Detailed Treatment Process
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Male, 77 years old Electronic Endoscopy Report Examination item: [Electronic gastroduodenoscopy, routine] Examination date: November 13 Examination images: (Esophagus, gastric body, duodenal bulb, descending duodenum, gastric antrum, gastric angle, cardia-gastric fundus) Diagnostic description: Esophagus: A new growth with ulceration is seen in the esophagus approximately 27-30 cm from the incisors, showing infiltrative growth and encircling about 3/4 of the esophageal circumference. The biopsy tissue is friable. Cardia: Smooth mucosa, no abnormality seen Gastric fundus: Mucous lake color unclear, moderate amount Gastric body: Mucosal hyperemia. Gastric angle: Arcature present, mucosal hyperemia, peristalsis visible. Gastric antrum: Mucosal hyperemia, some vessels slightly visible. Pylorus: Pyloric opening round, contraction visible. Duodenum: No obvious abnormality in the bulb or visible descending portion Endoscopic diagnosis: Esophageal Ca; congestive exudative-chronic atrophic gastritis Helicobacter pylori: - Biopsy sites: Gastric antrum: 2 pieces; Esophagus: 4 pieces; Doctor's recommendation: Await pathology, consult thoracic surgery
Pathology Report Date received: November 13 Sampling method: [Electronic gastroduodenoscopy] Report date: November 19 Clinical diagnosis: Esophageal Ca; congestive exudative-chronic atrophic gastritis Pathological diagnosis: 1. "Gastric antrum" (2 pieces): Mild chronic inflammation of the gastric mucosa with mild atrophy and moderate intestinal metaplasia (incomplete type). 2. "Esophagus" (4 pieces): Esophageal squamous cell carcinoma.
Medical Record (handwritten scan, some characters may have recognition errors) November 16 Specialist outpatient clinic Dysphagia for 2 years. New growth with ulceration and infiltration at 27~30 cm from the incisors, encircling 3/4 of the circumference. Currently tolerating regular diet. Past history of "cerebral infarction" (?) and "hyperthyroidism". P/E: Superficial lymph nodes (-). Imp: Esophageal occupying lesion Plan: Hospital admission registration 2. Chest CT plain scan, abdominal ultrasound, electrocardiogram, enhanced brain MRI
Imaging Diagnostic Report Department: Outpatient Thoracic Surgery Examination time: November 16 Clinical diagnosis: Esophageal tumor Examination name: Chest CT plain scan Radiological findings: Thickening of the mid-esophageal wall. Localized pleural thickening bilaterally. Solid small nodule in the left lower lobe (se3img27), approximately 0.5 cm in diameter. No abnormal density shadows in either lung field. Lung markings clear bilaterally. No abnormality in the hilar regions bilaterally. Tracheobronchial shadows normal as shown. No abnormally enlarged lymph nodes in the mediastinum. Radiological diagnosis: Thickening of the mid-esophageal wall. Localized pleural thickening bilaterally. Solid small nodule in the left lower lobe (se3img27), please correlate with clinical findings. Report time: November 16 Review time: November 17
