Detailed Treatment Process
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Male, 62 years old Electronic gastroscopy report Endoscopic findings: Esophagus: A large mass was seen from 30 cm from the incisors to just above the Z-line, with deep ulceration on part of the surface covered by dirty exudate. The lesion was friable and bled easily. The Z-line was visible. Cardia: Patent Gastric fundus: Mucosa normal, clear mucous lake Gastric body: Mucosal folds regular Gastric angle: Smooth, normal curvature Gastric antrum: Mucosa red and white, predominantly red, with scattered flat erosions Pylorus: Round Duodenum: Bulb and descending portion normal Endoscopic diagnosis: Chronic atrophic gastritis (erosive); neoplasm in the middle to lower esophagus Biopsy sites: Three samples from the esophagus Physician recommendation: Hospital admission Examination date: July 31
Pathology consultation report from outside hospital Receipt date: August 8 Referring institution: Certain hospital Slide numbers: 1, G18-15223 quantity: HE × 1; 2, / quantity: /; 3, / quantity: /; 4, / quantity: / Original pathologic diagnosis: (Esophagus) Severe squamous dysplasia, suspicious for malignancy. Clinical summary: / Consultation opinion: (Esophagus, biopsy) High-grade squamous intraepithelial neoplasia. Note: This is the individual consulting pathologist’s opinion and is for reference by the original pathologist only. Report date: August 8
Ultrasound Doppler report Submission date: August 10 Department: Thoracic oncology Examination: Liver, pancreas, spleen, adrenals, neck and supraclavicular regions, retroperitoneum, kidneys Ultrasound findings: 1. Solid nodule in the left supraclavicular region (lymph node; correlate clinically) 2. No obvious masses in bilateral neck, right supraclavicular region, liver, spleen, gallbladder, pancreas, abdominal cavity, retroperitoneum, or bilateral adrenals 3. Bilateral renal vessels normal
Radiology report Department: Thoracic oncology Clinical diagnosis: Esophageal cancer Requested study: Esophagogram Examination: Esophagogram Radiographic findings: Irregular filling defect with niche formation in the middle to lower thoracic esophagus, approximately 8 cm in length, with mucosal destruction and local narrowing. Barium passage was slow. The remainder of the esophagus appeared normal. The cardia opened normally. Radiologic impression: Possible malignant tumor (MT) in the middle to lower thoracic esophagus; please correlate clinically. Examination time: August 14, 14:44 Report time: August 14, 16:44 Verification time: August 14, 16:50
Gastroscopy report Examination date: August 16, 07:30 Findings: Esophagus: Irregular ulcer occupying half the circumference at 30–40 cm from the incisors, friable with surface erosion (four biopsies taken, hemostasis performed). The scope could still pass. Cardia: Opens and closes well. Gastric fundus: Smooth mucosa. Gastric body: Mildly congested and edematous mucosa. Gastric angle: Smooth mucosa. Gastric antrum: Congested and edematous mucosa. Pylorus: Round Duodenal bulb: Normal. Diagnosis: Esophageal malignant tumor (nature pending pathology)
Gastric mucosal biopsy pathology report Submission date: August 17 Department: Thoracic oncology Referring hospital: This hospital Specimen sites: Gastric antrum (block), gastric angle (block), greater curvature of gastric body (block), lesser curvature of gastric body (block), cardia (block), gastric fundus (block) Chronic inflammation: Present Activity: Present Atrophy: Present Intestinal metaplasia: Present Dysplasia: Present HP: Other histologic changes: Histologic diagnosis: (Esophagus, biopsy) Poorly differentiated carcinoma, favoring squamous cell carcinoma. Lauren classification: Report date: August 21
Outside hospital pathology consultation report Receipt date: September 4 Consultation opinion from this hospital: (Esophageal biopsy) Small cell carcinoma with squamous differentiation. Immunohistochemistry performed at this hospital (5261): P63 (partial +), CK5/6 (focal +), Syn (−), CD56 (−), CgA (−), P16 (−), CD57 (−), Ki-67 (LI: 80%) Consultation date: September 6
CT report Examination date: November 2 Department: Thoracic surgery, bone and soft tissue surgery Region: Chest (lungs, mediastinum) + supraclavicular area (plain + contrast) Findings: After chemotherapy for “esophageal small cell carcinoma,” the esophageal wall below the carina level in the posterior mediastinum is markedly thickened. There are enlarged lymph nodes in mediastinal station 8 and a large soft-tissue mass around the esophagus measuring approximately 10.2 cm × 6.0 cm, extending down to the esophageal hiatus. The mediastinal mass shows marked enhancement on contrast, larger than on September 3. Bilateral thoracic symmetry, mediastinum midline. Tiny nodule in right upper lobe unchanged. Remainder of lung fields clear. Multiple soft-tissue nodules in mediastinal station 1R and left supraclavicular region unchanged, largest short-axis diameter ≤ 1.0 cm. No obvious enlarged lymph nodes in right supraclavicular region. Impression: After chemotherapy for “esophageal small cell carcinoma,” the esophageal tumor and mediastinal lymph node metastases are larger than before.
CT report Examination date: January 21 Department: Thoracic radiation oncology Region: Chest (lungs, mediastinum) + supraclavicular area (plain + contrast + 3D reconstruction) Findings: After chemoradiotherapy for “esophageal small cell carcinoma,” the esophageal wall below the carina is markedly thickened with a large surrounding soft-tissue mass measuring approximately 9.2 cm × 6.9 cm, extending to the esophageal hiatus. Internal low-density areas have increased compared with December 4. Bilateral thoracic symmetry, mediastinum midline. Tiny nodule in right upper lobe unchanged. Patchy opacity in right lower lobe and patchy shadows in both lungs. Multiple enlarged lymph nodes in mediastinal station 1R, station 8, and left supraclavicular region; largest in station 1R with short-axis diameter approximately 2.3 cm, increased from previous. Mild right pleural thickening. No obvious enlarged right supraclavicular lymph nodes. No obvious bone destruction. Multiple low-density nodules in the liver and soft-tissue nodule near the cardia. Impression: 1. After chemoradiotherapy for “esophageal small cell carcinoma,” esophageal tumor with increased internal necrosis; 2. Mediastinal station 1R lymph node metastasis, enlarged from before; 3. Patchy opacity in right lower lobe and bilateral lung patches, likely inflammatory, possibly radiotherapy-related infection; 4. Mild right pleural thickening; 5. Multiple hepatic nodules and soft-tissue nodule near the cardia—further evaluation recommended. Gastroscopy showed a large mass at 30 cm from the incisors; pathology favored squamous cell carcinoma. Ultrasound revealed a solid supraclavicular lymph node suggestive of metastasis. Three months later, immunohistochemistry confirmed small cell carcinoma with squamous differentiation. Post-chemotherapy imaging showed enlarged esophageal tumor and mediastinal lymph node metastases. The patient died two years after the initial diagnosis.