Chapter 151 - 126: Insurmountable Gulf
Instant takedown!
Lightbox number two.
"Head CT scan, plain. A crescent-shaped hyperdense shadow is visible in the right frontotemporoparietal lobe. The ventricles are compressed, and the midline structures are shifted to the left. Primary diagnosis: acute subdural hematoma with cerebral herniation."
Lightbox number three.
"Abdominal X-ray, upright plain film. Free air is visible under both sides of the diaphragm, presenting as a sickle-shaped radiolucent shadow. Primary diagnosis: gastrointestinal perforation."
Lightbox number four.
"Left lower limb X-ray, AP and lateral views. Discontinuity of the bone cortex is visible at the junction of the middle and lower thirds of the tibia, with a fracture line present. Alignment and apposition are acceptable. Primary diagnosis: tibial shaft fracture."
He walked to the last lightbox.
This was a rather poor-quality chest CT scan.
Jiang He paused for two seconds.
"Bowel loops and air-fluid levels are visible in the left thoracic cavity. The heart and mediastinum are shifted to the right. The contour of the left hemidiaphragm is lost. Primary diagnosis: traumatic diaphragmatic hernia."
After reporting on the last scan, Jiang He looked at the examiner. "Sir, I’m finished."
The examiner was holding a standardized answer key.
He stared blankly at the wall clock.
Fifty-five seconds.
Five diagnoses, not a single word wrong.
Even his descriptions of the key radiological features perfectly matched the key points on the answer key.
To borrow a phrase from that student, Wa... it was a complete and total takedown.
The utterly shocked examiner picked up his pen and wrote "100" on the score sheet.
"Full marks. Go to Zone D."
"Thank you."
Jiang He pushed open the back door of Zone C.
At the end of the hallway was the final station, Zone D.
The layout of Zone D was similar to Zone A, also consisting of individual booths.
But the lighting here was brighter, and on the desk lay a detailed medical file and several recent medical articles in both Chinese and English.
Zone D tested prognosis and postoperative plan formulation.
Jiang He sat down in the chair and pulled out the file.
The medical record showed a 65-year-old male patient who had undergone a pancreaticoduodenectomy (Whipple procedure) for "pancreatic head ductal adenocarcinoma."
The exam question required: Based on the postoperative pathology report, assess the patient’s risk of recurrence and formulate a postoperative adjuvant chemotherapy plan.
Jiang He flipped to the pathology report on the last page.
[Tumor size: 4cm x 3cm, surgical margins negative (R0 resection).]
[Lymph node dissection status: 10 lymph nodes dissected in total, 2 of which were positive.]
Looking at these two lines, Jiang He immediately understood the core concept this question was testing.
In 2008, the commonly used tumor staging system was the 6th edition of the AJCC TNM staging system.
In the 6th edition guidelines, any lymph node metastasis, regardless of the number of nodes involved, was uniformly classified as N1 stage.
Following conventional thinking, the standard answer to this question should be: The patient is T3N1M0, Stage IIB.
Recommendation: standard adjuvant monotherapy with gemcitabine.
Any other student competitor, or even a regular attending physician, would have written this answer.
But Jiang He didn’t.
He was keenly aware of the flaws in this traditional staging system.
When the total number of dissected lymph nodes is insufficient, relying solely on the number of positive lymph nodes leads to a severe stage migration.
In other words, the patient’s actual condition was far more severe than the staging indicated.
And the solution to this flaw was precisely the topic of the paper he had just published in the *Chinese Journal of Surgery*—the Lymph Node Ratio (LNR).
’This question... is very targeted.’
’Feels like it was aimed at me.’
’It’s as if they want to put me to the test.’
Jiang He picked up his pen and wrote his answer seriously:
[I. Prognostic Assessment:]
[According to the traditional AJCC 6th edition staging, the patient is N1, but this assessment method has limitations.]
[In this case, a total of 10 lymph nodes were dissected with 2 positive, so the Lymph Node Ratio (LNR) = 2/10 = 0.2.]
[According to my recently published paper (Note: LNR System Assessment), when LNR ≥ 0.2, the patient belongs to the high-risk recurrence group, and their postoperative disease-free survival (DFS) and overall survival (OS) will be significantly poorer than patients with an LNR
[II. Postoperative Plan:]
[Given the patient’s high LNR and extremely high risk of recurrence, the intensity of standard gemcitabine monotherapy is insufficient to control micrometastases.]
[A combination chemotherapy regimen is recommended, with the first choice being gemcitabine combined with capecitabine (the GemCap regimen).]
After writing this, Jiang He put down his pen.
Although this answer was likely different from the standard answer for 2008, that wasn’t important.
What was more important was demonstrating his own value and the value of his LNR paper.
Jiang He took his answer sheet, walked out of the booth, and handed it to the examiner collecting the papers outside.
The examiner took the paper and glanced at its contents.
"Student, this exam is supposed to be answered according to current clinical guidelines." The examiner frowned and asked, "What is this LNR metric you’ve used?"
Jiang He didn’t answer. The examiner asked again, "Are you citing... uh, your own paper?"
"In any case, this isn’t mentioned in the textbooks, and the chemotherapy regimen you’ve written goes beyond the single-agent standard. Are you sure you want to submit this?"
Jiang He said, "Sir, this is a cutting-edge clinical development. If you assess this patient according to the traditional N1 staging, he will develop liver metastases within six months post-surgery. You can submit my paper for review."
The examiner frowned.
The competition rules stipulated that any paper with a controversial answer or one that deviated from the standard could not be graded directly and had to be submitted to the expert panel for review.
"Fine. Go to the waiting area. The score for this station won’t be available until after the expert panel has reviewed it."
Jiang He nodded and, leaning on his crutch, walked toward the contestants’ waiting area at the other end of the hall.
...
「Meanwhile, in the observation room.」
On the large screen, Jiang He’s scores for Zone A, Zone B, and Zone C were all displayed as 100.
But the status bar for Zone D was lit up in yellow, showing "Under Review."