腫瘤內(nèi)科病歷中英文對照.doc

1、Xie Yan huaXie yan hua, bed 38,female, 40 years old, was born in Fuya ng, An hui provin ce.The patie nt was admitted to our departme nt for gastric cancer for more than 2 years and pelvic metastasis for more tha n 10 mon ths.The patient wastreated at the peoples hospital of Taihe county for six year

2、s of abdominal pain and eight days of melena,OnMay28, 2O14.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 sig net-ri ng cell carci noma, inv adi ng muscular layer, size of 3cm

3、x3cm; the upper and lower margin n egative;4 of 10 lymph no des positive around lesser curvature and 3 of 3 lymph no des positive around greater curvature.After the operation, the patient un derwe nt 6 courses of PCF regime nchemotherapy in thishospital, which is not clear enough.The patient was adm

4、itted to radiotherapy and chemotherapy department of our hospital on December 14th,2016 for pelvic mass after gastriccancersurgery .CA199 was slightly elevated in the local hospital, and there was no obvious abnormality in CEA and CA125, but the lesi on was n ot clear.PET-CT exam in ati on showed an

5、 astomoticrecurrenee, peritoneal seeding, gastroscopy and pathology: notumor cells were found.Given the patients 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

6、 pelvic massfor 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

7、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 8.5x 5 x 4cm and 14 x 13 x 8cm,microscopy, immunohistochemical staining, and clinica

8、l 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 depa

9、rtment.The diet,sleep and defecation during the course of the disease are normal, and the weight change is not obvious.主 訴：胃癌術(shù)后 3 年余，盆腔轉(zhuǎn)移 10 月余?，F(xiàn)病史：患者 因“間斷上腹痛 6 年，黑便 8 天”就診于太 和縣人民醫(yī)院。 2014.6 于太和縣人民醫(yī)院行胃癌根治術(shù)，術(shù)后病理 示：胃小彎潰瘍型腺癌，部分為印結(jié)細(xì)胞癌，侵及肌層，腫塊3cmx3cm大??；上下切緣陰性；小彎淋巴結(jié)(+)4/10，大彎淋巴結(jié)(+) 3/3.術(shù)后患者于該院行PCF方案化療6程，具體

10、不詳?；颊咭蛭赴┬g(shù) 后盆腔包塊于 就診我院日間放化療科，患者自行當(dāng)?shù)蒯t(yī) 院查CA199輕度升高，CEA CA125未見明顯異常，未明確病變性質(zhì)， 行 pet-ct 提示吻合口復(fù)發(fā)、腹腔種植可能，復(fù)查胃鏡及病理：未發(fā) 現(xiàn)腫瘤細(xì)胞?？紤]患者既往胃癌病理，予以DF方案化療1程。后患者因“盆腔腫物 9 月余”就診于安徽醫(yī)科大學(xué)第一附屬醫(yī)院，于 全麻下行雙側(cè)附件切除術(shù)，術(shù)中見：子宮增大如孕 2 月大 小，形態(tài)正常，漿膜面光滑，右側(cè)卵巢實性分葉狀增大，大小約 15 x 12X 10cm表面光滑，左側(cè)卵巢實性分葉狀增大8X 6X 4cm表面光滑，雙側(cè)輸卵管外觀正常，盆底光滑。病理：(雙卵巢)大小分別 為8.5 x 5x4cm及14x 13x 8cm鏡檢并結(jié)合免疫組化標(biāo)記及臨床病 史 符 合 轉(zhuǎn) 移 性 低 分 化 腺 癌 ( Krukenberg 瘤 ) 。 免 疫 組 化 ： CK(+),CK7