Volume 104 · Issue 34 · 2024

Gallbladder polyp is a common disease of gallbladder, the incidence of gallbladder polyp in China is about 5%~10%, and the trend is increasing year by year. The patients with gallbladder polyps had no obvious clinical symptoms, which was more than that found by ultrasonography during physical examination. At present, the diameter of gallbladder polyps>10 mm is still used by clinicians as the main surgical indication for cholecystectomy. According to the data, about 80% to 90% of gallbladder polyps are cholesterol type polyps and benign gallbladder polyps. For these patients whose gallbladder is removed due to benign gallbladder polyps, we consider that we can continue to observe or retain the gallbladder, without having to bear the adverse consequences that may be caused by gallbladder removal. Based on the literature analysis at home and abroad, this paper discusses the surgical treatment of gallbladder polyps and the results of postoperative pathological diagnosis, and reminds the majority of clinicians to be careful when removing gallbladder polyps.

To further standardize lung cancer prevention and treatment measures in China, enhance the quality of diagnosis and treatment, improve patient prognosis, and provide evidence-based medical guidance for clinicians at all levels, the Chinese Medical Association convened experts from respiratory medicine, oncology, thoracic surgery, radiotherapy, imaging, and pathology to develop the Chinese Medical Association guideline for clinical diagnosis and treatment of lung cancer (2024 edition). This consensus resulted in several updates from the 2023 edition. The 2024 guidelines highlight that the risk of lung cancer in smokers remains higher than that of non-smokers even 15 years after quitting. Additionally, a new lung cancer incidence risk model is expected to become a critical tool for screening high-risk groups. In pathology, the guidelines now include pathological evaluation of surgically resected lung cancer specimens following neoadjuvant therapy and suggest that immunohistochemical staining of certain transcription factors may aid in the classification of small cell lung cancer (SCLC). In molecular detection, the guidelines propose simultaneous detection of driver gene variations based on both RNA and DNA from specimens. The new edition also provides detailed descriptions of patient selection and surgical requirements for thoracic sub-lobectomy, aligned with the 9th TNM staging. Moreover, the guidelines expand treatment options, approving more therapies for immunoadjuvant and EGFR-TKI resistant lung cancer patients, as well as additional drug options for advanced non-small cell lung cancer (NSCLC) patients with EGFR mutations, EGFR 20 insertions, ALK fusions, and MET exon 14 skipping. These recommendations are based on state-approved drug applications, international guidelines, and current clinical practices in China, integrating the latest evidence-based medical research in screening, diagnosis, pathology, genetic testing, immune molecular marker detection, treatment methods, and follow-up care. The goal is to provide comprehensive and reasonable recommendations for clinicians, imaging specialists, laboratory technicians, rehabilitation professionals, and other medical staff at all levels.

To summarize and analyze the clinical characteristics and prognosis of thoracic SMARCA4-deficient undifferentiated tumor (SMARCA4-UT).

A retrospective analysis was conducted on the clinical data of 51 patients with SMARCA4-UT who were diagnosed in the First Affiliated Hospital of Zhengzhou University from January 2018 to December 2023, and 52 patients with SMARCA4-intact non-small cell lung cancer (SMARCA4-iNSCLC) expression admitted during the same period were used as controls. The Kaplan-Meier survival analysis and log-rank test were used to analyze the survival difference between the two groups of patients, and the Cox regression model was used to explore the factors influencing the prognosis of the two groups of patients.

In the SMARCA4-UT group, there were 50 males and 1 female, with the age of (63.8±9.7) years. Compared to the SMARCA4-iNSCLC group, the SMARCA4-UT group exhibited a higher proportion of male patients and smokers, as well as a higher Ki-67 level (all P<0.05). SMARCA4-UT is mainly characterized by solid lesions with poor adhesion, and some of them exhibit rhabdomyoid morphology. Immunohistochemistry revealed negative results for BRG1, thyroid transcription factor-1, P40, NapsinA, and others were mostly negative, while some patients were positive for spalt-like transcription factor 4. There were a relatively large number of cases with Ki-67≥30% (47/51, 92%). Among the 10 patients in the SMARCA4-UT group who underwent next-generation sequencing genetic testing, 6 patients were found to have SMARCA4 mutations, often accompanied by TP53 (8/10, 80%), STK 11(3/10, 30%), KRAS(2/10, 20%), with fewer common driver gene mutations. The average tumor mutation burden was 16.12 mutations/Mb. Compared with SMARCA4-iNSCLC patients, the median overall survival of SMARCA4-UT patients was significantly shorter (12 months vs 45 months, P<0.001), and the median overall survival of patients with stage Ⅲ-Ⅳ SMARCA4-UT treated with immunotherapy was longer than that of patients without immunotherapy (23 months vs 7 months, P=0.027). The results of the multivariate Cox regression model analysis indicated that SMARCA4 deficiency is a risk factor for prognosis in patients with SMARCA4-UT and SMARCA4-iNSCLC [HR=7.954(95%CI： 2.764-22.890), P<0.001].

