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"R. SILVESTRINI" STRUTTURA COMPL

Referta: TESTA GERARDO, nato/a iI28/03/64; Richiesta n. 4041664; Data esame: 22/01/2004

Oirettore Dr. E. GENTILE

Pravenienza Esterno -

Data Esame: 22/01/2004 Data Referto: 22/01/2004

Cad. Paz 21887

Nome TESTA GERARDO Nato/a il 28{03/1964

Richiesta n" 04041664 Residente in

Motiva Esame

Esami TC TORACE (senza e con contrasto) -TC ADDOME SUP. (senza e con contrasto)

•

Referta

L'esame Ie del torace, Gon m.d.c., ill esili di intervento dl esofagectomia del 30 inferiore con anastomosi esofago-gastrica, linfoadenectomia mediastinica, exeresi di cisti aerea del lobo inferiore dx, non mostra segni di recidiva locale, non linfonodi aumentati di volume.

In corrisponden a del lobo superioriore di dx in sede mantellare opacita' rotondeggiante con diametro di 1 cm., gia' segnalata nel precedente esame TC del 27-11-03.

Esiti pleuroparenchimali aile basi e fibrosi agli apici con piccole bolle di enfisema dei lobi superiori.

L'esame TC dell'addome, con m.d.c. non

pa osp enomegalia con piccola formazione ipodensa in sede sottodiaframmatica del lobo dx, con diametro di 2,3 cm.

II Medico Esecutore:

Dott. Giuseppe Bufalari

iI Y.ai1. to re:

Dott. Giuseppe Bufalari

T.S.R.M.:

Egidio Lamonica

Reterta: TESTA GERARDO, nato/a iI28/03/64; Richiesta n. 4041664; Data esame: 22/01/2004

AZIENDA OSPEDALIERA 01 PERUGIA DIPARTIMENTO 01 DIAGNOSTICA PER IMMAGINI

IIR. SILVESTRINIII

STRUTTURA COMPLESSA 01 RAOIOLOGIA

Oirettore Or. E. GENTILE

Pravenienza Esterno •

Data Esame: 22/01/2004 Data Referta: 22/01/2004

..

Cod. Paz: 21887

Nome TESTA GERARDO Natala iI 28/03/1964

Richiesta n° 04041664 Residente in

Mativa Esame

" Esami TC TORACE (senza e con contrasto) -TC ADDOME SUP. (senza e con contrasto)

r: ,~

Aeferta

L'esame TO del torace, con m.d.c.; in esiti di intervento di esofagectomia del 3° infeliole

con anastomosi esofago-gastrica, linfoadenectomia mediastinica, exeresi di cisti aerea del lobo inferiore dx, non mostra segni di recidiva locale, non linfonodi aumentati di volume.

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Esiti pleuroparenchimali aile basi e fibrosi agli apici con piccole bolle di enfisema dei lobi superiori.

L'esame TC dell'addome, can m.d.c., non mostra lesioni ripetitive.

Epatosplenomegalia can piccola formazione ipodensa in sede sottodiaframmatica del lobo dx, con diametro di 2,3 cm.

II Medico Esecutore:

Dott. Giuseppe Bufalari

"MdL~,

Datt. Giuseppe Bufalari

T.S.R.M.:

Egidio Lamonica

265988

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Universita deg/i Studi di Peruqia

U.O. "R. SILVESTRINI" - Azienda Ospedaliera di Perugia Oirettere Prof. Rodolf 0 Ribacchi

'.2 +39-075-5782340/16 123 184

r::!; anat.istol.silvestrini@ospedale.perugia.it

............. ---_ _---------_ _-- -_ -_ _-_ _- __ _-": _-- -_ _--- .. _ .. __ _-_ - - _---_ - ..

ERTO N.

12~

Tipe Esame ISTO

TESTA GERARDO

M

Data Nascita 28/03/1

Provenienza

INT

Ospedale "R. Silvestrini"

0300 - S.C. Chirurgia - Prof G. Noya

Data Accettazicne

02/12/2003

---------_ .. _-------_ ... _---_ .. _-_ .. _ .. ...,----------------- ..... -- ... - .... -------- ... ---~-- .. --------- .... --- .. -------- ... --------------

Materiale Inviato - Notizie Cliniche

ESOFAGO. TRANCIA ESOFAGEA. L1NFECTOMIA MEDIA?TINICA. CISTI AREA LOBO INFERIORE POl~\ OX. BIOPSIA EPATICA. + UN PRELIEVO ESAMINATO IN ESTEMPORANEA.

"'sam'Ol Macroscopico

Esofago: resezione polare superiore 30 ~~ di esofago; neoplasia ulcerata del cardias infiltrante l'esofago, estesa fino alla tonaca muscolare. -Prelievi-

1 10
11 · . 14
15 26
27
28
29 · . 30 N. 4
32
33
34 · . 35 frammenti di mucosa in senso laterale sri frammenti di mucosa in senso laterale dx sezioni seriate in senso cranio-caudale trancia esofagea

trancia esofagea ( i.nv , sep.) linfonodi pericardiali

~n one 0 grande curva gastrica (Est. N° 276) linfonodo mediastinico

biopsia epatica

cisti aerea del polmone

Diagnosi Microscopica

1 26

Adenocarc Lnorna pr eva l ent ernei.ce a cellule a castone dr.L cardias infiltrante 1a sottomucosa e 1a tonaca mu

27 - 28
29 - 30
31
32
33
34 - 35 osa e con diffusione al 1/3 inferiore dell'esofago lungo i linfatici della tonaca propria della mucosa, della sottomucosa e della tonaca muscolare fino alla trancia esclusa.

Non si rinvengono cellule neoplastiche.

Metastasi di carcinoma a cellule a castone in 1/3 linfonodi. Linfoadenite cronica in 2/2 linfonodi.

Vaso e tessuto fibroadiposo.

Nodulo fibrose.

Piccola bolla enfisematosa. Fibrosi.

Antracosi.

~ \ .

Perugia,

17/1212003

Istltuto dl Rlcov.to • CUi'll. Car_Hare Scl.ntlnco 'Ita Alp.montl435. 20141 Milano

101,02/57_1 fax 02/57489208

Dipartimento di MedicinQ

Unite. FQrmQcologiQ ClinicQ e Nuovi FQrmQci Direttore

Dr. Filippo de Braud Tel. 02-57489482 Fax 02-57489581

REFERTO 01 FARMACOLOGIA CLINICA E NUOVI FARMACI

(~ Egregio collega grazie di averci riferito iI ...

Paziente'

N. CCOa03S873

TESTA GERARDO

Eta.: 39

Sesso: M

Data di nascita : 28/03/1964

DIAGNOSI

Adenocarcinoma dell'esofago distale pT2 pN1 trattato con chirurgia radicale in data 1 dicembre 2003. Nelle indagini preoperatorie la T AC mostrava la presenza di un nodulo all'apice polmonare destro di incerto significato --> quindi in corso di intervento e stata esegita biopsia di alcune aree del polmone destro che sono descritte essere "cisti aeree".

PROGRAMMA

In relazione al tipo di malattia, all'eta del paziente e allo stadio patologico suggerirei di considerare un trattamento chemioterapico 0 un trattamento chemioradioterapico con finalita adiuvante.

Si spiega che la final ita. sarebbe quella di ridurre iI rischio di una ricaduta e che I'indicazione non e sostenuta da evidenze forti ma che nell'insieme gli studi clinici sembrano dimostrare un vantaggio a favore del trattamento e in particolare c'e uno studio Americano (McDonald et al) che dimostra un

-. vantaggio daUa combinazione di chemio e radioterapia. La scelta di quest'ultima opzione non e spesso condivisa in Europa e comunque deve essere discussa insieme ai Hadloteraplstl, rna la scelta di un trattamento sistemico e a mio awiso conveniente.

