2022年 · 第60卷第02期

The patient, a 52-year-old male, was admitted to the hospital on 19-Nov-2020 due to "upper abdominal discomfort for more than 3 weeks". The patient experienced upper abdominal discomfort without obvious trigger, no fever, jaundice, nausea and vomiting, and no diarrhea and blood in the stool more than 3 weeks ago. On November 12, 2020, the results of CT examination of abdomen in a foreign hospital showed that large patches or cord-like low-density shadows in the liver may occupy space, combined with intrahepatic bile duct dilatation; The results of abdominal dynamic enhanced MRI showed that: (1) massive abnormal signal shadow in the right lobe of the liver, with irregular cord-like segmentation-like enhancement after enhancement, and low signal filling defect in the right branch of the portal vein, which was considered as massive liver cancer with portal vein tumor thrombus (PVTT); (2) Liver cirrhosis; (3) Splenomegaly. Deny the history of hypertension, diabetes, hepatitis, tuberculosis, etc., and deny the history of drug and food allergies; The smoking history was 30 years, with an average of 20 cigarettes/d; The drinking history was 30 years, and the average liquor was 350 ml/time, 3 times a day. There was no family history of similar hepatitis or liver cancer. Admission physical examination: General vital signs were stable, Eastern Cooperative Oncology Group Performance Status (ECOG-PS) 0, soft abdomen, no tenderness and rebound pain, 2 cm under the costs of the liver, unpalpable spleen, no yellowing staining of the skin and sclera, and no edema of both lower limbs. Laboratory tests: alpha-fetoprotein (AFP)>1 210 μ g/L, total bilirubin 16.9 μ mol/L, direct bilirubin 8.1 μ mol/L, total protein 72.0 g/L, albumin 39.4 g/L, ALT 47 U/L, AST 45 U/L, prothrombin time 12.1 s, international normalized ratio 1.01, hepatitis B surface antigen 6 535 U/ml, hepatitis B E antigen 4.10 COI, hepatitis B E antibody 0.699 COI, hepatitis B core antibody 0.008 COI, hepatitis B virus quantification 2.36×10³U/ml. Upper abdominal plain scan + multiphase enhanced CT was reviewed after admission (Figures 1 and 2). The results showed: (1) a mass in the right lobe of the liver with a maximum cross section of 135 mm ×104 mm, which was considered as hepatocellular carcinoma; (2) Embolus formation in the main trunk and right branch of the portal vein; (3) Liver cirrhosis and splenomegaly. Diagnosis: (1) Hepatocellular carcinoma with PVTT type III (cT3N0M0), Barcelona stage C, Chinese liver cancer stage IIIA, and liver function Child-Pugh grade A (5 points); (2) Chronic hepatitis B; (3) Liver cirrhosis (compensatory stage); (4) Splenomegaly.

The patient, a 38-year-old female, was admitted to our hospital on December 2, 2020 due to "upper abdominal pain for 2 weeks". In November 2020, the patient experienced intermittent epigastric pain, accompanied by nausea and vomiting, and gradually appeared yellowing of the skin and sclera, but there was no special discomfort. An enhanced CT examination was performed in an external hospital, and the results showed abnormal enhanced shadow near the hilum of the left inner lobe of the liver, which was considered as tumor, gallbladder stones and bile duct stones. Hepatitis B was diagnosed for 2 weeks and treated with propofol and tenofovir; Yu Nothing Special. There were no obvious positive signs in physical examination, and the general condition was good. The results of liver function tests showed that total bilirubin was 586.7 μ mol/L, alpha-fetoprotein was 5,884 μ g/L, and CA19-9 was 2,205 U/ml. The ultrasound results showed that the hilar bile duct was weakly echoic, considering carcinoma, accompanied by intrahepatic bile duct dilation, gallbladder mud formation, liver cirrhosis, and splenomegaly. Contrast-enhanced ultrasound showed abnormal perfusion of the left inner lobe of the liver, considering the possibility of intrahepatic cholangiocarcinoma, accompanied by tumor thrombosis at the distal end of the left hepatic duct; The hilar bile duct, right hepatic duct, and the proximal end of the left hepatic duct did not see contrast entering, so bile mud was considered. MRI enhanced scan of upper abdomen showed that: (1) the left and right hepatic ducts, common hepatic ducts, and the lower segment of the common bile duct were filled with defects, mild enhancement, and the lower wall of the common bile duct was obviously enhanced, considering cholangiocarcinoma, and intrahepatic and extrahepatic bile duct dilatation; (2) Liver cirrhosis, splenomegaly and portal hypertension; Cholecystitis, gallstones with fluid accumulation around the gallbladder. The results of magnetic resonance water imaging were considered as high cholangiocarcinoma (Figure 1). CT angiography showed: (1) abnormal enhanced nodules in the proximal segment of common hepatic duct-left hepatic duct, dilatation of intrahepatic bile duct and common bile duct, drainage state of hilar bile duct, and abnormal enhanced nodules in the running area of bile duct in the medial segment of left lobe of liver, considering the possibility of cholangiocarcinoma; The small branch of the left hepatic artery runs in the lesion area; The proximal left branch of the portal vein is adjacent to the lesion; (2) The common bile duct is dilated and the adjacent right hepatic artery is compressed; (3) Liver cirrhosis, splenomegaly and portal hypertension; Thickening of the gallbladder wall.

The patient, a 64-year-old male, was seen in Zhejiang Provincial People's Hospital on March 16, 2020 due to "choking after eating for half a year". Six months ago, the patient had no obvious trigger to suffocate from eating infarction, eating solid food obviously, and had no symptoms of vomiting and gastrointestinal bleeding. During this period, the symptoms were repeated, and the choking symptoms were slightly worse than before. Previous history of type 2 diabetes for 18 years, insulin subcutaneous injection to control blood glucose; There was no history of abdominal surgery, no history of smoking or drinking. Physical examination: soft abdomen, deep tenderness in the upper abdomen, no rebound pain, no abdominal mass, mobile voiced sound (-), and no percussion pain in both kidney areas. Laboratory test: hemoglobin 140 g/L, white blood cell count 9.45×10⁹/L, gastrin 132 ng/L; Tumor markers: carcinoembryonic antigen, CA19-9, CA125 and CA72-4 were not abnormal. Gastroscopy revealed a bulging lesion 40 cm from the incisors, circular wall for 3/4 weeks, involving the cardia and fundus mucosa (Figure 1). The results of biopsy pathology showed that esophageal-cardia malignancy may be of mesenchymal tissue or epithelial tissue origin, and extensive tissue necrosis can be seen (Figure 2). The results of PET-CT examination showed that the local wall of the lower thoracic segment of the esophagus was annularly thickened, the maximum diameter of the lesion was 5.7 cm, involving the cardia, and the maximum uptake value was 29.3; Enlarged lymph node shadows can be seen below the gastric cardia (Figure 3). The results of enhanced abdominal CT scan showed that the lower esophagus and the gastric wall of cardia were thickened, and the enhanced scan showed enhancement; Perigastric lymph nodes were enlarged (Figure 4).