Detailed Treatment Process
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Female, 62 years old Report Information Report time: July 5, 08:22:57 Department: Imaging site: Pancreas Imaging Findings The body and tail of the pancreas are enlarged with a low-density mass measuring approximately 54 × 33 mm. The mass has an irregular shape and ill-defined borders. Enhancement is less than that of the normal pancreatic parenchyma. Several enhanced lymph nodes are seen in the surrounding area. The lesion encases the splenic vessels. The left anterior renal fascia is thickened, and the interface between the lesion and the left adrenal gland is unclear. Several irregular, heterogeneously enhancing nodules are present in the liver, with the largest measuring approximately 21 mm. Multiple rounded cystic lesions are also seen in the liver. Multiple small calcifications are noted in the spleen. The gallbladder, both kidneys, and the right adrenal gland show no significant abnormalities. No obvious fluid collection is seen in the abdominal cavity. Imaging Conclusion Occupying lesion in the body and tail of the pancreas, suggestive of pancreatic cancer, with encasement of the splenic vessels and possible involvement of the left adrenal gland. Multiple liver metastases. Multiple hepatic cysts. Multiple small calcifications in the spleen.
Discharge Summary Admission date: July 6, 10:43 Discharge date: September 1, 09:00 Outpatient diagnosis: Pancreatic occupying lesion Admission diagnosis: Malignant tumor of the pancreatic body and tail; secondary malignant tumor of the liver; hepatic cysts Discharge diagnosis: Malignant tumor of the pancreatic body and tail (T4N0M1, stage IV); secondary malignant tumor of the liver; hepatic cysts Admission Status The patient was admitted with “left abdominal dull pain and discomfort for more than two weeks.” Physical examination: Alert, normal breathing, fair mental status. No jaundice of skin or sclera. Abdomen flat, no visible venous varices, gastrointestinal peristalsis, umbilical hernia, or spider angiomas. Abdomen soft, no muscle guarding, no tenderness or rebound tenderness. Liver and spleen not palpable below the costal margin. Murphy sign negative. No liver or kidney percussion tenderness. No shifting dullness. Bowel sounds present. No edema in the lower extremities. Main Laboratory Results July 6 [Complete Blood Count + C-Reactive Protein]: White blood cell count 5.25 × 10⁹/L, neutrophil percentage 64.3%, neutrophil absolute value 3.38 × 10⁹/L, red blood cell count 4.42 × 10¹²/L, hemoglobin 128 g/L, platelet count 208 × 10⁹/L, C-reactive protein 0.5 mg/L; July 6 [Serum Amylase]: Amylase 154 U/L↑; July 6 [Coagulation Profile + D-Dimer/FDP (urgent)]: Fibrin(ogen) degradation products 1.10 μg/ml, D-dimer 0.18 DDU μg/ml, thrombin time 17.7 seconds, prothrombin time 11.00 seconds, international normalized ratio 0.96, fibrinogen 2.61 g/L, activated partial thromboplastin time 23.8 seconds↓; July 6 [B-Type Natriuretic Peptide]: BNP 20.0 pg/mL; July 6 [Renal Function + Cystatin C + Liver Function (new 3) + Phosphorus + Magnesium + Lipids (4 items) + Free Fatty Acids]: Total bilirubin 12.2 μmol/L, direct bilirubin 3.1 μmol/L, alanine aminotransferase 12 U/L, aspartate aminotransferase 14 U/L, total protein 73.8 g/L, albumin 46.8 g/L, urea 4.55 mmol/L, creatinine 61.0 μmol/L; July 6 [Cardiac Markers (rapid)]: CK-MB 1.2 ng/ml, myoglobin 18.40 ng/ml, troponin I 0.00 ng/ml; August 26 [Complete Blood Count + C-Reactive Protein]: White blood cell count 9.87 × 10⁹/L↑, neutrophil percentage 45.8%, neutrophil absolute value 4.52 × 10⁹/L, red blood cell count 4.24 × 10¹²/L, hemoglobin 117 g/L, platelet count 603 × 10⁹/L↑, C-reactive protein 9.3 mg/L; August 