In relazione al timore che la terapia possa creare disturbi quando la malattia a gia stata guarita si conferma che si tratta di una scelta non definitiva e che potra essere modificata in relazione all'insorgenza di effetti collaterali.

Si raccomanda di ripetere TAC torace e addome e CA 19.9 + CEA prima di iniziare la terapia.

('

Milano, 02/01/2004

Cordial mente

Ambulatorio diOncologia medica N. 04-0M1-00010 - cod. operatore Z00120 - pagina 1 di 1

\

Sarvizio di Si him a Clinica a Microbiologia OSPEDALE R. elL ST HI I POLICLIMICO MONTELUCE

nCDlIl'H rLI\\IQ.ln

M~~~~"nl~ r '1 (n7 , """'I J.\JU.LQ • I. \VV I

TESTA GERARDO Data nase.! 28/03 I 964

n .... .., 1 rQl:;I. J.

Primaiio: MARIO nQMAG~tOLI

AEFERTO

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f'OC'.'\TTU'!'l!;\ .... fu.nl !nl~Hj

ACIDn URrea

nT! TmllHUII :~T/!.[ r ~f'~J.li'J\'_\J.!H1 ;\.!~n~L.

--------------------------

--------------------------

1 « .,,,

1 7 J .L""

TOT,...I T:"'COTT\T IIU.U~J.\.Ii.I\ .. i.t.·J.

rn 11 ! tl ~ I[i~f\.l:'

M"UI lII~i\.U •

140 - 220

CI't _ t'7/\ .JV .£. f v

FOLLOW·UP

AZIENDA OSPEDALtERA 01 PERUQIA

o Ambulatorio.

o Day-Hospital

o Ricovero

"NLl_j

.. -~ .

10

Tipo lesione 0 11·",,,,,,,,Jetjone,2·,,..w1u11biJt,3·WlUloblle,4·ml .. rablle,S·miSl.) Tipo dolore 0 (1._.,2·_UCo,3·~ ..... ,4·rnls1tI) Inten. dolore 0 IU3,4) Tlpo trattamento LU U_j LU Protocollo n. UJ LU U Cicio I mese UJ

ANAMNESI E SINTOMATOLOGIA

LESIONI VALUTABILI

4) 5) 6)

Altra oblettlvita clinica

'ndaginl ,adiologiche

CONSULENZE

S'TUAZIONE PAZIENTE: (I) Vlvtnt •• IIbe,o mal.ni. 12) Vlvente cori IIC. tee, 13) Vlvonl. can m.lattl. ,.sldui'''14) Vivonte In ,emltsione(5) ven e con me as malama (7)T,asl"lIo ad an,o cenno (8) Pe,so al Follow·Up (9) Deceduto p<I' noopll.11 (10) D .. edutei p.r Illrt c,au •••

TIP'TRATTAMENTO: 11) NeS!~nl 'flapl, 12) Follow·Up cllnlco 13) Chemlol .. lpl •• dluvante (4) Chlmloterlpll Nloldluv.nto IS) Chemlotlraplal6) Chemlo!. Locoreglonale (7) Rx. lerlpll p,eoperalorll (8) RI. te,apla postop<lratorll 19) Rx. te,apla (10) Chlrurgla radicil. (11) Chlrurall palliltlv. (12) Chl,urgl. dlagnostlce (13) Ormonotorapl. ablatlv. (14)

OrmOnitlrplladdltlva (15) Immunoterapla (lSIT.repia dl supporto (17) SeoRosclul. (18) Attro' ,

SEDE MALATIIA E RISrOSTA,AL TRATIAMENTO:

I RISPOST A T6:f1"LE': '·n::.·

LLJUJLULU

U Durata (mesi) I I I I

1 T. primitivo

2 cute - sottocute 3 linfonodi

S'polmone 6 fegato

7 cervetlo 8 pleura

9 altri visceri

1 - RC. 2· RP. 3 - MO 4 - S. 5 • P. 6 - NV.

1 - recidiva. 8 - NED.

9 • too early

...... I,.:~ ''' .

TOSSICITA/GRADO WHO

"'11

1 E

GB '."u.uuu'Uuuuuuu'.,.uu.,uu_,_,_u,uuuuu,

2 Gastrointestinale __ u_,.u'UUUUUUuu.uu.u ••• uuu_ •••••••••••• u

Ves .u •••••• • •• u. __ .u __

Prot. u ••••• u •.•.••••••••••• Alb .. uuu ••••...• _ •••••••• _ Elettr .... uu •• uu .••• u •• _·· •• uuuu ••• _.·· •• uu···········

3 Renale .. u ••••••••••••• u ••• ,.'u.uuu ••••••• u.u ••••••• u_.u •••••• u.u,.u··u ••••

4 Polmonare .

Formula Uuu •.••• u_._ •••

yoGT u ••• _ •••••• _ •••••• I.DH · .. uu •••

5 Febbr. (dowutAallnI1_1 u ••••••••••• uu ••••••• __ ••••••••••••••••••••••••••••••••••••••••••.•••••••.• u ••• u •• u...... Pt , _.u.u •• uu ••••••••••••••••.••••.•• "'U. Sider/Trans u_ ••••••••• _ ••• " ••• u.uu •••••• u

6 Allergies ·.·.· · _ ··· ····_ ·u ••••• _ ••• u •••••••••••• " •. " ••.• ,:u __ .••••.••••. ,"" Hb '''" ''" " !-It .. Cupremia .····· .. · .. · .. "" .. m'.·"······u_····· ••••• ••

7 Cutene •....... · "u ••••••••••••• u ••••• " •••••••••••• _ •••••••••••• _ ••• " •••••• - ••• ', •• - •••••••• " •• " ••.••• 7 •• "".- Glic : " _._ Az, CEA .. " _ .. " _u •••••• _ ••••••••••• _ •••••• u ••••

8 Sistema pilitero ,,,··.· ....• u,,u ••••••• m" ... 'u.,,u,, ••••••••• ,, •••••••••••

Creat u ••••••• ,,_ •••• Uric.

Ca _ •..... _ .. _u""._. p __ ..

9 Infezione ItpoIicIre Ioc:eiz.j .. _ .•...... __ ..........•..... " .... " ... u •••••••••• __ ." ••• m •••••••••

10 Cardiaca uu •••••••• __ •••••• " ••• "" •••••••••••••••• u ••••••••• _ .•• " •• 'u ••••••• _ ••••• " •••••••

11 Neurologica u_" •••••• u •• u"" ••••• ""u ••• , .•••• u •••• " ••• u.u,,.u ••• , •• uu, ••••• u •••• " •••••••••• "",, •••••• ,,:u

12 DoIore .. u.u. __ •••••• u.,,· •••••• h ••••• u •• u ••••••••••••• m"' ••••••••••••••••••••• __ .•• _ ••• _ •••• "u ••••••••. u ••••••••. _uu •••

Na __ ".' m ••••••• K . __ u •••••••••• __ .,, __ •• ,,_

Fosl. AJ;, ",huu U' __ "_"" __ '''''_'''''U'''''_UU.''

SGDT ISGPT " __ u,,._, " __ ""h_"UU""U

iis, Feci ,,"_u'uU"_""""'_'"'''_h''_U''UU''''' Es: Urine "_"uhh"_"U_U •• u .• ·""U .. "h •• uu''.

13 ·AItr •.... "."u ••• _"'uuu"u .. u.u,,,"u ••• u,,,,,,,'uuu •• ,,,, •• ,, •. ,,_._ .. u"'_u"""U'''''''U_'''''U'_''_''''U,. Bit tot,/dir. u.'"._." •••• u,.

TERAPJA: u._.",,,._.'uuu.,,.uu,,.uu., ••• ,, ••••• u"uuuu "u",,. cicio n. , .. "" " """ .. "u •••• u., u •• ,,_._ parte ,"u •• " •• u""uu""_.", "u" •••• ".uu"u",_.u ••• " ••• " .. ,,

Schema dosi/m2 " "u •• "_ .. u __ u .. .. •• ,,"u_,,,_._,._ Dosi teoriche "_u •• _."".:.""". __ ""._ •• ,,, '.""uuU •• U"_' Reali (%) ·_""_._ u_uu""" u ".u""."",.,,.uu.

