomen. Laboratory tests : CA19-9 93.6 kU/L, CA24-2 23.2 kU/L. Abdominal CT showed multiple occupied masses in the abdominal cavity, the largest one was located in the retroperitoneum next to the VI segment of the right liver, about 7.9 cm ×7.5 cm in size, with uneven density, calcification and translucent shadow of adipose tissue, and three occupied masses in the liver, the largest one was about 3 cm ×2 cm in size, and one occupied mass in the right pelvic floor, about 2 cm ×2 cm in size. Upper abdominal liver contrast-enhanced ultrasound: the liver occupied the space and no contrast medium entered. Positron emission computed tomography examination showed no concentration at the occupied place. Past history: Bilateral adnexal + total hysterectomy + omentectomy + appendectomy + lymph node dissection due to immature solid teratoma of right ovary 25 years ago. Postoperative pathological diagnosis: immature solid teratoma of right ovary involving omentum and appendix with lymph node metastasis (4/21). Intraperitoneal chemotherapy with cisplatin was administered 6 times from the 3rd postoperative day. Thereafter, no recurrence and metastasis were found at the patient's annual outpatient follow-up. Preoperative diagnosis: ovarian growth teratoma syndrome. Two liver space-occupying fine needle biopsies were performed under the guidance of interventional ultrasound. Pathological combined with immunohistochemical analysis confirmed that it was a mature teratoma. Liver space-occupying resection + laparoscopic assisted pelvic floor nodule resection + retroperitoneal mass resection was performed. During the operation, the liver occupied multiple masses, ranging in size from 0.5 to 3 cm, and was gray-white and hard in texture (Figure 1）。 Intraoperative frozen sections showed a little brain tissue, but no cancer cells and abnormal cells. The postoperative pathological diagnosis was mature solid teratoma of the liver, retroperitoneum and pelvic floor peritoneum. The patient recovered smoothly and was followed up for 2 years without tumor recurrence or metastasis.

A 72-year-old female was admitted for "abdominal pain, abdominal distension with cessation of exhaustion and defecation for 4 d". Physical examination: No abnormalities were found in bilateral breasts. The abdomen is swollen, irregular intestinal haptics seem to be visible on the right side of the abdomen, abdominal muscles are tense, tenderness and rebound pain are obvious, the intestinal sound is hyperactive, the percussion is drum sound, and the mobile voiced sound is negative. CT examination showed intestinal effusion and gas accumulation, space-occupying lesions of ascending colon with intestinal stenosis, and multiple swollen lymph nodes around it (Figure 1）。 Color ultrasound examination of soft tissue on the body surface showed that there were multiple swollen lymph nodes in the left axilla, unclear cortical and medullary structure, Ti-RADS grade 4 (Figure 2）。 Colonoscopy showed that the colonic lumen was narrow, colonoscopy was difficult to pass, and there was no abnormality in the intestinal mucosa. Laboratory tests: Serum carcinoembryonic antigen 26.58 ng/ml, tumor antigen 12 567.0 U/ml, tumor antigen 1 532.49 U/ml, cytokeratin 19 fragment 12.56 U/ml. "Palliative colonectomy" was performed. Pathological examination revealed that metastatic lobular carcinoma of breast was found in 10/18 of the peripheral lymph nodes. Immunohistochemical staining showed: ER (+ + +), PR (-), CK7 (+), CK20 (-), GCDFP-15 (+), P53 (-). After reexamination of breast color ultrasound and MRI, no abnormalities were found. Under the guidance of color ultrasound, "left axillary lymph node biopsy" was performed. Pathological examination showed that breast metastatic cancer could be seen in the tissue. Immunohistochemical staining showed: ER (+ + +) (Figure 3), PR (-), CK7 (+), Ckpan (+), CK20 (-), GCDFP-15 (+), P53 (-), TTF-1 (-), Napsin A (-), ck5/6 (-), HER-2 (-), consistent with metastatic lobular carcinoma of the breast. The TAC regimen was given 6 cycles of chemotherapy followed by oral AI sequential endocrine therapy. The patient's re-examination found that the serum tumor markers continued to rise. The examination showed that there was no abnormality in bilateral breast glands, and the swollen lymph nodes in the axillary were increased and enlarged compared with before. "Modified radical mastectomy for left breast cancer + left axillary lymph node dissection" was given. Postoperative pathological examination showed that there was no abnormality in breast glands, and 6/15 of the axillary lymph nodes showed breast metastatic cancer. Immunohistochemical staining showed: ER (+ +), PR (-), CK7 (+), P120 (-), GCDFP-15 (+), P53 (-), TTF-1 (-), Napsin A (-), ck5/6 (-), HER-2 (-), Ki67 index 10%. The patient is currently undergoing fulvestrant maintenance therapy and is in stable condition.