2022年 · 第37卷第11期

A 44-year-old female was admitted for 1 d with abdominal pain. With vomiting once, no abdominal distension, no anal cessation of exhaustion and defecation. Physical examination: A mass of 5 cm ×5 cm in the right lower abdomen was palpable, and tenderness was positive. Laboratory test: white blood cells 10.8×10⁹/L. The patient had a history of two previous deliveries, a history of cesarean section more than 10 years ago, and recovered well after operation. Emergency transvaginal ultrasound showed a 52 mm ×41 mm liquid dark area on the lateral side of the right ovary of the pelvic cavity with a wall thickness, and the possibility of intestinal dilatation was considered (Figure 1). Abdominal CT showed a circular cystic focus of about 47 mm ×35 mm in the right adnexal area, with unclear surrounding fat space and irregular flaky effusion in the pelvic cavity; The pelvic small intestine is slightly dilated and has fluid effusion (Figures 2 and 3). Laparoscopic exploration was performed in the emergency department. During the operation, about 50 ml of pale blood fluid was seen in the pelvic cavity, a 3 cm ×3 cm gap was seen in the right uterine broad ligament, and part of the small intestine was imprisoned in it. The blood supply was basically normal (Figures 4 and 5). Endometriosis nodules of 0.5 cm ×0.5 cm were seen on the surface of the left ovary. The small intestine in the broad ligament was completely pulled out, and the blood supply color was normal. Postoperative diagnosis: broad ligament hernia. The patient recovered well after surgery and was discharged 4 d after surgery.

A 58-year-old female was admitted with "intermittent right lower abdominal pain for 2 weeks". Physical examination: tenderness in the right lower abdomen, no rebound pain. Laboratory tests : CEA 18.23 ng/ml, CA19-9 98.71 U/ml, CA72-4 35.06 U/ml. Ultrasound: Multiple cystic-solid heterogeneous hypoechoic in the head of the pancreas, the larger one was about 4.5 cm ×4.2 cm in size, with unclear boundaries and irregular shape, and grade I blood flow signal was shown on Doppler flow imaging (Figure 1). Abdominal CT: Multiple cystic solid masses in the head and tail of the pancreas, mainly cystic components, with irregular soap bubble-like changes in shape. The length diameter of the pancreatic head lesion is about 4.7 cm, with punctate calcification in it, the enhanced posterior cyst wall and its internal septum are slightly enhanced, the pancreatic duct in the body of the pancreas is obviously dilated, the outline of the pancreatic tail lesion is not clear, the boundary with the posterior wall of the stomach is not clear, the splenic artery and vein are compressed, and the local lumen is narrowed (Figure 2). Total pancreatectomy + splenectomy was performed. During the operation, multiple tumors in the head of the pancreas and the tail of the body of the pancreas were seen, which were tough in texture. There was a cystic cavity in the tumor, and a large amount of jelly-like matter was seen in it. The largest one was about 5 cm in diameter, and the boundary with the surrounding tissues was unclear, and the mobility was poor. Postoperative pathology: tumor cells were obviously atypical, nuclear deviation, scattered in the mucous sac-like structure of cells, and mucus was seen outside the cells (Figure 3); The pathological diagnosis was pancreatic colloid carcinoma (PCC), which showed nerve invasion, carcinoma involvement in the fibroadipose paravascular of the splenic portal, and no carcinoma involvement in the surrounding lymph nodes.

A 14-year-old female was seen for "2 weeks after discovery of neck mass". Physical examination: the trachea was to the right, and the bilateral lobes of the thyroid gland were diffuse Ⅱ ° enlargement, with hard texture and nodular feeling, and no enlarged lymph nodes were palpable in the neck. Color ultrasound examination showed that a solid nodule of 2.4 cm ×2.1 cm ×2.6 cm was found in the left lobe of the thyroid gland, with non-smooth edge and aspect ratio<1. Dense punctate strong echoes are seen in nodules, and mostly divergent punctate strong echoes are seen in other glands; Multiple hypoechoic nodules in the left cervical regions II, III, IV, V, and right cervical regions IV and VI (Figure 1). Pathological examination by fine needle puncture showed papillary carcinoma of the left thyroid lobe (diffuse sclerosis subtype) and metastatic carcinoma of the left cervical lymph node (Figure 2). CT examination showed that the volume of the left lobe of the thyroid gland increased, reaching down to the left upper mediastinum, and the adjacent tissue structure was compressed. Irregular low-density shadows were seen in the left lobe, and the trachea shifted slightly to the right. Multiple slightly enlarged lymph node shadows in the bilateral neck (Figure 3). Total thyroidectomy + bilateral central group lymph node dissection + bilateral functional neck lymph node dissection were performed. Diffuse enlargement of bilateral thyroid lobes was observed during the operation. A mass of about 4.0 cm ×3.5 cm ×2.5 cm in size was found in the left lobe, which was hard and did not invade the capsule. Multiple enlarged and fused hard lymph nodes were found in bilateral tracheal paraesophageal sulcus, anterior trachea and bilateral lateral cervical areas of the neck. Postoperative pathological examination showed: (left and right lobes) papillary thyroid carcinoma (diffuse sclerosis subtype) with Hashimoto's thyroiditis, and tumor thrombus (+) was found in extensive lymphatic vessels and a small amount of blood vessels (Figure 4); Lymph nodes: Metastatic cancer was found in left central group (11/13), right central group (3/9), left zone II (5/9), left zone IV (6/12), left carotid triangle (1/2), right zone II (1/3), right zone III (2/7) and right zone III and IV (1/8). No metastatic carcinoma was found in left III area (0/2) and left V area (0/4); No cancer was detected in front of the larynx; Immunohistochemical examination showed that tumor cells D2-40 (lymphatic endothelium +), CD31, CD34 (vascular endothelium +). BRAF V600E Wild type. There were no postoperative complications, and thyrotropin inhibition was given. After 4 weeks, serum thyroglobulin<0.040 ng/L, no residual or recurrence was found, and radionuclide treatment was performed 2 months after operation.

A 21-year-old female was admitted to the hospital for "physical examination found a mass in the right lobe of the liver for 1 d". Abdominal ultrasonography: cystic-solid echo space-occupying sonography of the abdominal cavity, ranging approximately 16.4 cm ×13.0 cm ×10.7 cm (Fig. 1A). Abdominal enhanced CT examination: huge mixed density mass behind the right lobe of the liver, containing fat and calcification, considering retroperitoneal teratoma, the right adrenal gland is likely to originate, the right kidney is compressed and displaced downward, and the right lobe of the liver is compressed (Figure 1B). Upper abdominal MRI plain scan + enhanced examination: huge space-occupying lesions in the right retroperitoneal space (liver-kidney space area), teratoma is mostly considered, and right adrenal medullary lipoma is not excluded (Figure 1C). Retroperitoneal giant teratoma resection was performed. Intraoperative findings: the tumor was located retroperitoneally, about 16 cm ×14 cm ×10 cm in size, with clear boundaries and acceptable mobility. The right lobe of the liver was obviously compressed and thinned, and the right kidney was displaced downward. The tumor was completely removed, and the tumor was solid tissue with a pale yellow appearance and a capsule was visible (Figure 2A). After incision, the tumor was yellow lipid-like substance and some cartilage-like tissue was visible (Figure 2B). Postoperative pathological diagnosis: retroperitoneal mature solid teratoma (Fig. 2C).