2023年 · 第61卷第05期

Osteolithiasis, also known as marble bone disease, chalk bone, congenital osteosclerosis, etc., is a genetic disease caused by increased bone mass due to osteoclast formation and functional defects. It has the characteristics of increased bone density and skeletal deformities^［1］。 Osteolithiasis is very rare, with a prevalence of approximately 1:500,000 in the North American population^［2］While no clear prevalence has been reported in China^［3］。 Osteolithiasis is often associated with fracture and osteoarthritis^［4］, hip replacement is currently recommended for patients with lithiasis with hip fracture or hip osteoarthritis to avoid the occurrence of poor fracture healing, secondary osteoarthritis, or femoral head necrosis^{［2，5, 6, 7］}, there has been limited surgical experience with this disease to date. Compared with healthy people, patients with osteolithiasis have the characteristics of high bone hardness, high fragility, and medullary cavity stenosis and occlusion. Therefore, hip arthroplasty for osteolithiasis is more challenging, and complications such as periprosthetic fracture, loosening of prosthesis and periprosthetic infection are prone to occur during and after operation^［8］Eventually, artificial hip revision is required.

The patient was a 60-year-old female. He was admitted to Cancer Hospital of Chinese Academy of Medical Sciences on May 12, 2022 due to "discovery of liver space-occupying lesions for 2 months". The patient was found to have liver occupying space during physical examination 2 months ago without conscious discomfort. He went to a local hospital for treatment. The results of abdominal enhanced CT examination showed that he had liver occupying space lesions, but cholangiocarcinoma was not excluded. Past history: 20 years history of hypertension, oral irbesartan, well controlled blood pressure. Hepatitis B history for 15 years, regular antiviral therapy. Family history: father died of cardia cancer. Preoperative laboratory tests: hemoglobin 146 g/L, platelet count 270×10⁹/L, ALT 21 U/L, AST 22 U/L, albumin 40.9 g/L, total bilirubin 10.1 μ mol/L, creatinine 58 μ mol/L, hepatitis B surface antigen positive, HBV DNA<100 cps/ml, alpha-fetoprotein 4.32 μ g/L, CA19-9 12 U/ml, carcinoembryonic antigen 8 U/ml, Child-Pugh grade A. The 15-min retention rate of indocyanine green (ICG) was 3.9% 5 days before surgery. The results of abdominal enhanced MRI suggested that the right posterior region of the liver occupied mass, which was considered as a malignant tumor (Figure 1). The results of gastroscopy suggested superficial gastritis; Colonoscopy showed no obvious abnormalities. The initial diagnosis was a space-occupying lesion of the liver. Because the preoperative imaging examination considered liver malignancy and family history of cardia cancer, laparoscopic anatomical right posterior zone resection of the liver was proposed for better oncological outcome.

