盆腔包块疑难病例讨论医生记录范文

盆腔包块疑难病例讨论医生记录范文
英文回答：
Case Discussion on Difficult Pelvic Mass.
Patient History:
The patient is a 45-year-old female who presented with complaints of pelvic pain and bloating for the past six months. She also reported irregular menstrual cycles and a feeling of fullness in her lower abdomen. On physical examination, a palpable mass was felt in the pelvic region. The patient has no significant past medical history and no family history of gynecological malignancies.
Diagnostic Workup:
The patient underwent a series of diagnostic tests, including transvaginal ultrasound, CT scan, and MRI. The imaging studies revealed a large pelvic mass measuring 10
cm in diameter, with irregular borders and areas of necrosis. Tumor markers, including CA-125, were within normal limits. A diagnostic laparoscopy was performed, and multiple biopsies were obtained from the mass for histopathological examination.
Histopathological Findings:
The histopathological examination revealed a complex ovarian mass with features suggestive of a borderline mucinous tumor. However, the presence of solid areas and necrosis raised concerns for a potential malignant transformation. Immunohistochemical staining was inconclusive, and further molecular testing was recommended to characterize the tumor subtype.
Multidisciplinary Discussion:
Given the complexity of the case, a multidisciplinary team involving gynecologic oncologists, radiologists, pathologists, and medical oncologists was convened to discuss the management options. The team considered the
possibility of a rare ovarian malignancy, such as a mucinous borderline tumor with high-grade transformation, and the need for comprehensive staging and debulking surgery.
Treatment Plan:
Based on the multidisciplinary discussion, the patient was scheduled for a total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and pelvic lymph node dissection. Intraoperative frozen section analysis would be performed to guide the extent of surgical resection. The
final treatment plan would be determined based on the histopathological findings and the extent of disease spread.
Follow-Up:
The patient would require close surveillance postoperatively, including regular imaging studies and
tumor marker assessments. Depending on the final histopathological diagnosis, adjuvant chemotherapy or targeted therapy may be considered. Long-term follow-up
would be essential to monitor for disease recurrence and assess the patient's overall prognosis.
中文回答：
盆腔包块疑难病例讨论。

病例讨论：
患者是一名45岁的女性，近6个月来出现盆腔疼痛和腹胀的症状。

她还报告月经周期不规律，下腹部有饱胀感。

体格检查发现盆
腔区可触及包块。

患者无明显的既往病史，家族中也无妇科恶性肿
瘤史。

诊断工作：
患者接受了一系列的诊断测试，包括经阴道超声、CT扫描和MRI。

影像学研究显示盆腔内有一个直径为10厘米的大包块，边界
不规则，且有坏死区。

肿瘤标记物，包括CA-125，均在正常范围内。

进行了诊断性腹腔镜检查，并从包块处获取了多个活检标本进行组
织病理学检查。

组织病理学结果：
组织病理学检查显示一个复杂的卵巢肿块，具有提示黏液性肿瘤的特征。

然而，实体区和坏死的存在引发了对潜在恶性转变的担忧。

免疫组化染色结果并不确定，建议进行进一步的分子学检测以确定肿瘤亚型。

多学科讨论：
考虑到病例的复杂性，我们召集了涉及妇科肿瘤学家、放射科医生、病理学家和医学肿瘤学家的多学科团队讨论治疗选择。

团队考虑了罕见的卵巢恶性肿瘤的可能性，如黏液性边界肿瘤伴高级别转变，并讨论了全面分期和减灶手术的必要性。

治疗方案：
根据多学科讨论，患者被安排进行全腹子宫切除术、双侧输卵管卵巢切除术、大网膜切除术和盆腔淋巴结清扫术。

术中冰冻切片分析将指导手术切除的范围。

最终的治疗方案将根据组织病理学结果和疾病扩散的程度确定。

随访：
术后患者需要密切监测，包括定期影像学检查和肿瘤标记物评估。

根据最终的组织病理学诊断，可能考虑辅助化疗或靶向治疗。

长期随访对于监测疾病复发和评估患者的整体预后至关重要。