2021年 · 第36卷第10期

A 56-year-old female was admitted to the hospital for "finding a left upper abdominal mass for 1 year". Physical examination: The upper abdomen is slightly swollen, the abdomen is soft, and there is no tenderness. A mass about 10 cm ×15 cm in size can be palpable in the left upper abdomen, which is soft in texture and has unclear boundaries. There is no history of surgery or trauma, and the history of contact with epidemic areas and epidemic water is denied. Enhanced CT of the abdomen and pelvis showed: a cystic mass with uniform density in the left upper abdomen, about 12.7 cm ×9.8 cm ×10.2 cm in size, which was closely related to the large curvature of the gastric body locally (Figure 1), the adjacent colon and small intestine were compressed and displaced, and no change was seen on enhanced scan. Laparoscopic exploration revealed a cystic mass in the small omental sac of the left upper abdomen with good mobility. During the exploration, the cyst wall ruptured, colorless clear fluid flowed out, and the patient developed anaphylactic shock. The adhesion between the mass and the surrounding tissues was released. It was found that the mass was closely related to the great curvature of the stomach, and the boundary was unclear. The gastric wall at the base of the mass was removed about 1 cm from the boundary of the mass, and the mass was completely removed. Pathological examination revealed that there were a few parasitic head segments and cyst wall-like structures in the cavity. Combined with clinical consideration, it was considered that the echinococcal morphology consisted of protocephalae, germinal cyst and cyst wall, which was consistent with hydatidosis (Figure 2）。 The patients were followed up for 10 months without recurrence.

A 90-year-old woman was admitted to hospital for "finding a left breast mass and areolar area neoplasm for 1 month". Physical examination showed that a 3 cm tough mass could be palpable in the outer lower quadrant of the left breast, with poor boundary and poor mobility. A 1.5 cm soft vegetation, dark red in color, was seen on the left areola skin. Breast color ultrasound showed hypoechoic mass in the left breast, with irregular shape and clear boundary. Mammography showed irregular high-density mass shadows in the left breast, with blurred edges, and small pleomorphic calcification shadows distributed in clusters in the mass. Chest CT examination showed suspected metastatic nodules in both lungs. Left breast mass excision + left breast areolar neoplasm excision under local anesthesia. During the operation, the left breast tumor was grey in color and tough in texture; The areola area neoplasms are 0.5 cm higher than the skin surface, gray-red in color and soft in texture. The postoperative pathology reported melanoma, Clark grade IV. Under the light microscope, the tumor cells were round and oval, the nucleus was deeply stained, the nucleoplasmic ratio was large, the mitotic images were more common, and melanin particles were visible in some areas (Figure 1）。 Immunohistochemical examination showed: HMB45 (+), MelanA (+), S-100 (+), Ki67 index (20%), C-erbB2 (-), ER (-), PR (-). The pathological diagnosis was primary malignant melanoma of the left breast. Pd-1 monoclonal antibody targeted therapy was given postoperatively, and the patient died of lung metastasis 5 months postoperatively.

A 64-year-old woman was admitted with "pain in the right lower abdomen for 8 h". Abdominal color ultrasound examination showed thickening of the appendix and inflammatory exudation around the appendix. Diagnosis: Acute appendicitis, emergency laparoscopic appendectomy. Intraoperative exploration showed that the appendix was edema and thickened, the appendix was about 6 cm long, the surface was covered with thin purulent coating, no perforation was seen, and no purulent effusion was seen in the right iliac fossa and pelvic cavity. An appendectomy was performed. On the second postoperative day, the patient did not exhaust or defecate, complaining of abdominal pain, abdominal distension, and intermittent vomiting. X-ray of the digestive tract revealed two liquid-gas planes in the middle abdomen and multiple intestinal dilatations (Figure 1）。 Considering the presence of symptoms of intestinal obstruction, gastrointestinal decompression was given. The symptoms of abdominal pain and bloating were not relieved. On the 4th postoperative day, an emergency CT of the abdomen showed that part of the small intestine herniated into the left subcutaneous side (Figure 2). Considering the presence of poke hole hernia, the patient was treated with emergency surgery. From the incision of the card hole on the left side, it was found that part of the intestinal prolapse between the abdominal wall muscle and the peritoneum was visible, about 6 cm long, and the color and peristalsis of the intestinal tube were good. The blood supply of the intestinal tube was checked to be normal, and it was repaid.

