Detailed Treatment Process
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Male, 28 years old in 2022 The following is an inpatient medical record Admission time: July 27, 2013, 11:40 Discharge time: July 30, 09:53 Hospital stay: 3 days Condition on admission: Admitted for “a right forearm mass discovered more than 4 years earlier.” More than 4 years previously, the patient noticed a mass at the site of a contusion injury to the right forearm. There was no pain, no chills or fever, and no pain, numbness, or restricted movement in the right upper arm. The patient did not seek medical attention at the time. The mass gradually enlarged and became painful. For further evaluation and treatment, the patient presented to our hospital today and was admitted through the outpatient department with a diagnosis of “right forearm mass.” Since the onset of illness, the patient’s mental status and appetite have been normal, bowel and bladder function has been normal, and there has been no significant change in strength or body weight. Specialist findings: On the dorsal ulnar aspect of the mid-to-upper right forearm, between the flexor carpi ulnaris and extensor carpi muscles, a mass approximately 2.0 cm × 2.0 cm × 2.0 cm was palpable. It was slightly firm, had clear borders, mild tenderness, and reasonable mobility. No fluctuation was felt. The overlying skin showed no redness or increased temperature. There was no obvious limitation of right upper limb movement. Auxiliary examinations: Electrocardiogram showed a normal tracing. Color ultrasound of the mass suggested an abnormal subcutaneous echo in the right forearm, nature to be determined. Admission diagnosis: Right forearm mass Hospital course: After admission, the patient completed relevant examinations and underwent excision of the right forearm mass. Postoperatively, anti-inflammatory, hemostatic, and symptomatic treatment was given. Condition at discharge: The patient was in generally good condition. The surgical incision was healing well, with no obvious redness, swelling, or exudation. He was discharged improved today. Discharge diagnosis: Right forearm fibroma Discharge instructions: ① Keep the wound dressing clean and dry; ② Return to the outpatient clinic for dressing changes and suture removal; ③ Follow-up
During the above hospitalization, an ultrasound report was available as follows Ultrasound findings: At the palpable “mass” on the right forearm, a subcutaneous hypoechoic lesion measuring approximately 1.7 × 0.6 cm was detected. It had clear borders, an irregular shape, and relatively heterogeneous internal echoes. No blood flow signals were seen on color Doppler. Ultrasound impression: Abnormal subcutaneous echo in the right forearm, nature to be determined; follow-up recommended. Examination date: July 27
After the surgery performed during the above admission, the pathological diagnosis of the specimen was as follows: Gross examination: Four pieces of gray-brown tissue were submitted, all processed. Pathological diagnosis: The submitted specimen (right forearm) is consistent with fibroma. The following is an admission record titled “26th Admission Record” Admission time: February 17, 2022, 11:02 History recorded: February 17, 2022, 11:38 History provided by: The patient himself (reliable) Chief complaint: Seven months after treatment for epithelioid sarcoma-like hemangioendothelioma of the right forearm. Present illness: In August 2009, following local contusion to the right forearm, the patient noticed a subcutaneous nodule approximately 0.5 cm in diameter. It was mobile, had a smooth surface, and there was no local redness, swelling, tenderness, skin numbness, or limitation of movement. There were no accompanying symptoms such as fever, night sweats, cough, or diarrhea. The patient did not pay much attention to it. The nodule gradually enlarged and by 2013 had reached 2 cm in size, accompanied by local pain and tenderness. The patient visited Hospital A for ultrasound, which showed an abnormal subcutaneous echo in the right forearm measuring approximately 1.7 × 0.6 cm, nature to be determined. On July 27, 2013, he underwent “local anesthesia right forearm fibroma excision.” He was told that the mass had not been completely removed. Postoperative pathology (131026) on July 30, 2013, indicated: submitted <right forearm> consistent with fibroma. The wound healed well after surgery. One month after surgery, a subcutaneous nodule was again palpable in the surgical area without tenderness or local redness or swelling. The patient did not attach sufficient importance to it. The nodule continued to enlarge gradually. By 2016 it had reached the size of a hen’s egg and was accompanied by local skin numbness and tenderness. The patient felt limited abduction of the right upper limb due to “distending pain.” On October 12, 2016, he visited the orthopedics department of Hospital B. Ultrasound showed a heterogeneous echo area in the subcutaneous tissue of the right forearm; fibroma could not be excluded. On October 13, 2016, ultrasound-guided percutaneous biopsy of the right forearm mass was performed. Pathology showed fibrous tissue proliferation with chronic inflammation; excision for definitive diagnosis was recommended. Further contrast-enhanced MRI and CT of the right forearm suggested possible recurrent fibroma based on the history. Chest X-ray and abdominal ultrasound showed no abnormalities. On November 4, 2016, he underwent excision of a right forearm soft-tissue tumor mass. Postoperative pathology on the same day showed patchy fibrous tissue proliferation with chronic inflammation; further immunohistochemical examination was recommended. The patient reported that at the time of suture removal a subcutaneous nodule approximately 1 cm in size was already palpable on the ulnar side of the surgical area. It was mobile and nontender. He was discharged before the immunohistochemistry results were available. In December 2016, two additional subcutaneous nodules approximately 1 cm in size were found on the radial side of the surgical area. In March 2017, a nodule approximately 1 cm in size was found beside the deltoid muscle of the right upper arm. It was mobile and tender. Because of repeated