2014年 · 第94卷第09期

A 79-year-old female was found to have a mass on the medial side of the root of her right thigh 3 months ago, without pain, chills, fever and other symptoms. I have experienced paroxysmal pain on the inside of the right thigh root for the past 2 months. Physical examination showed a mass of 50 mm ×50 mm in size on the medial side of the right thigh root, which was hard in texture, normal skin color, low skin temperature, mild tenderness and poor mobility. B-ultrasound showed abnormal echoes at the root of the right thigh, the nature of which is to be determined (Figure 1)。 Routine admission blood test: red blood cell count 3.07×10¹²/L, hemoglobin 86 g/L, hematocrit 28.3%, RBC distribution width 47.6%, suggesting macrocytic anemia. MRI showed an oval space-occupying focus in the subcutaneous fat at the root of the right thigh, 45 mm ×37 mm ×32 mm in size, with a clear boundary, and the solid part around the focus showed T₁Signals such as WI (FIG. 2A), T₂WI slightly higher signal (Figure 2B), T₂WI – SPAIR and DWI significantly high signal (Figure 2C,Figure 2D), with a T in the center₁WI slightly lower, T₂WI, T₂WI – SPAIR and DWI low signal, interspersed with small speckled flaky T₁WI and other signals, T₂WI higher signal, T₂WI – SPAIR and DWI high signal shadows. The lesions of enhanced scan showed thick-walled annular enhancement with irregular inner edge, and unenhanced areas were visible inside (Figure 2E)。 The MRI diagnosis was malignant tumor. The gross pathology of the operation showed an oval mass in the subcutaneous fat at the root of the right thigh, with a size of 50 mm ×40 mm ×30 mm, only part of the capsule was seen, the incision surface was tender, and part of coagulative necrotic tissue was seen in the center. Intraoperative rapid pathology revealed small round cell malignancy with microscopic changes such asFIG. 3A。 Immunohistochemical results showed that Ki-67 (+, 90%), CD20 (+), PAX5 (+), Bcl-6 (+), MUM1 (+), LCA (+), CD99 (partial +) (FIG. 3B, 3C)。 Pathological diagnosis: nonspecific diffuse large B-cell lymphoma (DLBCL) (right thigh root).

The patient was a 24-year-old female with "menopause 35^＋2The patient was transferred from another hospital to the obstetrics department of Beijing Chaoyang Hospital with a small amount of hemoptysis, 5-10 ml/d, bright red in color, without dizziness, chest tightness, asthma, dyspnea and other discomfort 1 day before admission. Chest X-ray examination at the local hospital showed that both lungs had heavy texture. No definite diagnosis and special treatment was given. At noon on the third day after admission, the patient had frequent hemoptysis, about 5 ml each time, bright red in color, accompanied by obvious left back pain, no palpitations, precordial pain, etc. Later, due to premature delivery, an emergency cesarean section was performed at night, and the operation went smoothly, giving birth to a son and a daughter. Postoperative ECG monitoring indicated sustained tachycardia, decreased blood oxygen saturation, and blood pressure fluctuation at 165-150/100-90 mmHg (1 mmHg =0.133 kPa). Routine blood tests showed a progressive decrease in hemoglobin and hematocrit. Physical examination: auscultation left lung breathing sound was weak, left lung percussion showed solid sound. Chest CT and chest ultrasound showed: left lung tissue atelectasis, left thoracic hemorrhage. Closed left thoracic drainage was performed urgently, and dark red non-coagulating blood was drained, with a volume of about 1 700 ml. After reexamination of the chest CT, a large amount of bloody effusion and a small amount of gas accumulation in the left pleural cavity were shown, which was slightly reduced compared with the previous film. The solid and dense shadow of both lungs with left lung atelectasis, compared with the previous film, the left upper lung local recruitment, the remaining no obvious change (Figure 1)。 The patient had a clear diagnosis of massive hemothorax on the left side and was indicated for surgery, so he underwent left exploratory thoracotomy in emergency department. A large number of blood clots in the left thoracic cavity were seen during the operation, and the amount of blood clots cleared was about 800 ml. Further exploration showed that a cyst with a diameter of about 6 cm in the left lower lung was ruptured, with blood accumulation in the cavity and active bleeding in the cyst wall. The consolidation of the left lower lobe was clear, and left lower lobectomy was decided. When the lower pulmonary ligament was released, it was found that an abnormal blood supply artery with a diameter of about 0.5 cm was located below the lower pulmonary vein and entered the lower lung from the subdiaphragm (Figure 2), considering that the abnormal blood vessels originate from systemic circulation, ligation, cutting, and removal of the diseased lung. Postoperative pathology: Lobectomy specimens, size 13 cm ×7 cm ×6 cm, visceral pleura is smooth, the section is dark red and tough, blood clots can be seen in the bronchial lumen, diffuse, flaky hemorrhage and consolidation area can be seen in the lung section, accounting for about 90% of the whole lung lobe section (Figure 3)。 Microscopic examination: Diffuse bleeding in the alveolar cavity of lung tissue with inflammatory cells and cellulose exudation, histiocytes phagocytosing hemosiderin in some alveolar cavities, coagulation blockage in bronchial cavity, abnormal thickening of venous intima with lumen occlusion in subpleura and interlobular septum, and artery-vein mutual migration, and reactive hyperplasia of lymph nodes submitted for clinical examination. Final diagnosis: pulmonary sequestration, intralobar type, secondary pulmonary hemorrhage. The patient recovered well after surgery and was discharged on the 5th day after surgery. Both mother and baby were healthy.

