Detailed Treatment Process
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Female, 62 years old Laboratory report Application time: December 6, 2022, 17:17 Collection time: December 7, 2022, 05:54 Preliminary diagnosis: Obstructive jaundice Serial No.\Item\Abbreviation\Result\Unit (Reference Range) 1 CA_125 CA_125 40.80 (0-22 U/ml) 2 CA_199 CA_199 >12000.00 (0-43 U/ml) 3 Carcinoembryonic antigen CEA CEA 648.24 (0-5 ng/ml) 4 Alpha-fetoprotein AFP AFP 3.36 (0-7 ng/ml) Received time: December 7, 2022, 08:06 Reported time: December 7, 2022, 10:04
Discharge record Admission time: December 6, 2022 Discharge time: December 19, 2022, 15:54 Admission diagnosis: Obstructive jaundice; Hypertension Discharge diagnosis: Cholangiocarcinoma occupying lesion; Obstructive jaundice; Liver dysfunction; Hypertension Admission status: The patient was admitted for “poor appetite and fatigue for more than 20 days with progressive worsening of skin jaundice.” Twenty days earlier, without obvious cause, she developed poor appetite, fatigue, and skin jaundice. There was no abdominal pain, no back radiation, no nausea or vomiting, no chills or fever, mild abdominal distension, no belching or acid reflux, no palpitations or chest tightness, no shortness of breath, and no obvious cough or sputum. She received symptomatic treatment at a local hospital (details unknown) with no obvious improvement, and the skin jaundice progressively worsened. An MRI at another hospital suggested a pancreatic head mass with retroperitoneal lymph node metastasis. She was seen at our outpatient clinic for further treatment and admitted under the diagnosis of “pancreatic occupying lesion.” Since onset, she had been alert, with fair appetite and spirit, fair sleep, and normal bowel and bladder function. Physical examination: Jaundice of skin and sclera; abdomen soft and flat, no visible intestinal patterns or peristalsis; liver and spleen not palpable below the costal margin; Murphy sign negative; mild tenderness in the upper middle abdomen; rebound tenderness negative; shifting dullness negative; bowel sounds 3-4 times per minute. Hospital course: After admission, relevant examinations were completed. On December 7, 2022, magnetic resonance cholangiopancreatography (MRCP 1.5T) showed cholangiocarcinoma with high biliary obstruction, suspected invasion of the pancreatic head; viscous bile; intrahepatic cystic lesions; and multiple enlarged retroperitoneal lymph nodes. On December 8, 2022, upper abdominal CT plain and enhanced scan showed intrahepatic bile duct dilatation, stenosis of the common hepatic duct and common bile duct, suggestive of cholangiocarcinoma; enlarged retroperitoneal lymph nodes with local fusion; rough margins of the common hepatic artery and pancreatic head, suggestive of invasion; concentrated bile in the gallbladder; hepatic cysts; tracheal diverticulum; and a soft tissue nodule in the anterior mediastinum, recommending follow-up. She received anti-infection, liver protection, and fluid support treatment. On December 8, 2022, ultrasound-guided percutaneous transhepatic biliary drainage was performed, with smooth drainage afterward and declining bilirubin. On December 12, 2022, ERCP with biopsy was performed, followed by acid suppression, enzyme suppression, anti-inflammatory, and liver protection treatment. Post-procedure, she had intermittent abdominal pain, with elevated white blood cells and bilirubin; antibiotics were adjusted. Her general condition was stable, but the family requested transfer to a higher-level hospital, so she was discharged. Pathology from the “ampulla” biopsy showed mucosal tissue with acute and chronic inflammatory cell infiltration in the lamina propria, plus a small amount of fragmented intestinal mucosal glandular tissue. Discharge status: The patient had no obvious discomfort. Physical examination: Alert, fair spirit, no obvious abnormalities on heart and lung auscultation, soft and flat abdomen, liver and spleen not palpable below the costal margin, no obvious tenderness or rebound tenderness, normal bowel sounds. Discharge orders: 1. Low-salt, low-fat diet with increased nutrition. 2. Further treatment at a higher-level hospital. 3. Follow-up in our department.
