Discharge summary from the inpatient medical record No. 9577/2026, Shalimov National Scientific Center of Surgery and Transplantology (English translation)
Translation of the Ukrainian original (3 pages, signed 13.10.2026). Numbers, units, dates and codes are kept as written. [blank] = form field not filled in; [sic] = as written in the original. Translator’s notes are marked as such and are not part of the document.
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APPROVED Order of the Ministry of Health of Ukraine 14 February 2012 No. 110
| ACADEMY OF MEDICAL SCIENCES OF UKRAINE | MEDICAL DOCUMENTATION |
| State Institution “National Scientific Center of Surgery and Transplantology named after O.O. Shalimov” | Primary record-keeping form No. 027/o |
| Kyiv, Akademika Shalimova St. 30 | APPROVED: Order of the Ministry of Health of Ukraine 14.02.2012 No. 110 |
| EDRPOU code 45233967 |
Department of Hepatobiliary, Visceral and Endocrine Surgery and Organ Transplantation
DISCHARGE SUMMARY from the inpatient medical record No. 9577/2026
To: Outpatient clinic at the place of residence (name and address of the health-care facility to which the summary is sent) [blank]
- Patient’s surname, first name, patronymic: Zherlitsyna Anastasiia Stanislavivna
- Date of birth: 25.04.1971 (day, month, year)
- Patient’s place of residence: Zhytomyr Oblast, Malyn [street address omitted on this site].
- Place of work (position): not employed.
- Dates: a) at the outpatient facility: onset of the disease [blank];
referral to hospital [blank]
- in hospital: admission 05.10.2026; discharge or death (underline): 13.10.2026 (“discharge” is marked)
- Full diagnosis (main disease, comorbidities and complications):
Main: C78.7 GIST of the stomach cT2N0M1 (hep), KIT exon 11 mutation. Stage IV. Morphologically confirmed 13.10.2026 Complications: [blank] Comorbid: Uterine leiomyoma. Endometrioma of the right ovary. Type 2 diabetes mellitus. Iron-deficiency anaemia.
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7. Brief history, diagnostic investigations, course of the disease, treatment given, condition on referral and at discharge
Complaints: general weakness. History of the present illness: ill since 08.2022, when multiple bilobar liver lesions, a paragastric mass and a pelvic mass were found. The process was initially regarded as metastatic leiomyosarcoma of the uterus, for which she received systemic therapy with gemcitabine, docetaxel, bevacizumab, later pazopanib and trabectedin, without a durable effect. After repeat biopsies and review of the histological material in 2023 the diagnosis was revised to GIST of the stomach with metastatic involvement of the liver. From 03.05.2023 she received imatinib 400 mg/day with a marked metabolic response and stabilisation of the disease until 2025. From 06.2026, PET-CT showed progression of the metastatic liver involvement. Molecular testing of 08.2026 found a primary KIT exon 11 mutation and secondary KIT exon 13 and exon 18 mutations, consistent with resistance to imatinib. PET-CT of 23.09.2026: further metabolic progression of multiple liver foci. Locoregional and surgical treatment methods were considered; thermal ablation of the left-lobe focus was judged technically inadvisable. On 30.09.2026 regorafenib 160 mg/day was prescribed; treatment had not been started at the time of admission. Admitted electively to department IV of the NSCST for further work-up and to decide the further treatment strategy. Copies of all investigations are attached to the case record.
Main investigations: 30.09.2026 complete blood count, blood biochemistry — see the case record. Within acceptable limits. 30.07.2026 cardiac ultrasound: left-ventricular myocardial contractility satisfactory. 02.10.2026 ECG: regular sinus rhythm, heart rate 70/min. Vertical electrical axis. ECG tracing without pathological changes. 23.09.2026 PET-CT from the “nadrivni” [sic] arches to the middle third of the thigh: PET/CT signs of increased metabolic activity in multiple foci of involvement of the liver parenchyma compared with the PET/CT of 19.06.2026, characteristic of progression of the main disease. Stable low-intensity mass of the uterine body and stable metabolic node of the uterine body without marked change. A stable FDG-negative mass of the gastric body persists. Radiotracer uptake in the oesophagus may be of inflammatory origin; however, further work-up — EGD — is recommended. No [“nshykh”, sic] other evidence of an FDG-positive pathological process found. 02.10.2026 EGD (fibro-oesophagogastroduodenoscopy): erythematous gastropathy. Duodeno-gastric bile reflux. 02.10.2026 video colonoscopy: status after appendectomy (1982). Single (3) neoplasias of the colon. Endoscopic signs of dolichosigma. Chronic internal haemorrhoids.
Sick-leave history: sick-leave certificate not required; not on sick leave at the time of admission. Life history: according to the patient, she has not had tuberculosis, venereal or other infectious diseases. Somatic diseases: denies. Regular medication: see the case record. Allergy history: denies. Oncological history: see diagnosis. Previous operations: 1982 appendectomy. Infectious history: unremarkable.
Tests:
| Date | Test name | Result |
|---|---|---|
| 13.10.2026 | D37001 — Test; histopathology; digestive | Pathohistological examination No. 4222/26: the fragment of the gastric mass consists of hyalinised tissue without viable tumour cells, which may be a consequence of the therapy given. In the liver trepan-biopsy material — metastasis of a gastrointestinal stromal tumour (GIST), spindle-cell variant, Low Grade. |
Surgical interventions:
| Date (day, month, year) | Time (hours, minutes) | Procedure / operation code | Name of the procedure / surgical operation | Specialist (surname, first name, patronymic, registration number) |
|---|---|---|---|---|
| Romaniv Ya. V. | ||||
| 05.10.2026 | 10:50 | 92514-39 | General anaesthesia | |
| 05.10.2026 | 11:33 | 30075-12; 30412-00 | Diagnostic laparoscopy. Incisional biopsy of the gastric neoplasm. Trepan biopsy of the focal lesion of liver Sg II–III under ultrasound guidance | Fedorov D.O. |
The post-operative period was without complications. As of 13.10.2026 there are no data for acute surgical pathology. The patient is discharged in satisfactory condition for observation and treatment by a surgeon, gynaecologist, oncologist and family doctor at the place of residence. All recommendations have been given.
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8. Treatment and work recommendations
- Observation and further treatment by a surgeon, gynaecologist, oncologist and family doctor at the place of residence.
- Limitation of physical load for 1 month.
- Omeprazole (or Proxium) 20 mg / 2 per day — 07:00, 19:00 — when taking NSAIDs.
- Nimesil 1 sachet — as needed.
- Review at the NSCST on the results of the oncology consilium, to decide on radical surgery.
Attending physician — Oleksandr Ostapyshen Head of department — Oleh Symonov [handwritten signature] 13.10.2026 [round stamp, text illegible]
Translator’s notes (not part of the document)
- The form gives the date of birth as 25.04.1971; the patient was born on 25.04.1976 (the 05.10.2026 pathology form also gives 1971).
- The summary contains no information on ascites, peritoneal findings or the ascitic-fluid cytology; the operation protocol of the laparoscopy is not part of it.
- The colonoscopy line gives “single (3) neoplasias of the colon” without size, removal or histology.
- The EGD result names the stomach and duodenum; the oesophagus is not described.
- ICD-10 C78.7 is the code for secondary malignant neoplasm of the liver.
- The street address of the place of residence is omitted on this site; it is in the original.