SMARCA4-UT is a rare undifferentiated tumour distinct from SMARCA4-iNSCLC, which is prevalent among elderly male smokers. It possesses high invasiveness and poor prognosis. The typical pathological characteristic is negative BRG1. Immunotherapy demonstrates a certain effect.

To compare the safety and short-term efficacy of robotic-assisted thoracic surgery(RATS) and video-assisted thoracoscopic surgery(VATS) in patients with non-small cell lung cancer (NSCLC).

A retrospective analysis of the clinical data of 2 058 NSCLC patients who underwent RATS and VATS from January 2021 to December 2022 in Xiangya Hospital of Central South University was conducted, including 1 006 males and 1 052 females, with the age of (57.3±9.9) years. According to the surgical approach, the patients were divided into RATS group (n=1 190) and VATS group (n=868). The nearest neighbor matching method was used to perform 1∶1 propensity score matching (PSM). A comparison was made about the intraoperative conditions and postoperative complication rates between the RATS and VATS groups before and after PSM. Furthermore, after PSM, a stratified analysis was conducted based on surgical approach, separately comparing the intraoperative conditions and postoperative complication rates between the VATS and RATS groups among patients who underwent lobectomy and segmentectomy, respectively.

After PSM, a total of 1 692 patients were included, with 846 patients in both the VATS and RATS groups. After stratification based on surgical approach, there were 503 patients in the RATS group and 548 patients in the VATS group for lobectomy, and 338 patients in the RATS group and 298 patients in the VATS group for segmentectomy. Before PSM, statistically significant differences were observed between the RATS and VATS groups in terms of intraoperative conversion to open thoracotomy, number of lymph node dissection/sampling stations, extubation time, total length of hospital stay, and total hospitalization costs (all P<0.001). After PSM, compared with the VATS group, the RATS group had a lower intraoperative conversion rate to open surgery [1.2% (10/846) vs 5.1% (43/846)], less intraoperative blood loss [(73.6±77.4) ml vs (112.6±239.3) ml], a greater number of sampled/dissected lymph node stations [(4.8±2.0) vs (3.7±1.8)], a shorter duration of drainage tube placement [(3.6±2.7) d vs (4.1±2.5) d], and a higher postoperative drainage volume [(273.9±183.0) ml vs (256.5±168.7) ml] (all P<0.001). There was no statistically significant difference in the incidence of postoperative complications between the two groups (P=0.108). The results of the surgical stratification analysis showed statistically significant differences between the two groups in terms of intraoperative blood loss, number of lymph node dissection/sampling stations, extubation time, and total hospitalization costs for both lobectomy and segmentectomy surgeries (all P<0.001). In lobectomy surgeries, the RATS group had a lower rate of intraoperative conversion to open thoracotomy than that of VATS group [1.6% (8/503) vs 7.7% (42/548), P<0.001]. In segmentectomy surgeries, the RATS group had more postoperative drainage volume than that of VATS group [(249.8±151.5) ml vs (218.7±132.9) ml, P=0.023]. There was no statistically significant difference in the incidence of surgical complications between the two groups for both lobectomy and segmentectomy surgeries (both P>0.05).

In the surgical management of NSCLC, RATS offers more advantages over VATS in reducing conversion rates to open surgery, minimizing perioperative adverse events, and facilitating faster patient recovery postoperatively.

To develop and validate clinical and radiomics models based on gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced MRI of dual-phenotype hepatocellular carcinoma (DPHCC) for preoperative differential diagnosis.

Two hundred and fifty inpatients of hepatocellular carcinoma (HCC) confirmed by postoperative pathology, who underwent Gd-EOB-DTPA-enhanced MRI were retrospectively included. A total of 172 inpatients (72 DPHCC and 100 non-DPHCC) were included in Institution 1 (the First Affiliated Hospital of Soochow University) as a training cohort (between January 2020 and July 2023) and 78 inpatients (44 DPHCC and 34 non-DPHCC) were included in Institution 2 (the Third People′s Hospital of Nantong) as an external validation cohort(between January 2019 and July 2023). The regions of interest of the tumor were delineated layer by layer in noncontrast phase, arterial phase (AP), portal venous phase (PP) and hepatobiliary phase (HBP) images. The software of FAE was used to extract the radiomics features of the images. Pearson correlation analysis and recursive feature elimination were used for feature selection. Each phase and combined radiomics models were established using logistic regression, linear discriminant analysis and support vector machine. Receiver operating characteristic curve and the areas under the curve (AUC) were used to evaluate and select the dominant radiomics model. The dominant radiomics model was combined with clinically independent predictors to construct a clinical radiomics model. Delong test was used to compare the performance of the models.

