2. 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
3. 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
4. Poorly Differentiated NeuroendocrineTumor
• NeuroendocrineTumors
• 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
5. Poorly Differentiated NeuroendocrineTumor
• 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.
6. Poorly Differentiated NeuroendocrineTumor
• 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
• RadiofrequencyAblation
• 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
7. Poorly Differentiated NeuroendocrineTumor
• 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)
9. 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
10. 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
11. 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 makeThoubs
(the traditional Sudani clothing)
• WatchesTV 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
12. 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
• NeutrophilAuto #: High: 7.6
• Basophil Auto #: Low: 0.00
• ProthrombinTime: 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
13. Medications and CurrentTreatments
• Received her first cycle of palliative chemotherapy on December 23, 2015
• Post PercutaneousTransabdominal 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
14. Medications and CurrentTreatments
• 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 MouthWash
• 10mL, oral solution,TID
• From 14/12/15
15. Medications and CurrentTreatments
• 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
16. Medications and CurrentTreatments
• 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
17. Medications and CurrentTreatments
• 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
18. 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
19. 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
20. Recommendations for FutureTreatment
• 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
