2014年 · 第94卷第26期

The latest global cancer surveillance report shows that breast cancer is one of the most common malignant tumors in women^[1]。 With the continuous deepening of research, modern breast cancer treatment has entered the era of classification treatment based on molecular typing. Following the guidelines for rational treatment of patients in different stages and categories is also the advantage of individualized oncology medicine. In the treatment of breast cancer, chemotherapy plays an important role in both the early stage of the disease and the stage of recurrence and metastasis. In clinical practice, appropriate regimens and standard doses should be selected to provide optimal treatment for patients.

Portal pulmonary hypertension (POPH) is a disease characterized by progressive increase of mean pulmonary artery pressure (mPAP) and pulmonary vascular resistance (PVR) and normal pulmonary wedge pressure (PCWP) due to pulmonary vascular disease on the basis of portal hypertension^[1]。 2% to 6% of patients with portal hypertension are diagnosed with POPH 4 to 7 years after onset, and 1% to 2% of patients with cirrhosis are complicated with POPH. This proportion is higher when patients with end-stage liver disease are evaluated before liver transplantation^[2]。 Most patients with POPH have no obvious symptoms in the early stage and often miss the best opportunity for treatment. From January 2012 to June 2013, four POPH patients were admitted to Beijing Chaoyang Hospital, which are summarized as follows.

A 62-year-old female was admitted to the hospital on 1 December 2011 due to abdominal distension for 4 months. The patient has developed abdominal distension without trigger since July 2011, progressive increase of abdominal circumference, decreased appetite, and depressed edema of both lower limbs. No fever, abdominal pain, and decreased urine output. No rash, limb sensory disturbance. The routine blood test in the local hospital showed that hemoglobin (Hb) was 84 g/L, and white blood cells and platelets were normal; Urine occult blood positive (+), protein (+); erythrocyte sedimentation rate 36 mm/1 h; C-reactive protein (CRP) 7.94 mg/L; normal liver function; Blood urea nitrogen 11.77 mmol/L, creatinine 123.5 μ mol/L, creatinine clearance 37 ml/min; Abdominal ultrasound: medium to large volume of fluid accumulation in the abdominal cavity; CT: Old tuberculosis in upper lobes of both lungs, peritoneal effusion. Multiple ascites examinations showed no tumor cells. Oral administration of furosemide was ineffective. Abdominal distension gradually worsens, urine output decreases, and 3 000 ml of ascites need to be discharged every other day. The patient's spirit has been acceptable since the onset of the disease. In the past 2 months, if ascites is not drained, the body weight will gain 1 kg every day. Previous history: He underwent surgical treatment for tuberculosis of left knee 50 years ago, and was treated with antituberculosis for 1 year after surgery. Has a history of hypertension for more than 10 years and is not well controlled. Hypothyroidism was found in June 2011 and was replaced with thyroxine. History of marriage and childbirth: The daughter was diagnosed with thalassemia (heterozygous), and the husband died of "cirrhosis" (details unknown). Physical examination: vital signs stable, anemic appearance, hemangioma visible on the skin of the trunk. Several swollen lymph nodes can be accessed under the bilateral axillary, with tough texture and no tenderness, and a diameter of about 1.5 to 2.0 cm. There was no distension in the jugular vein, the heart boundary was not large, and grade II soft blowing-like murmur could be heard in the precordial area. No abnormalities were found in the physical examination of both lungs. Abdominal distension, abdominal circumference 89 cm, no abdominal wall varices. There is no tenderness or rebound pain in the whole abdomen. High abdominal wall tension. The liver was 6 cm below the costs, tough in texture, uneven in surface, with nodular sensation, untouched spleen, mild percussion pain in the liver area, positive mobile voicing, and depressed edema in both lower limbs.