26 [Renal Function + Cystatin C + Liver Function (new 3) + Lipids (4 items) + Phosphorus + Magnesium]: Total bilirubin 5.4 μmol/L, direct bilirubin 2.0 μmol/L, alanine aminotransferase 94 U/L↑, aspartate aminotransferase 46 U/L↑, total protein 69.0 g/L, albumin 37.0 g/L↓, urea 5.18 mmol/L, creatinine 38.0 μmol/L↓; August 26 [Procalcitonin]: Procalcitonin 0.11 ng/ml; August 26 [D-Dimer/FDP (urgent)]: Fibrin(ogen) degradation products 5.40 μg/ml↑, D-dimer 0.90 DDU μg/ml↑; August 26 [Blood Gas and Glucose Analysis]: pH 7.395, PO₂ 29.9 mmHg, PCO₂ 52.1 mmHg, oxygen saturation 48.0%, standard base excess 7.0 mmol/L↑, actual base excess 5.9 mmol/L↑, standard bicarbonate 28.8 mmol/L↑, bicarbonate 31.9 mmol/L↑, potassium (whole blood) 4.0 mmol/L, sodium (whole blood) 132 mmol/L↓, chloride (whole blood) 94.0 mmol/L↓, ionized calcium 1.17 mmol/L, glucose (whole blood) 9.9 mmol/L↑, lactate 1.5 mmol/L, total hemoglobin 10.9 g/dl↓↓. Special Examinations and Important Consultations July 7, Routine echocardiography (cardiac ultrasound + left ventricular function + TDI + 3DE): Mild aortic regurgitation; July 8, Chest plain scan: Scattered fibrotic strands and calcifications in both lungs; thickening of bilateral apical pleura; abdominal abnormality noted—please correlate with abdominal imaging. July 15, Chest plain scan: Exudative consolidation in both lower lobes, bilateral pleural effusions with partial atelectasis of both lower lungs—suggest follow-up after treatment; fibrotic strands and calcifications in the right upper lobe; thickening of bilateral apical pleura; July 15, Lower and upper abdominal plain scans: Postoperative changes following pancreatic body and tail resection + total splenectomy + microwave ablation of liver lesions + lysis of intestinal adhesions. Several nodular mixed-density lesions in the liver—please correlate with MRI for tumor viability; small amounts of gas under the liver capsule and in the abdominal cavity, scattered exudative fluid in the abdominopelvic cavity with drainage tubes in place; localized edema and thickening of a segment of small bowel in the mid-upper abdomen—please follow clinically; cholecystitis with biliary stasis. July 22, Lower and upper abdominal plain scans: Postoperative changes following pancreatic body and tail resection + total splenectomy + microwave ablation of liver lesions + lysis of intestinal adhesions. Several nodular mixed-density lesions in the liver—please correlate with MRI for tumor viability. Compared with July 15, gas in the abdominal cavity and under the liver capsule has been largely absorbed. Scattered exudative fluid in the abdominopelvic cavity with drainage tubes—fluid has decreased slightly; localized edema and thickening of small bowel in the mid-upper abdomen has largely resolved—please follow clinically; cholecystitis with biliary stasis; bilateral pleural effusions with partial atelectasis of the right lower lung—please correlate with chest CT. August 9, Fluid around drainage tube, bilateral lower abdominal cavity fluid, subdiaphragmatic fluid, perihepatic fluid, perisplenic fluid, pelvic fluid, fluid under incision: No obvious fluid around drainage tube; no obvious abdominal fluid; no obvious subdiaphragmatic fluid; no obvious perihepatic or perisplenic fluid; no obvious pelvic fluid; no obvious fluid under incision. July 12 Pathology (X22-03488): “Pancreatic body and tail + spleen.” Pancreas: Adenocarcinoma, grade II (5 × 5 × 3 cm), with perineural invasion. “Liver nodule ②” and “greater omentum nodule”: Metastatic carcinoma. Pancreatic resection margin, spleen, peripancreatic lymph nodes (fatty tissue), and liver nodule: Negative. July 18 (I22-08374): “Pancreas”: Adenocarcinoma, grade II. Tumor