MR diagnostic report Registration time: December 7, 2022, 7:42:19 Report time: December 7, 2022, 10:15:42 Clinical diagnosis: Examination: Magnetic resonance cholangiopancreatography (MRCP 1.5T) Imaging findings: The liver was normal in size and shape with homogeneous signal. A localized soft tissue mass was seen at the hepatic hilum to the lower common bile duct, showing iso-T1 and slightly long T2 signal. The surrounding area and lower common hepatic duct showed abrupt “rat-tail” interruption. Intrahepatic bile ducts, left and right hepatic ducts, and common hepatic duct were dilated, with soft vine-like changes in intrahepatic branches. Enhanced scan showed irregular thickening of the bile duct wall with marked enhancement, unclear boundary with the pancreatic head. Multiple enlarged retroperitoneal lymph nodes were present with enhancement. Cystic long T1 and long T2 lesions were seen in the upper right posterior segment and lateral segment of the left lobe of the liver, with clear borders and no enhancement; the larger one measured about 21 mm. Intrahepatic vessels were normal. No dilatation of intra- or extrahepatic bile ducts. The gallbladder was not enlarged, with short T1 and slightly short T2 signal inside. The spleen was normal. No obvious peritoneal effusion. MRCP showed “rat-tail” interruption of the lower common hepatic duct with dilatation of intrahepatic bile ducts, left and right hepatic ducts, and common hepatic duct, and soft vine-like changes in intrahepatic branches. The gallbladder was not enlarged, with smooth wall and reduced intraluminal signal. The pancreatic duct was not dilated. No peritoneal effusion. Diagnostic impression: Cholangiocarcinoma with high biliary obstruction and suspected invasion of the pancreatic head; viscous bile; intrahepatic cystic lesions; multiple enlarged retroperitoneal lymph nodes.
CT diagnostic report Requesting department: General Surgery, Hepatobiliary and Pancreatic Ward Registration time: December 8, 2022, 7:43:23 Report time: December 8, 2022, 10:49:51 Clinical diagnosis: Examination: Upper abdominal CT plain and enhanced scan Imaging findings: Bilateral thoracic symmetry, slightly increased lung markings, no obvious abnormal densities in lung parenchyma, tracheal diverticulum, patent main bronchi. Mediastinal window showed midline mediastinum with a nodular soft tissue density in the anterior mediastinum, clear border, diameter about 17 mm. No obvious free pleural effusion. Liver normal in size and shape. Intrahepatic bile duct dilatation, stenosis of common hepatic duct and upper common bile duct with nodular and ring-like persistent enhancement of the wall after contrast. Ring-like enhancement in the lower common bile duct. Oval low-density non-enhancing lesions in the liver, larger one in the right lobe about 16×20 mm. Enlarged gallbladder with increased bile density. Slightly atrophic pancreas with mild pancreatic duct dilatation. Normal spleen without abnormal enhancement. Multiple enlarged retroperitoneal lymph nodes with heterogeneous density, appearing fused, unclear borders with common hepatic artery and pancreatic head. No obvious peritoneal effusion. Diagnostic impression: Intrahepatic bile duct dilatation, stenosis of common hepatic duct and common bile duct, suggestive of cholangiocarcinoma; enlarged retroperitoneal lymph nodes with local fusion, rough margins of common hepatic artery and pancreatic head, suggestive of invasion; concentrated bile in gallbladder; hepatic cysts; tracheal diverticulum and anterior mediastinal soft tissue nodule, recommend follow-up.
