Oncology department of Shanghai Shuguang Hospital Affiliated to shanghai University of Traditional
Chine Medicine
The scripts of Ward Round in English——R ectal Adenocarcinoma
上海中医药大学附属曙光医院——肿瘤科
英语查房剧本——直肠腺癌
Chief: Dr.Zhong Yi 钟薏
Attending Dr. Liu Hong Jie 刘宏杰
Resident Dr. Zhang Yan Bo张彦博
Intern Chen Xuan 陈旋
Patient Shu Jia He 束家和
A． Morning shift
情景A：交班
OFFICE：办公室
Chief: ok! let's begin our morning shift.
主任：好，现在开始晨交班。
Intern: DEC 10th 2007,morning shift. total number of the patients is 34,including 1 new admission, no critical patients. all the patients are in stable condition.
the new admission in Bed No.12 is Mr. Wang yong,,male,61y.Who's chief complaint: low rectal adenocarcinoma ,received Mile’s operation 20days ago. diagnosis at prent: low rectal adenocarcinoma.That's all for today's morning shift.
实习医生：2007年12月10日晨交班，病人总数34人，新病人1人，危重病人0人，病人病情稳定。
新病人12床，王勇，男性，61岁，因“低位直肠腺癌，Mile’s 术后20天”入院.目前诊断：直肠癌。
Chief: I'm glad to e all the patient in stable condition. Since we have new admission today, I would like
to choo Mr. Wang for today's director ward around. Doctor chen, plea give us a ca report for newly admitted patient.
主任：患者大都病情稳定，我很高兴，我们收了新病人，那我就选这位王先生作为今天主任查房的对象。陈医生请你给大家汇报一下病史。
B．Ca Prentation
情景B: 病史汇报
Intern: the new admission in Bed No.12 is Mr. Wang yong,,male,61y.
实习医生：新病人12床，王勇，男，61岁。
Chief complaint: low rectal adenocarcinoma ,received Mile’s operation 20days ago.
主诉：低位直肠腺癌，Mile’s 术后20天。
History of prent illness: More than 2 years ago, the patient began to suffer from inferior and umbilical abdominal pain. The pain was accompanied by intermittent fecal incontinence for more tha
n 6 times a day without any reason. The stool was in mi-formed and liquid-mucoid form. The pain can be alleviated after bowel movement without an西安到广州高铁
y associated fever, naua or vomiting. Six months ago, the patient occasionally noted blood in his stool. Five month ago he went to the local clinic and was diagnod with hemorrhoids. But with no subquent relief after some undetailed treatment. Five days ago, he came to our hospital for further exam. The doctor at our-patient department gave him a colonoscopy exam. Under the colonoscopy , A friable, ssile lesion, 15 to 20 mm in diameter, was identified very low in the rectum; examination of a biopsy specimen of the lesion disclod adenocarcinoma. And he received abdominoperineal rection nineteen days ago in our hospital. He was admitted on Dec 9th for further exam and treatment.
现病史：患者两年余前出现下腹部及脐周疼痛伴有间歇性大便失禁，每日6次左右，大便夹有黏液，质地稀。泻后痛减。发病期间未见发热、恶心、呕吐。6月前患者偶然发现便中带血。并于5月前前往就近医院诊治，当时诊断为“痔疮”，经过一些治疗，具体不祥，未见明显改善。患者5天前，来我院做了进一步检查。我院门诊予以直肠镜检查。在直肠镜下，在直肠下段近肛门处发现一个易出血的息肉，直径在15 -20mm，病理提示为腺癌。19天前患者于我院接受了经腹会阴直肠切除术。患者为求进一步诊治收治入院。
History of past illness: There was a 10 year history of diabetes that was controlled with diet and Gluc
ophage.
既往史：患者右糖尿病史10年，口服格华止250mg tid及饮食控制。10年前行肾结石体外碎石术。
Personal history: He had a 40-pack-year smoking history but had discontinued smoking five years.
个人史：他有40年吸烟史，最近5年中断吸烟。
Physical exam:
体格检查：
T: 37.2 P:86bpm R:18/min BP:115/70mmHg
The patien长沙两日游
t was awake alert ,moderately obe, no anemic appearance, no jaundice, An examination of his heart and lungs showed no abnormalities.
患者神情，中度肥胖，无贫血貌，无黄染，心肺听诊无殊。
Abdomen: 涤亲溺器
flat，an operative scar and the praeternaturalis anus in lateral abdomen. no mass was dictated through both deep and superficial palpation, no voluntary muscle guard, no rebound tendern
ess. The liver and spleen couldn’t be palpated.