Terapia Concomitante

Commento: .... "u

APPUNTAMENTO PER IL

o Ambulatorio

o Day-Hospital

o Ricovero

Esami richiesti: emato-biochimici Radiologici ."u,u""""""._.

Scintigrafici Altri ...

PROGRAMMA TERAPEUTICO:

I

~~7

AZIENOA OSPEDALII:RA 01 pt~UGIA

10 'r"1 '·.1

, " ,'; .. -:~

P.S. (ECOGJ' "L.1

P.A.

Tlpo. ' .. 101'1,0 (1· __ ,2 .... "",_.,H.IIIIIIIIo,4·mIou!IbIle.$·I111 .. ) Tlpodolore 0 (1.-.2·.....-,3· ........ •• Inten. dolor.O It;UC) ,TIpotrattam,nto LU UJ LU Protocollo n. LlJ LU U Cicio I mesa .LLJ

ANA.,NESiE stNtOMATOLOGIA

.... j_ '~ •. ~ ... it j' k('Mlli.i~·· lJk b~ I· y_ r= '. tft;;t ... ~.. ~

LE;SJ()Ni VALUl'ABILI

··""'Gb

1)

2) . 3)

5) 6)

Altr. oblettlvlti cllnlca

.' .~ .... I .

Indaglnl radlologlche

Altra Indaglnl

CONSULENZE

~ ." i

........................ _ ... ~ .............•. ~H.~ ...

SITUAZIOHE PAZlE YO.le con reo. loc. (3) VI.tnt, eo. m.I.1IIa .... dU. (4) VI .. ",. In "ml .. I ... (5) VI.,.It eon mll.otoll (8) YI ... It _

"",1.111. In Trurerllo lid .n .... ce.I .... (81 """" .1 FoIIow·Up ") Docedul. por .00.., •• 1. (10) DIced",. por "I" ceUIi. .

TlPlTllAlTAMEHrO: (I) Hon.~ .. I •• (2) Follow-Up cll.leo (31 C_lolor.pl. IIdIUYI.It (e) Ch.mrol.rlpla Noolldlu ... " (5) Chomlo'er,pll fe) Ch.mlot. Loco .. gro .... ·(71IlL 'trlpla prIOpI,lIorlll'I.RI. lerlple poatoptrllDfIIl9) RI.ltfIpllll0j ChlMal, radle," Ill) Chlrvrgll palllillva 112) ChlrurOIl dllgnOltlel (131 Ormonol.rapla Ibl.llva (IA) O~ .HIIlva (11) IlIIIIIIHIoft"plt(lI) t ... ,..III IUPPOrto (17) SConosclu .. (II) Artro

4 ossa S"polm9n&r'''''''''''I' - .. " 6 feato.·(········

- _"_" 9 .... _.. ..

.Zcerv~"o

8 pfeur& . '9a1t6 ;Vis(:1'!ir,I .. '.,

" n , ••••••••••• _ •••••• :;~,'.i',;;:..t:~i.·;~ .• :.:: 1 .

1 .. RC. 2 - RP. 3 - MO 4-·S; 5 .. P;6 -·NV.:· 7- . recidiv8,.sr- NED, .:;:9 . ~' .. ~QO '!lrly., +.«.

' •••••• ; ••••••••••••••• : •••••••• , " •••••• ~ ••••• _ " _.~.- ~."' ""._.- •• ', ' ' •••• ! ~~ ••

TOSSlCITA)ORApoWf!i)' _' .. 'l. 'j ,- II I

",,'. '"

1 Ematolog!i: •.. >.~ ,.:.v ;:::, : .

~.ur;r;e .

'.2 .~G8stro;~~in8kl _ .. : .. ; S:.::L.,,:: .

~ .flilnala': .. ;, : ......•........ :: ::."j' , .

;~ ~n/orfr'" " ~"',:~~~····t:···--······t·jl~~~,:.;.~;:,-~~/.~, ~ : , .

';W~~i~~~~::~~=~:~~;~·~

Vel : .

GB ..•.......... : ...•..............................................

Formula .. : .

Pt ; .

Prot .;.: :.;; .. , AJb, , , .

Elett': ................•.....•................. . .. , .. . .•.........•.

y-GT : I.DH ......................•.

Sider (i"rans _ .

Cupremia : .

CEA ..

Hb !it .

Gfic , Az ..........•................

1: ::c·~7~.:r.:~;:::::::::::::~:::::t::~.:::::'::::::;::::::::::::::::::::::::::::::::::::::::::'::::::':.::::: ~~ :;rr.::~~:::::::::::::~:::::::::::::;~:~i~::::"~:;:::::::::::::':::::.:::::::::::::::::::::::::::::::::::::::::::.:

13 ·Altr .

Na ......•.........•............ f( .

Fosf. AJ,;, .

sGOT/SGPT : :- :: : .

Bit tot./dir .

lis, !'ee; -: .•..• , .

.•.. , .•. : '. ':; : .. : ," " ;., : cicio n. . parte ; : .

. :':: : : ,; .. : ,.;;: .•...• , ". Dosi teoriche Reali (%) .

I erapia Concomitante ..

• , " ••••••• ,- ••••.. ,.,' •••••• • ••••..••• ~ ••• ;, •••••••• ;, ••. ;., ", " .•••••. :,.~;... ••••.••• • .••••...... _.,.t ;;, •• ~_;. ",' ~"',

.......... : ,; :: , "'.;.:: ..• :, ...•... , ..

'.'

........................... _ .

. .

.................................................

Esami richiesti: emato-biochimici

Radiologici .

APPUNT AMENTO PER IL

o Ambulatorio

o Day-Hospital

o Ricovero

SCintigrafici .

Altri .

_- .. :'J

. PROG_I=IAMMA TERAPEUTICO:

~'~,: . " .,' .

............ .. ~~ ~ ' : ".n.~: .. ~ ,~, "" .: J, _......... h; , ; : .. , ,:-.:: ;, , : ;;. ::: , •. ~ .. ~; ~: : .n::. ;c :.~ ., :. •• .;,. -. .. ,...... /. :.. .. .• ,., ". ", '. ' •• '''.0' l',": ,...... •••• ..;.,.... ., •• :.: _. ., .. -.,. , •• ,., .:.i... .,' " ~i i:._"_ '.:

............... ~: ::- : •.•.• ; ; ..........•... ;.,.;.1.'.: ; .: .. , .. ::,:.~ ,.-." '. .. ,.!.,.,;,:;.~ ; .•. :.,~,~ .. ::.~;~l:";.:~;~: ~:~;.:.~',;.~!;.:, .. ; .. ,~.~.~~ ;:', ;.~: ~~ .. ::~;:.: '.~.~.;~~.;.·~T:.~:·.-~:~L~; .. .. .. , .. -;" : .. ::.<~.~., ~~;.: ~~:;:.;:';,;J..~.:.~;~~;. ",

-."< ,'; ... ;' .. "

.. _ ........•. , " ·· .. " ~.;.···'.'"·t;····· ••••••• .-: ~,., .. ,; " ,:~ ~;(':.~: ;,.;';~ .. ~.;.;.: , ;, ~::,.: - ....••• - .: .

. I

·.

AzrENDA DSPEDALIEr,A

SeTvizi; di Siochimica Clinica a Hicrobiologia

W ... 10 ......... 1... "71 (f\1 ,

Ita'd J.'I,oU.&,Q I J. \\1", J

TESTA GFRARon

aSrrDAl! R. SILVESTRHH I ~CLICLINICC HotHELUC£ P£RUGIA

Data I/Q~,", ••

1')0 I 1'1, I et i 4U I V'oJ I JU"t

Pag. 2

n"~",,,,,,;", Whorn Onlol"'(\"nl T r t .l.IIlGI rv , IIMIUU nVllnUIlU,-J.

