Detailed Treatment Process
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Male, 64 years old. Radiology report Department: Respiratory Medicine Clinical diagnosis: Pulmonary shadow Examination: Chest CT angiography (CTA) Radiological findings: The bilateral thoracic cages are symmetric with no obvious abnormalities. The trachea is midline and the tracheobronchial tree is patent. There is a solid subpleural nodule in the right upper lobe (Im179), measuring approximately 22 mm in longest diameter. Scattered lucent areas are seen in both lungs, accompanied by a few patchy opacities with irregular morphology, ill-defined borders, and heterogeneous low density. Bilateral hilar structures are clear, with no obvious abnormalities in morphology, size, or position. The mediastinum is midline. No enlarged lymph nodes are seen in the mediastinum. CTA shows no obvious abnormalities in the pulmonary arteries. Radiological diagnosis: 1. Solid subpleural nodule in the right upper lobe, newly appeared compared with the scan of October 22 last year; malignancy cannot be excluded and further investigation is recommended. 2. Mild infection in both lungs, similar to previous imaging. 3. Pulmonary emphysema. 4. No obvious abnormalities in the pulmonary arteries on CTA. Examination time: March 28 00:00:00 Report written: March 30 19:23:24 Report reviewed: April 1 08:42:07
Discharge summary Department: Comprehensive Oncology Admission date: March 29 Discharge date: April 2 Outpatient diagnosis: Pulmonary shadow Admission diagnosis: Pulmonary shadow Discharge diagnosis: Pulmonary shadow Main symptoms and signs on admission Pulmonary nodule discovered one week earlier. Main laboratory results March 29 routine blood test: hemoglobin 133.0 g/L, red blood cell count 4.32 × 10¹²/L, white blood cell count 10.20 × 10⁹/L↑, neutrophil percentage 75.9%↑, lymphocyte percentage 18.2%↓, monocyte percentage 5.1%, eosinophil percentage 0.2%↓, basophil percentage 0.6%, absolute neutrophil count 7.74 × 10⁹/L↑, absolute lymphocyte count 1.86 × 10⁹/L, absolute monocyte count 0.52 × 10⁹/L, absolute eosinophil count 0.02 × 10⁹/L↓, absolute basophil count 0.06 × 10⁹/L, platelet count 317 × 10⁹/L, hematocrit 0.398 L/L↓, mean corpuscular volume 92.1 fL, mean corpuscular hemoglobin 30.8 pg, mean corpuscular hemoglobin concentration 334.0 g/L, red cell distribution width CV 12.1%, plateletcrit 0.310↑, red cell distribution width SD 41.2 fL, platelet distribution width 10.5 fL, large platelet ratio 22.2%, mean platelet volume 9.7 fL, serum amyloid A <2.50 mg/L. March 29 coagulation panel: prothrombin time 11.70 sec, INR 1.05, activated partial thromboplastin time 28.50 sec, thrombin time 14.40 sec, fibrinogen 2.93 g/L, D-dimer 0.243 mg/L, fibrin(ogen) degradation products 1.17 ug/mL, antithrombin III 101.00%. March 29 cardiac markers: myoglobin 74.29 ng/mL↑, NT-proBNP 16.9 pg/mL, troponin T 0.011 ng/mL, CK-MB 3.230 ng/mL. March 29 biochemistry: γ-glutamyl transferase 34.8 IU/L, ALT 20.8 IU/L, AST 15.3 IU/L, AST isoenzyme 3.4 IU/L, alkaline phosphatase 82.0 IU/L, total bilirubin 7.0 umol/L, direct bilirubin 3.0 umol/L, total bile acids 3.96 umol/L, total protein 68.8 g/L, albumin 43.0 g/L, globulin 25.8 g/L, α-L-fucosidase 11.7 U/L, albumin/globulin ratio 1.7, prealbumin 218.0 mg/L, uric acid 300.3 umol/L, urea nitrogen 6.04 mmol/L, creatinine 81.9 umol/L, cystatin C 0.73 mg/L, retinol-binding protein 33.2 mg/L, glucose 8.74 mmol/L↑, potassium 4.00 mmol/L, sodium 144.30 