2022年 · 第37卷第09期

The child, a 1-year-old male, was admitted to hospital for "intermittent fever for half a month". Physical examination: Abdominal swelling, palpable in the left lobe of the liver, 5 cm below the xiphoid process. Laboratory tests: ALT 50 U/L, AST 89 U/L, lactate dehydrogenase 1 004 U/L, hydroxybutyrate dehydrogenase 722 U/L; Epstein-Barr virus IgG positive, cytomegalovirus IgG positive, Epstein-Barr virus nuclear antigen IgG antibody positive. Blood pathogenic microorganism surveillance: increased number of Burkholderia cepacia complex, Epstein-Barr virus sequences. Tumor markers: alpha-fetoprotein 1.22 ng/ml, carcinoembryonic antigen 0.93 ng/ml. Color ultrasound: Heterogeneous echo in the left lobe of the liver, showing a hypoechoic area about 56 mm ×43 mm in size. CT: A slightly lower density mass shadow was seen in the left lobe of the liver, with poor right boundary and clear left boundary, about 38 mm ×42 mm ×51 mm. The enhancement scan showed mild uneven enhancement (Figure 1). No abnormalities were found on plain chest CT scan. After the consultation in the ultrasound department, "ultrasound-guided puncture and drainage of liver mass" is not recommended. The patient has repeated fever, the liver occupies a larger space than before, and the efficacy of anti-infective treatment is not good. Left lobe tumor resection + hilar lymph node resection were performed. Short-term recovery after surgery is possible. Pathology: Epstein-Barr virus-positive NK/T cell proliferative disease, combined with immunophenotype and EBER in situ hybridization considered as: (1) extranodal NK/T cell lymphoma, nasal type; (2) Epstein-Barr virus-positive NK/T cell proliferative disease tumor stage (Figure 2). Immunohistochemistry: CD3 (+), CD20 (-), PAX-5 (-), CD5 (-), CD2 (+), CD7 (-), CD56 (-), TIA-1 (+), GrB (+), Ki-67 (~70% +), CD4 (±), CD8 (+), EBNA-2 (-). In situ hybridization: EBER (+). Detection of postoperative lymphoma gene rearrangement: There is monoclonal rearrangement (+ + +) at the D β-J β locus of TCRB, suggesting that lymphoma may be. The child's pathological diagnosis was clear, and the family members were informed that NK/T cell lymphoma was prone to haemophilocytic syndrome, with rapid progression and poor prognosis. Chemotherapy was recommended as soon as possible, but the family members refused to continue treatment, and they were lost to follow-up after discharge 11 days after surgery.

A 29-year-old male patient. The main cause of "distension and pain in the left upper abdomen for 2 weeks" was admitted to hospital. Physical examination: tenderness in the left upper abdomen. Abdominal B-ultrasound: A cystic mass was seen in the middle and lower levels of the spleen, about 14 cm ×11 cm in size, with clear boundaries, dense punctate echoes and no separation. Abdominal CT: giant cystic mass occupation of the spleen (Figure 1). Tumor marker CA19-9: 128 U/ml. B-ultrasound-guided cyst puncture extracted 200 ml of pale yellow fluid, and CA19-9 in cyst fluid was>10 000 U/ml. Cytological examination of cyst fluid showed no evidence of malignant tumor. Laparoscopic fenestration of splenic cyst under general anesthesia. The middle and lower poles of the visceral surface of the spleen were obviously bulged, squeezing the tail of the pancreas and the splenic blood vessels upward. There was about 200 ml of non-coagulated blood around the spleen, considered due to puncture. At 0.5 cm of the junction between the free part of the cyst wall and the spleen tissue, ultrasonic scalpel and electrocoagulation were used to stop hemorrhage, and the cyst wall was removed with a size of about 8 cm ×10 cm. The visceral surface of the cyst has a trabecular appearance, with vertical and transverse fibers and blood vessels (Figure 2). The omentum was tamponed on the exposed surface of the cyst and a drainage tube was placed. The patient recovered well after surgery, and no abnormalities were found on CT scan one week later. The abdominal drainage tube was removed and the patient was discharged. Pathology: The cyst wall is partially lined with flat epithelium, which conforms to the true cyst of the spleen. Serum CA19-9 was re-examined 7 days later: 1 673 U/ml. CA19-9 after 3 months: 228.7 U/ml. After 5 months, serum CA19-9 was 23.63 U/ml, and no recurrence of splenic cyst was found on CT (Figure 3). There was no recurrence of splenic cyst on ultrasound 1 year after surgery, and serum CA19-9: 25.38 U/ml.