--- ... -----_ ... ---- ... -- ------ ----------_ ... -- ... -- --- ...... --- --------- ----_ ......... --- -- ............ -- ... -- -- ... -- ......... --- ...... --_ ............ ---------- ..... ---_ ...... -_ ... -_ ... -- ...

DEERI ZrOt~E

REFERTO

11111T/\' 1\1 lIITt'IInA VIU In VJ. IUIJUI\n

VALORI Dr RIFERIMENTO

------_ .. -- --- ----- ---- ---------- ---_ ---------- -_ --_ --- --- --- .. -----_ - --- ----- -- ----- ---- -_ -- -- -- ---

----------- ------------

1 If If U HOC H 1 ~ 1 C A

------------------------

CA 19.9

11/ .... 1 V/lt"

fiiio a 37.0

•

-.------------------------------------------------------------------------------ .. _------------------------------------------------

.. - - - - - - --_ - --- - - - _ - - _"" - - -- - - - - - - - --- - -- - - - - - -- - - - --- - - -- - - -- - --- - - - - -- - -- ----_ .. - ...... --_ .. --- - _ -- ---_ .. --- - _-- - ---- - --- -_ .. - --- ----- ---

UNIYk' DI mUR~ :

VIlLORI 01 RIFBRIMNNTO

AZIKNDA OSPEDltLURA

Servizio di Biocbimica Clinica e Microbiologia omnm R. SILVESrmI i POLICLIKlCO MOftrELUCB PBRUGIA

Matrieola . on .

YBSTA GERARDO Data aasc.: 28 / 03 I %4

Primio: MARIO ROMAGNOLI

Data ssec.:

ago 1

.. - -it - --- -- -- --- .. _ .. - .. -- -_ .. --- _ .. -- .. - --- .. _ --- -- - -- -- --- - - -- - - --- --- -- - .. - ---- .. - - --- .. -- -- _ .. -- - -- --- - -- ---- ---

.. -- .. ~-- .. -- -- ----- ---- _----
KHOCROKO
.. --~- .. - --- -- _ .. - -- --- - - --~-
GLOBULI BmCllI 5.66 xlMetul U - 9 0
GLOBULI ROSSI 4.39 xl DODOm! al (M) 4.3 - 5.8 (F) 4.0 - 5.Z
llMOGLOBIHI. 14.6 .... IJl (K) 13-17 (Fl 12 - 16
51UJ
EMATOCRIfO 1.1. '.l ~ (M) 38 - 52 (F) }7 - 47
't"l.J •
MeV 90.6 fL 82.0 - 97.0
• Mel! 29.9 pg 27.0 - 33.0
KCIIC 33.0 gJdi 32.0 - 36.0
ROI 12.5 % 11.6 - 1}./
mSTRINR m.o xlaOO/a! 140 - 440
HPV 11.6 & 7.8 - 11.0
LIMFOCm 38.7 20.0 - 51.0
MOKOCm 6.7 i.0 - 12.0
NEUTROVILI '" 42.0 - 75.0
J".I
EOSl!IOFlLI 2.1 , fino a b.O
•
TII.SOFILI 0.4 ~ fino a q n
• •• u -------- ---------------

Laboratorio Urgenze "onteluce

rues

11:59

PAGE 1/1

AZIENDA OSPEDALIERA

URGENZE ED EMERGENZE CLINICHE Servizio di Biochimica Clinica e Microbiologia POLICLINICO MONTELUCE PERUGIA

PXillldxio:Prof.MARIO ROMAGNOLI

.,

Matricola: 77

Paziente : TESTA GERARDO

Rep. ric. : (ONCOLOGIA D.H. 37)

., Data esec.: 16 / 3 / 2004

Pag. 1

E S A M E Referto Un. misura Valori di rif.
- ----- -------- -
GLOBULI BIANCHI 4.50 xl000 3.6 - 9.6
GLOBULI ROSSI 4.75 x1000000 U. 4.5-6.3 D. 4.2-5.4
EMOGLOBINA 14.3 g/dL U. 14 - 18 D. 12 - 16
EMATOCRITO 42.9 % U. 38 - 52 D. 36 - 46
PIASTRINE 148.0 xl000/ul 140.00 - 440.00 II Primario:Prof.M.Romagnoli

, .

-- - - -- - -- - _- -- -- - -- -_ .. _ .. -- _-_ .. -----_ .. -_ ..... -- _ ... - - -_ .. - - ---- --- -_. - -- - -- - - --- _--- ---_ .... - -- - --- ---- _ .. _ .. -- ---_ .. -- - _ .. --- --- --- --- ------

: UNITA' DI mUla :

VlLLORI Dl RmRIMENTO

AZIENDA OSPEDAI.IERA

Smizio di Biocbimica Clinica e Microbio!ogia OSPEDALE R. SII.VESTRlNI i POLICLINICll MomLUCE PKRUGIA

llatricnlil . n" '

~ESTA GERARDO Data aasc.: 2& f 03 f 964

Prisario: MARIO RONAGNOI.I

Data esec.: 30 /1 /

,g. i

-- - ... -- -- - --- --_ .... ---_ .... --_ .... -- - _ .. -_-_ .... _ .......... - --- _ .. - - _ .. - -_ .... - --- _-- --- -- -- --- --- --- -_ .. -_ .. - --_ .. -- - --- - ---_ .. -_ ...... - -- -- ... -_ ............ ----_ ... -

'-
---------- --_ .. -------- -- .. ~
KMOCROMO
- -- ---- ... -_ ... - _ ..... --_ .. -- -- ---
GhOBULI BII.NCllI ' r :\10UOlul 1.6 U
J.iJ.u
GI.OBUI.I ROSSI 4.&9 .1000000/,1 (H) U - 5.S (F) 4.0 - 5.2
EMOGLODINI. 14,6 gJdl (M) 13-17 (F) 12 - 16
EmOCmO 44.3 (M) 38 ... 52 (P) 37 ... 47
MeV 90.6 fL 82.0 - 97.0
MCH 29.9 pg 27.0 - 33.0
• ReliC 33.0 gfdl 32.0 - 36.0
RDY 12,5 • 11.6 - 13.7
•
PIASTRINE m.o xl0DD/ul 140 - 440
KPV 7.8 - 11.0
LlNFOCm 38.7 20.0 - 51.0
MONOen! 6.7 1.0 - 12.0
GEUTROmI <0' x 4Z.0 - 75.0
J".1
EOSINOFlI.I " , fino a 6.0
•• I
BASOm! 0.4 fino a 2.0 \ ;.~.

LJ Ambulatono

o Day-Hospital

o Rico\lero

N. LL.j,

fOLLOW-UP

10

Tlpc lesione 0 1\'""",nal.siono.2·nonV!lutabilr.J.vaiutabile.4·lTisurabile.5·mi~al Tipo dolore 0 11·ass.nt e. l·_ .s-. ;'C9!aIe.4·mi~ollnten. dolore 011.2.3,4 tipotr~ttamento u_j LU u_j Protocollo n. LU LU U Ciclo/mese UJ

ANAMNESI E SINTOMATOLOGIA

LESIONI VALUT ABILI 1)

2)

3)

4) .

. . ..

"-u"",,

~

5)

6) , , ..

Altra obiettivita clinica .

Indagini radioiogiche

Alire indagini .

CONSULENZE .

ad aIIro e .... uto "'" '!Itte couse .