Paroxysmal nocturnal hemoglobinuria (PNH) is a hemolytic disease caused by acquired genetic mutations in hematopoietic stem cells. Phosphatidylinositol glycoside-A (PIG-A) gene mutation in hematopoietic stem cells of PNH patients causes the disorder of glycoinositol phospholipid (GPI) anchor synthesis, which leads to the loss of membrane proteins connected to the cell surface through anchors, and then causes a series of functional changes of cells. Clinically, hemolytic anemia, different degrees of bone marrow failure, thrombosis and smooth muscle dysfunction are often manifested. 1999, Araten et al.^[1]Small amounts of CD55 were found in the peripheral blood of most healthy people^–and CD59^–Erythrocytes and neutrophils, and PIG-A gene mutations can be detected, but these people did not progress to typical PNH. In 2005, it was found that the cellular stage of PIG-A gene mutation in healthy people is different from that in PNH patients. The PIG-A mutation in healthy people occurs in the later stage of hematopoietic progenitor cells-colony-forming cells, while the mutation in PNH patients occurs at the level of pluripotent hematopoietic stem cells (HSC), which causes a series of pathological changes with the expansion and differentiation of PIG-A mutated HSC^[2]。 However, the whole process of PNH pathological mechanism cannot be fully elucidated, and in vitro and in vivo studies have also confirmed that there are other factors besides PIG-A gene mutation that can lead to the proliferation of PNH clone^[3]。

Pancreatic cancer has high malignancy, poor prognosis, lack of obvious symptoms and signs in the early stage of the disease, and 5-year survival rate<5%。 During the development of pancreatic cancer, many abnormalities of molecular markers such as genes, proteins and biological enzymes can occur. These markers include oncogene in situ, tumor suppressor gene, apoptotic gene activation and inactivation, and abnormal expression of telomerase reverse transcriptase (hTERT), urokinase plasminogen activator (uPAR), miRNAs and Mucin (MUC), etc. Molecular imaging makes imaging develop from gross morphology imaging to microscopic morphology, biological metabolism, gene imaging, etc. It can monitor the abnormalities of cellular and molecular levels in the development of pancreatic cancer at the level of molecular biology early, which will greatly improve the diagnosis and treatment level of pancreatic cancer and improve the prognosis of patients. The expression of mucin in pancreatic cancer and its targeted imaging value will be reviewed as follows.

Pituitary adenoma accounts for about 10% ~25% of intracranial tumors, and the incidence rate ranks second among intracranial tumors^[1]。 Although pituitary adenoma is a benign tumor, due to the special position of pituitary gland and important endocrine function, pituitary adenoma causes serious harm to patients, even life-threatening. Although the surgical treatment, drug therapy and radiotherapy of pituitary adenoma have made great progress, the diagnosis, treatment and prognosis of pituitary adenoma are not satisfactory because the mechanism of pituitary adenoma development is not fully understood^[2]。 In recent years, the study of phosphatidylinositol 3-kinase/protein kinase B/mammalian rapamycin target protein (PI3K/AKT/mTOR) signaling pathway in the development of pituitary adenoma has attracted more and more attention^[3]The role of the PI3K/AKT/mTOR signaling pathway and its inhibitors in pituitary adenomas is reviewed below.