mmol/L, chloride 102.80 mmol/L, calcium 2.33 mmol/L, phosphorus 1.29 mmol/L, magnesium 0.78 mmol/L, lactate dehydrogenase 157.0 IU/L, homocysteine 12.2 IU/L, creatine kinase 133.0 IU/L, CK isoenzyme 9.0 U/L, total cholesterol 3.60 mmol/L, triglycerides 1.46 mmol/L, HDL 1.14 mmol/L, LDL 1.46 mmol/L, apolipoprotein A1 1.53 g/L, apolipoprotein B 0.48 g/L↓, lipoprotein(a) 30.40 mg/L, small dense LDL cholesterol 0.34 mmol/L, haptoglobin 224.92 mg/mL↑ March 29 blood typing: ABO group O, Rh positive, antibody screen negative March 30 biochemistry: HbA1c 6.4%↑ March 30 urinalysis: color yellow, clarity slightly cloudy, specific gravity 1.028, glucose negative, protein 2+, bilirubin negative, urobilinogen normal, pH 5.5, occult blood ±, ketones negative, nitrite negative, leukocyte esterase negative, casts 2.0#/uL↑, non-squamous epithelial cells -, squamous epithelial cells 7.4/uL, hyaline casts +, mucus threads +, crystals negative, bacteria 124.20/uL↑, red blood cells 10.9000/uL, white blood cells 43.8000/uL↑, granular casts +, epithelial cells 7.9#/uL. March 30 cryptococcal antigen negative March 30 QuantiFERON-TB: negative T-cell immune response to Mycobacterium tuberculosis, TB1-N 0.003, TB2-N -0.003, lymphocyte culture + interferon (baseline N) 0.039, M-N 8.670 March 30 rheumatology + interleukin panel: all listed autoantibodies negative or below threshold March 31 HIV/syphilis: HIV Ag/Ab negative, syphilis chemiluminescence negative March 31 hepatitis markers: all negative except HBsAb 14.34 mIU/mL↑ April 1 microbiology: epithelial cells <10/LF, white blood cells >25/LF, normal flora, Haemophilus not grown April 1 (1-3)-β-D-glucan <37.5 April 1 vitamins: within normal ranges April 1 serum protein electrophoresis: albumin 56.7%, α1 4.1%, α2 10.2%, β1 5.8%, β2 5.4%, γ 17.8%, A/G 1.3 April 1 seven tumor autoantibodies: all low or negative Special examinations and consultations March 29 ECG: normal April 1 brain MRI: a few ischemic foci; high-signal focus in right sulcus, possibly vascular; suggest follow-up April 1 abdominal ultrasound: fatty liver April 1 lymph node ultrasound: no enlarged lymph nodes in neck, axillae, or inguinal regions April 2 pathology report: not released Course and treatment outcome After admission, the patient completed the workup, including systemic evaluation and CT-guided lung biopsy. He is currently in stable condition and is being discharged. He was advised to follow up on the pathology results and determine the next steps according to the specific subtype. Outpatient follow-up is recommended; return promptly if any discomfort develops. Comorbidities are listed in the discharge diagnosis. Condition at discharge Alert, general condition fair. Discharge medications and instructions 1. Seek medical attention promptly at a local hospital or our emergency department if any discomfort occurs. Bring the discharge summary and imaging materials to follow-up visits. 2. (omitted) 3. Follow up on the pathology results; further management will depend on the specific subtype. 4. Continue care for other conditions at a general hospital. Treatment outcome: improved
Routine pathology report Department: Comprehensive Oncology Gross: fragmented tissue, total diameter 1 mm, entirely submitted. Pathological diagnosis: (Right lung) atypical cells infiltrating fibrocollagenous tissue, suggestive of spindle cell tumor. Immunohistochemistry does not provide clear origin. Because of limited tissue volume, complete resection and further evaluation are recommended. CK (focal +), WT-1 (focal +), Calretinin (-), GATA3 (+), TTF-1 (SPT24) (-), Napsin A (-), Ki-67 (15%+), BAP1 (retained), Vimentin (+), P40 (-), STAT6 (-), Desmin (focal +), S-100 (-), CD34 (-), SMARCA4 (retained), MyoD1 (-), CK5/6 (-), D2-40 (partial +), MC (-), SS18 (-), CK8/18 (focal +), SMA (partial +), ALK (D5F3) (-). Report date: April 12