• lIPO TRATI AMENTO: 111 Nessuna terapia (2) Follow-Up ciinico 13) Otemioterapia adiu.onte 141 Chemioterapia Neoadiuvante (5) Chemioterapia (6) Chemio!. Locoregionale (l) Rx. terapia preoperatoria : (8) Rx. terapia pcs!operaton. (9) R'.torapia (10) Chirurgia radicale (11) Chiru'llia pamativ. (12) Chirutgla diagnosti<;a (13) Ormonoterapia _biativ, (14) Onnonoterapia additiwl15) ImmuQO!erapia (t61 :. r .. apia di suppollD 117\ Sconosciut. (IB) Ahro

1 T. prjmitivo

2 cute - sottocute 3 linfonodi

tl'SPQST A TOT AL.E

LJ_J LLJ LU LU

U Durata (mesi) I I I I

.SEDE MALATTIA E RISPOSTA AL TRATTAMENTO;

... :.: ,: .

. 4 ossa' 5"polmone 6 fegato·

· 7 .. cel'Vello 8 pleura

9 alti'i Yisceri

................................. , •••••••••••••••••••••••••.••••••• n ••••••••• " • ••••••• •••••••••••••••• .. ••••••••• ::"t" •••...

1 • RC. 2 • RP. 3 .. MO 4 .. S. 5 .. P. 6 .. NV.

7 - recidiva. 8 .. NED.

9 .. too early

TOSSICITA/GRADO WHO

II

1 Ematologica .; .

2 Gastrointestinale ; ; :........ Ves :;,,1;... Prot Alb. ..

3 Rehale GB Elett .

4 Polmo~e.. Formula y-GT 1.0H .

5 Febbre .,....." 1IMI...uj Pt. Sidtlr/Trans .

6 AIIergica Hb !it Cup.emia ..

7 Cutanaa Glic : Az. CEA ..~

Creat Uric. .. ..

S Infezione jIpIc:iIicaIe 1ocIiz.1 .

10. Cardi_ .

1,· Neurologica ; : ..

· 12 Oolore ..

13 ·Altr ..

. ~ . .;... . .

Na K ..

Foaf. Al;.' .

SGOT/SGPT .

Bit tot./dir ~ ..

iis. Fact .- : : .

Es: Urine .

TERAPlA: cicio n ; parte .

Schema' dosi/mz ; Dosi teoriche Reali (%) .

· Terapia Cullcomitaf1te ..

. ~:: .::."0'_:::- ,. ..;;,_., .• ~ " .••••.•••.••.••.••.•••

Commento: ..

Esami richie~i: e~ato-biochimici

Radiologici .

APPUNTAMENTO PER IL

o Ambulatorio

o Day-Hospital

o Ricovero

LULLJLU

SCintigrafici .

Altri .

PROGfiAMMA TERAPEUTICO:

................................. ,.......................................... . , , , ."........................ . " •............. , , ' " , ~ .

AZIENDR 05PEDALIER~1 Ur~E)E}4ZE ED EiT1ERGEJ~2E CLli\;ICl"iE Set'V1ZIO dl BIOchlmlca Cllnica e ~~~

~JLILL1NICO MON"i-CLUC[ PERUGIA ~lrimariG:Pl~ofQMARIO ROMAGNJlI

d i tel i,

~JBUL I BLANCH 1 GLOBUL I RO!3S I

E iYiOGLOB I NA

ENrn OCi~ I ro

IS. 80

xiOOO

3.6

9«6

Do 4 .. 2"-5" 11

5.26

x 1000000

u, 4~ 5'~"CB .3 U~ 14 - 18

D. 12 i6

13.3

g/CiL

120.0

GL ICE~lI{i

'i~ZOTE~i I A Cr:{Lf~TININH

13IL_l F~UBINA "fUT;~L..[ 'BILIFlUBINA DIRETTn

53

mg/cii mg/dl

bO

10

110 50

31

;' It '.:..

mY/G'l mg/dl ,':lgldl mg/dJ

2.

;:':1 no 3 1 .. 20· Fi no d o~ ilol)

r:' OS ;::.- U ii'i"-

FOSFATRSi ALCALINA SCDJO

r~'DTri~~S I C}

inf /n.t

mg/dl UI/l ",Eq/L

CLUF<O

102 1222

mEq/L flif::q/L LI/L

L D H

:;, E'c..'

nu 1. J

FOLLOW·UP

AZIENDA OSPEDA!.IERA 01 PERUGIA

o Ambulalorio

o Day-Hospital

o RicoVero

N·LU

ID

S.C.m2 I

P.A.

Tipo leslone 0 (1· ........ 1esIone.2·11QII'''''_,I· ..... IabIIe •• ·_Ie,S·mi''') Tlpo dolore 0 [H_l.,2·somatIco,3· ........ ,4·mIs1o) Inten. doloreD (1;2,3,11 Tipo trattamento LU U_J L_j_J Protocollo n. LJ_J LU U Cicio I mese LU"

ANAMNESI E SINTOMATOLOGIA

LESIONI VALUTABILI

1) . 2) ,

',-",,-,', .

6)

Altra obleltlvita clinica

Indaginl radioioglche

AlIre Indaglni

CONSUlENZE , .,

. i' ",' .

SITUAZIONE PAZIENTE: (I) Vlv""' •• liber. m.'allia (2) Vlvont. con ree. loc. (3) VIVonto con molllli. reeldul'i4) Vlnnl. In reml •• ,o .. (5) Vlvonto con me .. stlll 6

molllli. (7) Trnferllo ad Iliro conlro (t) Per.o ., 'onow·up (9 Decedulo . .

. • 0 ow· p cllnlco (3) Chemlolerapl. adlu.ante (4) Cllemtote,lpIlI HeGtdlu.anl. (5) Chemlottrapla (51 Cheml". Locoreglon.1e (7) Rt.

terapl. preoperatorl. (8) Rx:'lerapll pollopetatorla (9) Rx. lerapla (101 Chlrurgla r.dlcal. (11) Chlrurgll polllttlVl (12) Chlturgla dlegnosllc. (13) Ormonoler.pl •• bl.IIVI (t41

Ormone .... pll.ddIIIVi (151Immunoterapl.ll&) Ter'p1a dl supporlO (17) ScanoscM, (Ial AIIrO'" ' , .

.-/.

NOME:ONCDLOGIA MEDICA SE;:Z.2 P. 1

The New England Journal of Medicine

..................................

cer';; a performance status of 2 or lower according to the criteria of the Southwest Oncology Group; adequate function of major organs (indicated by a creatinine concentration no more than 25 percent higher than the upper limit of normal; a hemogram within the normal limits; a bilirubin concentration no more than 50 percent higher than the upper limit of normal; a serum aspartate aminotransferase concentration no more than five times the upper limit of normal; and an alkaline phosphatase concentration no more than five times the upper limit of normal); a caloric intake than 1500 kcal

days after surgery, with treatment beginning within 7 working days after registration; and the provision of written informed consent according to institutional and federal guidelines. When a patient was registered, surgeons and pathologists from the Southwest Oncology Group reviewed the patient's surgery and pathology reports to confirm the completeness of the resection.

...... Alb .

Treatment Plan

.. :::~~ .. :::::::::::::::::::::::.

After undergoing gastrectomy, patients were to surgery alone or to the

assigned

-s , •••••••••••.••••••••••••••• _ •••••••••

radiation. Randomization was performed 20 to 40 days after surgery by means of a dynamic balancing procedure that included stratification according to the tumor ..' :age (Tl to T2, T3, or T4) and the nodal status (no positive nodes, one to three positive nodes, or four or more positive nodes).

The regimen of fluorouracil and leucovorin was developed by the North Central Cancer Treatment Group= and was administered before and after radiation. Chemotherapy (fluorouracil, 425 mg per square me~bodv-surface area per day, and leucovorin, 20 mg per square meter day, for 5 days) was initiated on 1 and was followed by

of radiotherapy. Treatment fields, dosimetry, l ogy reports, and preoperative tumor imaging review before treatment began. Plans that wer cause of the risk of toxic effects on critical or to treat the appropriate target volumes were COl apy was begun. At these reviews, 35 percent of were found to COntain major or minor deviatio col, most of which were corrected before the sn

A final radiation) revealed major

of the treatment plans.