The age of the training cohort was (59.6±10.4) years, in which there were 135 men (78.5%). In the external validation cohort, the age was (57.8±9.2) years, including 56 men (71.8%). The maximum diameters of the lesions [M (Q₁, Q₃), 4.7 (2.6, 7.5) vs 2.7 (1.8, 4.4) cm, P<0.001] and the proportion of the multiple lesions (39.5% vs 16.7%, P<0.001) in the training cohort were higher than those in the external validation cohort. In the training group, the proportion of patients with hepatitis B virus (HBV) infection in the DPHCC subgroup (66.7%,48/172) was higher than that in non-DPHCC subgroup (49.0%,49/78,P=0.021). In the external validation cohort, the AUC (95%CI) of the PP [0.835 (0.733-0.937)] and combined radiomics models [0.786 (0.681-0.891)] were significantly higher than that of noncontrast phase [0.451 (0.319-0.584)], AP [0.566 (0.435-0.696)] and HBP models [0.496 (0.363-0.629)] (all P<0.05). There was no significant difference in AUC between PP radiomics model and combined radiomics model (P=0.189). The AUC between the radiomics models and clinical-radiomics models, which were brought into clinically independent variable HBV, showed no significant difference (all P>0.05).

Gd-EOB-DTPA-enhanced MRI radiomics model based on portal venous phase may be available for discriminating DPHCC from non-DPHCC before operation.

To evaluate the clinical efficacy of transoral robotic surgery (TORS) with the da Vinci robot system in the treatment of oropharyngeal squamous cell carcinoma (OPSCC).

A mixed cohort study was conducted to collect and analyze the clinical data of OPSCC patients who underwent TORS at the Eye & ENT Hospital, Fudan University between July 2020 and February 2023 (TORS group). OPSCC patients who underwent conventional surgery between January 2016 and September 2020 were included as the control group. The baseline information, incidence of complications and follow-up data were compared between the two groups.

A total of 166 patients were included, with 102 cases (81 males and 21 females) in the TORS group [mean age: (59.1±9.8) years] and 64 cases (54 males and 10 females) in the control group [ mean age: (57.6±9.7) years]. Compared with the control group, the TORS group had lower postoperative bleeding rate [2.9% (3/102) vs 10.9% (7/64), P=0.035] and infection rate [1.0% (1/102) vs 18.8% (12/64), P<0.001]. No statistically significant differences were observed in tracheotomy rate [46.1% (47/102) vs 59.4% (38/64), P=0.070] and median length of hospital stay [8 (7, 10) d vs 10 (4, 12) d, P=0.088]. After propensity score matching, compared with the control group, the TORS group had lower postoperative infection rate [0 (0/31) vs 19.4% (6/31), P=0.032] and median length of hospital stay [7 (7, 10) d vs 10 (8, 12) d, P=0.031]. No statistically significant differences were found in postoperative bleeding rate [3.2% (1/31) vs 6.5% (2/31), P=1.000] and tracheotomy rate [22.6% (7/31) vs 45.2% (14/31), P=0.060] between the two groups. Moreover, 1-and 2-year disease-free survival rates were 96.3% and 94.6% in the TORS group, and 90.6% and 84.3% in the control group, respectively (P=0.233). The 1-and 2-year cancer-specific survival rates were both 100% in the TORS group, and 96.9% and 93.8% in the control group, respectively (P=0.539).

TORS for OPSCC is associated with high clinical safety and favorable oncological outcomes.

To investigate the clinical characteristics of heterotopic cervical pregnancy (HCP).

A retrospective analysis was conducted based on the general clinical data, assisted reproductive technology (ART) data, diagnosis and treatment data, and pregnancy outcomes of 17 patients diagnosed with HCP who received ART at the Reproductive Medicine Center of Peking University Third Hospital from January 2011 to April 2022.

