2016年 · 第96卷第46期

Hepatocellular carcinoma (HCC, hereinafter referred to as liver cancer) is the sixth largest cancer in the world, with about 740,000 new cases every year, half of which are in China. The mortality rate of liver cancer in China ranks third among malignant tumors^[1]。 During the development of hepatocellular carcinoma, portal vein tumor thrombus (PVTT) is easily invaded into the portal vein. The incidence rate of PVTT is 44.0% ~62.2%^[2]。 Once PVTT occurs in patients with liver cancer, the disease progresses rapidly, intrahepatic and extrahepatic metastasis, portal hypertension, jaundice and ascites can occur in a short time, and the mean median survival time is only 2.7 months^[3]It is the main adverse factor affecting the prognosis of liver cancer and the "bottleneck" to improve the curative effect of liver cancer. Therefore, the treatment of PVTT is of great significance in the clinical diagnosis and treatment of liver cancer. Due to the lack of high-level clinical research evidence for the treatment of PVTT, various treatment measures are not effective, and there is no international consensus on the treatment of PVTT. European and American countries take Barcelona (BCLC) staging as the treatment standard, and the main treatment strategy is sorafenib, while Southeast Asian countries including China believe that PVTT patients should be treated comprehensively. In May 2016, the National Collaborative Group on Hepatocellular Carcinoma with Tumor Thrombosis launched the first Chinese Expert Consensus on Multidisciplinary Diagnosis and Treatment of Hepatocellular Carcinoma with Portal Vein Tumor Thrombosis (2016 Edition)^[4]It provides a standardized diagnosis and treatment process and method for the treatment of PVTT, which will further improve the overall efficacy of PVTT patients in China. However, the treatment of PVTT still faces many difficulties, such as the formation mechanism of PVTT is still unclear, the lack of effective clinical treatment, the low surgical resection rate and the high recurrence rate. Colleagues at home and abroad should strengthen the research in these aspects.

A 54-year-old female was seen 7 months after the discovery of a left submandibular mass. In May 2015, a left submandibular mass appeared without obvious trigger, about 1.5 cm in diameter, hard in texture, non-tender, and without adhesion to surrounding tissues, and was not diagnosed and treated. In August 2015, I felt that the tumor had enlarged to about 4 cm in diameter. B-ultrasound examination in the local hospital suggested that the left submandibular gland cyst was possible (2.8 cm ×1.8 cm) and the left submandibular lymph node was enlarged (2.6 cm ×1.2 cm). Extraction of left submandibular mass was performed in November 2015. Preoperative blood test routine: white blood cells 6.85×10⁹/L, hemoglobin 134 g/L, platelets 204×10⁹/L, coagulation function: prothrombin time (PT) 20.1 s, activated partial thromboplastin time (APTT) 68.1 s, prothrombin activity, fibrinogen and D-dimer were normal. The patient had no previous coagulation tests and had no bleeding or thrombosis-related symptoms. The operation went smoothly, there was no abnormal bleeding after operation, and the wound healed well. Pathological report: (left submandibular mass) Most of the lymph node structure was destroyed, a large number of atypical lymphoid cells diffusely infiltrated, and some areas showed a star-like image. The cells were medium-large, with little cytoplasm and light staining, and the nucleus was round, oval, irregular, with obvious nucleoli and large mitotic images. Immunohistochemistry Results: Immunohistochemistry: CD2 positive (+ + +), CD3 negative (-), CD4+ + +, CD5-, CD7-, CD8-, CD30+ + +, MUM1+ + +, BCL-2+ + +, PD1-, anaplastic lymphoma kinase (ALK) -, CD19-, CD20-, Pax5-, CD56-, CD10-, Ki-67>90% +, BCL6-, CD23-, CD35-, MPO-, CD38-, CD138-, GramB-, Lysozyme-, TDT-, TIA-, CD21-, EBER-. ALK-negative anaplastic large cell lymphoma was diagnosed in pathological consultations in many hospitals. In December 2015, he went to the Institute of Hematology, Peking University. The blood routine was normal, the biochemistry showed normal electrolyte and liver and kidney function, and the lactate dehydrogenase was 170 U/L. Coagulation function : PT 19.4 s, APTT 56.8 s. No lymphoma cells were found in bone marrow smear and immunotyping, and no tumor was found in bone marrow biopsy. After surgical resection, PET-CT showed no clear metabolic active lesions in the whole body. The patient had no fever, night sweats and weight loss since the onset of the disease. He was admitted and diagnosed with ALK-negative anaplastic large cell lymphoma stage Ia with abnormal coagulation function to be investigated.