Follow-up of Patients

Follow-up of both groups occurred at three-rr twO years, then at six-month intervals for three thereafter. Follow-up consisted of physical examir blood count, liver-function testing, chest radiograj ning as clinically indicated. The site and date 0

and the date of death, if the

Statistical Analysis

Our study . was originally designed to indue With a two-sided alpha level of 0.05, the study I

80 percent power to detect a 50 percent relative ( vival (equivalent to a hazard ratio fur death on.5) •

95 percent power to detect j 60 percent relative lapse-free survival (a hazard ratio for death or relap ever, since enrollment was higher than expected, th monitoring committee approved an amendment

Chemoradiotherapy consisted of 4500 cGy of radiation at cGy per day, five days per week for five weeks, with fluorouraci1,.(_ 400 mg per d!uare meter per day) and leucovorin (20 mg per square meter per ay) ,.2!l-the first fuUr and tTle last Wee days of radiOl1ierapy. One month after the ~pletIon of radiotherapy, two fiVe-day cycles of fluorouracil (425 mg per square meter per day) plus leucovorin (20 mg per square meter per day) were given one month apart. The dose of fluorouracil was reduced in patients who had grade 3 or 4 toxic effects.

The 4500 cGy of radiation was delivered in 25 fractions, five days per week, to the tumor

to detect a 40 percent difference in survival (a haz

and a 40 percent difference in relapse-free survive

The two stratification factors, the T stage (three N stage (three levels), were included as covariates gression analysis.s? The examination of other pote (age, race, the extent [D level} of the dissection, and the primary tumor) yielded no significant effects, ables were not included in the analysis. All eligibk included in the analyses of survival and relapse-free s to the intention-to-treat principle,

margins resection. rumor

bed was by preoperative computed tomographic (C'I') imaging, barium roentgenography, and in some instances, surgical clips. The presence of proximal T3 lesions necessitated treatment of the medial left hemidiaphragrn. We used the definitions of the Japanese Research Society for Gastric Cancer for the delineation of the regional-lymph-node areas.l7·18 Perigastric, celiac, local paraaortic, splenic, hepatoduodenal or hepatic-portal, and pancreaticoduodenallvmph nodes were included in the radiation fields. In patients with rumors of the paracardial and

coded as local if tumor was detected in the surgica

residual stomach, or gastric bed, as regional if tumo in the peritoneal cavity (including the liver, intraabd nodes, and peritoneum), and as distant if the rnerast side the peritoneal caviry. All eligible patients in the therapy group who received any treatment were in analysis of toxic effects.

The srudv was monitored by the data and safety rna mittee of the Southwest Oncology Group. Ax two pl the committee assessed whether the trial

radiation was not required. Exclusion of the splenic nodes was allowed in patients with antral lesions if it was necessary to spare the !eft kidney. Radiation was delivered with at least 4- MV photons. Doses were limited so that less than 60 percent of the hepatic volume was exposed to more than 3000 cGy of radiation. The equivalent of at least two thirds of one kidney was spared from the field of radiation, and no portion of the heart representing 30 percent of the cardiac volume received more than 4000 cGv of radiation. Fluorouracil (400 mg per square meter) and leucov~rin (20 mg per meter) were administered as an .

analyses resulted in the continuation of the study unt

time for the reporting of final data.

RESULTS

Demographic Characteristics

Between August 1,1991, and July 15,195 tients were registered. Forty-seven patients ( were deemed .

margins, had disease other than adena

J ,--I '---'

erabie in a previous trial.'?

on pathological examination, or were regls the specified time limit. Of the rernainin. rients, 275 were: r~nrl"",I,, ~"": -: - - J

Quality Assurance for Radiotherapy

Prior annr{w~ 1 ..... ~,...}.,. ~ --- _.

iDEDALf t SILVESTmr I POUCLlNICa I«JNTELUCE mUGU

" '.--.-----~-

I Col 11'1 13CJ(AIWU Um rui.dC.: 21 I 03 I 964

PwiW.a: MARIO ROMAGNOLI

Data £4££:.: 12 I 3 I 04

---------------_ .. _--------------------------------_ .. _------------------------------------------------------------

DESCRIZIONE

REfERTO

UNlTA' 01 IIIS" A

-----------------------------------------------------------------------_ .. _----------------------------------

.. ..:..;1 .. ..

. _-----------------

",

i

"' /

24 ur II FiJia <4 45
V"I.
1 , UIll fiJia .. 45
"
17U UH' 1Ufuli.;;- 80 - 320 bambklG ( 1200
'11.
j' liT" 7 - 49
rJ Ul/1. ... _----------------

CHINlea

.... _- --------------

'A rOTALE A DlRETrA

1M AI T lU'"L"

90 iiiJdl an - 11 n •
II riU
~I w9/iU. 10 - SO
"
.uv ilililL 0.50 - 1.40
1.0S * iili/iU. F1.llo <4 1.00
UO wild.! Fino <4 US
U 91tJd.! 6.2 - U -_ ....... _--------------- ..... _-------_ .. _-_ .. _ .. __ ... - ...... _------------------------------------------_ ... _----------_ .. __ .. _----

'\

)

AZIENDA aSPEDALIERA

Suvi.zi.. d.i. Bi.ud'..iir.ic4. CUrJ.u t lticu;bluLlS.l4 OSPEDALE R. SILVESTRINI I POL1CLINICa IIIl/ITELUCE PERUGIA

*

1liW.cul4.: 108 {OJ} TESTA GERARDO Dw r.a4C.: 28 I OJ I 964

P.ti.iw.o: IIMIIa KOJIAGNOU

Dm ute.: 12/3/04

.... - - -- _ --- .. -- ---_ --- -- -- --_ .. ------- -- -_ - .. -------------- --- --- --- ---- -- _ --- .. ----- .. --------- -- --- -- -------- _--- .. _----

DESCRlzrONf

UNITA' DI NISURA

VALORI D1 RlfERIMENTa

.... _-- ..... _------------- .. _--------- ... _----- .. _----- .. _---- ..... -- .. _------ .. _------------- ... _----- .. _--- ........... _-- ... _-------------------------------

----- -- --- -_ -- ...... --- .. - .... _-
EJlOCROMO
---------------------- ----
GLaBULI BIANCHI US * xlooalill 3.6 - 9.6
GUlZULI ROSSI ," il DOODOC/fiJ, {III 4.3-U (F) 4.0 - 5.2
"01'1
ESfJHU81NA 11 II sid! (til 13 - 17 {f} 12 - 16
,.f.U'
EMATOCRlrO " . • {II} 38 - 52 IF) 37 - 47
Iflill •
MCU 88.2 11 82.D - 97.0
tL
ItOI 29.5 Pi 27~Q - Jl.O
ileHC 33.5 gld.! 32.0 - 36.0
~ 12.9 • 1!.6 - 13.7
•
• PrAmINf 156.U xlaaC/ill 14il- m
MPV " . * & U - 11.0
".w
LINfQCITI hH.J • ~ 2a.Q - 5U
•
l4OJIOZITI U.9 • 1.8 - 12.0
•
NEUTROmI IU • • 42.0 .. 15.0
•
EOSINGFILI , I • ~i.nG a. U
... 1
BASOm! 0.4 • 6i.nvo. 2.0
1 ------ .... _----- .. _----- .. _-- ..

ELETTROFGRESI PROTEICA

------- .. _---- .... _- .. _-- .. _-- ...

"DJIUTU, ML.UU""nn

ALFA f ALFA 2 EETA ; /lETA 2 GAMMA cOlIRma

66.3 • • 53.0 - 64.0
•
, , • • 4.5 .. 7.5
•• u •
7.3 • 7.0 - 12.0
·
6.0 • 5.0 - 8.0
•
3 • 2.5 - 6.0
•
13.4 ID.a - 2G.D
gIGRAZIO~E NaRUALE -.,. -,,'= . -------------------

------- ---- ---------------

CALera SOOIa PQTASSrO

9.2

1M , ..

iii~fdl iiiq!l. ;£qjt

8.5 - 10.7 135 - 155

• , - , < J.. .l.,J

Segue ••

FOLLOW·UP

AZIENOA OSPEOALIERA 01 PERlJGIA

o Ambulatorio

o Day-Hospital

o Ricovero

N·LLJ

IDIIIIII Data COGNOME .~~?r~ ....