The age of 17 HCP patients was (34.2±1.5) years, all of whom occurred after the application of ART; Among them, 11 cases had a history of uterine cavity operation. All 17 patients had vaginal bleeding, with only 1 case accompanied by abdominal pain. The gestational age at the diagnosis of HCP was [6⁺² (5⁺²-6⁺⁴)] weeks. Two patients underwent conservative observation and were closely followed up. Both of them had intrauterine pregnancy until full-term and underwent cesarean section; One patient underwent ultrasound-guided cervical pregnancy reduction surgery, resulting in miscarriage due to premature rupture of membranes at 18⁺¹ weeks of intrauterine pregnancy; One patient underwent ultrasound-guided cervical pregnancy reduction surgery, followed by uterine artery embolization, hysteroscopy, removal of cervical pregnancy lesions, and curettage due to excessive bleeding; One patient underwent uterine artery embolization, hysteroscopy, cervical pregnancy lesion clearance, and curettage due to excessive vaginal bleeding; One patient underwent hysteroscopy examination, cervical pregnancy lesion removal surgery, and uterine curettage due to embryo arrest during intrauterine pregnancy; 11 cases underwent ultrasound-guided cervical pregnancy lesion clearance surgery, all of which resulted in live births. Among the 13 delivery patients, 4 cases were premature and 9 cases were full-term; 5 cases of vaginal delivery and 8 cases of cesarean section.

The most common clinical manifestation of HCP is vaginal bleeding. Ultrasound guided cervical pregnancy lesion clearance surgery is safe and feasible, and with good pregnancy outcomes.

The clinical data of five patients diagnosed with olfactory neuroblastoma (ONB) who were admitted to the Department of Pediatrics, Beijing Tongren Hospital Affiliated to Capital Medical University from January 2012 to January 2024 were retrospectively analyzed. Two males and three females aged 6.2 (5.7-15.8) years were included. The symptoms mainly covered nasal congestion, increased nasal secretions, headache, decreased vision and so on. Pathological grade Ⅱ, Ⅲ and Ⅳ was identified in two cases, one case and two cases, respectively. Modified Kadish stage B, C and D was detected in one case, two cases and two cases, respectively. All patients underwent surgery, chemotherapy, and radiation therapy. Among the five patients, four survived and one died. The follow-up time was 22.3 (10.4-56.4) months, and the recurrence rate was 0. ONB should be suspected when tumors are presented in the upper and middle parts of the nasal cavity, especially dumbbell shaped masses that grow towards the nasal cavity and intracranial area based on imaging. The multimodality therapy of ONB comprising of surgery and chemotherapy, can achieve good therapeutic effects and prognosis, but long-term follow-up is required.

To explore the clinical and pathological characteristics of squamous cell carcinoma arising in ovary mature cystic teratoma (MCT) and primary ovarian squamous cell carcinoma (POSCC). Retrospective analysis was conducted on the clinical and pathological characteristics, immunophenotype and prognosis of five cases of ovarian squamous cell carcinoma (OSCC). Next generation sequencing (NGS) test was performed on one case of POSCC to analyze its molecular genetic characteristics. The age of five patients (including four MCTs and one POSCC) ranged from 43 to 68 years. There were one case of simultaneous involvement of both ovaries, one case of left ovary, and three cases of right ovary. Microscopically, four cases of tumors were composed of MCT and squamous cell carcinoma. Among which, one case only showed squamous cell carcinoma components and no accompanying lesions were found in the surrounding area. Immunohistochemistry staining showed that all cases were positive for p40, CK5/6, p63; P53 was positively expressed in two cases; and the proliferation index Ki-67 ranged from 30% to 50%. One POSCC NGS test harbored 12 somatic mutations, among which 3 mutations with clear or potential clinical significance were BRCA1 gene (p.G263fs), TP53 gene (p.R273C), and ERBB2 gene (copy number amplification). Four patients underwent ovarian cancer debulking surgery; one patient underwent radical resection of ovarian cancer and platinum-based chemotherapy was given after surgery. During 3-10 months of follow-up, 3 patients died; 1 patient was alive; and 1 patient was lost to follow-up. OSCC is a kind of ovarian cancer with low incidence rate. Most of these tumors arise from malignant transformation of MCT. POSCC is extremely rare. The treatment mainly involves surgical resection, supplemented by platinum-based combination chemotherapy after surgery. OSCC progresses rapidly, and has a poor prognosis.

