Patient: Room 112By Bana Hadid

History• Physical History• 42 years old• Female• Sudanese• Patient was previously healthy• Two weeks c/o of abdominal

pain that developed suddenly• Right hypochondrial pain

• Nausea and vomiting• Patient noticed a change in

urine and stool color• No fever• No decreased level of

consciousness

• No change in bowel habits• Obstructive jaundice• Shortness of breath at times

• Psychological History• Had many psychological support

sessions due to patient being anxious and having a low mood

Diagnosis

• High grade/poorly differentiated neuroendocrine tumor of the gallbladder• With metastasis to the:• Mesentery and the vessels• Right lobe of the liver

• The porta-hepatis is obstructed• Lymphadenopathy• No pancreatic masses

Poorly Differentiated Neuroendocrine Tumor

• Neuroendocrine Tumors • Relatively uncommon• A group of tumors that have benign

and malignant potential (netpatientfoundation.org)

• Poorly differentiated (high grade) neuroendocrine carcinomas• Large cell neuroendocrine and small

cell carcinomas (netpatientfoundation.org)

• Cells that look very abnormal• Likely to grow more quickly• More likely to spread (macmillan.org)

• Start treatment a little quicker• The treatment is most likely going to

be a chemotherapy based treatment since it is known to act well on faster growing cells (netpatientfoundation.org)

• Diagnosed by:• Biopsy• Blood tests• Urine tests• Ultrasound scan• CT scan• MRI scan• PET/CT scan

Poorly Differentiated Neuroendocrine Tumor

• Other treatments include: (netpatientfoundation.org)• Systemic therapies that affect the entire body:• Radionuclide therapy (a # of different radioactive agents available)

• The dose of radiation is high enough to stabilize the tumor and potentially shrink the tumor• Benefits:

• Ability to deliver radiotherapy directly to the cancer tissue with minimal damage to normal tissue • Extremely well tolerated with only minor side effects for the majority of patients

• Immunotherapies• New anti-cancer drugs - Sunitinib and Everolimus have recently been shown to

be beneficial for patients with certain types of pancreatic neuroendocrine tumors• They work by interfering with the development of blood vessels to the tumor and

they also disrupt the ability of the tumor cells to grow.

Poorly Differentiated Neuroendocrine Tumor

• Other treatments include: (netpatientfoundation.org)• Local therapies to target specific areas of the body:

• Radiation• Uses high-energy x-rays to destroy cancer cells, while doing as little harm as possible to normal cells

(macmillan.org)• Surgery

• To remove the high grade neuroendocrine tumor• Radiofrequency Ablation

• Uses radio waves and heat to destroy cancerous cells• Cryotherapy

• Uses extreme cold produced by liquid nitrogen to destroy cancerous cells• Can be used to treat tumors on the skin and inside the body

• Embolization/Irradiation• If the tumors are causing pain or other symptoms, they may be treated with palliative intent, such as

embolization for liver metastases and irradiation treatment for brain and bone deposits• The aim is to block the blood supply to the part of the liver containing tumor; this cuts off the oxygen

and nutrient supply, and the tumor may stop growing or even shrink for a period of time.

• Clinical trials• To receive new, experimental treatments

Poorly Differentiated Neuroendocrine Tumor

• No distinctive neuroendocrine features by light microscopy• Immunoperoxidase staining or electron microscopy identifies

neuroendocrine features• In a group of 51 patients in a study done by the NCBI• Many patients had high-grade tumor and metastases in multiple sites• The retroperitoneum, lymph nodes, and mediastinum were frequently

involved• None of the patients had syndromes associated with low-grade

neuroendocrine carcinoma (i.e. carcinoid syndrome)

Clinical features and Treatment Results in a Group of 51 Patients with Poorly Differentiated

Neuroendocrine Tumor

Reason for Current Admission

• Patient had increasing right upper quadrant abdominal pain• Patient had a yellowish body (jaundice)• Weight loss• Tumor was obstructing bile ducts• Patient had generalized fatigue and weakness• Due to the liver metastasis not filtering out the toxins of the body

Assessment• Physical• Jaundice• Spiking fever• Hypotensive with profuse

diarrhea (on 17/12/15)• Edema of the feet because:• Pressure from the disease is

obliterating the lymphatic flow from thigh to abdomen

• Albumin levels are low due to malnutrition and poor oral intake

• Patient is bedridden; lack of movement

• Abdominal distension because of tumor (not because of gases

and fluids)• Hepatomegaly• Not tender

• Decreasing yellowish discoloration of the sclera

• No nausea or vomiting• Normal pupil size• No nightmares• Has woken up suddenly at night,

2-3 times before• Pain fluctuates from day to day• Sometimes sleeps all night;

sometimes cannot sleep all night because of pain

Assessment• Social• Patient is no longer a visitor to

Qatar; she is a resident• Came to Qatar in September

• Started chemotherapy with the help from the clinical pharmacist and the hospital

• Married• 1 son and 4 daughters:• 2 are in Qatar, and 3 are in Sudan• Girls’ Ages: 15 months, 9 years, 18

years, and 21 years (the 21 yr old studies Physics)

