关闭

服务支持

我们很高兴能帮助你,在这里,我们给你不同的选择,以获得与我们联系。

欢迎您致电,专业顾问将为您服务!
400 6868 021
我们重视个人信息的安全与保护,您的个人资料将不会被透露给任何第三方机构和个人。
关注我们
7x24 热线
400-6868-021

公司动态

公司荣誉

肺癌会诊案例

发布时间:2015-06-12 09:08:07作者:瑞弗健康
姓名:南京蒋先生
年龄:57岁  工作:公司员工
患病:早期肺癌
治疗医院:Loma Linda 大学医学中心


初患


2014年年初,南京的蒋先生与往年一样,来到医院例行他每年都必做的常规体检。但是检查结果却与往常体检有了很不一样的地方——蒋先生的右上肺似乎有什么不明阴影。

 

CT检查显示,蒋先生在右肺上叶尖段见团片样高密度影,形状不规则,周围可见毛刺,并牵拉局部胸膜,病变性质未明。医生告诉蒋先生,情况可能不乐观,右上肺的包块可能是肿瘤,也就是说他可能已经患上了肺癌。

 

肺癌?蒋先生似乎感到不太相信。因为他身体向来很好,而且最近也并没有咳嗽、发热、盗汗之类的不舒服的现象,更没有医生说的胸闷、头晕、视力减退之类的癌症典型的临床表现。他的饮食、睡眠及大小便一直以来都是正常的,没有感染病史、遗传病史和慢性病史,检查也没有其他指标表现的有异常。他仔细的咨询了医生。医生告诉他,他吸烟及饮酒40余年,而且量已经达到吸烟10/天,饮酒250/天,这样的量确实有一定几率引起癌症。医生还提到,从现况看来,如果真是是肿瘤,那蒋先生的肺癌还属于早期癌症,最好尽快做手术治疗。

 

蒋先生一听早期癌症,就觉得这个病不宜拖,很快遵照医生意见进行了手术。包块切下来后,医生诊断为:肺癌。虽然蒋先生手术前检查一切正常,手术进行顺利,术后也并未感到任何不适。但是对于患者的家属来说,癌症终究是一个重大的疾病,总觉得难以完全放心。手术是成功了,那以后会怎么样呢?万一手术没切干净怎么办?万一还有几个癌细胞还在身体里,以后复发了怎么办?手术后应该怎么治疗和保养才能防止复发?化疗是不是会有效一点?肺癌基因检测结果什么意思?

 

这种种解不开的疑问,让癌症的阴影在蒋先生的亲人心里挥之不去,就像被判了死刑一般,压得全家人喘不过气。此后,他的家属开始奔走于国内各大医院为他咨询癌症的相关问题。但国内专家的回答都非常简单——“化疗吧?”“不用管!什么都不用做!”而家属对于这样公式化的回答显然感到不够放心,为了寻找他们想要的答案,他们一直坚持寻找在各个平台上。




部分病例档案

 

姓名

蒋先生

 

 

年龄

57

性别

诊断

右上肺包块:中-低分化腺癌(T1N0M0

诊断日期

入院诊断日期2014.3.17

是否初诊

初诊

是否手术

是(手术日期:2014.3.20

化疗

放疗

 

入院治疗记录

入院时间:2014317

现病史:患者于入院前20余天前行常规体检,行X胸片检查,发现右上肺占位,至当地医院进一步行CT检查提示:右肺上叶尖段见团片样高密度影,形状不规则,周围可见毛刺,并牵拉局部胸膜,病变性质未明。患者病程中无咳嗽、咳痰、发热、盗汗;无胸闷、呼吸困难,无声嘶;无头痛、头晕、无视力减退;无关节疼痛、肿胀。患病以来饮食、睡眠及大小便无改变。

 

既往疾病情况

既往体检。否认“高血压、糖尿病、冠心病”病史。否认“肝炎、肺结核”等传染病史。无药物过敏史。

患者吸烟及饮酒40余年,吸烟10/天,饮酒250/天。

无家族遗传病史及传染病史。家属无类似疾病史。

入院诊断:右上肺包块

手术日期:2014320

诊断:右上肺包块:中-低分化腺癌(T1N0M0

 

影像学检测报告

术前319CT检查:两侧胸廓对称,胸壁软组织及肋骨未见明显异常。两侧胸膜腔未见积液。两肺纹理稍多,右上肺见不规则结节影,见分叶,余肺未见明显实质性病变。气管居中通常,两肺门对称,无增大增浓。纵膈居中,未见明显肿大淋巴结,冠脉少许钙化,心影及大血管无异常,两膈面光整。 印象:右上肺不规则结节

术后DR 胸部正侧位检查:右上肺切除术后,右侧胸腔见引流管,右肺缩小,气管右偏,右肺门结构稍乱,左肺纹理尚清,左侧肺门不大,心影未见明显异常,右膈抬高,两膈光整,两肋角锐利。 印象:右肺上叶切除术后改变。