A 55-year-old male was admitted to the hospital on March 30, 2022 due to "dull pain in the upper abdomen for 1 month, and the liver was found to occupy space for more than half a month". One month before admission, the patient had persistent dull pain in the upper abdomen without obvious trigger, no fever, nausea, vomiting, diarrhea, yellowing of the skin and sclera, etc. The examination results in the local hospital showed "liver occupying space, cirrhosis, splenomegaly". The abdominal CT examination results in our hospital showed multiple space-occupying lesions in the liver, and liver cancer was considered. Diagnosed with "chronic hepatitis B" for more than 10 years, and began taking entecavir orally half a month ago. The patient was mentally acceptable at admission, with a Karnofsky functional status score of 100, a US Eastern Cancer Collaborative score of 0, and a body mass index of 25.3 kg/m²。 Physical examination: There was no yellowing stain in the skin and sclera of the whole body; Flat abdomen, no abdominal varicose veins, no tenderness and rebound pain, no palpable mass; The liver and spleen were not palpable under the costs, there were no moving voiced sounds, and intestinal sounds were 4 times/min. Admission to improve laboratory tests: hepatitis B surface antigen (+), e antibody (+), core antibody (+); Hepatitis B virus DNA quantification 2.13×10⁴U/ml, alpha-fetoprotein 1 869 μ g/L, abnormal prothrombin 24 521 mAU/ml; There were no abnormalities in hematuria stool routine, liver and kidney function, coagulation function, thyroid function and myocardial enzyme spectrum. MRI of hepatobiliary pancreas showed: 121 mm ×121 mm ×146 mm size T1WI mild mixed signal and T2WI mixed high signal shadow were seen in the left and right junction area of the liver, and some lesions were fused, which was considered malignant, and hepatocellular carcinoma was more likely; Abnormal lymph node shadows with a maximum short diameter of 16 mm were seen in the hilar area, and lymph node metastasis was considered (Figure 1); The standard liver volume for software analysis was 1 316 ml, the estimated residual liver volume after radical surgery was 879.5 ml, and the proportion of residual liver after primary resection was 66%. PET-CT showed: multiple low-density foci in the liver, and metabolism was significantly increased, considering hepatocellular carcinoma; Abnormal lymph node shadows were seen in the liver-stomach space and hepatic hilum, and the maximum standard uptake value was 2.6. Metastasis was considered. Preoperative diagnosis: primary hepatocellular carcinoma with lymph node metastasis [China liver cancer staging (CNLC)] -stage IIIB; Chronic hepatitis B; Liver cirrhosis, splenomegaly; Liver function Child-Pugh Class A.

The patient, a 45-year-old male, was admitted to the hospital on 07-Jul-2021 due to "pain in the right upper abdomen for 18 h". The patient had right upper abdominal pain without obvious trigger, which was persistent tingling, accompanied by nausea, no vomiting, accompanied by sweating and dizziness, melena relieved twice, no red after flushing, no fear of cold and fever, chest tightness, acid reflux and heartburn, hematemesis, hematochezia and other discomfort. He took Huoxiang Zhengqi liquid orally for treatment, but the abdominal pain did not improve significantly. He improved abdominal CT and other related examinations in the local hospital, and considered "liver cancer rupture", so he went to our hospital. Has a history of hepatitis B "small three yangs" for more than 20 years. Physical examination: There was no obvious yellowing stain in the skin and sclera of the whole body, flat and soft abdomen, tenderness and rebound pain in the right upper abdomen, no muscle tension, negative mobile voicing, and weakened intestinal sounds. Emergency total abdominal CT enhanced scan showed (Figure 1): a mass in the right lobe of the liver, about 10.3 cm ×9.6 cm ×9.0 cm in size. The plain scan was mainly low-density, with a higher-density shadow. The enhanced scan showed obvious necrosis of the mass, and more thickened arterial blood supply was seen in the arterial phase, and no contrast medium was leaked. Considering the possibility of malignant neoplastic lesions combined with rupture and bleeding, liver cancer was likely; A low-density nodule with a maximum diameter of about 1.4 cm was seen at the edge of the seven segments of the liver, with uneven and obvious enhancement in the arterial phase, and decreased enhancement in the portal vein phase. Multiple low-density nodules were also seen in the liver, which was considered metastatic tumor or liver cancer sub-focus. The nodules in the left outer lobe, left inner lobe and caudate lobe of the liver are discontinuous adjacent to the liver capsule, and there is more fluid and blood accumulation in the abdominopelvic cavity and omental sac, and the liver is ruptured to be drained. Emergency laboratory tests: ALT 236 U/L, AST 892 U/L, creatinine 193.7 μ mol/L, estimated glomerular filtration rate 49.7 ml/min 1.73 m²), hepatitis B surface antigen (+), e antibody (+), core antibody (+). No tumor markers were detected in the emergency department. Admission diagnosis: liver cancer (Chinese liver cancer stage-Ⅱb), complicated with rupture and hemorrhage; intrahepatic metastases; Hepatitis B small triple yang; Acute hepatic insufficiency; Acute renal insufficiency.

Professor Tu Tongjin, a veteran of the Red Army, founding major general and former president of the Academy of Military Medical Sciences, died in Beijing on the evening of April 3, 2023 at the age of 109 due to ineffective medical treatment.