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Sample Narrative Case Summary
Case Number: 1 -CL
Tumor Type: Rhabdomyosarcoma of the Left Maxillary Sinus
History: CL is an 10 year old boy (DOB 4/01/1994) diagnosed with a rhabdomyosarcoma of the left maxillary sinus via transnasal biopsy (Specimen #S95-12345) in April 2002 following presentation with nasal obstruction, left sided facial swelling, and palpable neck lymph nodes. No disease was evident on bone marrow biopsy and aspirate, bone scan or lumbar puncture. Treatment plan included chemotherapy and radiation therapy. Chemotherapy was given between 4/28/02 and 12/1/02 on a pediatric protocol #5678. CL received 30 daily treatments of radiation therapy (7/3/02 - 8/22/02) for a total of 54 Gy. CT scans dated (8/01/02) and (11/01/02) showed no significant change in the size or extent of the residual tumor. CL's facial features were unchanged (MD Progress Note, 12/01/02). A nasal endoscopy performed in January 2003 revealed residual malignant tumor "essentially similar to original biopsy" (Specimen #96 - 91011). CL began daily Alternative Modality A on 1/01/03. A CT scan dated 6/1/03 showed a slight decrease in the largest dimensions of the mass as compared to the 12/1/02 CT scan. Similarly, a CT scan dated 12/1/03 showed a marked decrease in the largest dimensions of the mass as compared to the 6/1/03 CT scan. A biopsy of the nasal wall performed in April 2003 showed no evidence of tumor (4/17/97, Specimen #S97-121314). An MD note dated 5/01/98 reported "no evidence of recurrence clinically". CL completed 18 months of daily Modality A in July 1997. He was last seen in March 2004, now 2.5 years after treatment and without evidence of disease. He is alive and well at the present time (October 2004).
Pathology:
- Biopsy, transnasal tissue, 4/12/95, (Specimen #S95-12345 , Hospital, Rockville, MD)
- Biopsy, soft tissue, left maxillary sinus and left nasal mucosa, 1/10/96, (Specimen #S95-91011, Hospital, Rockville, MD)
- Biopsy, left lateral nasal wall/maxillary antrum, anterior nasal mass, 4/17/97, (Specimen #S97-121314, Hospital, Rockville, MD)
Radiology:
- CT scan, 4/20/95, Bone scan, 4/20/95
- CT scan, 4/24/95, MRI, head and neck, 4/25/95
- CT scan, head and neck, 5/8/95
- CT scan, head and neck, 8/201/95
- CT scan, head and neck, 11/01/95
- CT scan, head and neck, 1/1/96
- CT scan, head and neck, 5/1/98,
- CXR, 5/1/98
MD Progress Notes:
- MD Progress Note, (12/1/95), Outpatient Clinic, Dr. W, Rockville, MD)
Chemotherapy Regimen #5678:
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