Prakash Shashi

doi:10.19080/ARGH.2024.21.556052

Advanced Pancreatic Cancer with Liver Metastasis

Prakash Shashi*

Nursing Faculty, College of Nursing, S. N. Medical College, Agra, Uttar Pradesh, India

Submission:September 04, 2024; Published:October 17, 2024

*Corresponding author: Prakash Shashi, Nursing Faculty, College of Nursing, S. N. Medical College, Agra, Uttar Pradesh, India

How to cite this article: Prakash S. Advanced Pancreatic Cancer with Liver Metastasis. Adv Res Gastroentero Hepatol, 2024; 21(1): 556052. DOI: 10.19080/ARGH.2024.21.556052.

Abstract

Background: Pancreatic cancer, which is often diagnosed at an advanced stage due to its asymptomatic early stages, is a highly aggressive malignancy with a dismal prognosis. This case study details the clinical course of a 42-year-old man with a history of persistent smoking, drinking alcohol, and chewing tobacco.

Case Presentation: The patient presented with fever, altered sensorium, jaundice, and stomach pain upon arrival; physical examination findings included pallor, hepatomegaly, jaundice, and abdominal pain. Laboratory tests revealed elevated liver enzymes, elevated bilirubin levels, and total leukocyte count. Imaging tests revealed pancreatic cancer metastases.

Management: The patient was treated with intravenous fluids, supportive care, and antibiotics. Nursing diagnoses included skin integrity impairment, imbalanced nutrition, poor breathing patterns, and hyperthermia. Apart from educating the family about lifestyle modifications, medication compliance, and coping techniques, the nursing care plan placed significant emphasis on symptom management, dietary assistance, skin maintenance, and infection prevention.

Follow-Up and Outcome: The patient received extensive management, including chemotherapy and palliative care techniques, but his condition progressively deteriorated. The prognosis remained poor due to the significant metastases and advanced stage of the disease.

Conclusion: This case illustrates the challenges associated with treating advanced pancreatic cancer with liver metastases. The statement underscores the significance of early identification and a multidisciplinary approach to treatment. By providing comprehensive and supportive care, nurses play a crucial role in symptom management and improving quality of life in palliative care settings.

Keywords: Pancreatic Cancer; Liver Metastasis; Jaundice; Palliative Care; Nursing Management; Advanced Disease; Symptom Management

Abbreviations: PDAC: Pancreatic Ductal Adenocarcinoma; CT: Computed Tomography; EUS: Endoscopic Ultrasound; MRI: Magnetic Resonance Imaging

Introduction

Pancreatic disease is an incredibly forceful threat with a dreary guess, essentially influencing worldwide malignant growth death rates. With a five-year survival rate of less than 10%, it is the seventh leading cause of cancer-related death worldwide. The asymptomatic onset of the disease, which frequently presents at an advanced stage with metastasis to distant organs like the liver, lungs, and peritoneum, is largely to blame for the aggressive nature of the condition [1]. The pancreas, an organ profoundly arranged inside the stomach hole, is vital for both endocrine and exocrine capabilities, entangling the clinical show of disease. The most pervasive kind of pancreatic malignant growth is pancreatic ductal adenocarcinoma (PDAC), addressing more than 90% of all cases. PDAC generally starts in the exocrine organs, especially the conduits, and habitually happens in the top of the pancreas. Jaundice, a symptom that frequently prompts medical evaluation, can be caused by tumours in this area blocking the common bile duct. There are both genetic and environmental risk factors for pancreatic cancer. Well-established risk factors include chronic pancreatitis, diabetes mellitus, and a family history of pancreatic cancer [2]. According to Lowenfels & Maisonneuve (2006), lifestyle factors such as smoking, excessive alcohol consumption, and obesity also significantly contribute to the development of the disease [3].

The patient in this case report had a number of these risk factors, including a long history of smoking, drinking alcohol, and chewing tobacco. Due to the absence of effective screening tools for the general population and the lack of specific early symptoms, early detection of pancreatic cancer is notoriously difficult. As this case demonstrates, the majority of patients present with advanced disease that frequently includes metastasis to the liver or other organs [3]. According to Ryan et al. [4], liver metastasis accounts for approximately half of all patients diagnosed with the disease [4]. The pancreas’ abundant blood supply and lymphatic drainage make it easier for cancer cells to spread metastatically [5]. The location of the tumor and the severity of the disease influence how pancreatic cancer presents clinically. Obstructive jaundice, dark urine, pale stools, and pruritus due to bile duct obstruction are common symptoms in patients with tumors in the head of the pancreas, like the one in this case. Another common symptom is abdominal pain, usually in the epigastric area and radiating to the back, especially when the tumor invades the surrounding nerves. According to Tempero et al. [1], fatigue, anorexia, and weight loss are also frequently observed signs of advanced disease. A 42-yearold man’s clinical course and treatment of liver metastasis and pancreatic head cancer are examined in this case report. Due to the advanced stage of the disease at diagnosis, the prognosis remained poor despite aggressive treatment and supportive care [1]. This case demonstrates the significance of a multidisciplinary approach to patient care and the critical need for improved strategies for early detection and intervention in pancreatic cancer.