The lower limbs were no edematous.
腹部检查：腹部平坦，腹部手术疤痕、侧腹部人工肛门，腹部潜触诊及深触诊未及肿块，无肌卫，无反跳痛，肝脾肋下未及。下肢无浮肿。
Laboratory test: Labortary test: blood routine test: Hb: 98g /l, WBC:8.9*10 9/l; stool culture: (-);仔的多音字组词
stool routine test: normal; OB : normal. Liver and kidney function: was within normal ranges.
试验：血常规：血红蛋白：98g/l，白细胞3.7109/l.。大便培养：（-），大便常规：正常，OB：正常，肝肾功能：未见明显异常。
A chest radiograph showed that the lungs were clear, without evidence of metastas, and that the cardiac, hilar , mediastinal pleural , and bony structures were normal.
胸部X线：双肺清晰，没有转移灶，心脏、肺门、纵隔、胸膜和骨骼正常。
C. Discussion
情景C: 病例讨论
Chief: thank you Doctor chen. Doctor Zhang(resident) did the patient had any sign of lymph noddota怎么玩
e or organ metastasis ? What is his tumor–node–metastasis classification?
主任：谢谢陈医生。张医生病人有什么淋巴和器官转移证像吗？他的TNM分期是什么？
Resident: The patient’s Diagnosis: Adenocarcinoma of the rectum, stage T2N 0M 0.
住院：病人诊断可以是直肠癌T2N 0M 0期。
Chief: Do you know what does T2N 0M 0 mean ?
主任：你知道T2N 0M 0代表什么吗？
Attending: T2might refer to a moderate tumor invation; N0 indicats the cancer cell lesions without the lmpth nods beside the rectum. M0 is refer to the no metastsis to the other organs.
主治：T2代表的是中等程度的肿瘤转移，N2代表淋巴转移到直肠以外，M0代表没有器官转移灶。
Chief: Not exactly. The staging of rectal cancers the tumor–node–metastasis classification system is according to WHO. T refer to the tumor. T1 lesions involve the mucosa with variable invasion into the
submucosa ; T2 lesions invade, but do not completely penetrate, the muscularis propria; T3 lesions are transmural and involve all layers of the rectum, including the rosa ; and T4 lesions involve adjacent structures, such as the bladder. N is refer to the lymph nod. N1 indicts the cancer cell lesions the lymphnods beside the cancer leveal;N2 indicts the cancer cell lesions the lymphnods at menterium ;N3
indicts the cancer cell lesions the lymph nods at abdominal aorta. M is refer to the metasis to the other organs.
主任：不完全正确。根据WHO直肠癌TNM分型，T1代表癌症侵犯粘膜并破坏粘膜下层；T2代表癌症侵犯范围未穿透固有肌层；T3代表癌症透壁型的侵犯所有层面，包括浆膜层，T4代表癌症侵犯已侵犯邻近组织，例如膀胱。N代表淋巴结，N1肿瘤层面的淋巴转移，N2代表肠系膜淋巴转移，N3代表腹主动脉周围淋巴结转移。M代表了邻近器官转移。
Chief: What kind of exam exam that the patient had took can support this T2N 0M 0 diagnosis ?
主任：有什么检查可以支持你的T2N 0M 0诊断吗？
Resident: Endoscopic ultrasonographic examination performed at this hospital shows an infiltrative
mass, 8 mm thick, in the rectum. The tumo顽强的反义词
r has invaded the mucosa, submucosa, and muscularis propria. However, the outside border of the muscularis propria appears smooth. Several lymph nodes are visible, but they are not enlarged and have normal echogenicity.
Endoscopic ultrasonographic staged lymph nodes.It is bad on their size and echotexture. In this patient, The lymph nodes we saw on ultrasonographic examination were not enlarged and had normal echogenicity.
住院医生：在该医院行经肛周内镜超声检查显示为厚约8 mm的直肠浸润肿块。肿瘤浸润粘膜、粘膜下层与固有肌层。然而，固有肌层外缘似光滑。见数个淋巴结，但不肿大，超声表现正常。淋巴结的内镜超声分期取决于大小与声像图特征。该病例为显微淋巴结累及，不肿大。超声所见淋巴结不肿大，声像图正常。
Chief: This is inpartly true. But it is important to remember that in rectal cancers, there can be microscopic involvement of the lymph nodes. Better methods for asssing lymph-node involvement are clearly needed; new agents that allow the evaluation of internal lymph-node architecture on MRI scanning may be helpful in cas such as this one. Doctor Liu do you know which examation is the most correct and easily accepted in the clinical?
