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杭州五舟出国看病服务机构

杭州五舟结肠癌远程会诊实例1

发布日期:2014-12-30  浏览次数:
患者介绍:
        贺女士(化名),河北唐山人,选择梅奥诊所进行结肠癌远程会诊,这次会诊主要想让梅奥诊所专家介绍患者有无去美国治疗的需要,并且对于患者腹部积水等症状提出解决方案。
中英文版会诊介绍由杭州五舟医疗人员根据患者病情资料整理撰写,中文版会诊结果和会诊医生的个人信息翻译、同国外医院对接等工作由杭州五舟医疗人员完成.会诊账户由杭州五舟海外医疗人员提供。
 
患者中文会诊要求
        患者贺女士(化名),女性,52岁,临床诊断“结肠癌伴腹盆腔、卵巢转移”。患者于2014年2月12日因“腹胀、便秘和排尿障碍2周”入院。腹部B超显示“子宫质地不均,左附件区及宫体右上方囊实性占位,大量腹水”,PET/CT示“双侧附件区囊实性肿块,实性部分FDG摄取增高,考虑双侧卵巢癌,肝包膜、网膜及腹盆腔肠系膜广泛种植,道格拉斯窝种植转移,腹膜后腹主动脉旁淋巴结转移,腹盆腔大量积液”;CA199异常升高(>1000U/mL)。2014年4月13日EGD示“浅表胃炎、胃息肉”;结肠镜示“距肛门6cm见宽蒂息肉1枚约0.7cm;肠镜见距离肛门60cm处降结肠发现隆起性肿块,占4/5周径,镜管无法通过”,经活检后报告“降结肠少量绒毛样类腺瘤不典型增生腺体,直肠绒毛状腺瘤伴中度不典型增生”。腹水内未发现肿瘤细胞。
        术前诊断:结肠癌伴腹盆腔、卵巢转移。
        患者于2014年6月13日行剖腹探查术+双侧卵巢切除术+大网膜部分切除术。术中取腹部正中切口进腹,探查示腹腔内少量略浑浊腹水,双侧卵巢囊实性转移灶,右侧直径15cm,左侧直径10cm,原发灶位于横结肠肝曲,肿块固定难以推动,大网膜呈饼状同横结肠肝曲病灶融合,肝曲处发现肿块,病灶直径8cm,且无法清除。膈顶、腹壁、盆底及肠系膜满布种植结节,大小0.5-3cm。考虑肿瘤无法根治性切除,原发灶无法切除。肠管无梗阻扩张.遂行顺双侧卵巢转移瘤切除+部分大网膜切除,并放置腹腔引流管拟术后行腹腔灌注化疗。结扎双侧卵巢动静脉与固有韧带后切除左右附件,大网膜肿瘤部分切除,缝扎残余,严密止血. 引流管3根分别位于脾窝、肝肾隐窝和盆底。标本送病理活检。手术顺利,术后活检示“左右附件中分化腺癌,首先考虑肠癌转移。部分大网膜浸润/转移性腺癌”。
患者于术后于2014.05.13、05.14接受5FU(1.5g)和DDP(80mg)腹腔热灌注化疗。灌注期间出现腹痛、恶心,否认白细胞下降等不良反应。2014年6月9日复查血常规:Hb 8.2g/L,6月10日予输血治疗(4个单位),无输血不良反应。
 
        患者自起病以来,体重明显减轻(2周内下降10公斤),伴纳差、乏力,轻度干咳。辅助检查:肝功结果示sGOT,r-GT轻度升高,血红蛋白稳定在9g/L,D-dimer升高,血白蛋白39g/L,其他结果无明显异常。 胸部X片显示轻度肺部感染,予头孢呋辛、阿拓莫兰(保护肝功)静点治疗。
患者既往情况良好,否认慢性病史,心肺功能正常,已婚,G0P0。父亲死于淋巴瘤,母亲糖尿病,一姐姐患有乳腺癌,具体不详。
患者今前往梅奥诊所(Mayo Clinic)进行会诊,获得治疗方案的相关意见,望就其个人情况予充分告知可行的治疗选择和随访方案(随访安排、辅助检查等),防止疾病的进一步进展。(结肠癌双侧卵巢、腹腔广泛转移,卵巢切除术后)
所提问题如下:
1、下一步的最佳治疗方案是否就是化疗+靶向治疗?具体方案哪个比较好?
2、有否更新更有效的药物或者其他治疗方案?
3、如何预防肠梗阻?出现梗阻怎么办?
4、如果阿片类镇痛药影响肠蠕动,有何好的止痛措施?
5、是否需要进行其他的相关基因检测?
6、如果在出现大量腹水,如何处理?