Discharge record Admission time: December 20, 2022 Discharge time: January 9, 2023, 09:36 Admission diagnosis: Obstructive jaundice; Malignant cholangiocarcinoma Discharge diagnosis: Malignant cholangiocarcinoma; Obstructive jaundice; Liver dysfunction; Hypertension Admission status: The patient was admitted for “progressive worsening of skin and scleral jaundice for 1 month.” One month earlier, without obvious cause, she developed progressive jaundice of skin and sclera, poor appetite, and fatigue. No abdominal pain, no back radiation, no nausea or vomiting, no chills or fever, mild abdominal distension, no belching or acid reflux, no palpitations or chest tightness, no shortness of breath, no obvious cough or sputum. MRI at a local hospital suggested a pancreatic head lesion with retroperitoneal lymph node metastasis. She had received anti-infection treatment at our hospital and was readmitted for further care under the diagnosis of “obstructive jaundice.” Physical examination: Severe jaundice of skin and sclera with scattered scratch marks; soft flat abdomen, no intestinal patterns or peristalsis; liver and spleen not palpable; Murphy sign negative; no tenderness or rebound tenderness in the whole abdomen; shifting dullness negative; bowel sounds 3-4 times per minute. Hospital course: After admission, examinations were completed. On December 20, 2022, liver and kidney function showed total bilirubin 162.5 μmol/L, direct bilirubin 133.7 μmol/L, indirect bilirubin 28.8 μmol/L, ALT 70.0 U/L, AST 56.4 U/L, total protein 62.4 g/L, albumin 29.4 g/L. She received liver protection, jaundice reduction, anti-inflammatory, fluid, and nutritional support, along with gemcitabine plus cisplatin chemotherapy. On January 3, 2023, percutaneous transhepatic biliary drainage was performed again. Her condition improved, liver function recovered, and jaundice lessened. The patient and family requested discharge. Discharge status: No obvious discomfort. Physical examination: Alert, fair spirit, mild jaundice of skin and sclera, no obvious abnormalities on heart and lung auscultation, soft flat abdomen, liver and spleen not palpable, no tenderness or rebound tenderness, normal bowel sounds. PTCD tube secure with smooth bile drainage. Discharge orders: 1. Low-salt, low-fat diet with increased nutrition. 2. Regular liver and gallbladder ultrasound follow-up; return for chemotherapy in 3 weeks. 4. Follow-up in our department. Physician signature: Record time: January 9, 2023
Discharge record Admission time: February 12, 2023 Discharge time: February 22, 2023, 09:52 Admission diagnosis: Malignant cholangiocarcinoma; Cholangiocarcinoma occupying lesion Discharge diagnosis: Maintenance chemotherapy for malignant tumor; Malignant cholangiocarcinoma Admission status: The patient was admitted for “skin and scleral jaundice for more than 2 months.” More than two months earlier, she had been hospitalized for jaundice. Cholangiocarcinoma was considered, and after active treatment her liver function improved and jaundice lessened. She received gemcitabine plus cisplatin chemotherapy. No nausea, vomiting, chills, or fever. Mild abdominal distension with yellow skin, eyes, and urine. No belching or acid reflux, no palpitations or chest tightness, no shortness of breath, no obvious cough or sputum. She was readmitted for further chemotherapy under the diagnosis of “malignant cholangiocarcinoma.” Since onset, she had been alert, with poor appetite and spirit, fair sleep, normal urination without frequency, urgency, or pain, and normal bowel movements. Physical examination: Mild abdominal distension, no intestinal patterns or peristalsis; liver and spleen not palpable; Murphy sign negative; no upper abdominal tenderness or rebound tenderness; shifting dullness negative; bowel sounds 3-4 times per minute. Hospital course: Routine pre-chemotherapy evaluation showed no contraindications. She received gemcitabine plus cisplatin chemotherapy combined with camrelizumab immunotherapy. No significant adverse reactions during treatment. She was discharged with normal spirit and appetite. Discharge status: Normal temperature, normal spirit, appetite, and bowel/bladder function, no special discomfort. Physical examination: Alert, fair spirit, no obvious abnormalities on heart and lung auscultation, soft flat abdomen, liver and spleen not palpable, no tenderness or rebound tenderness, normal bowel sounds. Discharge orders: 1. Regular follow-up at our hospital (liver/gallbladder, chest CT, blood counts, tumor markers); 2. Rest, nutritional support, and management of chemotherapy side effects; 3. Follow-up in our department. Record time: February 22, 2023