The clinical presentation, treatment, and follow-up of two boys with type 1 Dent disease who exhibited a Bartter-like phenotype were retropectively analysed. The related literature of pediatric patients with type 1 Dent disease who had hypokalemia and metabolic alkalosis was screened through databases such as PubMed, CNKI, and Wanfang until February 1, 2024, and common features among these patients were summarized through literature review. A total of 7 literatures were included, and 9 children were included in the analysis. All patients were male, presenting with significant low molecular weight proteinuria and hypercalciuria. Other prominent characteristic phenotypes included short stature (7/8), hypophosphatemia (8/9), and rickets (6/8). Seven previously reported patients had missense or nonsense mutations, while 2 patients in this study carried possible pathogenic mutations in the CLCN5 gene, c.315+2T>A (p.?) and c.584dupT (p.I196Yfs*6), respectively. Five patients were able to maintain blood potassium levels around 3 mmol/L with oral potassium chloride solution combined with non-steroidal anti-inflammatory drugs (ibuprofen or indomethacin). The follow-up showed that 2 patients developed chronic kidney disease stage 4 and stage 3 at the age of 13 and 21 years, respectively. The phenotypic overlap between Dent disease and Batter syndrome is considerable,with the distinguishing feature being the presence of significant low molecular weight proteinuria. Patients with type 1 Dent disease presenting with the Bartter-like phenotype have a high prevalence of short stature, hypophosphatemia, and rickets. Non-steroidal anti-inflammatory drugs can be used to correct hypokalemia in patients under periodic renal function assessment.

This article reports a patient with fever, lymph node enlargement and ferritin elevation complicated with septic shock. Combined with the results of lymph node biopsy, the initial diagnosis was Castleman's disease (CD). After combined anti-infection, rehydration and boosting pressure, and thalidomide, cyclophosphamide, and prednisone (TCP) regimen treatment, the condition improved. One month later, the patient reappeared with hyperthermia with acute liver failure. A second lymph node biopsy and lymphoma gene mutation examination were performed to determine the etiology. Genetic testing revealed a homozygous mutation in the PRF1 gene. Further testing showed that the patient's parents also carried the same PRF1 gene mutation, thereby confirming the diagnosis of familial hemophagocytic syndrome (FHL). FHL is rare in adults and has a high mortality rate. In the early stage of the disease, the symptoms are atypical and easy to be missed, so early diagnosis is particularly critical. Following treatment with hemophagocytic syndrome (HLH) -94 regimen, the patient's bilirubin levels gradually decreased and his body temperature returned to normal, and allogeneic hematopoietic stem cell transplantation (allo-HSCT) is currently planned.

Plasma-rich acute rejection (PCAR) is a rare rejection after renal transplantation with poor prognosis. Two cases of PCAR were diagnosed in our center, and significant results were achieved after treatment with bortezomib. Case 1: 33-year-old male with mixed rejection 8 months after renal transplantation, with more than 50% of the inflammatory cells in the interstitium being plasma cells. Conventional treatment was ineffective, and the condition improved after the addition of bortezomib. After 5 years of follow-up, the patient developed multiple new anti-HLA site antibodies, but his renal function was stable and there was no serious infection. Case 2: 51-year-old male with chronic antibody-mediated rejection (cABMR) diagnosed 2 years after renal transplantation and over 50% of interstitial inflammatory cells were plasma cells. After hormone shock, immunoglobulin and bortezomib combined therapy, it improved. Repeated biopsies after 1 year showed a significant reduction in plasma cells, but cABMR remained. Renal function remained stable after 2 years of follow-up. This study provides a useful reference for the treatment of PCAR.

This article reports the diagnosis and treatment of a patient with Graves disease with pretibial myxedema. After completing relevant laboratory tests, examinations and skin histopathology, this patient was definitively diagnosed with Graves' disease complicated with pretibial myxedema, and was treated with local compound betamethasone injection in the lesion, and topical encapsulation of mometasone furoate cream + tretinoin cream at the skin lesion. After 12 weeks of treatment, the skin lesions of both lower limbs were significantly improved compared with before.

Head and neck tumors are tumors originating from the oral cavity, pharynx, larynx, nasopharynx, nasal cavity (sinuses), salivary glands and other parts, and their recognized treatment mode is comprehensive treatment based on surgery; However, for tumors with rich blood supply in the head and neck, it is easy to cause severe blood loss during operation, and preoperative embolization treatment can significantly reduce intraoperative bleeding. At present, there is no consensus on the indications for preoperative embolization of tumors with rich blood supply to the head and neck. This paper introduces the research progress of preoperative embolization for head and neck tumors with rich blood supply, which provides reference for clinical decision-making.

Glucagon-like peptide-1 receptor agonist (GLP-1RA) plays an important role in the treatment of type 2 diabetes and obesity. However, the effect of GLP-1RA on gastric emptying may have important implications for perioperative management, especially with regard to fasting and drinking preparation before anesthesia. This review aims to comprehensively analyze the physiological effects of GLP-1 and GLP-1RA, especially the effects on gastric emptying and its mechanisms, as well as the effects on anesthesia management and perioperative period, and to explore the potential impact of this property on preparation for fasting and drinking before anesthesia.