P.S. (ECOG) ···til

Sltuazlone del paz. LU Kg. I

S.C.m2

I

P.A.

Tipo lesione 0 (1· ....... 1ni>ne,2·nonvtl.1IbiIt,3-"'.II~~,I.m_Ie,5·mitI.) Tipo dolore 0 (1·"_,2·00matJc0,3·ri",roIe,l •• 'is"') Inten. doloreO (1,2,3,4) Tipo traHamento LU UJ LU Protocollo n. L.LJ LU U Cicio I mese LU

ANAMNESI E SINTOMATOLOGIA

LESIONI VALUTABILI 1)

2)

3)

4) .

5) 6)

Allra oblellivita cllnica

Indaglni radlologiche

Alire Indaglnl

CONSULENZE

mallilia m Traalerno Id Illro cenl 0 • U 0 per a Ire cI •• e.

NTO: (I) Neu~n. I,,"pla (2) Follow·Up cllnleo (3) Chemlolerapll adJ ... ntl (4) Chlmloterapiti Heoldlun.11 (5) Chamlolerapl. (6) Chamlol. locoreglon.te (7) Rx.

I""pll praoperalarla (8) Rl:,erapta po.loperalorll (9) RI. lerapla (10) Chlrurgla radl .. ", (11) ChIlU';'" palHatln (12) Cftlrur;la dlagnil$lIe.(13) Ormonolerapl. ablallYt (14)

Ormonflltpil .CI4IllIv. (15) l_o1er'lll. (16)Tero,,1 dI suppo,IO (17) Sconil$clU1t (18) Allro·· .

\

AZIENDA OSPEDALIERA

Servizio di Biochimica Clinica e Microbiologia POLICLINICO MONTELUCE I OSPEDALE R. SILVESTRINI PERUGIA

Matricola : 583

Paziente : TESTA GERARDO

Rep. ric. : (ONCOLOGIA D.H. 37)

Primario: Prof. MARIO ROMAGNOLI

Data esec.: 14 I 7 I 2004

Pag. 1

CODlCE :

DESCRIZ IONE

REFERTO

: UNITA' DI MISURA :

VALORI DI RlFERlMENTO

• EMA'lOLOGIA
GLOBULI BIANCHI 5.55 . xIOOO 3.6 - 9.6
" GLOBOLI ROSSI 4.70 xl0000DD U (4.5-6.3), D (4.2-5.4)
EMOGLOBINA cgp g/dL U (14 - 18), D (12 - 16)
EMATOCRITO % 1l (38 - 52), 9 (36 46)
Mev 88.3 fl 82 - 97
MCH ·30.9 pg 27 - 33
MCHC 34.9 g/dL 32 - 36
RDW 14.9 * % 11.6 - 14.5
PIASTRINE 102.0 * xlOOO/ul 140.00 - 440.00
MPV 12.4 fl 8.0 - 13.0
LINFOCITI 16.0 , . % 20.5 - 51.1
• MONOCITI 4.3 % I - 10
GRANULOCITI 77,9 * % 42 - 75
EOSINOFILI 1.6 % Fino a 5
BASOFILI 0.2 % Fino a 1
• CHINlCA CLIIUCA
GLICEMIA 77 mg/dl 60 - 110
AZOTEMIA 20 mg/dl 10 - 50
CREATININA 0./9 mg/dl 0.6 - 1.4
'~, ACIDO URIeo 4.1 mq/dl U (3.4-7.0), D (2.4-5.7)
COLESTEROLO 162 mg/dl 160 - 220
.• ~ TRIGLICERIDI 226 * rug/al 40 - 165
BILIRUBIN! TOTliLE 8.10 * mg/dl Fino a 1.20
BILIRUBINA DIRETTA 3.~6 ., mg/dl Fino a 0.40
PROTEINE TOTALI 8.5 grldl 6.3 - 8.4
ALBUMINA 3.6 gr/dl 3.5 - 5.5
MAGNESIO 2.5 mg/dl 1.5 - 2.6
CALCIO 8.8 mg/dl 8.0 - 10.5
• FOSFORO U mg/dl 2.5 - 5.0
FOSFATASI ALCALINA 64& * UI/L 80 - 320
AST (GOT) "'1(\ UI/L
4U4'J
* mIL Fino A 40
GAMMA-GT 205 * miL U (Fino 51), D (Fino 33)
AMILASI 32 U1/L Fino a 100
SODIO 137 mEq/L 135 - 155
POTASSIC 4.6 mEq/L 3.6 - 5.5
CLORO 98 mEq/L 98 - 110
L D H 1199 * UI/L 230 - 450
iff Segue .. Primario: Prof. MARIO ROMAGNOLI

Data esec.: 14 I 7 / 2004

\

AZIENDA OSPEDALIERA

Servizio di Biochimica Clinica e Microbiologia POLICLINICO MONTELUCE I OSPEDALE R. SILVESTRINI PERUGIA

Matricola : 583

Paziente : TESTA GERARDO

Rep. ric. : (ONCOLOGIA D.H. 37)

pag. 2

- ----------- ... -------.;.-~--------------..;-------------- .. --------------------------------------------_ ....

COOleE :

DESCRIZIONE

REFERTO

UNITA' 01 MISURA :

VALORI 01 RIFERIMENTO

• ELETTROFORESI PROTElCA

VEDI ALLEGATO

• VES I' ora

15

2 - 15

•

Il primario~I/oMAGN01I

•

.\

AZIENDA OSPEDALIERA PERUGIA SERVIZIO ANALISI CHIMICO CLiNICHE

TESTA GERARDO

camp. nr. 18 del 14/07/2004 10 583

Reparto :ONCOLOGIA D.H .

•

. ,

Elettroforesi delle Sieroproteine
Frazioni Yo Int. rif. %
Albumina 46,6 < 56,1- 65,7
• Alfa 1 5,4 3,1- 6,0
Alfa 2 10,7 8,0 -13,0
Beta 1 .... 6 < 4,9 7,4
Beta 2 4,6 3,1- 6,1
Gamma 28,1 > 10,3 - 20,0
Rapp. A/G : 0,87 P. T.: gjdl RIDUZIONE DELLA ETEROGENEITA' DELLE IMMUNOGLOBUUNE POLICLONALI. SI

CONSlGLIA IMMONOFISSAZIONE.

rt Respensabile

AZIENDA OSPEDALIERA

Servizio di Biochimica Clinica ,e Microbiplogia OSPEDALE R. SILVESTRINI / POLICLINICO KOilTELUCI!

PERUGIA

t t

Matricola : 1770 TESTA GERARDO Rep. ric. : (ONCOLOGIA DB 31

Prl.ll1ari(l: MARIO ROMA!:NOLI

Data esec.: 14' I 7 I 04

... .. ..;.. .. ' ... ,. __ .~-r ... - ........ - ... ':""--;-~---

\ : DESCRIZIONE : " REFERTo : UNITA '01 MISURA: VALORI DI~IE1RDlENtp

I,

.... -------- .. _------ .... ----------------------------------------------------------------_ ... ----------- ...... -----------;.~---------- ...... .,.-------

"

MARKERS EPA'!'I'!'E

antiHBc

TITOLO antiHBs Anticorpi anti HCV

P SITlVO POSITIVO NEGATIVO

NEGATIVO ' ii.,(

mUI/ml

Negativo Negative Immune >10 Negative

-r"i.

