2021年 · 第59卷第08期

The patient, a 44-year-old female, was admitted to hospital on July 23, 2020 mainly because of "conscious right breast mass for 11 years, rapid increase for more than 2 years, and ulcer for 1 month". Eleven years ago, the patient found a tumor in the upper quadrant of the right breast due to self-examination, and went to a local hospital. Ultrasound examination showed that the maximum diameter was about 2 cm. Pathological examination of the tumor puncture showed breast fibroadenoma, but the patient was not treated. In the past 2 years, the tumor has gradually increased compared with before, but there are no symptoms such as breast pain, nipple hemorrhage and discharge, and no diagnosis and treatment have been given. One month ago, the tumor increased rapidly with ulceration and bleeding. Due to hemorrhagic anemia, the ulceration, bleeding and anemia were controlled after symptomatic treatment such as blood transfusion and albumin transfusion in other hospitals. The patient came to our hospital for further treatment. The patient has a history of hypertension for more than 10 years and can be controlled by drugs. He has a history of polycystic liver complicated with polycystic kidney disease for 20 years, without relevant treatment, and his liver and kidney function is still normal. Left lobectomy was performed more than 20 years ago, and the postoperative pathological findings were unknown. Physical examination showed a huge mass in the right breast, and a secondary mass protruding outward in the outer lower quadrant, with a maximum diameter of about 40 cm. The skin of the right breast was ulcerated, red and swollen, with persistent slow bleeding around the tumor, no orange peel sign, no dimple sign, and no obvious tumor in the left breast. No clearly enlarged lymph nodes were palpable in bilateral axillary and clavicular bones (Figure 1）。 After admission, the relevant examinations were completed. The image of breast ultrasound showed that the right breast had mixed echoes occupying the space, and the volume was large and could not be measured. Multiple punctate strong echoes could be seen in it, and the blood flow signal was abundant. The results of chest CT examination showed a huge mass in the right anterior chest wall with uneven density, partially beyond the scanned area. The CT value was-10~25 HU, irregular in shape, unclear in boundary with the soft tissue of the chest wall, and no clear bone destruction was observed. The enhanced scan showed uneven enhancement, no enhancement in the low density area, and mild enhancement in the solid area. Considered as a malignant tumor, sarcoma may? There were no clear metastases in both lungs, and right pleural effusion (Figure 2）。 The pathological examination of thick needle puncture was performed, and it was considered to be a fibroepithelial tumor of the breast. The possibility of phylloid tumor was high, and the representation of puncture tissue was limited. Whether there were borderline or malignant components needed to be further clarified after complete resection. Whole body bone scan showed no tumor metastasis, gynecological ultrasound showed left ovarian cystic space occupying, uterine fibroids, abdominal ultrasound showed polycystic liver, polycystic kidney, splenomegaly, abdominopelvic effusion. CT examination of the head showed no definite metastasis. The preoperative diagnosis is considered as breast phyllodes tumor with tumor surface ulceration and bleeding, complicated with infection, anemia, hypertension, polycystic liver, polycystic kidney, hypoalbuminemia, electrolyte disorder, etc. After multi-disciplinary consultation and discussion in our hospital, after daily wound dressing change, anti-infection, correction of anemia, hypoalbuminemia and other symptomatic support, the right breast mass resection was performed on August 13, 2020.

The patient, a 29-year-old female, was admitted to the Department of General Surgery of our hospital on July 29, 2020 due to "physical examination found right goiter tumor for more than 1 month". A 2.3 mm ×4.6 mm hypoechoic nodule in the right thyroid gland with irregular shape, unclear boundary and aspect ratio greater than 1 was revealed on neck ultrasound during the patient's physical examination 1 month before admission; TI-RADS Class 4b. The patient usually has no neck pain, tenderness, skin redness, swelling and ulceration, no fear of heat, excessive sweating, no difficulty in speaking, hoarseness, and no discomfort such as choking and coughing after drinking water. Fine needle aspiration cytology of thyroid in other hospital showed that abnormal cells were visible, which tended to papillary thyroid carcinoma. There was no previous history of neck surgery or radiotherapy. Familial genetic history and familial tumor history were denied. After admission, the relevant examinations were completed, thyroid stimulating hormone 1.640 mU/L, free thyroxine 16.77 pmol/L, free triiodothyronine 3.94 pmol/L, thyroglobulin 2.65 μ g/L, thyroglobulin antibody 526.60 U/ml, thyroid peroxidase antibody 49.75 U/ml, thyrotropin receptor antibody 0.603 U/L, and whole segment parathyroid hormone 52.2 ng/L. The results of neck CT examination showed: low-density small nodule shadow in the right thyroid lobe, blurred edge, and obviously enhanced by enhanced scan; The right lobe of the thyroid gland is scattered with multiple speckled very low density shadows, which are considered gas; There is no abnormality. Preoperative diagnosis: right goiter tumor, possible thyroid cancer. The patient had the willingness to implant his chin. After full communication with the chief surgeon, the plastic surgeon consulted and evaluated the surgical indications. The patient's facial lower vestibule was short and had the surgical indications.

PatientMale, 65 years old, was seen on February 4, 2020 mainly due to "intermittent chest tightness and shortness of breath for more than 10 years, aggravated by 1 week". More than 10 years ago, the patient began to intermittently experience chest tightness and shortness of breath after activity, and fullness and discomfort after eating. Five years ago, the physical examination of chest CT found "right diaphragmatic hernia" without any treatment; One week ago, the above symptoms worsened, so I went to our hospital for treatment. The patient had no prior history of trauma. Physical examination: the thorax is symmetrical, the respiratory mobility of the right lung is obviously weakened, the drum sound can be heard, the lung boundary is unclear, the respiratory sound of the right lung disappears, no dry and wet rales are heard, and intestinal sounds can be heard; No obvious abnormalities were observed in the left lung; The abdomen was flat and soft, without tenderness and rebound pain, without palpable mass, without palpable under the costal margin of the liver, with drum sound during abdominal percussion, negative mobile voiced sound, and no intestinal sound. CT examination of the thorax and abdomen showed right atelectasis, partial defect of the right diaphragm, and most of the small intestine and mesenteric hernia into the thoracic cavity (FIG. 1A，1B), left and right hemihepatic separation (Figure 1C）。 Diagnosis: Right congenital diaphragmatic hernia, right atelectasis, incomplete intestinal obstruction, congenital liver dysplasia.