Imaging Diagnostic Report Clinical diagnosis: To be determined Requesting physician's requirement: Assist in diagnosis Examination site and name: Chest CT plain scan Radiological findings: Thorax symmetric bilaterally, trachea central, no mediastinal shift. Suspicious thickening of the mid-to-lower esophageal wall. Increased lung markings bilaterally, with scattered spotty and linear opacities in both lungs. Small cystic lucencies in the right middle lobe and left lower lobe. No obvious hilar enlargement bilaterally. Pleural thickening bilaterally. No obvious pleural effusion. No obviously enlarged mediastinal lymph nodes. Heart shadow not obviously enlarged. Calcification at the edges of the aorta and coronary arteries. Liver scanned shows multiple small low-density shadows. Radiological diagnosis: Suspicious thickening of the mid-to-lower esophageal wall, please correlate with clinical findings for further examination. Scattered spotty and linear opacities with calcifications in both lungs, pulmonary bullae in right middle lobe and left lower lobe; pleural thickening bilaterally. Aortic and coronary atherosclerosis. Multiple small low-density shadows in the liver, please correlate with abdominal examination. Examination time: November 20 14:06:02 Report writing time: November 20 16:21:36 Report review time: November 23 9:25:37
Immunohistochemistry Report Referring hospital: This hospital Department: Intensive Care Medicine ICU Date received: November 26 Specimen name: Esophagus Immunohistochemical diagnosis: "Esophagus" basaloid (poorly differentiated) squamous cell carcinoma. Tumor cells: CgA(-), Syn(-), CD56(-), ki-67(90%), p53(+++), 34βE12(+), P63(+), P40(+). Report date: November 30
Pathology Report Referring hospital: This hospital Department: Intensive Care Medicine ICU Date received: November 26 Gross findings: Esophageal segment length: 8 cm, circumference 4 cm. Ulcerative mass 4.5 × 2.5 × 0.6 cm located 2.5 cm from upper margin and 2 cm from lower margin. Gray-white, firm, invading muscularis. A-E: mass; F: "upper margin" tissue 1.5 cm; G: "lower margin" tissue 3 × 2.5 × 2 cm; H: dissected surface. Pathological diagnosis: "Esophagus" basaloid (poorly differentiated) squamous cell carcinoma, ulcerative type, 4 × 2.5 × 0.6 cm, invading adventitia. "Upper and lower margins" and dissected surface all negative. Report date: November 30
Pathology Report Referring Hospital: This hospital Department: ICU, Critical Care Medicine Date Received: November 26 Gross Description: A. "Paraesophageal lower esophagus LN" – a mass of tissue measuring 1.5 cm. B. "Carina" – one piece of tissue measuring 1 cm. C. "Azygos vein LN" – one piece of tissue measuring 1 cm. D. "Cardiac LN" – a mass of tissue measuring 2 × 2 × 0.5 cm. E. "Left gastric" – one piece of tissue measuring 5 × 3 × 3 cm. F. "Lesser curvature of stomach LN" – two lymph nodes measuring 0.2–0.5 cm. Pathological Diagnosis: "Paraesophageal lower esophagus lymph node" (0/1), "Carinal lymph node" (0/1), "Azygos vein lymph node" (0/1), "Cardiac lymph node" (0/3), "Left gastric lymph node" – adipose tissue, "Lesser curvature of stomach lymph node" (0/3). All negative. Report Date: November 30