Colorectal cancer (CRC) is the third largest tumor in incidence worldwide after lung cancer and breast cancer. According to the Global Cancer Epidemiological Statistics (GLOBOCAN), about 600,000 people die from CRC worldwide every year^[1], making it the fourth most fatal tumor in the world. Although the incidence of CRC in China was far lower than that in western developed countries in the past, in the past 40 years, with the rapid development of economy, the change of national living habits and dietary structure and the acceleration of aging process, the incidence and mortality of CRC in China have shown an obvious upward trend. CRC has become one of the major malignant tumors that endanger the health of our residents, which brings a heavy burden to the social economy and medical undertakings. Colorectal cancers are mostly sporadic, and 70% ~90% of colorectal cancers are related to diet factors. A large number of immigrant epidemiological and etiological studies suggest that the difference in the incidence of colorectal cancer between East and West is mainly due to dietary nutritional factors. Therefore, optimal diet will be beneficial to prevent and treat most colorectal cancers.

Glucocorticoids are steroid hormones secreted by the adrenal cortex under the control of the hypothalamus-pituitary-adrenal axis (HPA). Endogenous glucocorticoids have a certain circadian rhythm, and play a very important role in physiological and pathological states such as body development, immune response, endocrine metabolism, inflammatory response, etc. Because hormones have strong anti-inflammatory activity and immunomodulatory effects, they are commonly used in clinical practice to treat inflammatory diseases, such as bronchial asthma (asthma for short), ulcerative colitis, and various skin diseases; Because hormones also have certain pro-apoptotic properties, they are also mostly used to treat hematological tumors such as Hodgkin's lymphoma, human acute lymphocytic leukemia (ALL), multiple myeloma and other neoplastic diseases and autoimmune diseases.

A 40-year-old male was admitted to hospital for "repeated coughing and expectoration for more than 20 years and dyspnea after activity for more than 2 years". More than 20 years ago, the patient coughed repeatedly without obvious trigger, and had a large amount of yellow thick phlegm, occasionally bloodshot, accompanied by left chest pain. Repeated visits to the local hospital showed left pleural effusion. At that time, the pulmonary artery systolic pressure was about 35 mmHg (1 mmHg =0.133 kPa) by ultrasound, and the diagnosis was "tuberculosis and tuberculous pleurisy". Diagnostic treatments such as streptomycin, isoniazid, rifampicin and ethambutol were given successively, but the effect was not good. Subsequently, the patient's cough, expectoration symptoms and left pleural effusion appeared repeatedly, and the anti-tuberculosis regimen was adjusted many times without obvious efficacy. Two years before admission, the patient began to show decreased activity tolerance, edema of both lower limbs and gradually aggravated, and pleural effusion was also more serious than before. Echocardiography revealed severe pulmonary hypertension. Chest CT showed scattered fibrous cord shadows, patch shadows and small nodules in the left lung. The bronchial wall of the left lung was thickened and the lumen was slightly enlarged. Pleural effusion: albumin 26.8 g/L, nucleated cells 450×10⁶/L, mucin assay (–), glucose 6.35 mmol/L, sodium 141.9 mmol/L, chloride 111.1 mmol/L, lactate dehydrogenase 38 U/L; Exfoliative cytology showed more proliferative mesothelial cells and a small number of lymphocytes. Left pleural biopsy showed fibrous tissue proliferation with a small amount of proliferating mesothelial cells. Erythrocyte sedimentation rate, serum C-reactive protein normal, tuberculosis antibody (–). Still considering "tuberculous pleurisy", it was adjusted to D1321ThOK regimen to continue anti-tuberculosis for 1 month. The patient still had repeated left chest pain and pleural effusion, and came to our hospital again in June 2013; Echocardiography showed enlarged right heart, smooth left atrial apex, and only right pulmonary venous return was detected; Cardiovascular multi-slice spiral CT pulmonary angiography (Figure 1) shows stenosis of the left pulmonary artery trunk and its branches, and compensatory thickening of the right pulmonary artery trunk and the right inferior pulmonary artery; The left pulmonary vein is slender (left superior pulmonary vein main trunk about 2 mm, left inferior pulmonary vein main trunk about 1 mm); Both merge into atresia at the left atrium; The right pulmonary vein was thickened, with a maximum diameter of 23 mm ×28 mm. Final diagnosis: congenital heart disease (left pulmonary vein atresia). The patient refused pneumonectomy and requested discharge. After more than half a year of follow-up, the patient still had repeated left pleural effusion. At present, pleural effusion is palliatively drained in local hospitals regularly and followed up closely.