Medical record Date: April 14 Chief complaint: Pulmonary shadow found on physical examination six months ago History of present illness: A pulmonary shadow was discovered on routine check-up six months ago. The patient was evaluated at our hospital; puncture showed a small number of atypical cells suggestive of neoplasm. He returns for further treatment. Past history: Hypertension negative; type 2 diabetes for 2 years, controlled with medication Personal history: Smoking index 400 Allergy history: none Family history: none Physical examination: alert, general condition fair Relevant investigations: PET-CT showed hypermetabolic subpleural nodule in right upper lobe with possible hilar lymph node metastasis and possible adrenal metastasis. Preliminary diagnosis: 1. Right bronchial malignant tumor, spindle cell type; 2. Type 2 diabetes Management plan: Recommend contrast-enhanced adrenal MRI Follow-up: outpatient Physician: ***
PET-CT report Brief history and purpose: CT performed locally on February 17 for fever showed a solid subpleural nodule in the right upper lobe. CT on March 28 at our hospital confirmed the nodule; puncture suggested malignancy, highly suspicious for metastasis. PET-CT now performed to assess surgical feasibility. Type 2 diabetes for 2 years, controlled with sitagliptin phosphate tablets. Appendectomy 30 years ago. Smoked for 40 years, more than half a pack daily; quit one month ago. Father had bladder cancer. Clinical diagnosis: Pulmonary nodule to be clarified Weight: 77 kg Injection time: 11:15:00 Examination: whole-body PET/CT Conclusions: 1. Hypermetabolic subpleural nodule in anterior segment of right upper lobe, suggestive of primary lung malignancy; high likelihood of right hilar lymph node metastasis; increased metabolism in left adrenal gland—follow-up to exclude metastasis 2. Tiny nodule in lateral segment of right middle lobe, possibly inflammatory; follow-up recommended; bullae in both upper lobes, scattered interstitial inflammation in both lungs 3. Nasopharyngeal inflammation, bilateral cervical reactive lymph nodes 4. Prostatic hyperplasia 5. Degenerative changes of the spine 6. Normal brain imaging Report date: April 16 ********* Pathology report Ward: Thoracic Surgery Specimen: right upper lobe Tumor number: solitary Tumor size: 21 × 18 × 15 mm Histological type: sarcomatoid carcinoma; based on HE morphology and immunohistochemistry, considered pleomorphic carcinoma (spindle cell component 99%, adenocarcinoma 1%). STAS: absent Pleural involvement: visceral pleural invasion into elastic layer (PL1) Vascular invasion: tumor invades vessel wall Neural invasion: absent Margins: clear, 45 mm from resection edge Lymph node metastasis: positive in station 10 (1/1), station 13 (1/1); negative in stations 2 (0/4), 4 (0/4), 7 (0/6), 11 (0/3) Pathological stage: pTNM T2N1MX Immunohistochemistry: CK (rare weak +), CK8/18 (rare weak +), EMA (focal weak +), TTF-1 (-), Napsin A (-), P40 (-), CK5/6 (-), SMARCA4 (+), GATA3 (focal weak +), ZEB1 (+), D2-40 (-), etc. Ki-67 80%+. ALK negative. Special stains: elastic fibers positive. Report date: May 30