2023年 · 第38卷第01期

A 24-year-old woman was admitted to the hospital because her spleen occupied space for 1 month after physical examination. No abnormalities were found on admission physical examination. Pumei-abdominal MRI plain scan + dynamic enhancement examination: cystic mass shadow at the upper pole of the spleen, about 8.3 cm ×7.6 cm in size, and no enhancement was seen after enhancement (Figure 1). Tumor markers : CA19-9>1 000.0 U/ml; CA125 108.00 U/ml. PET-CT: cystic low-density foci in the spleen with marginal calcification, metabolic defect, considering cyst with calcification. Partial splenectomy was performed. During the operation, a cyst with a diameter of about 7 cm at the upper pole of the spleen was seen, accompanied by calcification, and adhered to the left lobe of the liver. The cyst was contained with pale yellow clear fluid. The arteries and veins of the upper pole of the spleen were separated and ligated at the splenic hilum, and the cyst wall was completely removed (Figures 2 and 3). Postoperative pathology: (splenic cyst wall) epithelial cyst (Figure 4). Reexamination of tumor markers on the 3rd postoperative day: CA19-9: 568 U/ml; CA125: 80.6 U/ml; Reexamination of tumor markers 1 month after surgery: CA19-9: 26 U/ml; CA125: 35 U/ml.

A 35-year-old female complained of "pain in the left upper abdomen for 3 months, 2 years after surgery for sigmoid colon cancer and 1 year after surgery for splenic metastases". In February 2019, the patient underwent laparoscopic radical sigmoid colonectomy (pT3N2a) in a local hospital due to colonoscopy with "blood in the stool", which showed sigmoid colon cancer. Postoperatively, irinotecan combined with Tegio chemotherapy was performed for 2 cycles, and XELOX chemotherapy was performed for 6 cycles. In August 2020, laparoscopic splenectomy was performed in an external hospital due to spleen occupation. Pathological examination revealed moderately differentiated adenocarcinoma, and intestinal cancer metastasis was considered. The patient experienced left upper abdominal pain 3 months ago. Gastroscopy revealed a proliferative lesion of gastric fundus ulcer with hemorrhage. CT and MRI examination showed: irregular mass under the left diaphragm, communicating with the gastric cavity, invading the left diaphragm, pancreatic tail, left adrenal gland, metastases in the left lower lobe of the lung, and metastases in the left lateral lobe of the liver. A multi-disciplinary team (MDT) discussion was conducted. Considering the secondary recurrence of bowel cancer after surgery, the patient's condition was complicated, accompanied by severe anemia, and the FOLFOX regimen chemotherapy was performed first. After 4 cycles of chemotherapy, CT revealed that the left subdiaphragmatic mass was smaller than before. The general condition of the patient improved, and the resection of recurrent intestinal cancer combined with gastric wedge resection, pancreatic tail resection, left adrenalectomy, partial diaphragm resection and reconstruction, left lower lobe wedge resection, and left lateral lobe metastasis resection were performed. Postoperative pathological examination revealed: abdominal tubular adenocarcinoma, moderately differentiated, invading the whole thickness of stomach wall, pancreas, adrenal gland, metastatic adenocarcinoma (lung, liver). FOLFOX regimen chemotherapy was continued 1 month after surgery.

A 78-year-old female was admitted to hospital for more than 2 years due to dull pain in her right upper abdomen. Two years ago, the patient developed dull pain in the right upper abdomen without obvious trigger. Hepatic hemangioma (2.0 cm ×1.4 cm) was found by abdominal B-ultrasound in another hospital, but it was not treated. After that, the patient's abdominal pain symptoms worsened. Previous hepatitis C viral for 15 years and oral antiviral treatment for 1 year. Physical examination: Mild tenderness in the right upper abdomen. Laboratory tests: Alkaline phosphatase 205.0 U/L, γ-glutamyl transpeptidase 152.0 U/L, AFP 24 005.90 ng/ml, PIVKA-Ⅱ 27 610.07 Mau/ml. Abdominal enhanced CT: S8/4 segment of the liver was scanned and two irregular arterial phase obviously enhanced foci were found. Some branches of the left branch of the portal vein showed filling defects. The largest cross section of the foci was 6.8 cm ×6.3 cm ×5.7 cm, and small nodular foci were scattered around the foci. Upper abdominal magnetic resonance enhanced imaging (Pumeixian): S8/4 segment of the liver was scanned and two irregular masses were fused with each other, with a range of about 7.6 cm ×6.1 cm ×5.8 cm, and scattered sub-foci were seen around the lesion (Figure 1); A filling defect was seen in the cavity of the left branch of the portal vein and extended into the branch of the portal vein in segment S3 (Figure 2). Because the patient had multiple tumors, huge tumors and portal vein tumor thrombosis, conversion therapy was performed after discussion by a multidisciplinary collaborative team. The patient first underwent transcatheter arterial chemoembolization (TACE) combined with hepatic arterial infusion chemotherapy (HAIC) once; External radiotherapy was initiated 10 d later (tumor + portal vein tumor thrombus; 200 cGy ×20 d); Four days after the start of radiotherapy, lenvatinib (8 mg/d oral; discontinued for 10 days due to fatigue and myalgia, and continued to take the drug after symptoms were relieved) and sintilimab (200 mg intravenous drip, once every 3 weeks) were added. After half a month, re-examination of CT showed that the lesion was reduced with reduced enhancement compared with before, so the original regimen was continued. After 4 months, re-examination of enhanced CT showed irregular low-density non-enhanced necrotic area in the lesion, and no definite enhancement was seen in the arterial phase around the whole lesion; Upper abdominal magnetic resonance enhanced imaging (Pumei display) showed a slight enhancement of the edge of the lesion and its internal septum on the enhanced scan (Figure 3), low signal in the hepatobiliary phase, and a filling defect in the left branch cavity of the original portal vein. This time, it was not clearly displayed, mRECIST PR (Figure 4); AFP 7.49 ng/ml; PIVKA-Ⅱ 16.09 Mau/ml. Then open partial hepatectomy + cholecystectomy was performed under general anesthesia. Pathological diagnosis: hepatocellular carcinoma, tumor beds were neoplastic necrosis. Long-term lenvatinib after discharge at the same dose as before. There was no recurrence and metastasis of tumor on CT examination in other hospitals 3 months after operation; AFP 8.04 ng/ml.