cells: Ki67 (20%+), P53 (70%+), MLH1 (+), MSH2 (+), MSH6 (+), PMS2 (+), HER2 (−), PD-L1 (−). Treatment Course After admission, preoperative evaluation was completed. On July 11, under general anesthesia, the patient underwent pancreatic body and tail resection + total splenectomy + ultrasound-guided microwave ablation of liver lesions + lysis of intestinal adhesions. Intraoperative findings: (1) Tumor: Located in the pancreatic body, approximately 6.0 × 5.0 × 3.0 cm, hard, without capsule, irregular shape, gray-white solid cut surface, loss of normal pancreatic architecture, hard and brittle texture, infiltrative growth invading the splenic artery and vein. Spleen approximately 8 × 5 × 3 cm. Obvious varices at the splenic hilum, greater curvature of the stomach, colonic mesentery, and omentum. Left adrenal gland invaded by tumor. Tumor base fixed. Partial invasion of transverse mesocolon. (2) Vessels: Splenic artery origin close to tumor but separable. Splenic vein occluded by tumor approximately 3 cm from the left edge of the superior mesenteric vein—divided and closed with 5-0 Prolene after division. Tumor caused iatrogenic portal hypertension. Left gastric artery arose from the right side of the celiac trunk and was not involved. Inferior mesenteric vein joined the mid splenic vein and was ligated. No vascular anomalies in the surgical field. (3) Lymph nodes: Some enlargement of groups 7, 8, 9, and 12, but soft. No obvious enlargement of group 16. (4) Abdominopelvic cavity: Three liver metastases identified—radiofrequency ablation performed by interventional team. No metastases found in stomach, small bowel, colorectum, or peritoneum. No ascites. (5) Procedure: Divided at the right edge of the superior mesenteric vein/portal vein using a 60 mm stapler. Splenic vein and artery handled separately. Intraoperative blood loss approximately 100 ml. No transfusion. Operative time approximately 180 minutes. Patient transferred to SICU for close monitoring. Postoperative care included anti-infection, acid suppression, and enzyme inhibition therapy. The patient developed delayed gastric emptying and fluid collection in the surgical field. Local puncture drainage, fasting, and parenteral nutrition were provided. Gastric decompression output gradually decreased. The patient tolerated semi-liquid diet without discomfort and was discharged. Complications Discharge Status The patient was in fair general condition with no significant complaints of abdominal pain or fever. Physical examination: Alert, normal breathing, good mental status. No obvious jaundice. Heart and lungs unremarkable. Abdomen soft, no tenderness, rebound, or guarding. No shifting dullness. No lower extremity edema. Incision healed well, sutures removed, drains removed. Post-Discharge Medications and Instructions 1. Follow-up with the chief physician in the outpatient clinic in 2–3 weeks. Subsequent treatment (Monday morning, Wednesday morning, Thursday morning, Friday afternoon, Saturday morning outpatient). 2. Balanced diet with increased protein intake. Small, frequent meals in the near term. Pay attention to nutrition and rest. 3. Seek prompt medical attention if abdominal pain or fever develops. 4. Arrange follow-up treatment in the Wednesday afternoon digestive tract tumor specialty clinic. Follow-up Plan Treatment outcome: Improved