Discharge record Admission time: March 12, 2023 Discharge time: March 24, 2023, 13:00 Admission diagnosis: Fever; Maintenance chemotherapy for malignant tumor; Malignant cholangiocarcinoma Discharge diagnosis: Maintenance chemotherapy for malignant tumor; Malignant cholangiocarcinoma Admission status: The patient was admitted for “fever for 3 days.” Three days earlier, without obvious cause, she developed fever up to 37.9°C with chills, general fatigue, and dry cough. No rash, abdominal pain, or diarrhea. No headache, palpitations, or vomiting. Home antipyretics failed to control the temperature. At our hospital on March 10, blood routine showed white blood cells 2.34 × 10⁹/L, neutrophils 13.2%, lymphocytes 59.3%, monocytes 25.4%, red blood cells 2.25 × 10¹²/L, hemoglobin 68 g/L. Chest CT showed nodules in upper lobes and interstitial changes in right lower lobe with anterior mediastinal nodule. Outpatient anti-infection and white cell elevation treatment improved the fever. She was admitted for further care under the diagnosis of “fever.” Since onset, she had been alert with poor spirit, poor appetite, basically normal bowel and bladder function, and stable weight. Physical examination: Alert, poor spirit, chronic disease appearance, no jaundice, no enlarged superficial lymph nodes, clear lung sounds without rales, soft abdomen without tenderness or rebound tenderness, no lower limb edema, negative pathological reflexes. Hospital course: Routine pre-chemotherapy evaluation showed no contraindications. She received gemcitabine plus cisplatin chemotherapy combined with camrelizumab immunotherapy. No significant adverse reactions. She was discharged with normal spirit and appetite. Discharge status: Normal temperature, normal spirit, appetite, and bowel/bladder function, no special discomfort. Physical examination: Alert, fair spirit, no obvious abnormalities on heart and lung auscultation, soft flat abdomen, liver and spleen not palpable, no tenderness or rebound tenderness, normal bowel sounds. Discharge orders: 1. Regular follow-up (liver/gallbladder, chest CT, blood counts, tumor markers); 2. Rest, nutritional support, and management of chemotherapy side effects; 3. Follow-up in our department. Record time: March 24, 2023
CT diagnostic report Registration time: April 1, 2023, 8:55:22 Report time: April 1, 2023, 10:04:54 Clinical diagnosis: Examination: Upper abdominal CT plain and enhanced scan Imaging findings: Post-comprehensive treatment for cholangiocarcinoma: Liver normal in size and shape with round low-density lesions, larger one in right lobe about 16 mm × 20 mm, no obvious enhancement. Enlarged gallbladder with increased density. Mild dilatation of intrahepatic and left/right hepatic ducts, local common bile duct stenosis with apparent wall thickening, blurred surrounding fat planes, and invasion of hepatic artery. Blurred fat planes around pancreatic head. Normal spleen without abnormal densities. Enlarged retroperitoneal lymph nodes. Multiple patchy low-density lesions below the abdominal wall with clear borders; wall enhancement on contrast, no obvious enhancement inside the cysts. Diagnostic impression: Follow-up after comprehensive treatment for malignant cholangiocarcinoma; increased gallbladder density; multiple cystic lesions below abdominal wall; enlarged retroperitoneal lymph nodes; hepatic cysts.
Outpatient record (scanned copy, may not match original 100%) April 4, 2023 Cholangiocarcinoma occupying lesion discovered nearly 4 months ago Female patient, 62 years old. In November 2022, she developed poor appetite, fatigue, and skin jaundice. CT on December 5, 2022, at another hospital showed occupying lesion. PTCD performed on December 8, 2022, with improvement in jaundice. ERCP with biopsy on December 12, 2022; pathology showed no cancer, only mucosal tissue with chronic inflammatory cell infiltration in lamina propria. From December 2022 to March 24, 2023, she completed 5 cycles of gemcitabine plus cisplatin chemotherapy and 2 cycles of camrelizumab immunotherapy. On March 10, blood routine at another hospital: WBC 2.24 × 10⁹/L ↓, Hb 68 g/L ↓. After transfusion and white cell elevation treatment, repeat on March 16 showed WBC 4.72 × 10⁹/L, Hb 86 g/L ↓. Current status: Fair spirit and appetite, no obvious discomfort. Enhanced CT (December 8, 2022, external): Intrahepatic bile duct dilatation, stenosis of common hepatic and common bile ducts, suggestive of cholangiocarcinoma. (April 1, 2023, external): Local common bile duct stenosis with apparent wall thickening, increased gallbladder density.