The child was a 7-year-old male. He was admitted to hospital on 20 November 2013 due to recurrent abdominal pain for 2 months and aggravation for half a month. Abdominal pain is mainly in the middle and upper abdomen, unbearable, refusing to press, abdominal pain can be alleviated when curled up, abdominal pain is aggravated when lying flat, accompanied by nausea and vomiting, vomit is the stomach content, and abdominal pain is slightly relieved after vomiting, accompanied by abdominal distension. The hospital diagnosed "acute necrotizing pancreatitis", given fasting, acid suppression, somatostatin, anti-infection, placement of nasojejunal tube for enteral nutrition and other treatments, and found pseudocyst formation, the child still had recurrent abdominal pain, for endoscopic retrograde cholangiopancreatography (ERCP) admitted to the gastroenterology ward of our hospital. Physical examination: No yellowing stain on the skin. Flat and soft abdomen, positive epigastric tenderness (+), negative rebound pain (–), muscle tension (–), presence of liver voiced area, and mobile voiced sound (–). After admission, they were treated with fasting, anti-infection, acid suppression, somatostatin, and fluid rehydration support. On November 21, they underwent ERCP + papillary sphincterotomy (EST) + endoscopic biliary drainage (ERBD) + nipple dilation. Small stones were seen in the lower part of the common bile duct on angiography. Small stones and bile flowed out were seen by nipple incision 0.2 cm. One 5Fr was placed^*4 cm bile duct stent, was transferred to the pediatric ward on November 25 for continued treatment, and was diagnosed as: acute necrotizing pancreatitis (severe); Pseudocyst of pancreas; choledocholithiasis; Acute cholangitis. On the same day, a nasojejunal tube was placed in the descending part of the duodenum under the guidance of a gastroscope, and enteral nutrition such as formula milk was performed, gradually increasing the amount, and intermittent injection was used for about 15 minutes each time, with an interval of 3 hours. The child experienced abdominal pain again at noon on November 30th, which was considered to be an enlarged pancreatic pseudocyst (about 10 cm in diameter measured by ultrasound). He was treated with fasting and anti-infection again. On December 2nd, he underwent drainage of pancreatic pseudocyst under B-ultrasound localization. Enteral nutrition started on December 3rd, and gradually transitioned to oral liquid diet. On December 17th, a small amount of chyloid substance was drained from the drainage tube of the child, which was considered to be chyloid leakage. On December 21st, the child's enteral nutrition and oral dietary calories could meet the physiological needs, urinary amylase dropped to normal, and there was no abdominal pain, so he was discharged with a drainage tube.

A 16-year-old male was seen in the Department of Stomatology, School of Stomatology, Lanzhou University, mainly due to pain in the right mandible and teeth for more than 2 weeks and poor chewing ability of teeth. The patient is 1.58 m tall and weighs 46 kg. The parents deny the marriage of close relatives. The patient has a full-term natural delivery, and his life and study are not restricted. The patient had a large head and a small face, the width of the acromion was 31 cm, the width of the medial canthus was 4.5 cm, the width of the fontanel was 2 cm, both shoulders were drooped, and the range of motion of the shoulder joint was increased. In the mouth, except for the lower occlusal central incisor and four upper and lower first molars, all the rest are deciduous teeth. X-ray examination showed that the frontal bone was square and round, the skull was obviously enlarged and unbalanced, and the head was large and the face was small (FIGS. 1A, B)。 The transverse diameter of the skull is enlarged, the bottom is relatively narrow, the fontanel is large but not closed, the cranial sutures are widened and separated, and the intersutural bone can be seen. The thoracic collapse was bell-shaped, and the ribs were thinned and walked abnormally. The distance between the clavicle and the acromion and sternum was widened, the scapula was high, the coracoid process and acromion of the bilateral scapula were dysplasia, the scapular glenoid became smaller and shallower, and the articular surface was hardened. Abnormal proportion of proximal phalanges to middle and distal phalanges in both hands (Figure 1C)。 The proportion of metatarsal, proximal phalanges and middle distal phalanges of both feet was abnormal, and the development of the first distal phalanges of both feet was small (Figure 1D)。 Curved tomography shows multiple embedded supernumerary teeth in the upper and lower premolar regions (Figure 1E)。 The size and morphology of the bilateral clavicle were abnormal, the right clavicle was short in development, and the middle part of the bone of the left clavicle was discontinuous, showing two primary ossification centers (Figure 1F)。 Chromosomal examination showed no abnormalities. Peripheral blood genomic DNA of patients and parents was extracted, and the exon of osteoblast transcription factor (RUNX) 2 gene was sequenced. Two missense mutation sites were found in Exon3 and Exon4 of RUNX2 gene of patients and parents (Table 1), c.432G>A and c.778C>T, respectively, and no mutation sites were seen in the remaining exons. c.432 G>A is a synonymous mutation found in the patient's mother and therefore is not a pathogenic mutation. While the Denovo mutation site c.778C>T present in the patient (Figure 2) is a pathogenic mutation that causes the arginine at position 190 of the RUNX2 protein to mutate to tryptophan.