Immunohistochemistry Report Department: Intensive Care Medicine ICU Date received: November 26 Specimen name: Esophagus Immunohistochemical diagnosis: "Esophagus" basaloid (poorly differentiated) squamous cell carcinoma. Tumor cells: CgA(-), Syn(-), CD56(-), ki-67(90%), p53(+++), 34βE12(+), P63(+), P40(+). Report date: November 30
Imaging Diagnostic Report Department: Thoracic Surgery Clinical diagnosis: To be determined Requesting physician's requirement: Assist in diagnosis Examination site and name: Chest CT plain scan Radiological findings: "Post-esophagectomy", intrathoracic stomach, gastric tube in place. High-density contrast in stomach, no anastomotic leak. Lucency in right pleural cavity. Metal skin staples on right chest wall with local swelling and minimal gas. Trachea central, no mediastinal shift. Patchy consolidations in both lower lobes, multiple fibrous shadows in both lungs. Heart shadow full. Slightly enlarged mediastinal lymph nodes. No obvious hilar enlargement. Upper pleural thickening bilaterally. Bilateral pleural effusions with lower lobe atelectasis. Radiological diagnosis: Post-esophagectomy changes, intrathoracic stomach, gastric tube in place, no anastomotic leak, right pneumothorax, postoperative changes of right chest wall with local swelling and minimal gas. Exudative consolidation in both lower lobes, multiple fibrous lesions in both lungs; bilateral pleural effusions with lower lobe atelectasis. Full heart shadow, slightly enlarged mediastinal lymph nodes; upper pleural thickening bilaterally. Examination time: December 4 14:04:36 Report writing time: December 4 16:16:21 Report review time: December 7 10:24:42
Discharge Summary Department: Thoracic Surgery Admission date: November 18 Discharge date: December 9 Outpatient diagnosis: Esophageal cancer (mid-thoracic) Admission diagnosis: Esophageal cancer (mid-thoracic) Discharge diagnosis: Esophageal cancer (mid-thoracic, squamous cell carcinoma, G3) pT4aN0M0 Stage IIIa Main symptoms and signs on admission Patient alert and oriented, breathing smooth. No enlarged supraclavicular lymph nodes bilaterally. Symmetric chest, equal tactile vocal fremitus bilaterally. Clear breath sounds in both lungs, symmetric respiratory movement, no dry rales. No abnormal precordial bulge, normal heart borders, HR: 80 bpm, regular rhythm. Soft abdomen, no tenderness or rebound, no masses. No edema in extremities. Remainder unremarkable. Main laboratory results November 19 Venous blood gas analysis: Sodium 141.0 mmol/L, potassium 3.70 mmol/L, chloride 108.0 mmol/L, pH (blood) 7.348, PCO₂ 49.8 mmHg, PO₂ 28.9 mmHg, oxygen saturation 48.6%, standard base excess 1.6 mmol/L, standard bicarbonate 23.1 mmol/L, bicarbonate 26.7 mmol/L, actual base excess 0.3 mmol/L. Complete blood count: White blood cell count 6.23 × 10⁹ /L, red blood cell count 3.99 × 10¹² /L, red cell distribution width 12.7%, hematocrit 0.363 L/L, mean corpuscular volume 90.8 fL, hemoglobin 124 g/L, neutrophils 72.6% (H), neutrophil absolute 4.53 × 10⁹ /L, eosinophils 0.7%, eosinophil absolute 0.04 × 10⁹ /L, basophils 0.8%, basophil absolute 0.05 × 10⁹ /L, monocytes 5.8%, monocyte absolute 0.36 × 10⁹ /L, lymphocyte absolute 1.25 × 10⁹ /L, lymphocytes 20.1%, platelets 143 × 10⁹ /L, mean platelet volume 8.9 fL, mean corpuscular hemoglobin 31.1 pg, mean