Discharge record Admission time: June 26, 2023 Discharge time: July 11, 2023 Admission diagnosis: 1. Cholangiocarcinoma; 2. Chemotherapy-induced myelosuppression; 3. Hypertension. Discharge diagnosis: 1. Malignant cholangiocarcinoma; 2. Chemotherapy-induced myelosuppression; 3. Hypertension. Admission status: The patient was admitted for “cholangiocarcinoma after 6 months of chemotherapy for surgical treatment.” Six months earlier, she had been hospitalized for skin and scleral jaundice. Cholangiocarcinoma was considered and treated actively with improvement in liver function and reduced jaundice, followed by gemcitabine plus cisplatin chemotherapy. No nausea, vomiting, chills, fever, or abdominal distension, but with yellow skin, eyes, and urine. No belching, acid reflux, palpitations, chest tightness, shortness of breath, or obvious cough/sputum. She was readmitted for surgery under the diagnosis of “malignant cholangiocarcinoma.” Since onset, she had been alert with poor appetite and spirit, fair sleep, and normal bowel and bladder function. Physical examination: Mild abdominal distension, no intestinal patterns or peristalsis; liver and spleen not palpable; Murphy sign negative; no upper abdominal tenderness or rebound tenderness; bowel sounds 3-4 times per minute. Hospital course: After admission, examinations were completed. Upper abdominal CT on June 28, 2023, showed bronchial infection in both lungs, anterior mediastinal cystic lesion, tracheal diverticulum, intrahepatic cystic lesion, increased gallbladder bile density, and left retroperitoneal infectious lesion (clinical correlation needed). No obvious surgical contraindications. On July 1, 2023, under general anesthesia, radical pancreaticoduodenectomy plus abdominal drainage was performed. Postoperatively, she received acid suppression, enzyme suppression, anti-inflammatory, fluid, and nutritional support. She recovered well and was discharged. Postoperative pathology results were pending. Discharge status: Fair general condition. Physical examination: Alert and fair spirit, mild abdominal distension, no intestinal patterns or peristalsis, liver and spleen not palpable, Murphy sign negative, no abdominal tenderness or rebound tenderness, well-healed wound, bowel sounds 3-4 times per minute. Discharge orders: 1. Rest and increased nutrition. 2. Suture removal in 3-5 days depending on wound healing. 3. Outpatient review in 1 month. 4. Follow-up in our outpatient clinic. Record time: July 11, 2023
Laboratory report Application time: June 27, 2023, 16:59 Collection time: June 28, 2023, 07:16 Preliminary diagnosis: Cholangiocarcinoma Serial No.\Item\Abbreviation\Result\Unit (Reference Range) 1 CA_125 CA_125 14.70 (0-22 U/ml) 2 CA_199 CA_199 33.41 (0-43 U/ml) 3 Carcinoembryonic antigen CEA CEA 3.15 (0-5 ng/ml) 4 Alpha-fetoprotein AFP AFP 2.78 (0-7 ng/ml) Received time: June 28, 2023, 08:09 Reported time: June 28, 2023, 10:10
CT diagnostic report Registration time: June 27, 2023, 17:08:37 Report time: June 28, 2023, 14:58:23 Clinical diagnosis: 1. Cholangiocarcinoma Examination: Upper abdominal CT plain and enhanced scan, chest CT plain scan Imaging findings: Bilateral thoracic symmetry. Increased bronchovascular markings with scattered patchy increased densities in both lungs, unclear borders. Patchy increased density in right lower lobe, unclear borders. Patent trachea and bronchi without stenosis or obstruction. Cystic low-density lesion in anterior mediastinum, clear border, about 11 mm × 14 mm. No enlarged lymph nodes in mediastinum or hila. No pleural effusion. Cystic gas density behind right trachea. Liver normal in size and shape with slightly heterogeneous density and round low-density lesions, clear borders, larger one about 15 mm × 23 mm, no enhancement in any phase. No dilatation of intrahepatic ducts. Gallbladder not enlarged with increased bile density. Normal pancreas and spleen without abnormal densities or enhancement. Patchy slightly high-density lesion in left retroperitoneum, unclear border with psoas, ring-like enhancement after contrast, markedly smaller than previous scan (March 19). No peritoneal effusion. Diagnostic impression: Bronchial infection in both lungs; anterior mediastinal cystic lesion; tracheal diverticulum; intrahepatic cystic lesion; increased gallbladder bile density; left retroperitoneal infectious lesion (clinical correlation required).
