Managing Patient With Pancreatic Cancer Case Study

Introduction

Pancreatic cancer is one of the deadliest cancers, partly because it is difficult to diagnose in the early stages (Chang & Kundranda, 2017). This paper presents a case study of a 72-year-old white male patient diagnosed with stage Ib pancreatic cancer. The patient underwent a Whipple procedure with gemcitabine as adjuvant therapy. The medical management, combined with nursing interventions, led to the patient’s improvement.

Pathophysiology of Disease Process

A healthy pancreas consists of five types of cells: acinar, secreting enzymes; ductal, producing bicarbonates; centro-acinar, serving as a transition between these two types; endocrine islets, generating hormones; and stellate cells, which are inactive (Kleeff et al., 2016). Malignant cells attack different parts of the pancreas, causing various types of cancer. The most prevalent pancreas tumors are adenocarcinomas, while acinar carcinomas, neuroendocrine tumors, colloid carcinomas, solid-pseudopapillary, and pancreatoblastomas occur more rarely (Kleeff et al., 2016). The term “pancreatic cancer” refers to the most frequent pancreatic tumor, called pancreatic ductal adenocarcinoma (Kleeff et al., 2016).

Risk Factors

Risk factors can be classified into non-modifiable and modifiable. Non-modifiable risk factors are sex, age, ethnic origin, gut flora, blood type, and family health history (McGuigan et al., 2018). Pancreatic cancer is considered the disease of the elderly because it is uncommon for young people to be diagnosed with it. McGuigan et al. (2018) state that 90% of those diagnosed with this illness are aged 55 years and above, and most patients are in their 70s and 80s.

Pancreatic cancer is more prevalent among males than females (McGuigan et al., 2018). Furthermore, in the US, African Americans are at a 50-90% higher risk of being diagnosed with pancreatic cancer compared to Caucasians (McGuigan et al., 2018). The disease is also common among individuals with ABO blood types (McGuigan et al., 2018). In addition, pancreatic cancer can be caused by gut microbiota, such as Neisseria elongata, Streptococcus mitis, Porphyromonas gingivalis, and Granulicatella adiacens (McGuigan et al., 2018). Lastly, a family history of cancer and genetic susceptibility increase the chance of developing pancreatic cancer.

Modifiable factors are mainly related to lifestyle choices. They include chronic pancreatitis, smoking, alcohol, obesity, and diet (McGuigan et al., 2018). A poor diet, such as foods and beverages high in fructose and saturated fatty acids, increases the risks of developing pancreatic cancer (McGuigan et al., 2018). Furthermore, obese people are at risk of developing pancreatic cancer because of reduced immunity (McGuigan et al., 2018). Overall, lifestyle choices are a major contributor to pancreatic cancer.

Morphology

The pancreas is a vital organ with multiple cellular functions that get disrupted after cancer invasion. About 95% of the pancreas consists of specialized epithelial cells, such as pancreatic duct cells, secretory epithelia, and pancreatic acinar cells (Stopa et al., 2020). In normal epithelial tissues, cell polarity should be maintained to ensure efficient functions. However, the physio-functions of the epithelial tissues are disrupted by malignant cells (Stopa et al., 2020). The digestive system is significantly affected by pancreatic cancer because the pancreas is responsible for the production, storage, and release of different digestive enzymes (Stopa et al., 2020). Overall, pancreatic cancer affects the cellular functioning of the pancreas and disrupts the operation of the digestive system.

Pathogenesis

Pancreatic malignant tumors arise from different parts of the organ. Most pancreatic cancers originate from the pancreatic intraepithelial neoplasia (PanIN), preneoplastic lesions, and precursor lesions (IPMNs and MCNs) (Kleeff et al., 2016). PanIN is the most common antecedent of pancreatic cancer and occurs in the small pancreatic ducts. PanIN contributes to the development of pancreatitis and causes epithelial injuries (McGuigan et al., 2018). The pancreatic adenocarcinoma develops through a series of stepwise mutations that result in specific precursor lesions, eventually causing invasive malignant cells (McGuigan et al., 2018). Cancer portrays an aberrant autocrine and paracrine signaling cascade that promotes migration, invasion, and proliferation of the malignant tumors to healthy cells (Kleeff et al., 2016). Different signaling molecules, such as TGF-α and its respective kinase receptors, activate pathways that promote the spreading of pancreatic cancer (Kleeff et al., 2016). The disease spreads quickly because of the pathophysiology associated with it.