corpuscular hemoglobin concentration 342 g/L. Coagulation profile: Thrombin time 14.20 seconds (normal ref 15.0), prothrombin time 10.50 seconds, INR 0.97 (normal ref 10.8), fibrinogen 3.76 g/L, activated partial thromboplastin time 31.40 seconds. Glucose, electrolytes, liver function, renal function + cystatin C: Sodium 143.0 mmol/L, potassium 4.00 mmol/L, chloride 108.0 mmol/L, creatinine 106.0 μmol/L (H), urea nitrogen 8.43 mmol/L (H), uric acid 326.0 μmol/L, total protein 57.3 g/L (L), albumin 34.1 g/L, prealbumin 217.0 mg/L, ALT 42 U/L, AST 36 U/L, LDH 158 U/L, GGT 48 U/L, ALP 66 U/L, total bilirubin 13.0 μmol/L, direct bilirubin 4.5 μmol/L, fasting glucose 5.01 mmol/L, serum bile acid 1.8 μmol/L, alpha-fucosidase 32.0 U/L, mitochondrial AST 6.0 U/L (L), A/G ratio 1.46, globulin 23.20 g/L, cystatin C 1.12 mg/L (H). Hepatitis C antibody, hepatitis B panel (+HBC-IgM): HBC IgM 0.08 (-) S/CO, HCV Ab 0.04 (-) S/CO, HBc Ab 7.84 (+) S/CO, HBe Ag 0.286 (-) S/CO, HBe Ab 0.98 (+) S/CO, HBs Ag 0.02 (-) IU/ml, HBs Ab 65.47 (+) mIU/ml. Blood typing: ABO B, Rh(D) positive. Syphilis screening: Negative. November 25 HIV antibody: 0.24 (-) S/CO. November 27 Complete blood count: White blood cell count 11.05 × 10⁹ /L (H), red blood cell count 3.39 × 10¹² /L (L), red cell distribution width 11.6%, hematocrit 0.300 L/L (L), mean corpuscular volume 88.5 fL, hemoglobin 108 g/L (L), neutrophils 86.9% (H), neutrophil absolute 9.61 × 10⁹ /L (H), eosinophils 0.1% (L), eosinophil absolute 0.01 × 10⁹ /L (L), basophils 0.1%, basophil absolute 0.01 × 10⁹ /L, monocytes 6.1%, monocyte absolute 0.67 × 10⁹ /L, lymphocyte absolute 0.75 × 10⁹ /L (L), lymphocytes 6.8% (L), platelets 221 × 10⁹ /L, mean platelet volume 6.8 fL (L), mean corpuscular hemoglobin 31.7 pg, mean corpuscular hemoglobin concentration 359 g/L (H). Liver and renal function + cystatin C: Creatinine 72.0 μmol/L, urea nitrogen 6.13 mmol/L, uric acid 187.0 μmol/L, total protein 51.1 g/L (L), albumin 31.6 g/L (L), prealbumin 168.0 mg/L (L), ALT 39 U/L, AST 53 U/L (H), LDH 196 U/L, GGT 32 U/L, ALP 47 U/L, total bilirubin 12.2 μmol/L, direct bilirubin 4.9 μmol/L, serum bile acid 0.5 μmol/L, alpha-fucosidase 34.0 U/L, mitochondrial AST 6.0 U/L (L), A/G 1.62, globulin 19.50 g/L (L), cystatin C 0.89 mg/L. November 28 Complete blood count: White blood cell count 11.76 × 10⁹ /L (H), red blood cell count 3.08 × 10¹² /L (L), red cell distribution width 13.4%, hematocrit 0.285 L/L (L), mean corpuscular volume 92.6 fL, hemoglobin 96 g/L (L), neutrophils 88.7% (H), neutrophil absolute 10.43 × 10⁹ /L (H), eosinophils 0.2% (L), eosinophil absolute 0.02 × 10⁹ /L, basophils 0.3%, basophil absolute 0.04 × 10⁹ /L, monocytes 4.5%, monocyte absolute 0.53 × 10⁹ /L, lymphocyte absolute 0.74 × 10⁹ /L (L), lymphocytes 6.3% (L), platelets 171 × 10⁹ /L, mean platelet volume 8.6 fL, mean corpuscular hemoglobin 31.1 pg, mean corpuscular hemoglobin concentration 335 g/L. Liver and renal function + cystatin C: Creatinine 92.0 μmol/L, urea nitrogen 6.85 mmol/L, uric acid 171.0 μmol/L, total protein 53.7 g/L (L), albumin 31.8 g/L (L), prealbumin 138.0 mg/L (L), ALT 31 U/L, AST pending retest U/L, LDH pending retest U/L, GGT 25 U/L, ALP 