A 61-year-old woman was admitted for "a mass in the left breast found on physical examination for 1 d". Physical examination: Both breasts were of normal size, symmetrical, without discharge, and a mass of 1.5 cm ×1.5 cm was palpable on the outside of the left breast, which was hard in texture, with poor borders, acceptable movement, no adhesion to the skin and muscles, and no mass was palpable in the right breast. The swollen lymph nodes were not palpable in the neck, supraclavicle, and groin. Breast ultrasound showed that 3 hypoechoic masses were visible in the upper outer quadrant of the left breast (Figure 1), the size is 11 mm ×8 mm, 7 mm ×4 mm, 5 mm ×4 mm, the local boundary is not clear, the edge is still regular, and the internal echo is not uniform. CDFI: A punctate blood flow signal can be seen in the large case, the flow rate is 7.2 cm/s, RI: 0.72, and the elasticity score is 2. Several lymph node echoes can be seen under the left axillary, the larger is 20 mm ×9 mm, some lymph node cortex is thickened, and the cortex and medulla are clearly demarcated. Ultrasonography showed hypoechoic mass of left breast, BI-RADS Class 4A. Mammography showed that three nodules with a size of about 13 mm ×13 mm, 14 mm ×8 mm and 8 mm ×4 mm were seen in the upper outer quadrant of the left breast, with poor borders, partially rough borders and uneven density. Hint: Left breast nodular shadow, BI-RADS class 4B. MRI plain scan and enhancement showed that multiple punctate and round masses were seen in the outer upper quadrant of the left breast, with low signal in T1WI, high signal in T2WI, high signal in DWI, and low ADC value. In the early stage of enhanced scanning, the lesions were significantly enhanced, while in the delayed stage, the lesions were reduced, and the boundary was unclear (Figure 2）。 Multiple swollen lymph nodes were seen in the left axilla, but no swollen lymph nodes were seen in the right axilla. Chest CT scan showed no abnormalities in both lungs and mediastinum. Ultrasound-guided puncture biopsy of the mass and axillary lymph node was performed. Pathological examination showed: (left breast mass) reactive lymphoid tissue proliferation, manifested by infiltration of a large number of small lymphocytes, plasma cells and immunoblastic cells, accompanied by interstitial fibrous tissue proliferation, and huge histiocyte proliferation was seen in some areas, which did not rule out the possibility of Rosai-Dorfman disease. Lymphocytes and a small amount of histiocytes were seen in the needle aspiration smear of the left axillary lymph node. The left breast mass resection was performed, and the postoperative pathological examination showed that it was consistent with Rosai-Dorfman disease of the breast (Figure 3）。 Immunohistochemical examination showed: proliferative histiocytes S-100 (+), CD68 (+), CD1a (-), proliferative lymphocytes partially CD20+, PAX-5+, partially CD3+, CD5+, immunoblastic cells CD30+, CD15-, Ki-67+ (about 30%), and CD21 showed FDC network.

A 54-year-old male was admitted for "chest pain and chest tightness for 2 weeks". Smoking history for more than 20 years. Physical examination: emaciated body shape, left chest respiratory mobility and speech trembling were weaker than those on the right side, left lung turbidity was detected by percussion, and left lung respiratory sound was weakened by auscultation. Chest CT examination revealed massive effusion in the left pleural cavity and compressive pulmonary dilatation in the left lung. Serum tumor markers: carbohydrate antigen CA125: 235.4 U/ml, alpha-fetoprotein: 1.4 ng/ml, carcinoembryonic antigen: 4.68 ng/ml, carbohydrate antigen CA72-4: 17.28 U/ml. Closed left thoracic drainage at bedside was performed, and pale yellow fluid was drained out. Routine biochemical examination of pleural effusion showed that white blood cell count was 722.0×10⁶/L, L-lactate dehydrogenase: 803 U/L, adenosine deaminase: 12 U/L, glucose: 5.7 mmol/L, pleural effusion carcinoembryonic antigen quantification 49.47 ng/ml. Pathological examination of pleural effusion revealed malignant epithelial tumor. Bronchial fibroscopy showed inflammation of the left lung bronchus. Enhanced CT examination of chest and abdomen showed extensive irregular thickening of left pleura, encapsulated effusion of left pleural cavity, and compressive atelectasis of left lung tissue (Figure 1）。 Indwelling thoracic drainage tube. In order to relieve the symptoms and confirm the pathological diagnosis, thoracoscopic clearance of left pleural cavity encapsulated effusion + pleural biopsy + pleural atresia was performed. During the operation, adhesions in the left thoracic cavity formed multiple encapsulated cavities, extensive pleural edema, multiple cauliflower growths, and easy bleeding at touch (Figure 2）。 The thoracic adhesions were bluntly separated, the wrapping space was opened, the pale yellow effusion was removed, and one piece of the diseased pleura and one piece of the tumor were taken for pathological examination. Talc powder was sprayed evenly on the thoracic cavity, and pleural atresia was performed. The results of postoperative pathological examination showed invasive growth of poorly differentiated adenocarcinoma tissue in pleural tissue and tumor (Figure 3，4）。 Immunohistochemical staining: CK8/18 (+), CK20 (-), CK19 (+), Vimentin (-), D2-40 (-), WT1 (-), CD7 (-), PSA (-), CK5/6 (-), AFP (-), Hepatocyte (+), CD34 (vascular +), consistent with metastatic hepatocellular carcinoma or hepatoid adenocarcinoma. The patient's chest symptoms were relieved after operation, and he refused radiotherapy and chemotherapy. Chest tightness and other discomfort recurred at the 5th week after discharge, and he only survived with tumor for 4 months.