Detailed Treatment Process
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Female, 42 years old The following is the discharge summary Department: Gynecology Admission time: September 6, 11:16 Discharge time: September 14, 10:00 Admission diagnosis: Ovarian malignant tumor (left, adult-type granulosa cell tumor) Discharge diagnosis: Ovarian malignant tumor (left, adult-type granulosa cell tumor) Brief history on admission: Gravida 2, para 0, abortion 1, living children 2. Menarche at age 17, menstrual cycle 5/30 days, moderate flow, no dysmenorrhea. Regular menses previously. Last menstrual period: September 2. The patient experienced prolonged menstrual spotting from June 2 to July 28, without postcoital bleeding, abdominal pain, fever, lower abdominal distension, lumbosacral pain, nausea, vomiting, urinary frequency or urgency, or changes in bowel habits. She was admitted on July 28 with a diagnosis of pelvic mass (possible left adnexal cyst). After completing relevant investigations, she underwent ultrasound-guided fractional curettage and intrauterine device removal on July 29. On August 5, she underwent laparoscopic exploration converted to laparotomy with left adnexal resection and pelvic adhesiolysis. Intraoperative frozen section suggested a neoplastic lesion of the left adnexa, most consistent with a sex cord-stromal tumor, pending paraffin sections and immunohistochemistry. She recovered well postoperatively and was discharged on August 9. Pathology reported on August 13: Grossly, a gray-white mass measuring 11.0 × 8.5 × 6.3 cm with intact capsule in the left adnexa; cut surface yellow, soft, solid with focal cystic areas measuring 1.0 × 3.0 cm and microcystic changes in solid areas. Attached fallopian tube measured 9.0 cm in length with circumference 0.7 cm and fimbriated end. A 1.0 × 1.0 × 0.2 cm cyst was noted on the tubal surface. Immunohistochemistry: tumor cells AE1/AE3 (+), CD56 (+), WT-1 (+), PR (+), Inhibin (+), Calretinin (partial +), FOXL2 (+), CK7 (scattered +), SF-1 (focal weak +), CAM5.2 (focal scattered +), Ki67 (hot spots approximately 10% +), CgA (−), CD10 (−), CD99 (−), SMA (−), S-100 (−), SYN (−), Desmin (−), ER (−), PAX8 (−); reticulin stain showed reticular fibers surrounding some tumor nests. Pathological diagnosis: left adnexal adult-type ovarian granulosa cell tumor, tumor size 11.0 × 8.5 × 6.3 cm; paramesonephric cyst of the fallopian tube, no tumor involvement. Since the previous discharge, the patient has been alert and in good spirits, with no abnormal vaginal bleeding or discharge, and no abdominal pain or distension. She was readmitted via outpatient clinic for further management with a diagnosis of ovarian malignant tumor. Since onset, the patient has been alert and in good spirits, with normal appetite, sleep, urination, and defecation. Physical Examination: T: 36.5°C P: 70 beats/min R: 18 breaths/min BP: 100/60 mmHg Gynecological examination: Vulva: married appearance. Vagina: patent. Cervix: smooth, no cervical motion tenderness. Uterus: anteverted, normal size, no tenderness. Adnexa: no obvious masses palpable. Major laboratory and special examination results during hospitalization (laboratory tests, X-ray/CT/MRI, pathology, etc.): Tumor markers: alpha-fetoprotein 3.54 ng/mL, carcinoembryonic antigen 0.85 ng/mL, squamous cell carcinoma antigen 0.40 ng/mL, human epididymis protein 4 24 pmol/L, carbohydrate antigen 199 5.60 U/mL. Ultrasound (units: mm): Cervix length 33. Uterus anteverted. Endometrial line visible. Bilateral endometrial thickness 5, endometrial echo slightly heterogeneous, no obvious blood flow signals. Uterine body dimensions: length 70, thickness 45, width 67. Internal echo: homogeneous. Right ovary: 32 × 21. Left ovary: absent (previously removed). No free fluid behind the uterus. Impression: slightly heterogeneous endometrial echo. Course and treatment: After admission, the patient completed preoperative evaluations. On September 9, she underwent R0 ovarian cancer staging surgery under general anesthesia (laparoscopic total hysterectomy + right salpingo-oophorectomy + high ligation of right ovarian vessels + omentectomy + pelvic lymphadenectomy + peritoneal biopsies) with lysis of intestinal and pelvic adhesions. Intraoperative findings included adhesions between the sigmoid colon and left pelvic sidewall as well as the left uterine wall, with edematous and friable tissues. The uterus was enlarged with surface inflammatory changes. The left ovary and fallopian tube were absent. The right ovary and fallopian tube appeared grossly normal. No ascites in the pelvis. No obvious abnormalities on the surfaces of the liver, stomach, intestines, bladder, omentum, mesentery, pelvic and abdominal peritoneum, or diaphragm. The procedure went smoothly. Postoperatively, she received anti-inflammatory therapy, fluid support, and nutritional supplementation. She recovered well, with return of bowel function and normal temperature, and was discharged. Treatment outcome: cured. Condition at discharge: Alert and in good spirits, afebrile, soft abdomen without tenderness, incision healing well (II/A), no vaginal bleeding or discharge. Post-discharge medications and recommendations: Discharge health education: Rest and maintain good nutrition. Avoid tub baths, sexual intercourse, and transvaginal ultrasound for 3 months. Pathology results should be checked 10 days postoperatively to determine the next treatment plan. The above is the discharge summary. Post-discharge pathology report: The right ovary showed follicular changes; the fallopian tube was unremarkable. No tumor was identified in the pelvic lymph nodes or other submitted tissues. All relevant sites were sampled except for pelvic fluid.