Detailed Treatment Process
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Pathology Report Sex: Female Age: 47 Specimen: Biopsy tissue Department: Surgical Ward Gross description: Right upper lobe resection specimen, 15 × 8 × 4 cm, with focal pleural adhesions. Cut surface: a gray-white mass measuring 2.5 × 2 × 1.8 cm was seen in the apical segment, with ill-defined borders, medium consistency, and close to the pleura locally. Pathological diagnosis or conclusion: Right upper lobe: adenosquamous carcinoma; invasion of visceral pleura. Frozen section margins: no carcinoma identified. Report date: August 16, 2012
(Same surgical specimen as the previous pathology report) Findings: 1. Resected left lower lobe, measuring 14 × 10 × 8 cm, with staple line 3.5 cm long. Pleural surface smooth, gray-black. Bronchial margin 0.1 cm long, 1 cm in diameter. Lung segments opened along the bronchus; a mass measuring 7 × 7 × 5 cm was found 3 cm from the bronchial stump beneath the pleura. Cut surface gray-white, medium consistency, with ill-defined borders and corresponding pleural retraction. Remaining lung parenchyma gray-red and soft. Two peribronchial lymph nodes identified. 2. (Group 5) Two lymph nodes, largest 0.5 × 0.5 × 0.2 cm, smallest 0.4 × 0.4 × 0.2 cm. 3. (Group 7) Three lymph nodes, largest 1 × 1 × 0.8 cm, smallest 0.4 × 0.3 × 0.3 cm. 4. (Group 8) One lymph node, 0.3 × 0.2 × 0.2 cm. 5. (Group 9) Two lymph nodes, largest 0.5 × 0.5 × 0.2 cm, smallest 0.4 × 0.4 × 0.2 cm. 6. (Group 10) One lymph node, 0.8 × 0.6 × 0.4 cm. 7. (Group 11) Three lymph nodes, largest 0.6 × 0.5 × 0.5 cm, smallest 0.2 × 0.2 × 0.2 cm. Impression: Routine diagnosis: Moderately to poorly differentiated carcinoma of the left lower lobe with extensive necrosis, morphologically suggestive of neuroendocrine carcinoma. Tumor size 7 × 7 × 5 cm. Carcinoma invades but does not penetrate the pleura. Bronchial stump and staple line free of carcinoma. No metastatic carcinoma in peribronchial or submitted (Groups 5, 7, 8, 9, 10, 11) lymph nodes (0/2, 0/2, 0/3, 0/1, 0/2, 0/1, 0/3 respectively). Immunohistochemistry: ALK (Ventana) negative, Napsin A negative, CK7 positive, CK5 positive, p63 (focal positive), TTF-1 negative, p40 negative, CK positive, Ki-67 positive (80%), CgA negative, Syn negative, CD56 negative. Special stain: Elastic fiber stain positive.
Discharge Summary Sex: Female Age: 46 Admission date: October 29, 2012 Discharge date: October 30, 2012 Outpatient diagnosis: Status post right upper lobe adenosquamous carcinoma T₂aN₀M₀ stage Ib Admission diagnosis: Status post right upper lobe adenosquamous carcinoma T₂aN₀M₀ stage Ib Discharge diagnosis: Status post right upper lobe adenosquamous carcinoma T₂aN₀M₀ stage Ib Main symptoms and signs on admission: The patient was admitted two months after lung cancer surgery. General condition good, normal temperature, no complaints. Main laboratory results: Complete blood count and liver and kidney function normal. Special examinations and consultations: None. Course and treatment outcome: Admission examinations completed. On October 29, the patient received the second cycle of chemotherapy with docetaxel 120 mg D1 plus carboplatin 0.2 g D1 and D2. No discomfort reported. Complications: None Condition at discharge: General condition good, normal temperature, no chest tightness or shortness of breath, appetite fair. Post-discharge medications and recommendations: 1. Director’s clinic Wednesday and Thursday afternoons, physician’s clinic Tuesday afternoon. 2. Next chemotherapy planned in three weeks to one month (total 4–6 cycles depending on condition). 3. Re-check complete blood count and liver and kidney function within one week after discharge; if abnormal, leukocyte-raising and liver-protective treatment required. Treatment outcome: Cured (√) Improved () Not healed () Death () Other ()