英文版会诊说明:
Referral Request
Ms. HE is a 52-year-old female with newly diagnosed ovarian cancer with peritoneal metastasis. She was admitted to the hospital on 3/13/2014 because of abdominal distention, constipation and urine disturbance developed 2 weeks ago. Abdomen ultrasound discovered “Heterogenous uterus, Solid cystic mass detected in right upper quadrant of uterus and left adnexa, and ascites”. Additional work-ups included PET/CT scan, which reported “Bilateral solid cystic masses within ovarian regions with elevated parenchymal radiotracer uptake. Diffuse implantation onto Glisson’s capsule, omentum and mesentery are visualized. Metastasis to the Doglas’s fossa and para-aortic lymph nodes is seen. Large amount of abdominal and pelvic effusion.” Laboratory tests showed highly elevated CA199(>1000). EGD showed “superficial gastritis and gastric polyps”. Colonoscopy found a broad-based rectal polyp 6cm proximal to the anus with a diameter of 0.7cm, and at the distance of 60cm to anus, a bugle mass occupying four-fifths of circumference is visible, with colonoscopy tube couldn’t pass. Biopsy from the colonoscopy reported “Descend colon: Small amount of papillary adenomatous dysplastic proliferative glands. Rectum: Papillary adenoma with moderate atypical proliferation”. No tumor cells were found in ascites.
Patient then underwent surgery on 5/13/2014. Abdominal exploration showed moderate amount of yellow ascites and solid cystic metastasis in bilateral ovary(Right lesion diameter: 15cm; Left lesion diameter:10cm). Primary lesion was seen on hepatic flexure of the transverse colon. The mass was firm, immobile, with a diameter of 8cm and adherent to a think rounded part of omentum. Diffuse abdominal implantations were seen on the diaphragm, abdominal wall, pelvic cavity and mesentery measuring 0.5-3cm. Radical resection of the primary tumor was not feasible. There was no bowel obstruction. A bilateral ovarian metastasis and partial omentum resection was performed. Bilateral ovarian artery, vein and ligament was obliterated. The mass on the omentum was partially removed and margin obliterated. Three drainage tubes were preserved from splenic recess, hepatorenal recess and pelvic cavity. Samples obtained during the procedure were sent to the pathologic department. Postoperative biopsy showed moderately differentiated adenocarcinoma and infiltrative/metastatic adenocarcinoma on the omentum. The patient underwent adjuvant chemotherapy of 5FU (given 1.5gram) and DDP (80mg) abdominal infusion on 6/6/2014 and 6/7/2014. She developed abdominal pain, nausea during the chemotherapy but was otherwise normal. The patient received a blood transfusion (4 units) due to low Hb(8.2g/L) on 5/13/2014. No adverse effect was seen with the transfusion.
The patient reported a loss of weight(10kg in 2 weeks), decreased appetite, and fatigue. Her liver function tests showed mildly elevated sGOT and r-GT, Hb 9g /L, elevated D-dimer, and blood albumin 39 g/L. The rest findings were normal. She also noted mild dry cough. Xray showed mild lung infection and the patient was given i.v. Cefuroxime and Atomalan ( to protect her liver function).
Ms.He was generally healthy in the past, without any known chronic disease. Her heart and lung function is within the normal range. She is married. G0P0. Her father died of lymphoma, while her mother was diagnosed with diabetes mellitus. Her sister was diagnosed with breast cancer with unknown medical details.
Ms. He wants to obtain second opinion from Mayo Clinic regarding her treatment. She specifically wants to know the available treatment options for her current condition and follow up plan (schedule, test) to prevent disease further progression.