Clinical Features

Early diagnosis of pancreatic cancer can be challenging, but this disease can be detected during advanced stages. Different methods are utilized for diagnosis, including imaging techniques, tumor markers, and clinical presentation (Zhang et al., 2016). The clinical presentations occur in the late stages, and they include progressive weight loss, dark urine, itching, vomiting, nausea, jaundice, abdominal pain, and anorexia (Zhang et al., 2016). Different types of tumor markers can be used for asymptomatic patients. For example, protein CA19-9 is used to assess the response to chemotherapy, early detection, or prognosis prediction (Zhang et al., 2016).

Other markers include macrophage inhibitory cytokine 1 (MIC1), carcinoembryonic antigen (CEA), and osteopontin (OPN) (Zhang et al., 2016). Lastly, imaging methods are employed for diagnosing cancer at different stages. Some of the common techniques include CT scanning, transabdominal ultrasound (US), magnetic resonance imaging (MRI), positron emission tomography (PET), and endoscopic retrograde cholangiopancreatography (ERCP) (Zhang et al., 2016). Overall, detection and diagnosis methods for pancreatic cancer continue to expand.

Patient History and Physical Assessment

Biographic Data

Age: 72.

Gender: Male.

Marital Status: Married.

Race: White.

Occupation: Retired manual worker of a local faucet factory.

Vital Signs: Ht.: 170 cm Wt.: 53 kg BMI: 18.3 (underweight).

BP: 128/76 mmHg Pulse: 82 Temp: 36.8°C.

Resp.: 24 Pain: dull, in the upper abdomen.

Source of History: The patient.

Reason for Seeking Care

“About two months ago, I started having tummy upsets, maybe once a week. But they were slight, so I just ignored them. But one month ago, my tummy pain became worse, and I had to take meds to ease it. My wife also said I looked yellowish.”

History of Present Illness

P: The patient complained about pain in the upper part of the abdomen, which worsened after eating fatty foods, drinking alcohol, and when lying down. It could be alleviated when the patient leaned forward.

Q: The patient assessed the quality of his abdominal pain as dull.

R: When asked to show the precise location of the ache, the patient pointed to the upper middle part of his abdomen. The pain radiated to the patient’s back in the supine position.

S: The patient rated his pain severity as a 7 on a rating scale from 0 to 10.

T: Over three months, the patient developed a loss of appetite and early satiety. This caused him to lose 18% of his body weight. The patient’s abdominal pain began two months before the appointment. It first occurred after the patient returned from his family celebration, where he consumed a lot of fatty food. The pain came and went, but during the past month, the pain worsened, and the patient took Ibuprofen to relieve it.

U: The patient’s understanding of the cause of his ache was stomach problems.

Past Health

• Childhood Illnesses: Chickenpox.
• Accidents or Injuries: None.
• Serious or Chronic Illnesses: None.
• Hospitalizations or Surgical History: None.
• Obstetric History: None.
• Immunizations: polio, measles, rubella, mumps; the last tetanus immunization was done at age 52.
• Last Examination: The most recent physical, vision, hearing examinations, and electrocardiogram were made at age 65 on 05/27/2014 during the pre-retirement examination. The latest chest x-ray examination was done on 02/13/2019. The most recent dental examination was performed on 06/18/2018.
• Allergies: None.
• Medications: Ibuprofen.

Family History

His paternal grandfather died at age 76 from CVA. His paternal grandmother had hypertension and died at age 68 from CAD. His maternal grandfather had cirrhosis and died at age 69 from liver failure. His maternal grandmother had a myocardial infarction and died at age 67 from cardiogenic shock. His father died at age 54 from lung cancer. His mother died at age 64 from CAD. His younger brother (aged 63) is alive and well. His aunt died at age 39 from breast cancer. His son (aged 41) is alive and well.

Review of Systems

Regarding general health, the patient reported weight loss (from 65 to 53 kg) over the last three months due to a loss of appetite and early satiety. The patient reported the yellowish color of his skin. He had occasional headaches that occurred once a month for the last three months. He voiced no complaints about his vision and hearing but said that he wore glasses for hyperopia when reading. The patient denied frequent colds, sinus pain, and nasal obstruction, as well as mouth pain and sore throat. He reported no neck pain or limited motion.