 

病理报告

2014.3.20 病理报告

标本:右上肺包块

病理诊断:“右上肺切除标本”:中-低分化腺癌(腺泡型为主,部分为实体型),肿块大小2X1.8X1.2cm3

支气管切缘(-)。找见“支气管旁”淋巴结(0/1)、“肺门”淋巴结:(0/1)、“第二肺门”淋巴结(0/2

“隆突下”淋巴结(0/1)均未见癌组织累及。肺表面肺大泡形成。

免疫组化报告(2014.5.22):5-FU+),CK5/6-),CK++),EGFR++),ERCC1-),Ki67++70%NapsinA-

P63-),RRM1+),TOPOⅡ(+),TTF-1+),β-Tubulin-),CDX-2-),CEA-),CK20-),Villin-),结合HE切片,符合腺癌。

 

 

基因检测报告

检查时间:201444

项目内容:

检测分类1:肿瘤治疗相关药物靶标检测——mRNA表达水平

1.检测内容:ERCC1BRCA1TSTUBB3TOP2ARRM1基因mRNA表达水平;EML4-ALK融合基因检测

2.检测方法:实时定量PCRReal time PCR

3.主要材料:ABI荧光定量试剂盒

4.主要设备:ABI7500荧光定量



 



 

瑞弗介入

终于在五月的某一天,他们通过网络找到了瑞弗健康。公司的医疗顾问通过对患者家属的充分沟通,对病人情况和家属需求有了详细的了解,也能充分理解家属急切的心情。瑞弗的医学博士告诉他们,因为蒋先生的癌症发现的很早,手术也很顺利,所以目前的情况还是比较乐观的。对于癌症的治疗,国外近期有不错的进展。如果感到国内的治疗情况有限,可以尝试国外的医疗。

 

瑞弗的相关专家还向他们介绍了美国医疗的现况和在癌症方面的成就,并根据他们的需求情况,向他们推荐了远程会诊服务项目,蒋先生一家当即表示想试试看。

 

于是,在安抚了蒋先生家属的情绪之后,公司经过快速的匹配,在接到病例的第2天就为家属安排好了洛玛琳达大学医学中心,肿瘤及血液中心的主任—— Dr. Chen 参加这次的会诊,为患者答疑解惑。

 

视频会诊在瑞弗医学顾问的主持下,进行了近1个小时。首先,Dr. Chen对蒋先生的患病经过进行了详细的回顾。

 

Dr. Chen指出,蒋先生目前的肺癌诊断属于Ia期,是非常早期的肺癌。这个时期的肺癌由于症状不明显,一般不易发现,通常只能通过体检察觉。在国外,对于像蒋先生这种长期吸烟的人群,医生都会建议每年进行低剂量螺旋CT检查,以筛查肺癌的情况。由于手术能够完全切除早期的肺癌,所以是最有效最直接的治疗早期癌症的手段。由于蒋先生的手术记录显示,切缘完整且阴性,区域淋巴结检查也是阴性,因此能判断蒋先生的肺癌确属早期,而且手术是非常成功的。但是因为考虑到癌症转移病灶的问题,所以建议在手术后进行一次全面的PET-CT检查,以排除可能的病变转移。Dr. Chen 还为家属详细的解答了病理检查结果中每项指标的意义,对于结果中免疫组化出现的EGFR阳性和基因突变检查结果阴性的情况也做了解释,让家属了解到这些检查的意义。

 

在整个会诊过程中,Dr. Chen不仅对蒋先生的疾病经过进行了详细的分析,还对蒋先生下一步的治疗给出了建议。他指出,针对这种早期的肺癌,手术如果全切较好,术后的化疗对患者来说,副作用的危害大于可能的获益。他还建议蒋先生应当对生活习惯及饮食做相应的调整,尤其是关于吸烟。“戒烟可以减少肺癌复发的风险,同时也可以减少患上其他癌症的风险。”Dr. Chen这样说道。


 

详细会诊意见

 

Recordreview: 

Based on 2014.3.20

病理

本:右上肺包

病理断:Adenocarcinoma [2X1.8X1.2cm3]with no positive lymph node identified

 

 

Diagnosis:Non-small Cell Lung Cancer, Adenocarcinoma 

 

STAGING — Thereis adequate information to determine the disease stage by the history, physicalexamination, laboratory testing, imaging, and tissue sampling are complete. 

Stagingis based upon the tumor node metastasis (TNM) staging system, which grades theprimary tumor characteristics (T), presence or absence of regional lymph nodeinvolvement (N), and presence or absence of distant metastasis (M)

 

T1

Tumor ≤3 cm diameter, surrounded by lung or visceral pleura, 

without invasion more proximal than lobar bronchus

T1a

Tumor ≤2 cm in diameter

 

N0

No regional lymph node metastases

 

Molecular tests:

IHC: noted EGFR++
PCR: no EGFR mutation, no ALK translocation 

Surgery: lobectomy with complete resection described.