recurrences, the patient returned to the orthopedics department of Hospital B. Immunohistochemistry performed on March 15, 2017, on the specimen from the November 2016 surgery suggested epithelioid sarcoma. The patient did not pursue further treatment at that time. On April 8, 2017, he developed pain in the right axilla when moving the right upper limb. A mass approximately 2 cm in size was palpable in the right axilla; it was tender, had a smooth surface, and was mobile. For further diagnosis and treatment, he presented to our department. Chest CT showed no abnormalities in the thorax. A nodular lesion was noted in the subcutaneous fat layer of the proximal anterior right upper arm. Pathology consultation indicated epithelioid sarcoma-like hemangioendothelioma / pseudomyogenic hemangioendothelioma. Considering it a low-grade malignant tumor, he received two cycles of systemic chemotherapy with “doxorubicin + apatinib” on April 12 and May 3, 2017. The chemotherapy course was uneventful. On the third day after the first cycle, the patient noticed that the right axillary lymph node had become smaller and softer, while the subcutaneous nodules in the right forearm appeared slightly larger with clearer borders and reduced tenderness. He continued oral apatinib throughout the chemotherapy period. At the end of April 2017, the dose was increased to 500 mg once daily, after which he developed grade 2 hand-foot syndrome with erythema, blisters, and pain at the extremities. The drug was stopped and symptomatic treatment was given, after which the condition improved. On May 5, 2017, MRI of the right upper limb showed a nodular shadow on the radial side of the right forearm (1.5 × 1.3 × 2.5 cm) and an enlarged right axillary lymph node (2.1 × 1.4 cm). For further management, the patient went to [redacted] Hospital. MRI of the right upper limb on June 21, 2017, showed that the right forearm mass (1.2 × 0.7 cm) and right axillary lymph node (1.3 × 0.9 cm) had decreased in size compared with the May 5 scan. He received two cycles of chemotherapy with “ifosfamide + doxorubicin + apatinib” on June 22 and July 14, 2017. Follow-up MRI showed a nodular shadow on the radial side of the right forearm measuring approximately 1.6 × 0.8 × 0.3 cm and no enlarged lymph nodes in the right axilla. On August 8 and August 28, 2017, he received chemotherapy with “doxorubicin + cisplatin + apatinib.” Follow-up examinations indicated stable disease. Maintenance chemotherapy with “doxorubicin 40 mg IV D1 + apatinib 250 mg PO daily” was given on December 11, 2017, March 12, 2018, June 11, 2018, and September 11, 2018. MRI of the forearm on March 29, 2019, showed postoperative changes of epithelioid sarcoma in the subcutaneous tissue of the right forearm. MRI of the right upper arm showed no obvious abnormalities. Multiple enlarged lymph nodes were present in the right axilla, the largest measuring approximately 1.8 × 1.1 cm, possibly metastatic. Compared with the MRI of December 7, 2018, the right axillary lymph nodes had enlarged, with no other significant changes. The current follow-up indicated disease progression. He received another round of systemic chemotherapy on April 1 and May 5, 2019: doxorubicin 40 mg IV D1 + cisplatin 60 mg IV D1-2. MRI of the right forearm on November 12, 2019, showed patchy abnormal signals in the subcutaneous tissue on the radial side of the right forearm, predominantly long T1 and short T2, with the largest lesion measuring approximately 1.5 × 1.1 cm and showing obvious enhancement after contrast. Chest CT revealed a cavity in the left lung apex, considered a neoplastic lesion. On November 22, 2019, the patient began third-line chemotherapy with toripalimab + recombinant human endostatin. Because the arm lesions did not shrink significantly, the regimen was changed to two cycles of doxorubicin + toripalimab as third-line treatment. Afterward, he continued intermittent oral apatinib targeted therapy. In November 2020, the mass in the right hand and arm enlarged markedly. He received two cycles of fourth-line chemotherapy: doxorubicin 20 mg IV D1 + toripalimab 240 mg IV D1. Efficacy assessment was progressive disease. In February 2021, he underwent extended resection of the right arm tumor and skin grafting at Hospital B, followed by adjuvant doxorubicin + PD-1 therapy. Over the subsequent six months, the patient felt gradual enlargement of the right axillary lymph nodes. More than one month ago, contrast-enhanced MRI in the outpatient clinic showed multiple nodular shadows in the right axilla, considered possibly metastatic lymph nodes with partial fusion. The patient occasionally experienced chest tightness that was relieved by oxygen inhalation. Today he presented to our hospital for further diagnosis and treatment. During the course of the disease, his mental status and appetite have remained good, bowel and bladder function has been normal, and body weight has shown no obvious change.
On April 5, 2023, a medical damage appraisal institution issued an “Appraisal Opinion” stating: Hospital A committed a fault by violating the duty of care. Hereinafter, Hospital A is referred to as the hospital. During physical examination, the hospital found “a mass approximately 2.0 cm × 2.0 cm × 2.0 cm on the dorsal ulnar aspect of the mid-to-upper right forearm, located between the flexor carpi ulnaris and extensor carpi muscles.” Color ultrasound revealed “a subcutaneous hypoechoic mass measuring approximately 1.7 × 0.6 cm.” Preoperatively, it was already known that the mass diameter exceeded 1 cm, so “fibrosarcomatous transformation should be suspected,” and the surgical plan should have included “adequate normal skin and sufficient deep fascia in the resection margins for this type of tumor.” However, the existing medical records do not confirm that the hospital exercised sufficient care regarding the nature of the right forearm mass and the design of the surgical plan. The above statement can be understood in plain language as follows: for masses larger than 1 cm in diameter, the surgical resection should include sufficient normal skin tissue and an adequate range of deep fascia. The hospital did not pay sufficient attention or importance to this during the operation.