英文版会诊结果:
This patient was not personally interviewed or examined. The history and examination findings are based on the clinical documentation provided and/or discussion with a physician or provider who had personally interviewed and examined the patient.I reviewed 29 pages of outside material.
HISTORY OF PRESENT ILLNESS
Ms. ** underwent abdominal exploration with bilateral oophorectomy and adenectomy and partial omentectomy for what was thought to be an ovarian carcinoma, but was subsequently found to be metastatic colon carcinoma. Patient had peritoneal metastases, liver metastases and ascites, though cytology for ascitic fluid was negative.             The patient was subsequently found to have a lesion in the hepatic flexure of the transverse colon that was near obstructing. The patient subsequently underwent chemotherapy with 5-FU and DDP (I assume cisplatin) June 6,2014 and June 7, 2014.
IMPRESSION/REPORT/PLAN
I reviewed 29 pages of outside material. Mayo has not reviewed the slides. We have no imaging studies but report of the scan shows liver metastases and peritoneal metastases as well as ascites. There are multiple questions asked.
1. Question regarding further chemotherapy and target therapy. I would suggest she be treated with FOLFOX. When she is more than six weeks from her surgery bevacizumab could be added to the program, but if she is to receive a colonic stent to prevent obstruction, then I would not give bevacizumab.
2. Is there any new medicine or treatment options suitable to the patient. See above. In addition, I would test for KRAS to see if there is a mutation. If there is no mutation, then cetuximab could be added to the chemotherapy regimen.
3. How to prevent bowel obstruction and what to do if there is one?
I would have her be seen by a gastroenterologist to consider a stent to see if this will help prevent an obstruction. Otherwise dietary measures will have to be taken as well as the use of laxatives. If there is an obstruction, she will need a diverting colostomy.
4. Opioid analgesics affect the bowel movements. Unfortunately opioids have that side effect and depending on the amount of pain she is having, they may be needed or could be eliminated.
5. Is there is any other gene screening indicated? See above. I would tests for KRAS to see if cetuximab can be added to the regimen.
6. How to deal with a large amount of ascites? This can be a problem and unfortunately chemotherapy is the only real chance of decreasing the ascites. I personally do not continue with paracenteses once ascites has accumulated because of the risk of continued infection, protein loss, and chance that the puncture site may not heal.
I hope this response has answered your questions.

中文版会诊结果:
        患者本人未接受问诊或体格检查。病史和体格检查结果来自临床文件和/或与曾为患者看诊和进行检测的医师或材料提供者讨论形成。
        本人查看了29页外部材料。
        现病史
        因诊断为卵巢癌,*女士接受腹部探查手术、双侧卵巢切术、腺切除术及部分网膜切除术,术后诊断为转移性结肠癌。患者病情发生腹膜转移、肝转移和有腹水(腹水细胞学检测结果呈阴性)。后发现患者在横结肠肝曲部位有病灶。随后患者在2014年6月6日和2014年6月7日接受5-氟尿嘧啶和DDP(我假定为顺铂)化疗。
        本人查看了29页外部资料。梅奥未进行病理会诊。我们没有拿到影像学片子,但影像学报告显示有肝转移和腹腔转移以及腹水。咨询者对上述情况提出了多个问题。
        1.关于进一步化疗和靶向治疗的问题。本人建议患者接受奥沙利铂(FOLFOX)治疗。患者术后满6周后可向化疗方案中加入贝伐单抗,但如果患者为防止发生肠梗阻而准备植 入结肠支架,则不建议施用贝伐单抗。
        2.是否有其他患者适用的新药或新的治疗选择?见上文。此外,我会检测结直肠癌基因(KRAS),以了解是否有基因突变。如果不存在基因突变,患者的化疗方案可增加西妥昔单抗。
        如果预防肠梗阻?如果有肠梗阻,任何处理?我会请消化科会诊,考虑置入支架防止发生肠梗阻。若不使用支架,则需进行饮食控制和使用泻药。如果发生一处梗阻,患者需要接受结肠造口术。
        3.阿片类镇痛药影响肠道运动。
        4.不幸的是阿片类有副作用,具体取决于患者服用的镇痛剂量,患者可以根据自己的疼痛情况决定继续用药或者停药。是否有任何其他基因筛查显示?见上文。我会让患者接受KRAS检测,以了解是否可以在治疗方案中增加西妥昔单抗。
        5.如何处理大量腹水?这是一个问题,而化疗是唯一能减少腹水量的方法。一旦发生腹水蓄积,我个人不会继续对患者行腹腔穿刺,因为这样做有发生持续感染、蛋白质丢失的风险,而且穿刺部位可能无法愈合。
诊断
肝和腹膜转移性结肠癌
希望这些回答能有助于解决您提出的问题。
会诊医生介绍:
        Joseph Rubin, M.D博士是梅奥诊所肿瘤学教授,是梅奥诊所内科肿瘤学医学顾问.是医院的肿瘤学奖学金计划的项目主任.他的主攻领域是胃肠道肿瘤治疗和胰岛细胞肿瘤的治疗.他曾参与介入放射学在临床治疗护理方面的发展,他的实验师与全美多家大型医药公司合作研发新型药物.除了胃肠道肿瘤的治疗以外他还参与了梅奥诊所大部分基因治疗项目来研发新的疾病治疗方案.他参与了多年的药品第一阶段研发.
学术职称:
肿瘤学教授
教育经历:
梅奥医学院肿瘤科研究员
梅奥医学院血液科研究员
梅奥医学院内科住院医师
库克县医院实习
南卡罗崃纳医科大学医学博士
 
 
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