A male patient suffered from sudden severe pain in lower abdomen and testis in August 2009, and was intermittently treated with cefuroxime lipid, tinidazole, azithromycin and levofloxacin for 81 days. After drug withdrawal, coagulase-negative staphylococci were generally cultured in semen; Anaerobic and L-type culture of viscoactinomycetes. Since there is no American Institute of Clinical and Laboratory Standards (CLSI) standard for Actinomyces viscosus, only the antimicrobials with large inhibition zones are listed here,>26 mm are: cefepime, amoxicillin, imipenem, doxycycline, minocycline, tetracycline, vancomycin, teicoplanin, tigecycline. On the 20th day of intravenous injection with amoxicillin, there was severe pain. After 2 weeks of switching to doxycycline, the symptoms improved. On the 7th day of changing cefepime, I felt severe pain again. Actinomycetes viscosus and Enterococcus faecium (associated bacteria) were cultured from semen. With vancomycin, amoxicillin/clavulanate potassium intravenously for 1 month, the pain was somewhat relieved, but it worsened after 2 days of stopping the drug. L-type viscoactinomycetes were cultured in urine (slow growth, 9 days), and viscoactinomycetes were grown in prostate fluid enrichment culture for 4 days. Those with inhibition zone>30 mm were minocycline, tetracycline, spectinomycin, amikacin and netilmicin; Rifampicin 42 mm. The patient went to Peking University First Hospital for treatment in June 2010. Since the susceptibility test for L-type bacteria is completed after restoration of the bacterial cell wall, drugs that do not act on the cell wall should be selected. After using rifampicin and minocycline for 5 days, the stinging pain in the urethra disappeared. Multiple reexaminations of urine routine were negative, and no viscoactinomycetes were detected in urine culture. On 22 Jul 2010, there were still L-type myxoactinomycetes in prostatic fluid culture, with rifampicin plus tetracycline. On September 8, 2010, semen culture showed no bacterial growth in L-type, and Actinomyces viscosus was cultured anaerobically. He continued to take tetracycline plus rifampicin. After that, according to the pain perception of the patient, it was estimated that rifampicin was resistant. On March 8, 2011, semen culture, L-type bacteria cultivated Actinomycetes myxosus, and the associated bacteria were Streptococcus hemolyticus. Change minocycline, tetracycline, doxycycline wheel medication. Once netilmicin was used, the patient's symptoms improved significantly, and his semen changed from yellow to white. Due to adverse reactions, it was changed to gatifloxacin or minocycline. In September 2010, MRI showed that the prostate was enlarged by 4.2 cm ×3.1 cm ×3.0 cm, the signal of the right side of the prostate was abnormal, the bladder wall was uniformly thickened, and the morphology and signal of the seminal vesicles, testes and epididymis on both sides were not abnormal. April 2011 re-examination of enlarged prostate volume , 4.5 cm ×3.8 cm ×3.5 cm. Partial prostate resection was performed in April 2011. Under the pathological microscope, broken prostate tissue, interstitial hyperplasia and focal glandular infarction were seen. After that, gatifloxacin or minocycline was taken once every 7 days. There was still viscoactinomycetes growth in semen bacterial culture in April 2012. After taking the medicine, the patient occasionally drank alcohol, and felt that the effect of the medicine was enhanced. After this combination, the lower abdominal pain and testicular pain gradually disappeared. Until March 2013, the semen bacterial culture was negative.