2022年 · 第60卷第01期

PatientMale, 69 years old, was admitted to our hospital on October 28, 2020 due to "repeated right upper abdominal pain for more than 3 months and aggravated for 5 days". The patient developed moderate pain in the right upper abdomen without obvious trigger 3 months ago, which was persistent, without fever, nausea and vomiting. Ultrasound examination in other hospitals showed that the right posterior lobe of the liver was solid and occupied, and liver cancer was possible; CT findings indicated that the right lobe of the liver occupied a huge space, which was considered as massive liver cancer. In the past 5 days, the patient felt aggravated pain in the right upper abdomen, but it was still tolerable. He denied a history of chronic diseases such as hypertension, diabetes, and coronary heart disease, a history of infectious diseases such as hepatitis and tuberculosis, a history of drug and food allergies, a history of smoking and drinking for more than 50 years, and his weight has not changed significantly recently. Admission physical examination: the abdomen was flat and soft, the liver and spleen were not touched, and the liver area was mild percussion pain. Alpha-fetoprotein 586.5 μ g/L, carcinoembryonic antigen 4.6 μ g/L, CA19-9 56.2 U/ml, ALT 69 U/L, AST 189 U/L, bilirubin normal. Hepatitis B surface antigen and hepatitis C antibody were negative. The results of abdominal enhanced CT scan in our hospital showed a huge mass in the right lobe of the liver, about 13.4 cm ×11.8 cm in size, which was considered as hepatocellular carcinoma; The right branch of the portal vein is squeezed by the tumor, and the lumen is slender; It is possible that the tumor invades the middle hepatic vein, and the tumor invades the right hepatic vein and the retrohepatic inferior vena cava tumor thrombus. The left hemihepatic volume was 499 cm³The patient's standard liver volume was 1 214 cm³； The results of gadoxetate disodium enhanced MRI of the upper abdomen showed that the right lobe of the liver occupied space, with a size of about 12.3 cm ×11.0 cm, which was considered to be a massive liver cancer with invasion of the right hepatic vein, tumor thrombus of the retrohepatic inferior vena cava, and invasion of the right adrenal gland (Figure 1）。 Clinical diagnosis: (1) Giant liver cancer of the right lobe of the liver with invasion of the right hepatic vein and right adrenal gland; (2) Inferior vena cava tumor thrombus.

PatientMale, 47 years old, was admitted to the First Medical Center of the People's Liberation Army General Hospital on June 15, 2018 due to "epigastric pain for more than 1 month and aggravated for 11 days". The patient was diagnosed with hepatitis B more than 30 years ago and took adefovir dipivoxil (10 mg/tablet, 1 tablet/d) orally for a long time. One month ago, the patient developed epigastric pain, which was intermittent and could be relieved by itself, but worsened after meals. There was no obvious relief after taking oral gastroprotective drugs (specificity unknown) by itself, and no further treatment was made. The patient felt that the upper abdominal pain was aggravated after waking up in the morning 11 days ago, and went to the local hospital. The ultrasound results showed strong echoic nodules in the right lobe of the liver, about 11 cm ×10 cm in size. Alpha-fetoprotein>24 200 μ g/L in this outpatient visit; Hepatobiliary and pancreatic enhanced MRI findings (Figure 1) Suggestions: (1) Multiple blood supply occupies the right lobe of the liver, the size is about 12.5 cm ×10.5 cm, local bleeding may be considered as malignant, hepatocellular carcinoma may be; (2) Cyst in the left lobe of the liver. Admission physical examination: There was no yellowing stain on the skin and sclera of the whole body, flat and soft abdomen, no gastrointestinal pattern and peristaltic waves, no varicose veins in the abdominal wall, no obvious tenderness and rebound pain in the upper abdomen, no palpation of the liver and spleen under the costs, negative Murphy's sign, existence of liver turbidity, percussion pain in the liver area, no percussion pain in the kidney area, no moving turbidity in the abdomen, no abnormal vascular murmur, no sound of air passing through water, and normal intestinal sound. Perfect laboratory tests after admission: HBSA,HBE antigen and HBB core antibody were all positive, and HBV DNA quantification was 1.11×10⁴U/ml, AST 70.1 U/L, total protein 84.0 g/L, total bilirubin 26.1 μ mol/L, indocyanine green 15 min retention rate was 7%, blood routine, renal function, electrolyte, coagulation function, etc. were normal. Admission diagnosis: (1) primary liver cancer of the right lobe of the liver Barcelona Clinical Liver Cancer Stage A; (2) Chronic hepatitis B complicated with liver cirrhosis; (3) Liver function Child-Pugh grade A.

PatientFemale, 63 years old, was admitted to the First People's Hospital affiliated to Shanghai Jiao Tong University on March 23, 2020 due to "physical examination found that the pancreas occupied space for 1 week". The patient was found to occupy the neck and body of the pancreas during physical examination in another hospital 3 days ago. No obvious positive signs were found on admission physical examination. Nothing special in the past. The patient is clear, energetic, poor appetite, average sleep, no special defecation, and no obvious weight loss. Tumor markers: CA19-9 371.3 U/ml, CA125 48.7 U/ml, CA242 166.77 U/ml, CA50 95.81 U/ml, and carcinoembryonic antigen 8.86 μ g/L, all of which were higher than the upper limit of normal. The results of enhanced CT examination of the upper abdomen showed that a slightly lower density mass shadow was seen at the junction of the cervical body of the pancreas, with a size of 36 mm ×27 mm and uneven density. It was in close contact with the adjacent common hepatic artery, proximal splenic artery and portal vein, which was considered as a possible malignant tumor at the junction of the cervical body of the pancreas. The results of enhanced MRI of the upper abdomen showed that a soft tissue mass was seen in the neck and body of the pancreas, with a size of 39 mm ×31 mm. After enhancement, the margins were enhanced, which was considered as cancer of the neck and body of the pancreas, with involvement and stenosis of splenic blood vessels. Preliminary diagnosis: malignant neoplasm of the neck and body of the pancreas.

PatientMale, 56 years old, was admitted to hospital on January 2, 2021 due to "repeated chest tightness and shortness of breath for more than 4 months". The patient had chest tightness, dizziness and shortness of breath after activity 4 months ago, which could be relieved after rest, but was not diagnosed and treated. Two months ago, he had sudden left limb weakness, accompanied by unclear speech and skewed angle of mouth. CT examination of the head was performed in the emergency department of our hospital, which showed cerebral embolism. After treatment with antiplatelet and stable plaque, the symptoms of left limb weakness were relieved compared with before. Echocardiography showed severe stenosis of the aortic valve. The patient had no previous history of hypertension or diabetes, and denied any history of contact with livestock. Physical examination at admission: temperature 36.5 ℃, pulse 78 beats/min, breathing 16 beats/min, blood pressure 132/72 mmHg (1 mmHg =0.133 kPa). Grade 3/6 systolic jet-like murmur could be heard in the auscultation area of aortic valve, but no abnormality was found in the auscultation of remaining heart and lung. Admission laboratory tests: blood routine white blood cell count 8.45×10⁶/L, neutrophil count 5.17×10⁶/L. Enhanced CT scan of head + thoracic aorta + coronary artery showed aneurysm-like dilatation of ascending aorta, old cerebral embolism of right frontotemporal insula, and no abnormalities were found on coronary CT angiography. Echocardiography showed congenital heart disease, aortic bilobar malformation with severe stenosis and mild regurgitation.