Pathology report Submission date: July 1, 2023 Clinical diagnosis: 1. Cholangiocarcinoma; 2. Chemotherapy-induced myelosuppression; 3. Specimen: Pancreaticoduodenal specimen, abdominal lymph nodes Gross examination: Partial gastrectomy and duodenectomy specimen: Stomach 7×5×2.8 cm, duodenum 21 cm long, pancreatic head 5.5×3.5×2.8 cm, common bile duct 5.5 cm long with 2 cm circumference. Smooth gastric and intestinal mucosa without masses or ulcers. Duodenal mucosal polypoid protrusion 1 cm in diameter, 11.5 cm from duodenal margin. Common bile duct without obvious rough areas or masses. Pancreas without masses on multiple sections. Gallbladder 9×3.5×2.5 cm containing dark green bile, no stones, rough mucosa, wall 0.2 cm thick. Five lymph nodes beside stomach (0.1-0.2 cm), one beside pancreas (0.2 cm). No lymph nodes beside duodenum. Note: Specimen opened, common bile duct incised; no obvious lesion seen grossly. Clinical doctor notified by phone to jointly identify lesion and sample. Pathological diagnosis: Post-chemotherapy pancreaticoduodenal specimen: No definite tumor in common bile duct or duodenal papilla. Congestion of vessels in common bile duct and duodenal wall with chronic inflammatory cell infiltration. No tumor in surrounding pancreatic tissue. Chronic inflammatory cell infiltration around pancreatic ducts with focal low-grade intraepithelial neoplasia of interlobular duct epithelium. Local fibrous hyperplasia around pancreas with cholesterol crystal clefts and infiltration of lymphocytes and foam cells. Negative margins (gastric, duodenal, pancreatic, common bile duct, gallbladder neck) for cancer. Gastric lymph nodes negative (0/5), peripancreatic lymph node negative (0/1). Duodenal submucosal lipoma. Chronic cholecystitis with mucosal epithelial necrosis. Note: 1. Refer to preoperative imaging. 2. Sampling performed jointly by pathology and clinical doctors. Diagnosis date: July 8, 2023
Outpatient record (scanned copy, may not match original 100%) Tumor markers (external hospital) CA199 CEA December 6, 2022 >12000 U/mL ↑ 648.24 ng/mL ↑ February 2, 2023 >1000 U/mL ↑ 314 ng/mL ↑ February 12, 2023 4240.07 U/mL 18.55 ng/mL March 12, 2023 1182.11 U/mL ↑ Not tested April 7, 2023 554.72 U/mL 5.54 ng/mL
Outpatient record (scanned copy, may not match original 100%) May 1, 2023 The patient completed 5 cycles of gemcitabine plus cisplatin and 4 cycles of camrelizumab. CA199 decreased to normal (33.4 U/mL on June 28, 2023). CT on June 28 showed no dilatation of intrahepatic bile ducts and disappearance of the mass shadow at the lower common bile duct. Pancreaticoduodenectomy performed on July 1, 2023. Pathology: No definite tumor in common bile duct or duodenal papilla; vascular congestion and chronic inflammation in walls; chronic inflammation around pancreatic ducts; focal low-grade intraepithelial neoplasia; local fibrosis; cholesterol crystal clefts (IV C0/7); duodenal submucosal lipoma. CT (July 6, 2023): Post-PD changes, hepatic cysts, retroperitoneal exudative lesion and multiple enlarged lymph nodes.
CT diagnostic report Registration time: August 17, 2023, 10:50:29 Report time: August 17, 2023, 15:36:16 Clinical diagnosis: 1. Postoperative malignant tumor chemotherapy; 2. Ampullary tumor Examination: Upper abdominal CT plain and enhanced scan, chest CT plain scan Imaging findings: Homogeneous liver parenchyma with several round low-density lesions, clear borders, larger one about 16 mm × 22 mm, no obvious enhancement. No intrahepatic duct dilatation. Gas in left hepatic duct. Gallbladder and pancreatic head not visualized. Residual pancreas without abnormal enhancement. Normal spleen without abnormal densities. Multiple nodular slightly high-density shadows in retroperitoneum with mild enhancement. Bilateral thoracic symmetry. Increased bronchovascular markings. Small patchy increased densities in lungs, unclear borders. Patent trachea and bronchi. Nodular soft tissue density in anterior mediastinum, maximum 8 mm. No pleural effusion. Diagnostic impression: Postoperative changes after cholangiocarcinoma resection; multiple hepatic cysts; gas in left hepatic duct; multiple enlarged retroperitoneal lymph nodes; mild interstitial changes in lower lungs; enlarged anterior mediastinal lymph node; clinical correlation and comparison with prior scans.