Pathology Report Received date: July 12 Referring hospital: This hospital Gross findings: Pancreatic body and tail: 9 × 5 × 3 cm. Cut surface shows a 5 × 5 × 3 cm mass, gray-white and firm. A–E: Mass. F: Resection margin. G–H: Spleen 10 × 5 × 4 cm, gray-brown cut surface, no obvious nodules. I: One peripancreatic LN 0.2 cm. J: “Liver nodule” tissue 2 × 1.5 × 1 cm. K: “Liver nodule ②” tissue, maximum diameter 1 cm, with a 0.8 cm gray-white nodule on the surface. L: “Greater omentum nodule” tissue, maximum diameter 2 cm, with a 1 cm gray-white nodule on the surface. Pathological Diagnosis Pancreatic body and tail + spleen “Pancreas”: Adenocarcinoma, grade II (5 × 5 × 3 cm), with perineural invasion. “Liver nodule ②” and “greater omentum nodule”: Metastatic carcinoma. Pancreatic resection margin, spleen, peripancreatic lymph nodes (fatty tissue), liver nodule: Negative. Report date: July 14
Report Information Report time: November 10, 19:03:38 Imaging site: Chest Imaging Findings Thorax symmetric, trachea midline, no mediastinal shift. Nodular lesion on the left chest wall. Scattered small patchy opacities in both lungs. Multiple small calcifications in the right upper lobe, left lower lobe, and left hilum. Scattered linear opacities in both lungs. Exudative consolidation in both lower lobes. Hilar shadows not enlarged. Thickening of bilateral apical pleura. Trace right pleural effusion and left pleural effusion with left lower lobe atelectasis. No obvious enlarged mediastinal lymph nodes. Heart size normal. Imaging Conclusion Left chest wall metastasis. Exudative changes in both lower lobes and bilateral pleural effusions. Compared with October 25: Increased exudation in right lower lobe; left lower lobe exudation and bilateral pleural effusions show little absorption—please correlate with clinical history and follow up. Scattered small patchy lesions in both lungs—please follow up. Scattered fibrotic strands in both lungs, multiple small calcifications in right upper lobe, left lower lobe, and left hilum. Thickening of bilateral apical pleura.
Report Information Report time: November 10, 19:05:58 Imaging site: Pelvis Imaging Findings Marked dilatation of small bowel. Multiple nodular lesions in the pelvis. Bladder poorly distended. Uterus normal in size and shape with smooth outline and homogeneous myometrium. No obvious abnormal densities in bilateral adnexa. No enlarged pelvic lymph nodes. Pelvic fluid. Pelvic bones intact. Imaging Conclusion Small bowel obstruction. Multiple pelvic metastases suspected. Pelvic fluid.
Report Information Report time: November 10, 19:07:56 Imaging site: Lower abdomen Imaging Findings Postoperative changes following pancreatic body and tail resection + total splenectomy + microwave ablation of liver lesions + lysis of intestinal adhesions. Small bowel shows postoperative changes with marked fluid-filled dilatation. Scattered fat stranding with exudation and fluid in the abdominopelvic cavity. Mass-like soft-tissue density in the left upper abdomen. Multiple nodular mixed-density lesions in the liver with ill-defined borders; largest in right lobe, approximately 31 mm. Scattered rounded low-density lesions in the liver parenchyma. Nodular soft-tissue density at the umbilicus, approximately 2 cm. Both kidneys and right adrenal gland unremarkable. Localized gallbladder wall thickening with layering. No obvious dilatation of intra- or extrahepatic bile ducts or pancreatic duct. Bladder poorly distended. Greater omentum thickened with multiple scattered small nodules in the abdominal cavity. Pelvic bones intact. Imaging Conclusion Postoperative changes following pancreatic body and tail resection + total splenectomy + microwave ablation of liver lesions + lysis of intestinal adhesions. Small bowel obstruction. Scattered exudation and fluid in the abdominopelvic cavity. Multiple intra-abdominal metastases, umbilical abdominal wall metastasis, multiple liver metastases, greater omentum thickening—suggest contrast-enhanced follow-up. Possible scattered hepatic cysts. Cholecystitis with biliary sludge and stones?