A 55-year-old male was admitted for prostatectomy. There was no abnormality in the preoperative examination. The surgical anesthesia was epidural anesthesia, and the puncture point was between L2 and 3. The puncture was successful, and the symptoms of right nerve root irritation appeared at the time of catheterization. The catheterization was abandoned, and the puncture was successfully inserted again in the same space. A total of 10 ml of 2% lidocaine and 5 ml of 0.75% ropivacaine hydrochloride (Nailepin) were given. The operation time was 30 min, the circulation and breathing were stable during the operation, and epidural analgesia was given after the operation. On the first day after surgery, the patient complained of decreased motor ability of right lower limb, and numbness in the skin of right thigh and right knee. The patient complained that the analgesic pump had been turned off by himself, so it was considered that it was related to the nerve root irritation symptoms during epidural catheterization, and the epidural catheter was removed after being given dexamethasone 5 mg and micobol 500 μ g through an epidural catheter; Neurological consultation, lumbar spine MR, electromyography nerve conduction velocity (NCV) examination of both lower limbs were performed, and intramuscular injection of micobau was given to treat. Lumbar spine MR showed lumbar spine hyperosteogeny. The electromyography report at 2 weeks after operation showed that the amplitude of the right femoral nerve potential was slightly decreased in the measurement of MW (Motor Wave), and the amplitude of the right lateral femoral cutaneous nerve potential decreased by 50% in the measurement of sensory nerve amplitude (SW) compared with the contralateral. Discharge 18 d postoperatively, paresthesia significantly improved, right lower limb muscle strength decrease still existed. One month after the operation, the numbness of the right lower limb improved significantly. The muscle strength of the right lower limb decreased without improvement, and it was aggravated after long-term walking, with occasional incontinence. Spinal conus injury was suspected and neurological consultation was repeated. Consultation results: The muscle strength of the lower limbs was slightly weakened, and the perineal skin felt normal; Thoracic MR was performed on suspicion of higher segment problems of the spinal cord. Abnormal MR results of thoracolumbar spine: Multiple tortuous filling defects were seen in the spinal canal at approximately T6 – 10 level (Figure 1), the T2 signal adjacent to the thoracic cord was obviously thickened, and after the enhancement, the tortuous blood vessels in the spinal canal were obviously enhanced, and about the T7 level communicated with the thickened right intercostal artery (Figure 2)。 Increased T2 signal in conus and cauda equina. After enhancement, no obvious abnormal enhancement foci and tortuous blood vessels were observed. Diagnosis: Multiple tortuous blood vessels in the spinal canal at about T6-10 level, communicating with the right intercostal artery at T7 level, consistent with spinal dural arteriovenous fistula; The corresponding T2W1 signal of thoracic spinal cord was increased, suggesting partial thoracic spinal cord degeneration. Degenerative changes of the thoracolumbar spine. After the diagnosis was confirmed, he went to Beijing Xuanwu Hospital for surgical treatment, and the symptoms disappeared after treatment.

A 24-year-old female went to Subei People's Hospital of Jiangsu Province 4 months ago due to chest tightness and asthma after activity. CT findings: Diffuse mass-like thickening of the anterior and posterior mediastinum, mediastinal pleura and lateral wall pleura, surrounding the mediastinum, left hilar vessels and pericardium, and enlarged mediastinal lymph nodes (FIG. 1A、FIG. 1B、Figure 1C、Figure 1D、Figure 1E、Figure 1F、Figure 1G)。 The patient was treated with HyperCVAD A + B regimen chemotherapy and recovered well. Re-examination CT showed that mediastinal mass and lymph node enlargement disappeared (Figure 1H)。 Pathological manifestations: diffusely distributed abnormal cells with large, deeply stained nuclei and little cytoplasm (Figure 2)。 Immunohistochemistry: CK (+); LCA, CD8, CD43, CD79 α, TdT (all + + +); CKpan, CD99 (both +); CD5, CK19, CD3 (all scattered +); Combined with the clinical diagnosis of lymphoblastic lymphoma (stage IV group B).