47 U/L, total bilirubin 10.0 μmol/L, direct bilirubin 3.8 μmol/L, serum bile acid 0.6 μmol/L, alpha-fucosidase 39.0 U/L, mitochondrial AST pending retest U/L, A/G 1.45, globulin 21.90 g/L, cystatin C 0.93 mg/L. November 29 Complete blood count: White blood cell count 12.92 × 10⁹ /L (H), red blood cell count 3.08 × 10¹² /L (L), red cell distribution width 12.2%, hematocrit 0.276 L/L (L), mean corpuscular volume 89.7 fL, hemoglobin 97 g/L (L), neutrophils 88.9% (H), neutrophil absolute 11.50 × 10⁹ /L (H), eosinophils 0.1% (L), eosinophil absolute 0.01 × 10⁹ /L (L), basophils 0.1%, basophil absolute 0.01 × 10⁹ /L, monocytes 4.6%, monocyte absolute 0.59 × 10⁹ /L, lymphocyte absolute 0.81 × 10⁹ /L (L), lymphocytes 6.3% (L), platelets 138 × 10⁹ /L, mean platelet volume 8.9 fL, mean corpuscular hemoglobin 31.4 pg, mean corpuscular hemoglobin concentration 350 g/L. November 30 Complete blood count: White blood cell count 10.32 × 10⁹ /L (H), red blood cell count 3.17 × 10¹² /L (L), red cell distribution width 12.1%, hematocrit 0.286 L/L (L), mean corpuscular volume 90.3 fL, hemoglobin 101 g/L (L), neutrophils 86.1% (H), neutrophil absolute 8.88 × 10⁹ /L (H), eosinophils 0.5%, eosinophil absolute 0.05 × 10⁹ /L, basophils 0.4%, basophil absolute 0.04 × 10⁹ /L, monocytes 5.1%, monocyte absolute 0.53 × 10⁹ /L, lymphocyte absolute 0.82 × 10⁹ /L (L), lymphocytes 7.9% (L), platelets 190 × 10⁹ /L, mean platelet volume 7.4 fL (L), mean corpuscular hemoglobin 31.8 pg, mean corpuscular hemoglobin concentration 352 g/L. Liver and renal function + cystatin C: Creatinine 81.0 μmol/L, urea nitrogen 5.66 mmol/L, uric acid 132.0 μmol/L, total protein 53.5 g/L (L), albumin 33.5 g/L (L), prealbumin 102.0 mg/L (L), ALT 27 U/L, AST 29 U/L, LDH 151 U/L, GGT 83 U/L (H), ALP 83 U/L, total bilirubin 11.1 μmol/L, direct bilirubin 5.5 μmol/L, serum bile acid 2.4 μmol/L, alpha-fucosidase 39.0 U/L, mitochondrial AST 5.0 U/L (L), A/G 1.67, globulin 20.00 g/L, cystatin C 0.86 mg/L. Liver and renal function + cystatin C: Creatinine 87.0 μmol/L, urea nitrogen 5.69 mmol/L, uric acid 149.0 μmol/L, total protein 52.7 g/L (L), albumin 31.6 g/L (L), prealbumin 112.0 mg/L (L), ALT 25 U/L, AST 26 U/L, LDH 165 U/L, GGT 33 U/L, ALP 52 U/L, total bilirubin 10.2 μmol/L, direct bilirubin 4.8 μmol/L, serum bile acid 2.5 μmol/L, alpha-fucosidase 40.0 U/L, mitochondrial AST 5.0 U/L (L), A/G 1.49, globulin 21.10 g/L, cystatin C 0.85 mg/L. December 1 Complete blood count: White blood cell count 9.76 × 10⁹ /L (H), red blood cell count 3.20 × 10¹² /L, red cell distribution width 12.8%, hematocrit 0.293 L/L (L), mean corpuscular volume 91.6 fL, hemoglobin 103 g/L (L), neutrophils 84.4% (H), neutrophil absolute 8.24 × 10⁹ /L (H), eosinophils 0.7%, eosinophil absolute 0.07 × 10⁹ /L, basophils 0.3%, basophil absolute 0.03 × 10⁹ /L, monocytes 7.1%, monocyte absolute 0.69 × 10⁹ /L, lymphocyte absolute 0.73 × 10⁹ /L (L), lymphocytes 7.5% (L), platelets 180 × 10⁹ /L, mean platelet volume 8.3 fL, mean corpuscular hemoglobin 32.1 pg, mean corpuscular hemoglobin concentration 350 g/L. Liver and renal function + cystatin C: Creatinine 86.0 μmol/L, urea nitrogen 7.34 mmol/L, uric acid 136.0 μmol/L, total protein 