A 38-year-old male was admitted to the Department of Nephrology, Peking University First Hospital on March 1, 2014 with "hemoptysis for more than 1 year, fatigue, macroscopic hematuria, edema of both lower limbs with rash for 2 months, and aggravation for more than half a month". One year ago, the patient developed fever and chills, with a maximum body temperature of 38.3℃, accompanied by cough, expectoration, and a few dark red blood clots in the sputum. An enhanced chest CT in an external hospital showed that "the right lung occupied space, the lymph nodes in the right hilum and mediastinum were enlarged, some lymph nodes were calcified, and there were multiple lymph nodes in the bilateral axillary, with a high possibility of malignant lesions" (Figure 1)。 After intravenous infusion of antibiotics such as ceftriaxone and azithromycin, phlegm relieving cough, anti-allergy and ready-for-use traditional Chinese medicine, the condition did not improve. The cough was aggravated with asthma, persistent low fever, fatigue, and occasional wrist and ankle joint swelling and pain. One month later, CT reexamination showed that the soft tissue shadow at the right hilar was significantly larger than before, and percutaneous pulmonary puncture was performed, and the pathological results showed "obstructive pneumonia with organizing pneumonia". Bronchoscopy showed no endotracheal new organisms, sputum smear showed no fungi or acid-fast bacilli, and sputum bacterial culture was negative. At that time, there was no proteinuria or hematuria in urine test, serum creatinine was 60 μ mol/L, anti-neutrophil cytoplasmic antibody (ANCA) and anti-nuclear antibody spectra were negative, and C-reactive protein (CRP), immunoglobulin and complement were all normal. Based on the above examination results, it was considered that "right lung cancer is likely", and right pneumonectomy was performed. During the operation, a consolidation area of 6.4 cm ×5.0 cm ×4.0 cm was seen in the right lung tissue, 4 cm away from the main bronchial margin. The postoperative pathological results showed "chronic suppurative inflammation of the bronchi with organizing pneumonia". After operation, bronchial stump was repeatedly infected to form bronchopleural fistula, right empyema, and the pus was cultured as Pseudomonas aeruginosa. The treatment was continuously treated with antibiotics such as ceftazidime and right thoracic cavity closed drainage. The patient developed macroscopic hematuria without trigger 2 months ago, which was bright red and lasted until after admission; At the same time, there was edema of both lower limbs and scattered symmetrical red papules, which could resolve spontaneously after repeated attacks. There was no discomfort such as skin itching, fever, low back pain, urinary tract irritation, etc., and there was no change in urine output, so no special treatment was given. One month ago, serum creatinine was found to be 416 μ mol/L, urine protein + +, and red blood cells were full of visual field. After symptomatic treatment with ready-for-use traditional Chinese medicine, serum creatinine decreased to 180 μ mol/L, but increased to 414 μ mol/L again after one week. Other tests: albumin 31.2 g/L, CRP 56.9 mg/L, peripheral blood leukocytes 5.82×10⁹/L, hemoglobin 81 g/L, platelets 209×10⁹/L, the percentage of eosinophils was normal. The urine volume is about 2 000 ml per day, and there is no fever. Since the onset of the disease, the patient has had good mental sleep, poor appetite, and no obvious change in stool compared with before. In the past two months, the weight has gained about 5 kg, and his vision is consciously blurred, and his vision has decreased significantly. Prior physical health, smoking for 20 years, 10 cigarettes/d. Engaged in automobile maintenance work for more than 10 years. Family history of genetic diseases and similar diseases were denied.

Depression and acute coronary syndromes (ACS) are important causes of global disease burden^[1]。 Epidemiological evidence has shown that depression is closely related to acute coronary syndrome^[2,3,4]。 Patients with cardiovascular disease are more likely to develop depression than the general population; Patients with depression are more likely to develop cardiovascular disease than the general population; When patients have both cardiovascular disease and depression, their prognosis of cardiovascular disease is worse than that of cardiovascular patients who do not have depression. However, the diagnosis rate of depression in patients with ACS combined with depression is low, only less than 1/3. Therefore, whether high-risk patients can be identified through effective early screening and effective treatment for patients with ACS combined with depression can be given to reduce the greater disease burden caused by the interrelationship between the two diseases still needs further exploration and research.

Kidney cancer is a malignant tumor that is highly resistant to traditional treatments including chemotherapy and radiation therapy. Scholars have used many immunomodulatory methods to treat kidney tumors. However, at present, traditional immunotherapy is still limited by low efficiency, high toxicity, and effective in some patients^[1]。 In recent years, tumor immunotherapy targeting immune checkpoint receptors has set off a revolution in tumor therapy^[2]。

Rapid eye movement sleep period behavior disorder (RBD) refers to dystonia disorder that occurs during rapid eye movement sleep period and manifests as abnormal behaviors associated with dreams^[1]。 These actions can be simple jokes, shouting, excessive twisting of limbs and torso, or complex actions such as slapping, cursing, gesturing, grabbing, punching and kicking, or even sitting up from bed, most of which are obviously aggressive.