Image 1: Radiology Report Sex: Female Age: 52 Department: Outpatient Clinical diagnosis: Status post right lung adenosquamous carcinoma (stage Ib) Requested by: Assist in diagnosis Examination: Chest CT Radiological findings: Post right lung surgery. Right residual bronchial stump unremarkable. Scattered linear opacities in the lower right residual lung and left upper lobe. Right pleural thickening. No enlarged mediastinal or hilar lymph nodes. Incidental heterogeneous liver density. Radiological diagnosis: 1. Post right lung surgery with scattered linear opacities in the lower right residual lung and left upper lobe, unchanged compared with the April 16, 2015 study. Follow-up recommended. 2. Incidental heterogeneous liver density. Reporting physician: Verifying physician: Examination time: September 24, 2016 19:54 Report time: September 25, 2016 16:46 Verification time: September 26, 2016 07:29
Laboratory Report (1) Sex: Female Age: 52 years Requesting department: Tumor Interventional Expert Clinic Specimen: Blood Test date: May 9, 2017 Clinical diagnosis: Malignant lung tumor Item Result Reference range Carcinoembryonic antigen 3.2 (smokers <5.0 ng/ml; non-smokers <3.0 ng/ml) CA125 8.00 (0–35 U/ml) Cytokeratin 19 fragment 1.67 (0–3.3 ng/ml) Collection date: May 8, 2017 09:04 Received date: May 8, 2017 10:06 Report date: May 9, 2017 14:10 Print date: May 10, 2017
Laboratory Report (2) Sex: Female Age: 52 years Requesting department: Tumor Interventional Expert Clinic Specimen: Blood Test date: May 8, 2017 Clinical diagnosis: Malignant lung tumor Item Result Reference range CA72-4 0.52 (0–10 U/ml) Neuron-specific enolase 9.336 (0–20 ng/ml) Collection date: May 8, 2017 09:04 Received date: May 8, 2017 10:06 Report date: May 8, 2017 14:19 Print date: May 10, 2017
Laboratory Report Sex: Female Age: 52 years Code/Item Result Reference range AFP (alpha-fetoprotein) 8.54↑ (0–7 ng/ml) Report time: May 9, 2017 10:01:24
Examination Report Details (2023) Report time: May 10, 2023 15:38:16 Female, 57 years old Ordering department: Convenience Clinic Examination: Non-contrast chest CT Findings: Post right lung surgery with scattered patchy and linear opacities in the surgical area, adjacent pleural thickening and adhesions. Residual bronchial stump well formed. Contralateral bronchus patent. Multiple nodules and patchy opacities in the right residual lung and left upper lobe; largest nodule in the right lower lobe (thin-slice Im191) measures approximately 13.6 mm in long diameter with irregular morphology. No obviously enlarged mediastinal or bilateral hilar lymph nodes. No obvious pleural effusion bilaterally. Diagnostic conclusions 1. Post right lung surgery: scattered patchy and linear opacities in the surgical area; regular follow-up recommended. 2. Multiple nodules and patchy opacities in the right residual lung and left upper lobe; short-term follow-up after anti-inflammatory treatment recommended.
Examination Report Details (2024) Report time: August 23, 2024 08:00:07 Female, 58 years old Examination: Non-contrast chest CT Findings: Post right lung surgery: scattered patchy and linear opacities in the surgical area, adjacent pleural thickening and adhesions. Residual bronchial stump well formed. Contralateral bronchus patent. Multiple nodules and patchy opacities in the right residual lung and left upper lobe; largest nodule in the right lower lobe (thin-slice Im192) measures approximately 13.6 mm in long diameter with irregular morphology. No obviously enlarged mediastinal or bilateral hilar lymph nodes. No obvious pleural effusion bilaterally. Diagnostic conclusions 1. Post right lung surgery: scattered patchy and linear opacities in the surgical area; regular follow-up recommended. 2. Multiple nodules and patchy opacities in the right residual lung and left upper lobe, essentially unchanged compared with the May 8, 2023 CT; follow-up recommended.
This lung cancer patient underwent surgery in 2012 and remained stable with no recurrence through 2024.