52.3 g/L (L), albumin 33.3 g/L (L), prealbumin 107.0 mg/L (L), ALT 40 U/L, AST 45 U/L (H), LDH 152 U/L, GGT 132 U/L (H), ALP 108 U/L, total bilirubin 9.2 μmol/L, direct bilirubin 4.6 μmol/L, serum bile acid 4.4 μmol/L, alpha-fucosidase 38.0 U/L, mitochondrial AST 6.0 U/L (L), A/G 1.75, globulin 19.00 g/L (L), cystatin C 0.88 mg/L. December 2 Complete blood count: White blood cell count 9.81 × 10⁹ /L (H), red blood cell count 3.28 × 10¹² /L (L), red cell distribution width 13.1%, hematocrit 0.300 L/L (L), mean corpuscular volume 91.5 fL, hemoglobin 105 g/L (L), neutrophils 82.8% (H), neutrophil absolute 8.11 × 10⁹ /L (H), eosinophils 0.9%, eosinophil absolute 0.09 × 10⁹ /L, basophils 1.1% (H), basophil absolute 0.11 × 10⁹ /L (H), monocytes 7.7%, monocyte absolute 0.76 × 10⁹ /L, lymphocyte absolute 0.74 × 10⁹ /L (L), lymphocytes 7.5% (L), platelets 204 × 10⁹ /L, mean platelet volume 8.6 fL, mean corpuscular hemoglobin 32.2 pg, mean corpuscular hemoglobin concentration 351 g/L. Liver and renal function + cystatin C: Creatinine 98.0 μmol/L, urea nitrogen 7.2 mmol/L, uric acid 166.0 μmol/L, total protein 54.3 g/L (L), albumin 34.2 g/L, prealbumin 122.0 mg/L (L), ALT 79 U/L (H), AST 91 U/L (H), LDH 206 U/L, GGT 120 U/L (H), ALP 97 U/L, total bilirubin 8.2 μmol/L, direct bilirubin 3.9 μmol/L, serum bile acid 2.6 μmol/L, alpha-fucosidase 38.0 U/L, mitochondrial AST 9.0 U/L, A/G 1.70, globulin 20.10 g/L, cystatin C 1.00 mg/L. December 7 Complete blood count: White blood cell count 6.78 × 10⁹ /L, red blood cell count 3.56 × 10¹² /L (L), red cell distribution width 13.8%, hematocrit 0.331 L/L (L), mean corpuscular volume 93.0 fL, hemoglobin 113 g/L (L), neutrophils 78.2% (H), neutrophil absolute 5.30 × 10⁹ /L, eosinophils 0.9%, eosinophil absolute 0.06 × 10⁹ /L, basophils 0.9%, basophil absolute 0.06 × 10⁹ /L, monocytes 6.2%, monocyte absolute 0.42 × 10⁹ /L, lymphocyte absolute 0.94 × 10⁹ /L, lymphocytes 13.8% (L), platelets 349 × 10⁹ /L (H), mean platelet volume 6.8 fL (L), mean corpuscular hemoglobin 31.7 pg, mean corpuscular hemoglobin concentration 341 g/L. Electrolytes, liver and renal function + cystatin C: Sodium 133.0 mmol/L (L), potassium 4.50 mmol/L, chloride 100.0 mmol/L, creatinine 89.0 μmol/L, urea nitrogen 4.47 mmol/L, uric acid 224.0 μmol/L, total protein 63.1 g/L, albumin 41.5 g/L, prealbumin 193.0 mg/L, ALT 40 U/L, AST 21 U/L, LDH 150 U/L, GGT 72 U/L (H), ALP 67 U/L, total bilirubin 8.4 μmol/L, direct bilirubin 4 μmol/L, serum bile acid 1 μmol/L, alpha-fucosidase 36.0 U/L, mitochondrial AST 5.0 U/L (L), A/G 1.92, globulin 21.60 g/L, cystatin C 1.16 mg/L (H). Special examinations and important consultations Pathology reports attached Course and treatment outcome (note surgery date, procedure name, transfusion volume and resuscitation) After admission, preoperative examinations were completed. On November 26, under general anesthesia, the patient underwent "mid-esophageal cancer resection + gastric esophagectomy anastomosis + jejunostomy (two-incision approach: right thoracotomy and upper midline abdominal incision, right apical thoracic anastomosis)". Intraoperatively, a mid-thoracic esophageal tumor approximately 3 cm long was found