___ • »r- ~ ;~ -------:-------------------------.:~------~-J~++-,~-----'--:..--

.-- NOTA:

,r

HBe Ag : NEGATIVO

Anti HBe : :POSITIVO

iAnti ~clqM : POSITIVO

....

Per il Primario

i.

'\I,

L

WENDA OSPEOAlIERA

Servilio diBiothiaica Clinica e Hicrobiologia OSPf_E R. SllVESTRINI / POllClIHIcn MONIElUCE

. mum

Hatricoh : 96 (03 ) TESTA GERARDO Data sasc.: 28 I 03 I 964

Pritario: HARIO ROMAGNOli

Data esec.: 21 I 10/04

~'-. --_ .. -- -- - .... _-----_ ..... -_ ... -- ----- -_ .. --- ..... ----- ... _-- - .. --- .. ---- .. --- .. ----- .. _---_ ...... -- ...... - -- --_ .... - .... ------ ..... ------ -_ .. -- .. --- -_ .... -_ .. _-

VAlORI 01 RIFERIHENTO

.... _ ...... --- .. - .. ----- .... ---_ .. -- ...... _-_ .... --_ .... __ .. -_ .. -- .. ------- ---- .. _- --_ .. -- .. _- - ... --- - ... _ .. ------- -- -- .. --_ .. --_ .... --- --- .... ------- .. --- .... ----- .....

EN I I H I

BIOCHIHICO

--- _ ... _--- .. _------- ........ --- ..

BIlIRUBIHA TOTALE BIlIRUBINA DIRfTTA PROTEIHE TOHl! _KINA

1.04 0.31 7.0 4.0

* 119/dl Ig/dl gr/dl gr /dl

Fino a 1.00 Fino a 0.25 6.2 • 8.5 3.5 - U

ASSETfO llPIOICO

.... ---- ....... _ -- .. -- ----- -- .... _-

,)

fR IGlI CERIO I

70

Ig/dl

50 - 170

-- ~-- - .. --- .. ----------- --- --- .... _ .. --_ .. ----_ .... --- --- - ... - - ------ -- -- --- - -- -- -- ---- --- .. - -- ------------ _ ........ --- .. --- _ .... - --_ .... - .. ------- ---

AZ lENDA OSPEDALIERA

Servizio di Biochimica Clinica e Microbiologia OSPEDALE R. SILVESTRINI / POLICLINICO MON'mUCE PERUGIA

Matricola: 16g2

TESTA GERARDO Rep. ric. : (ONCOLOGIA DB 37

Primario: MARIO ROMAGNOLI

Data esec.: 13 / 7 / 04

Pag. 1

. h

~l"--"---------------------------------------------------------------------------------------------------- ... --- ... ,.I.- .. ~---- .. -- ..... -- ..... ----

DESCRIZIONE

. UNITA' Dr KISURA :

VALORI Dr RmRI}!l!~to

______________________________________________ ... L~~~ .. ... --.- .. -~-..;~oo!:~- .. --------

IMMUHOCBIMICA

CEA

CA 19.9

2.5 36.4

ng/ml U/ml

fino aS~O fino a 37.rr

--------------------------------""!'-------------r----------~.------.-----------------------"':"~------------~----------~-J~.,t'i----------

.,

Per il Primario

\ '

,; .

•

WENDA DSPEDAUERA

Servizio oi Biochieica Clinica e Micrabiologia OSPEuALf R. SILVESTRIHl I POUCLINICO HOHTELUCE mum

Matricala : 9b (03 )

• TESTA GERARDO

Data aase.: 28 / 03 / 964

Primia: MARIO ROMAGHOLr

Data esee.: 11 /10 / 04

._---------- .. ---------------------------------- .. ------------------------------------------------------------------------------

i :

DESCRIIIONE

REFERTO

: UNlTA' Dr nISURA :

VALOR I 01 RlfERIHEHTO

.................... -_ - .. -- -- -_ -- --_ .. 'O- __ __ _ .. __ __ __ .. __ __ __ .. _ .. ..

:, ----------,,---------------
EHOCROKO
--- -- -------- ---_---------
6l6BULI mneHI 1.39 xl000jul 3.6 - 9.6
GlOBUlI ROSSI 4.31 xl000000/ u 1 (H) u - 5.8 (F) U - 5.2
EHOGLOBlNA 13. I g/dl (M) 13 - II (F) 12 - 16
EHATOCRITO 40.5 % (H) 38 - 52 (F) 37 . 41
Kev 94.0 IL 32.0' 97.0
HeH 31.8 pg 27.0 . 33.0
HCHC 33.S g/dl 32.0 - 36.0 '_'
ROW 11.5 t % 1l.6 - 13.7
PIASTRIHE' 119.0 i xlOOO/ul 140 . 440
lINfOClTI 28.4 20.0 . 51.0
MONDCITl 6.5 1.0 - 12.0
NEU1ROFJLI 62. S 42.0 . 7S.0
.) EDSIHOfILI 1.0 fino a 6.0
BASOFILI 0.6 fino a 2.0 -- -- - __ ...... - -- - --_ - ---_ .. ---
ElETTRDFORESJ PROTEICA
---- ---_- --- _- _--_ -- -_--_ ..
ALBUHINA SB.! 56.1 - bS.7
ALFA 1 4.3 3.1 - 6
alfA 2 1&.7 8 - 13
BElA 1 5.9 4.9 • 7.4
BETA 2 5 3.1 . 6.1 .1
GAMKA 16,5 10.3 - 20
COMKEHTO n I GRAll ONE NORMAL[
.. ----- ----- ------ ---_ ---- ..
COAGUlAIIOHE
----_ .. ----- --- --- ---- -----
TE3T uJ QUICK 100 70 - 100
J.U 1.0 0.8 - 1.2
TEHPO 01 TROHBOPltPARZlAl 30 secondi 26 - 35
~ FrBRlNOSfNO 313 mg! 150 - 400
Segue .. FOLLOW·UP

AZIENDA OSPEOALIERA 01 PERUGIA

o Ambulatorio

o Day-Hospital

o Ricovero

N·LU

I I I I Data IQSk{I-\104

··~'T'a. . ~." .....

COGNOME . .,. . NOME u-

101.,

P.S. (ECOG)'@

OIAGNOSI

S.C.m2

P.A.

" \

Tipo lesione 0 ~·_lesione,2·non,,_~,3·Yllullblle,~·m_,S·_) Tlpo dolore 0 rll"2·r'3-VI"""Ie,~.mlll') Inten. doloreO 11,2,3,4)

Tipo trattamento Ll._j Ll_j LJ_J ProtocOllo n. LU U CicIo I mese Ll..J

ANAMNESI E SINTOMATOLOGIA

jt' ~

fII·· .

LESIONI VALUTABILI

1) ...

",:.

6)

Altra oblettlvlta cllnlca

Indaglni radiologlche .

AlIre indaglnl

CONSULENZE .

. ~"" .

SITUAZIONE PAZIENTE: 11) Vlvenl •• IIber. miIIUl. (2) Vlvonle con tee. loc. (3) Vlvonlo con mll.ttl. re.ld.ii(4) Vlv.nt. In 'emission. (5) 'IIv'nll con m.' •• 'lsl (6) VI.onl. con mlla'1I1 (7) T .. slefllo ad allro cenlro (8) Por.o II Follow·Up (9) Docedulo par neoplasia (10) Deceduto per "lira c~use.

TIPI TRATTAMENTO: (I) Noss nllor. II 2 01 • . p. eoed ••• nle (5) Chlmlolerapla (6) ChemiOl. Loooreglonilo (7) Ill.

rap" pr.opera orla (8) RI. lerapla po.'opera'arll (9) Rt. 'oropla (10) Chlru,gla radlca'" (II) Chlrurgla p.III.It.1 (12) Chlrurgl. dlagnosllc. (13) Ormonolarapll ability. (14)

Ormonellrpla addltlva (151Immunot.rapll (16ITI"pll dlsupporlo (17) Sconolclull (18) Altro ". .