主任：你说得没错。重要的是要记住，在直肠癌中会出现淋巴结的显微累及。显然需要较好的方法来评估淋巴结累及；MRI扫描评估肠道淋巴结结构新因素将有助于诸如本病例的评价。刘医生什么样的检查在临床上是准确率最高最易被接受的吗？
Attending:The pathological diagnos is the most important .Examination of the rected rectum and sigmoid showed a mass, 3 by 2 by 0.5 cm , that was a moderately differentiated adenocarcinoma with transmural invasion into the perirectal fat,There was invasion of blood and lymphatic vesls in the submucosa and extramurally, and four of nine lymph nodes contained cancer. So the pathological diagnos is T3N2M0.
主治医生：病理学诊断是最重要的。通过对患者切除的直肠和乙状结肠检查，发现一个3*2*0.5cm 肿块。提示未一中等分化的腺癌。透壁侵入肛周脂肪组织，延伸到切除范围内0.2cm。伴有粘膜下层和肠壁外的血液和淋巴侵犯。4/9淋巴结中发现癌细胞。原位癌分级为T3N2M0。
Chief: Yes,you are right.And what’s the further therapy for this patient?
主任：那么这位病人进一步的治疗是什么呢？
Resident: The current patient is to offer postoperative radiation with the administration of concurrent and maintenance 5FU-bad chemotherapy
住院医生：当前实际处理切除后分期T2或T3病例的方法是，术后放疗同时服用与维持氟尿嘧啶类的化疗。
Chief: I agree with you. A number of prospecti胖猪
ve and respective randomized trials have confirmed the value of postoperative chemotherapy f奶奶灰头发图片
or patients with rected stage T2 or T3 rectal carcinomas. The rent study showed benefit in terms of survival or local control with the oxaliplatin and fluorouracil bad regimen.. Doctor Chen do you know the pharmacologic action of fluorouracil?
主任：我同意你的看法。许多前瞻性和回顾性随机试验肯定术后化疗对切除分期T2与T3直肠癌的价值。早期研究显示术后联合放疗与化疗优于单独切除、放疗或化疗。另一研究结果显示，根据生存率或局部控制评价，加甲酰四氢叶酸钙或左旋四咪唑或两者无效应。陈医生你知道氟尿嘧啶的药理作用吗？
Intern: It inhibits the thymidylate syntheta decreas the intracellular concentration of thymidine monophosphate, which in turn leads to the inhibition of DNA synthesis.
实习医生：氟脲嘧啶抑制胸腺核苷酸合成酶减少细胞内胸腺嘧啶核苷一磷酸浓度，从而抑制DNA 合成。
Attending: 5FU combining oxaliplatin is the current standard chemotherapeutic agent ud in the adjuvant treatment of rectal cancer. 5FU inhibits thymidylate syntheta, an enzyme that is critical in the conversion of uridine to thymidine. And what dosage do you choo for this patient?
主治：氟尿嘧啶联合奥沙利铂是当前辅助治疗直肠癌的标准化疗药物。氟尿嘧啶抑制胸腺核苷酸合成酶，是尿嘧啶转变成胸腺嘧啶的关键酶。那么你们将为这位病人选择什么合适的剂型？
Resident: Xeloda, an oral prodrug of 5FU, allows the delivery of fluorouracil dosing similar to that achieved with an infusion schedule without the risk of morbidity from central ,oxaliplatin, forms interstrand and intrastrand DNA cross-links and DNA have been shown to improve survival in patients with metastatic colorectal cancer when ud in combination with 5FUand CF
住院医生：卡培他滨（希罗达xeloda）是氟尿嘧啶前药，其释出剂量可与静脉注射相仿但无中枢神经导管与注射泵并发症。依连洛特肯（定位异构转化酶II抑制剂）与奥沙利铂，其形成DNA股间与股内交联与DNA加合物类似于其他铂化合形成物，在联合氟尿嘧啶与亚叶字幕
酸应用中，均显示改善转移结肠癌患者的生存期的作用。
Attending：The platinum has the 3 generations ,which are cisplatin ,carboplatin and the oxaliplatin. The side effects of the platinums are nearly same.