invading the adventitia, making the procedure difficult. The patient returned safely to SICU postoperatively. Postoperative care included anti-inflammatory, expectorant, acid-suppressing, and intravenous fluid supportive treatment. The patient's general condition is now stable, and discharge for convalescence is arranged. Complications: None Condition at discharge (symptoms and signs) Alert and oriented, breathing smooth. Clear breath sounds in both lungs, slightly reduced on right, no dry rales. HR: 80 bpm, regular. Chest wounds well approximated, no redness, swelling or exudate. Soft abdomen, no tenderness. Remainder unremarkable. Post-discharge medications and recommendations 1. Follow-up in thoracic surgery outpatient clinic; further treatment recommended after surgery. 2. Take medications on time as prescribed. 3. Avoid infection (small frequent meals, regular diet one week after discharge), strengthen nutrition, sleep in semi-recumbent position. Treatment outcome: Cured
Nuclear Medicine Report Clinical diagnosis: Esophageal malignancy Requested: T3, TPO-Ab, T4, FT3, FT4 Specimen: Venous blood Sampling time: Following year January 6 06:02 Receipt time: Following year January 6 08:48 Report time: Following year January 6 14:17 Number Item Result Reference 12014 T3 1.36 (0.92-2.79 nmol/L) W12015 T4 112.60 (58.1-140.6 nmol/L) W12016 FT3 5.09 (3.5-6.5 pmol/L) W12017 FT4 14.87 (11.5-22.7 pmol/L) W12018 TSH 0.30 (0.25-5 mIU/L) W12019 TG-AB 17.09 ↑ (<13.6 IU/mL) 12022 TPO-Ab 54.12 ↑ (0-35 IU/mL) Report date: Following year January 6 Print time: Following year January 6 14:18
External Cytology Consultation Opinion Date received: Following year April 15 Report date: Following year April 18 Specimen: (Pleural fluid) smear Pathological diagnosis: Malignant tumor cells present, suggestive of poorly differentiated carcinoma.
Death Record (partial) Admission date: Following year April 8 Time of death: Following year April 30 10:27 Emergency diagnosis: 1. Post-radical esophagectomy; 2. Hyperthyroidism; 3. Multiple lacunar infarcts; 4. Right kidney stones and cyst; 5. Prostatic enlargement and calcification Admission diagnosis: 1. Post-radical esophagectomy; 2. Hyperthyroidism; 3. Multiple lacunar infarcts; 4. Right kidney stones and cyst; 5. Prostatic enlargement and calcification Death diagnosis: 1. Post-radical esophagectomy with widespread metastases; 2. Severe pneumonia with septic shock; 3. Hyperthyroidism; 4. Multiple lacunar infarcts; 5. Right kidney stones and cyst; 6. Prostatic enlargement and calcification Main laboratory results: April 8 Venous blood gas: pH 7.451 (H), bicarbonate 25.9 mmol/L, actual base excess 2.3 mmol/L. Complete blood count: White blood cell count 4.91 × 10⁹ /L, hemoglobin 85 g/L, neutrophils 79.8% (H), platelets 65 × 10⁹ /L (L). Coagulation: Thrombin time 16.30 seconds, prothrombin time 11.20 seconds, INR 1.04, fibrinogen 2.76 g/L, APTT 29.7 seconds. CRP 60.30 mg/L (H). BNP 59.0 pg/mL. Cardiac markers: CK-MB 168.6 ng/ml (H), myoglobin 42.90 ng/ml, troponin I 0.03 ng/ml. Procalcitonin 0.36 ng/ml. Renal function + cystatin C + electrolytes + liver function + CK: Sodium 131.0 mmol/L (L), potassium 4.80 mmol/L. ……………..