• Boy’s Age: 16 years• Sometimes wants to talk to

people; other times doesn’t want to do anything and just wants to

sleep• Talks to friends on the phone• Tells them she’s doing well, even if

she’s not (because that is in her nature; she wants to make people feel happy)

• In Sudan, patient would make Thoubs (the traditional Sudani clothing)

• Watches TV as a pastime: ½ the time: regular channels, ½: religious channels

• Huge element of distress for the husband since he really wants his wife to get better

• Primary Language: Arabic• Religion: Islam

Assessment• Lab Results• Gradually dropping hemoglobin: 7.8

• No apparent bleeding source• Could be

• due to the chemotherapy• Dilutional because of IV fluids• Vs iatrogenic due to many blood tests

• High bilirubin (causes Jaundice)• High INR

• Platelet: High: 540• Tendency for bleeding• Longer time to clot• Cause: liver not making clotting factors

• Which are proteins that are made by the liver

• Sign of liver malfunction due to the cancer• RBC: Low: 2.8• Hct: Low: 23.6

• RDW-CV: High: 18.0• Neutrophil Auto #: High: 7.6• Basophil Auto #: Low: 0.00• Prothrombin Time: High: 18.3• Creatinine: Low: 26• Sodium: Low: 126• Chloride: Low: 86• Total Protein: Low: 63• Albumin: Low: 32• ALT: High: 63• AST: High: 185• Glucose: High: 9.9

• There is no way of local/surgical treatment

• Has been mobile• Patient has difficulty swallowing

capsule medications

Medications and Current Treatments

• Received her first cycle of palliative chemotherapy on December 23, 2015• Post Percutaneous Transabdominal Catheter drain• Lorazepam – PRN (when patient needs to sleep, but cannot)• Was put on Ceftriaxone due to• Cholangitis/bacteremia E. Coli sensitive strain• After the course of antibiotics• Repeated culture/sensitivity was negative

• Afebrile• Hemodynamically stable

Medications and Current Treatments• Ceftriaxone Int Infusion• Sodium Chloride 0.9% 100 mL, 2g=20mL, Rate: 200mL/hr Infuse over

30 mins IV, q24hr• Duration: 2 weeks from 21/12/15-08/01/16

• Dexamethasone• 4mg=1mL, BID, Infuse over 15 mins IV• Duration: 3 days from 27/12/15-30/12/15

• Gabapentin• 300mg, oral capsule, BID• Duration: 28/12/15-07/01/16

• Magic Mouth Wash• 10mL, oral solution, TID• From 14/12/15

Medications and Current Treatments• Magnesium Hydroxide• 20mL, oral suspension, BID• From 22/11/15

• Nystatin• 500,000=5mL, oral suspension, TID• Duration: 7 days from 25/12/15-01/01/16

• Octreotide• 20mg, intramuscular injection, q4wks• Duration: 1 dose from 07/12/15-04/01/16

• RABEprazole• 20mg, oral tablet, daily,• From 22/11/15

Medications and Current Treatments• Sennosides A & B• 2 oral tablets, daily• From 22/11/15

• Lorazepam• 1mg, oral tablet, q8hr, PRN anxiety• Duration: 8 days from 29/12/15-06/01/16

• Metoclopramide INT Infusion• Sodium Chloride 0.9% 50mL, infuse over 30 mins IV, TID, PRN

nausea/vomiting• From 12/12/15

• Simethicone• 84mg, oral chew tablet, TID, PRN as needed for gas• From 28/12/15

Medications and Current Treatments

• Morphine (PRN)• 10mg, subcutaneous injection, q1hr, PRN pain• Duration: 10 days from 25/12/15-04/01/16

• Morphine continuous IV infusion 80mg• Sodium Chloride 0.9% 42.67 mL, Rate: 2mL/hr• From 17/12/15

Impressions• Responded well to her first

cycle of palliative chemotherapy• No nausea or vomiting• No abdominal pain• Afebrile• Keeping an adequate oral fluid

intake• Family is happy about starting

chemotherapy• Jaundice is getting better• Sometimes has pain in

abdominal area

• Sometimes feels fatigued, weak, and lethargic• Sometimes has shortness of

breath• Accesses morphine PRN for this

• Pain is in control• Edema of the lower limbs• Generally in a good mood

Impressions on December 30, 2015

• Elevated mood• Edema in the feet is less• Liver size and abdominal mass is at least 50-70% smaller• Shortness of breath has decreased• Does not feel the need for a lot of pain medications• Was sitting in a chair outside of her room• There is still a little jaundice• Reported nausea a few mornings ago but responded well to

Metoclopramide

Recommendations for Future Treatment

• Continue chemotherapy since patient can respond to the treatment• Send patient to gastroenterology team to see if a stent can be put

in the bile ducts to keep them open for drainage and to improve her jaundice• Patient will need stenting in both ducts and 2 guide wires have to be passed

• Ultrasound of the abdomen• Continue Ceftriaxone• Repeat blood cultures

• Manage symptoms as they arise• Change capsules to syrups due to difficulty swallowing• Psychological Recommendations:•To be visited by the spiritual advisors since patient felt better after the

advisor’s previous visit•Provide psychological support to patient and family as needed

THANK YOU