2022年肿瘤内科病历中英文对照 .pdf

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1、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 peoples hospital of Taihe county for six years of a

2、bdominal pain and eight days of melena,On May 28, 2014.She underwent radical operation of gastric cancer at the People s 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; th

3、e 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 rad

4、iotherapy 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 名师资料总结 - - -精品资料欢迎下载 - - - - - - - - - - - - - - - - - - 名师精心整理 - - - - - - - 第 1 页，共 4 页 - - - - - - - - - no ob

5、vious 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 patients previous gastric cancer pathology report, she was treatde with 1 course of DF regimen.Then th

6、e 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 m

7、orphology, 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

8、) 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 名师资料总结 - - -精品资料欢迎下载 - - - - - - - - - - - - - - - - - - 名师精心整理 - - - - - - - 第 2 页，共 4 页 - - - - - - - - - tumo

9、r).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 weigh

10、t 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。2014.6于太和县人民医院行胃癌根治 术，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 3cm3cm 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

11、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 2017.8.10全麻下行 双侧附件切除 术，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151210cm ，表面光滑，左 侧卵巢实性分叶 状增大 864cm ，表面光滑， 双侧输卵管外 观正常，盆底光滑。病理：（ 双卵巢）大小名师资料总结 - - -精品资料欢迎下载 - - - - - - - - - - - -

12、 - - - - - - 名师精心整理 - - - - - - - 第 3 页，共 4 页 - - - - - - - - - 分别为 8.5 54cm 及 14138cm ，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。名师资料总结 - - -精品资料欢迎下载 - - - - - - - - - - - - - - - - - - 名师精心整理 - - - - - - - 第 4 页，共 4 页 - - - - - - - - -