Specific issue:
1. Patient is an active smoker 
2. No PET-CT or CT of abdomen and pelvis performed prior to surgery


Conclusions

1. Stage Ia non-small cell lung cancer, adenocarcinoma with completed resection with no positive margin, no evidence of regional lymph node involvement.  
2. EGFR test by IHC is not a reliable marker at this stage for response to EGFR Tyrosine kinase inhibitor, a FDA approved medication for EGFR targeting. EGFR mutation tests are the most predictable marker for EGFR targeting response and yet the current results were all negative. Although clinical trials are in progress to address this issue. It is not clear if any benefit can be derived from taking such medication in this case. 


Recommendations:
1. Smoke cessation: Tobacco use is the most preventable cause of cancer, and accounts for 21 percent of worldwide total cancer deaths. Approximately one-half of all smokers die of a tobacco-related disease, and adult smokers lose an average of 13 years of life due to this addiction. Smoking is the strongest risk factor for lung cancer, increasing risk 10 to 20-fold. Smoking is also implicated as a causative factor for leukemia as well as cancers of the oral cavity, nasal cavity, paranasal sinuses, nasopharynx, larynx, esophagus, pancreas, liver, stomach, cervix, kidney, large bowel, and bladder. Therefore, it is crucial that patient stop all smoking including second hand expose. The risk will not completed eliminated even after stopping but it will be reduced significantly. Smoking also cause direct lung injury and result in emphysema and chronic obstructive lung disease, which is devastating for quality of life. 
2. I recommend whole body PET-CT test [some centers do skull base to thigh which is fine], about two months after patient surgery date. The test should not be done too close to surgery as post-surgery tissue recovery will give false positive signal and should not be done if patient has any ongoing infection, i.e. pneumonia which will give false positive signal as well. This is recommend due to the fact that patient did not have complete staging information prior to surgery. 
3. Stage Ia disease will not benefit from additional adjuvant chemotherapy or radiation after definitive lobectomy surgery. In addition, side effects for such adjuvant therapy are harmful for patient including radiation pneumonitis, marrow suppression, infection etc. 
4. I recommend no chemotherapy or radiation. IF any doctors recommend such treatment, it is must carefully discuss and find out the rationale, if any. I do consider that EGRF targeting is an area of interest, but it will be unlikely benefit based on current disease profile. This can be discussed further as I am not sure the sensitivity for the molecular test result given to me. It is also clear that essentially all active smokers are EGFR mutation negative and will not benefit from EGFR targeted therapy.
5. I recommend every 6 months of Body CT scan with and without contrast for cancer screening. IF patient develop any new symptoms, such as headache, pain with no clear attributable cause, excessive fatigue, weight loss, or night sweat, etc, a screening CT can be done sooner.
6. Due to the risk from smoking, patient should have a good thorough inspection of nasopharyngeal, oral cavity and pharynx [by ENT doctor] and GI screening such as upper gastrointestinal endoscopy [by GI doctor] at least once in near future. 
7. Life style modification: It is estimated that sedentary lifestyle is associated with 5 percent of cancer deaths. For people who do not smoke, exercise is one of the most important modifiable risk factors (along with weight control and dietary choices).  
8. Take Vitamin D and calcium supplement. An increment of 25 nmol/L in the serum 25(OH)D level was projected to result in a 17 percent reduction in total cancer risk in men, extrapolated from data from the US Health Professionals Follow-Up Study. This incremental level of serum 25(OH)D is not readily achieved with diet (one glass of milk is predicted to increase the plasma level only by 2 to 3 nmol/L), and would require supplementation with at least 1500 IU vitamin D daily.
9. Increase food intake in greens. Folate is present in green, leafy vegetables, fruits, cereals and grains, nuts, and meats. Folic acid, a synthetic form included in supplements, has many of the same biologic effects as folate, but is more bioavailable. Folate is important in DNA synthesis, methylation, and repair, as well as in the regulation of gene expression.




Summery prepared by 
CS Chen, MD, Ph.D.

Loma Linda University Cancer Center


尾声

 

通过在这次会诊过程中Dr. Chen的耐心回答和细心指导,使家属对肺癌有了更深层次的了解。他们告诉瑞弗,对于即将要面对的蒋先生的治疗和康复,他们充满了信心。



瑞弗温馨提示:

肺癌是非常常见而又会被忽略病症,建议患者及其亲人在病症诊断不确定时一定要选择一家正规的咨询机构和权威专家,避免造成误诊,延误最佳治疗时机!


总浏览量:4937

想了解更多资讯

请扫描下方二维码关注瑞弗健康公众平台


分享到
© 2015 瑞弗健康. Alnl Rights Reserved.
沪ICP备14001925号
Design by ocean   SERM | SEPC