2025年 · 第105卷第02期

The patient, a 27-year-old female, was admitted to the Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital on March 11, 2024 due to "intermittent cough and fever for 2 months". In the past 2 months, he has developed fever, accompanied by irritating cough, fatigue, night sweats, gradual swelling of neck lymph nodes, and weight loss of 5 kg. Past physical fitness. Laboratory tests showed high-sensitivity C-reactive protein of 191.14 mg/L and erythrocyte sedimentation rate of 96 mm/1 h; Tumor markers, angiotensin converting enzyme, tuberculosis T lymphocyte detection, autoantibody screening were all negative. Chest CT showed multiple asymmetric enlarged lymph nodes in the mediastinum and both pulmonary hilums (shown by arrows in Figure A), and the enhancement scan showed mild uniform enhancement (shown by arrows in Figure B). Positron emission computed tomography (PET-CT) indicated that many lymph nodes and many extranodal organs in the whole body were metabolically increased to varying degrees, and lymph node infiltration was possible. Under bronchoscopy, multiple white nodules were seen in the mucosa of the airway and left and right main bronchial openings (Figure C), partially fused into pieces, and the texture was tough. Bronchial mucosal biopsy of right upper lobe showed chronic inflammation of bronchial mucosa, focal mucosal erosion with granulation tissue formation, and special staining was negative. Endoscopic ultrasound lymph node biopsy showed pathological indication of atypical cell infiltration (shown by arrow in Figure D, hematoxylin-eosin staining ×40), immunohistochemistry: CD30 (+), CD15 (+), CD20 (-), CD3 (-), pairing box gene 5 (PAX5) (weak +), octamer-binding transcription factor 2 (OCT2) (+), B lymphocyte-specific activation of OCT-binding protein 1 (BOB.1) (-), consistent with Hodgkin's lymphoma (HL). Clinical HL diagnosis is clear. After 4 cycles of chemotherapy, the Deauville score was 4, and the symptoms such as cough, fever and night sweats were significantly relieved. After adjusting the chemotherapy regimen for 4 cycles of chemotherapy, the Deauville score was 2; The consolidation treatment was continued, the clinical symptoms disappeared, and no recurrence was observed at follow-up. The typical clinical manifestation of HL is painless lymphadenopathy with continuous lymph node involvement. Airway involvement is rare, with an incidence rate of about 1.9%, among which obstructive polypoid lesions are the most common, and may also be manifested as superficial mucosal ulcer formation. Pathology is the gold standard for diagnosing HL airway involvement. HL airway involvement is not a determinant of HL staging and prognosis. In addition to systemic treatment, interventional or surgical intervention is feasible for patients with severe airway obstruction caused by HL airway involvement.

The patient, a 59-year-old female, underwent extensive hysterectomy + pelvic lymph node dissection in the Department of Obstetrics and Gynecology, the Second Affiliated Hospital of Soochow University in June 2022 due to the diagnosis of "cervical squamous cell carcinoma stage IIA1 (FIGO 2018)". Postoperative pathology showed that poorly differentiated squamous cell carcinoma of the cervix infiltrated 1/3 of the cervical muscle layer without involving the internal cervical orifice; No clear nerve or vascular invasion was detected; Cancer involvement was seen at the vaginal margin; No cancer involvement was seen in bilateral parauterine and bilateral adnexes; No cancer metastasis was found in the pelvic lymph nodes submitted for examination. A total of three times of high-dose brachyloading adjuvant radiotherapy of vaginal stump were performed after surgery. The process was smooth, and the Karnofsky functional status score was 80 points. In September 2023, he went to the Department of Orthopedics, the Second Affiliated Hospital of Soochow University due to "right hip pain for more than 10 days". He denied a history of trauma and hormone application, and had no long-term single-action skeletal stress; Specialist examination showed positive bilateral "4" sign and negative straight leg elevation test; Detection of bone metabolic markers showed osteocalcin 8.82 μ g/L, amino-terminal propeptide of type I collagen 16.80 μ g/L, carboxy-terminal peptide of type I collagen 138.00 ng/L, 25-hydroxyvitamin D 40.47 μ g/L, and parathyroid hormone 31.77 ng/L. Pelvic MRI showed that the sacral bone was not continuous, T1W1 showed linear low signal (shown by arrows in Figure 1, which is the fracture line), and T2 lipid pressure image showed flaky high signal foci (shown by dotted circles in Figure 2, which is the bone marrow edema area); The bone of the right pubic bone was interrupted, and a flaky T2 lipid pressure like a hyperintensity focus was seen in it. Dual-energy X-ray bone mineral density measurement (DXA) showed that lumbar spine (L_1~4) Bone density was 0.789 g/cm² with a t-value of-2.7, suggesting osteoporosis. The clinical diagnosis was pelvic failure fracture after radiotherapy for cervical cancer. Failure fracture refers to stress fracture caused by decreased bone mineral content or elasticity, resulting in decreased bone strength. It is more common in patients with postmenopausal osteoporosis, post-radiotherapy osteoporosis and long-term hormone therapy; It is often manifested as a fracture line with callus formation, accompanied by local bone density reduction and other osteoporotic manifestations. It is common in sacrum, pubic bone, ischial bone, etc., and can be single or multiple. Pelvic failure fractures after cervical cancer radiotherapy tend to occur in unilateral or bilateral sacral ears. The fracture line is serpentine or creeping, parallel to the sacroiliac joint, and the bilateral shape is "H", which needs to be distinguished from traumatic fractures, pathological fractures caused by bone metastases and osteoporotic fractures. For the detection of pelvic failure fractures, the sensitivity and specificity of pelvic X-ray examination are low; In the early stage of fracture, the detection rate of occult fracture by MRI was higher than that of CT. The fracture lines were T1WI and T2WI low signal, and the peripheral bone marrow edema showed diffuse T1WI low signal and T2WI high signal. The edema area of bone marrow in enhanced scan showed uneven enhancement, but the fracture line was not enhanced. Reasonable radiation dose, three-dimensional conformal radiotherapy and intensity modulated radiotherapy were adopted to reduce the damage to normal tissues by radiotherapy, and appropriate imaging methods were selected to improve the detection rate of cervical cancer fracture after radiotherapy. Regular monitoring of bone mineral density after radiotherapy for cervical cancer and appropriate intervention measures for patients with osteoporosis will help to reduce the incidence of pelvic failure and fracture and improve the quality of life of patients.