Operating Surgeon's Handwritten Response to Family Complaint: I. Regarding the patient's condition and tumor status Male, 78 years old. Admitted for progressive dysphagia. Gastroscopy confirmed mid-esophageal squamous cell carcinoma. Preoperative CT at our hospital showed mid-esophageal tumor without mediastinal lymph node metastasis (see attachments 1, 2). Enhanced CT could not be completed due to hyperthyroidism. Systemic examination revealed no evidence of metastasis, so PET/CT was not indicated. On November 26, the patient underwent two-incision radical esophagectomy with regional lymph node dissection. One month postoperatively, left mediastinal lymph node metastasis was found and radiotherapy was given on January 6. During radiotherapy, severe reactions occurred, followed by cachexia and multi-organ metastases. The patient died on April 30. II. Regarding treatment plan selection Treatment options (surgery, chemotherapy, radiotherapy) and associated risks were discussed with the family at the time of consultation. The family indicated they did not want chemotherapy or radiotherapy. After comprehensive assessment, surgery was the best option, and the family agreed after discussion. III. Regarding appropriateness of surgical plan The patient was elderly (78 years). Department discussion led to principles of precise surgery, minimal additional trauma, and shortened anesthesia time while ensuring tumor and lymph node removal and patient safety. The lesion was 27 cm from the incisors; right apical thoracic anastomosis via two incisions fully met treatment standards and did not require a three-incision approach. Postoperative pathology confirmed complete resection with negative upper and lower margins and dissected surface (attachment 3). Surgery duration was 2 hours 55 minutes, confirmed by anesthesia records. The patient recovered smoothly without complications and was discharged. This was already a good outcome for a 78-year-old. IV. Regarding lymph node dissection Extended lymph node dissection and three-incision surgery are unsuitable for a 78-year-old due to high risk of severe postoperative complications. We nevertheless performed systematic lymph node dissection of five groups (9 nodes total), all negative for metastasis (attachment 5). This matched preoperative assessment and confirmed the surgical plan. Unfortunately, a new left paratracheal lymph node metastasis appeared shortly after surgery. The family attributes this to incomplete surgery, and some doctors suggested a three-incision approach could have prevented it: 1. Comparison of all pre- and postoperative CT scans shows this was a new lymph node. Our radiology department reported on January 4: "New soft tissue mass in mediastinum, suspicious for metastatic lymph node enlargement." The family claims another doctor reviewed films and said the node was already metastatic in June, leading them to believe the surgical team overlooked it. However, the esophageal cancer diagnosis was only made in November—how could there have been lymph node metastasis six months earlier? 2. The new node was on the left mediastinum. Both three-incision and right thoracotomy approaches would be unable to visualize or dissect it. V. Regarding disease progression The tumor was locally advanced (T4a, stage IIIa) with high malignancy. Pathology showed a 4.5 cm mass invading the adventitia (full-thickness esophageal wall) and poorly differentiated squamous cell carcinoma. These factors explain the rapid progression. Although early postoperative metastasis is uncommon, it is seen clinically. VI. Regarding postoperative chemoradiotherapy Given the patient's advanced age, immediate postoperative chemoradiotherapy was inappropriate, consistent with the preoperative plan. Adjuvant therapy would only be considered after recovery of physical strength following complete tumor resection. VII. Regarding personal conduct As an experienced thoracic surgeon, I am well aware of the risks and responsibilities involved and would never describe this as "a simple operation." Additionally, due to my own hip condition, I am no longer able to cross my legs. Note: This report is consistent with the one submitted to hospital administration. Signed by the operating surgeon Following year May 26
The family's main complaints after the patient's death focused on: inadequate preoperative staging and metastasis risk assessment; use of plain CT instead of enhanced CT before surgery, potentially missing micrometastases and leading to an inappropriate surgical plan. The patient appeared in good health preoperatively (even accompanying out-of-town guests on sightseeing trips). The doctor reportedly told the family orally that the patient was "very optimistic." At discharge, high recurrence risk was not clearly communicated, creating a large gap between family expectations and the actual outcome (death about five months postoperatively). The surgeon's response to the complaint emphasized: 1) the family explicitly declined chemoradiotherapy preoperatively, so surgery was chosen as primary treatment; 2) the operation went smoothly without complications, which was already notable for a 78-year-old; 3) the mid-thoracic tumor 27 cm from the incisors made right apical two-incision anastomosis standard, with no need for three incisions; 4) extensive lymph node dissection was avoided in the elderly to prevent complications; 5) the new left-sided lymph node was outside the dissected field and represented new metastasis, unreachable even with a three-incision approach; 6) serosal invasion and high malignancy made death within six months consistent with the disease's natural course; 7) because the family declined chemoradiotherapy, discharge instructions did not stress follow-up adjuvant therapy.