Regarding the respiratory system, the patient noted having bronchitis in adolescence but denied having any current breathing problems. He did not report having any cardiovascular diseases or precordial pain, as well as any problems with the peripheral vascular system. The patient mentioned several issues with the gastrointestinal system: a loss of appetite, abdominal pain after eating, early satiety, and diarrhea. Research shows that these symptoms often lead to weight loss and occur because the tumor in the pancreas causes gastric outlet obstruction (Zhang et al., 2016). Regarding the urinary system, the patient reported having dark urine, which is characteristic of pancreatic cancer and can be explained by the tumor’s blocking of the common bile duct (Zhang et al., 2016). The patient noted no issues with the genital, musculoskeletal, neurologic, hematologic, and endocrine systems.

Functional Assessment

• Self-Concept: College education; adequate income; Christian.
• Activity/Exercise: Able to perform ADLs; does moderate exercise three times a week.
• Sleep/Rest: Sleeps 6-7 hours a night with no interruptions; no daytime naps.
• Nutrition: High intake of fatty foods, added sugars, and caffeine.
• Interpersonal Relationships: Gets along well with his wife and son; has several friends.
• Coping/Stress Management: No current stress.
• Drug, Tobacco, and Alcohol Use: Drinks beer and red wine occasionally.
• Home Environment: Safe neighborhood; all the necessary conveniences.
• Intimate Partner Violence: None.
• Occupational Health: Retired; did not report any past workplace hazards.
• Spiritual Health: Attends church every Sunday.
• Health Promotion: Diet changes are recommended.

Physical Exam

• Constitutional: cachectic, explained by weight loss because of a loss of appetite.
• Head and face: head normocephalic, with no lesions, lumps, or tenderness; face symmetric, with no involuntary movements.
• Eyes: confrontational visual fields intact; EOM intact and PERRL; sclera yellowish with no lesions.
• Ears: Both tympanic membranes gray; light reflex and landmarks intact bilaterally.
• Nose: Not deformed; mucosa pink.
• Mouth and Throat: Gingivae and mucosa pink, with no lesions or masses; teeth in good repair.
• Neck: Supple; full range of motion; no palpable lymph nodes, which may be the sign of the absence of metastases; trachea midline.
• Back: Symmetrical posture; normal gait cycle.
• Musculoskeletal: Full range of motion; symmetry of joints and bones.
• Lungs: Breath sounds clear bilaterally.
• Chest: Respirations even and relaxed; chest expansion symmetric.
• Heart: RRR with normal S₁ and S₂; no extra sounds or murmur.
• Skin: Color yellowish; warm; no lesions. The yellowish color of the sclera and skin is the sign of jaundice, caused by the tumor’s blocking of the common bile duct (Zhang et al., 2016).
• Breasts: No lymph nodes.
• Extremities: Symmetrical with no atrophy or swelling; warm.
• Neurologic: No tremors or atrophy; plantar reflexes flexor bilaterally.
• Abdomen: Tenderness in the mid epigastric region, with insidious onset; abdominal mass palpable in the epigastrium.
• Genitalia: No inflammations or lesions; testes symmetric and descended, with no masses.

Diagnostic Studies

An abdominal CT scan showed a 2.8-cm hypodense mass in the head of the pancreas with no invasion of vascular structures and no lymph node involvement. ERCP demonstrated bile duct obstruction, which is explained by the tumor’s blockage of the duct carrying bile from the liver through the gallbladder to the duodenum. This blockage caused jaundice in the patient. The mass in the pancreatic head was biopsied, and the biopsy revealed low-grade pancreatic adenocarcinoma.

Blood tests measuring the patient’s CA 19-9, CEA, and bilirubin levels were carried on. The CA 19-9 level was 74 U/ml; the CEA level was 2.7 ng/ml; the bilirubin level in serum was 14.4 mg/dl with a conjugated fraction of 12.8 mg/dl. CA 19-9 was higher than normal (<37 U/ml) but predicted the resectability of the tumor because the level was lower than 100 U/ml (Chang & Kundranda, 2017). The CA 19-9 level rises in pancreatic cancer because it is produced by cancerous cells or by normal cells in response to tumors; however, it may also rise in other diseases (McGuigan et al., 2018). The patient’s CEA level was normal (≤3 ng/ml) (Chang & Kundranda, 2017).

The blood test measuring bilirubin in serum was performed to determine whether the jaundice was liver-related. Since the total bilirubin level was increased but less than 40 mg/dl, with an increased concentration of conjugated bilirubin, posthepatic (obstructive) jaundice could be diagnosed (Kumar & Gill, 2018). Obstructive jaundice was also seen at ERCP, which showed bile duct obstruction by the pancreatic head mass. The obstruction blocks the bile duct, which increases the amount of conjugated bilirubin in serum, causing jaundice.

