肿瘤内科病历中英文对照(4页).doc
-肿瘤内科病历中英文对照-第 4 页Xie Yanhua Xie yanhua, bed 38,female, 40 years old, was born in Fuyang, Anhui province.The patient was admitted to our department for gastric cancer for more than 2 years and pelvic metastasis for more than 10 months.The patient was treated at the people's hospital of Taihe county for "six years of abdominal pain and eight days of melena",On May 28, 2014.She underwent radical operation of gastric cancer at the Peoples Hospital of Taihe County on June,2014. The pathology report:Gastric ulcer type adenocarcinoma, partially signet-ring cell carcinoma, invading muscular layer, size of 3cm x 3cm; the upper and lower margin negative;4 of 10 lymph nodes positive around lesser curvature and 3 of 3 lymph nodes positive around greater curvature.After the operation, the patient underwent 6 courses of PCF regimen chemotherapy in this hospital, which is not clear enough.The patient was admitted to radiotherapy and chemotherapy department of our hospital on December 14th,2016 for pelvic mass after gastric cancer surgery .CA199 was slightly elevated in the local hospital, and there was no obvious abnormality in CEA and CA125, but the lesion was not clear.PET-CT examination showed anastomotic recurrence, peritoneal seeding, gastroscopy and pathology: no tumor cells were found.Given the patient's previous gastric cancer pathology report, she was treatde with 1 course of DF regimen.Then the patient was admitted to the First Affiliated Hospital of Anhui Medical University Because of pelvic mass for more than 9 months.Then she underwent bilateral uterine appendages resection under general anesthesia on August 10,2017.Intraoperative presentation: uterus pregnancy 2 months size, normal morphology, serosal surface smooth, right ovary solid lobulated increase, the size of 15 x 12 x 10cm, smooth surface, the left ovary solid lobulated increased 8 x 6 x 4cm, smooth surface, bilateral tubal normal in appearance and smooth appearance of normal pelvic floor.Pathology report: (double ovary) size was 8.5 x 5 x 4cm and 14 x 13 x 8cm, microscopy, immunohistochemical staining, and clinical history were consistent with metastatic poorly differentiated adenocarcinoma (Krukenberg tumor).Immunohistochemistry: CK (+), CK7 (+), CEA (+), SMA (-), Desmin (-), CA125 (-), alpha -inhibin (-), Vin (-), Ki-67 (+, around 20%).For the sake of further treatment, the patient was admitted to our department.The diet,sleep and defecation during the course of the disease are normal, and the weight change is not obvious.主 诉：胃癌术后3年余，盆腔转移10月余。现病史：患者2014.5.28因“间断上腹痛6年，黑便8天”就诊于太和县人民医院。，术后病理示：胃小弯溃疡型腺癌，部分为印结细胞癌，侵及肌层，肿块3cm×3cm大小；上下切缘阴性；小弯淋巴结（+）4/10，大弯淋巴结（+）3/3.术后患者于该院行PCF方案化疗6程，具体不详。患者因胃癌术后盆腔包块于2016.12.14就诊我院日间放化疗科，患者自行当地医院查CA199轻度升高，CEA、CA125未见明显异常，未明确病变性质，行pet-ct提示吻合口复发、腹腔种植可能，复查胃镜及病理：未发现肿瘤细胞。考虑患者既往胃癌病理，予以DF方案化疗1程。后患者因“盆腔肿物9月余”就诊于安徽医科大学第一附属医院，于，术中见：子宫增大如孕2月大小，形态正常，浆膜面光滑，右侧卵巢实性分叶状增大，大小约15×12×10cm，表面光滑，左侧卵巢实性分叶状增大8×6×4cm，表面光滑，双侧输卵管外观正常，盆底光滑。病理：（双卵巢）大小分别为8.5×5×4cm及14×13×8cm，镜检并结合免疫组化标记及临床病史符合转移性低分化腺癌（Krukenberg瘤）。免疫组化：CK(+),CK7(+),CEA(+),SMA(-),Desmin(-),CA125(-),-inhibin(-),Vin(-),Ki-67(+,约20%)。今患者为求进一步治疗就诊我科，病程中患者饮食睡眠可，二便可，体重变化不明显。