Medical Management

Surgical Management

The patient was considered eligible for resection. The rationale for this decision was that the tumor was located within the pancreas and did not adhere to arteries or venous vessels (Masiak-Segit et al., 2018). Before the surgery, an internal/external biliary drain was inserted to relieve the symptoms of jaundice and prevent acute cholangitis. According to recommendations, drainage should be performed in patients with high bilirubin levels (the cutoff point ranging from 11.7 mg/dl to 23.4 mg/dl), persistent pruritus, and cholangitis (Masiak-Segit et al., 2018). Given the elderly age of the patient and his high bilirubin levels, the biliary drainage was justified.

One week after the placement of the drainage, the pylorus-preserving pancreaticoduodenectomy with cholecystectomy, also called the Whipple procedure, was conducted under general anesthesia. It is the most common surgery used for resecting pancreatic head tumors and involves the removal of the pancreatic head, the gallbladder, the curve of the duodenum, and the common bile duct (Zhang et al., 2016). The removed tissue had negative margins and was classified as moderately differentiated ductal adenocarcinoma.

Pharmacologic Management

In this patient, chemoradiotherapy was not administered before the surgery. The reason for this is that current evidence shows no benefits of neoadjuvant therapy for patients with resectable pancreatic tumors, and it is indicated only for borderline resectability or unresectability (Kleeff et al., 2016). Three weeks after the surgery, he was prescribed adjuvant therapy with a regimen of gemcitabine of 1,000 mg/m2 IV once a week for three of every four weeks for six months. According to recommendations, adjuvant therapy should be administered to all operated patients in an acceptable postoperative condition regardless of their pTNM stage (Tuprin et al., 2020).

There is robust evidence that gemcitabine is effective as adjuvant therapy for preventing recurrence (Tuprin et al., 2020). The prescribed dosage and the timing of chemotherapy administration are justified by the recommendations, according to which adjuvant therapy should be administrated within three months after surgery and should last six months (Tuprin et al., 2020).

Rehabilitation Techniques

The patient responded well to the treatment. On the sixth day after the surgery, the CT scan showed postoperative changes with no fluid collections. On the seventh day, several staples and the feeding tube were removed, and a day later, the JP drain was withdrawn, and the patient was transferred to a rehabilitation facility to undergo physical therapy for deconditioning. Three weeks after the operation, the patient continued rehabilitation, but his condition improved, and he needed no opioid pain medication. He overcame poor appetite and was able to eat solid foods.

Nursing Management

Nursing Diagnoses and Interventions

The first NANDA nursing diagnosis related to this patient was Acute Pain. The patient complained about abdominal pain, which he rated as 7 on a 0 to 10 scale. The nursing intervention was the prescription of analgesics and limited bed rest since the patient’s pain aggravated in the supine position. The second diagnosis was “Imbalanced Nutrition: Less Than Body Requirements” (Herdman & Kamitsuru, 2018, p. 162).

According to the recommendations, the intervention included diet education and oral nutritional supplements since the patient suffered from malnutrition and weight loss and should have been optimized before the surgery (Martin-Perez et al., 2020). The third diagnosis was “Risk for Surgical Site Infection” (Herdman & Kamitsuru, 2018, p. 421). The intervention was measuring the patient’s vital signs every four hours and noting and reporting any abnormal results to the healthcare provider.

Changes in Health Status Related to Interventions

The interventions for acute pain led the patient to report maximal pain relief and no interference with ADLs. Due to the dietary interventions, the effects of cachexia on the patient were alleviated. The intervention aimed at preventing infection ensured that the patient did not develop complications related to postoperative infections.

Evaluation of Patient Outcomes

As a result of nursing interventions, the patient’s functional status improved. The patient safety could be assessed as protected. Finally, the patient’s satisfaction could be considered high as the patient reported contentment and comfort.

Conclusion

Pancreatic malignant tumors affect the functioning of the pancreas, thus undermining the work of the digestive system. In the reviewed case, the patient’s pancreatic cancer was detected at an early stage. The tumor was located within the pancreas and did not involve vascular structures, so it was resectable. The adjuvant treatment with gemcitabine was necessary to avoid cancer recurrence. Nursing interventions helped to address the patient’s malnutrition, relieve pain, and prevent infection.

References

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