Case Presentation

A 42-year-old man with a history of smoking, drinking, and chewing tobacco came to the clinic with symptoms that had gotten worse over the past few months. His underlying grumbling was jaundice, which he originally saw as a yellowish staining of his skin and sclera. Additionally, he experienced pale-colored stools and darkened urine. He also mentioned that his pruritus was getting worse and worse. His medical history Several risk factors for pancreatic cancer were noted in the patient’s medical history: Ongoing Smoking: The patient had a 20-year history of cigarette smoking, with a utilization of roughly one pack each day. Alcohol Consumption: He said he drank three to four standard drinks a day on a regular basis. Tobacco Biting: as well as smoking, he had a long history of biting tobacco, which he had been utilizing for more than 15 years.

Smoking and excessive alcohol consumption have been linked to the development of pancreatic cancer, so these risk factors are significant. Due to the carcinogenic properties of tobacco smoke and smokeless tobacco, chronic tobacco use has been linked to an increased risk of pancreatic ductal adenocarcinoma (PDAC) [5]. Symptomatology and Examining the Body Among the patient’s symptoms were: Jaundice: This is the most obvious symptom, and it is caused by the skin and sclera turning a yellowish colour. It is caused by high levels of bilirubin because the bile ducts are blocked. Abdominal Pain: Consistent with the pain that is frequently associated with pancreatic cancer, he described a dull, persistent ache in the upper abdomen that extended to his back. Loss of Weight: The patient reported a significant weight loss of about 15 kilograms over the past few months, which is a common symptom of cancer. Digestive Symptoms: He observed alterations in bowel habits, such as pale stools, which are frequently associated with biliary obstruction. The following observations were made during the physical examination: Scleral Icterus: Provable evidence of bilirubinuria. Abdominal Mass: A palpable, tender mass in the right upper quadrant of the abdomen that may be an indication of an enlarged pancreas or lymph nodes Tenderness in the Epigastric Area: palpable pain that suggests the tumour may have invaded the organs or tissues around it. Bilirubin, alkaline phosphatase, and transaminases, among other liver enzymes, were found to be elevated in tests conducted in the laboratory. Obstructive jaundice, most likely caused by a tumour in the head of the pancreas that blocks the common bile duct, was confirmed by these findings.

Analytic Imaging and Biopsy Imaging studies were carried out in order to provide a deeper understanding of the disease’s scope:

Contrast-enhanced computed tomography (CT) scan: The scan revealed a 4 cm-wide mass in the pancreas’ head. Multiple hypodense liver lesions and significant bile duct obstruction were associated with this mass, indicating metastatic spread. The imaging discoveries affirmed the presence of liver metastases. Endoscopic Ultrasound (EUS): An EUS was performed to give nitty gritty pictures of the pancreas and encompassing designs. It guided the biopsy procedure and confirmed the presence of a pancreatic mass. Biopsy: To obtain tissue for histopathological examination, a percutaneous biopsy of the pancreatic mass was carried out. The biopsy results affirmed the determination of pancreatic ductal adenocarcinoma (PDAC), a typical and forceful type of pancreatic malignant growth. Organizing and Visualization The patient was diagnosed with stage IV pancreatic cancer based on the clinical presentation and diagnostic findings, which indicated that there was distant liver metastasis. This arranging was affirmed by:

Imaging Studies: The CT scan and EUS revealed liver metastases in addition to the pancreatic primary tumour. Biopsy Results: PDAC, which is known for its poor prognosis and resistance to treatment, was confirmed by histological examination. Patients with stage IV pancreatic cancer typically have a poor prognosis. Patients with metastatic disease typically have a median survival time of three to six months, and there are few curative options [6]. The patient’s advanced age, the extent of his liver metastases, and a history of significant lifestyle risk factors further complicated his prognosis. Plan of Treatment and Response The treatment plan focused on systemic chemotherapy to manage the cancer and alleviate symptoms due to the disease’s advanced stage. The patient was begun the FOLFIRINOX routine, which incorporates: Leucovorin, a form of folic acid, enhances fluorouracil’s effectiveness. Fluorouracil (5-FU): A pyrimidine simple that impedes DNA union. Irinotecan: An irinotecan subordinate that restrains topoisomerase I, forestalling DNA replication. Oxaliplatin, a platinum-based medication that binds to DNA and prevents it from replicating, The patient had a limited response despite the aggressive nature of this regimen.

He required dose adjustments and supportive care due to several side effects, including neutropenia, nausea, and vomiting. The treatment did not significantly slow the disease’s progression and only provided a small amount of relief. The focus shifted to palliative care as the cancer progressed and the patient’s quality of life deteriorated. This comprised: Symptom Management: Medications and treatments like bile duct stenting are used to treat pain, jaundice, and digestive issues. Supportive Care: Managing symptoms, maintaining comfort, and providing psychological and emotional support to the patient and his family This case shows how difficult it is to treat advanced pancreatic cancer, especially when it has spread to the liver. The poor prognosis underscores the need for ongoing research and advancements in treatment options, despite the best efforts to control the disease and improve quality of life.

Discussion

Pancreatic cancer is one of the hardest diseases to treat in oncology because of its aggressiveness, tardiness in symptoms, and poor response to traditional treatments. The patient in this case, who was 42 years old when it was discovered that she had liver metastases and pancreatic head disease, typifies the typical clinical progression of this injury. The prognosis and available treatments were significantly affected because the disease had progressed by the time of diagnosis. The deep anatomical location of the pancreas makes early diagnosis more difficult. According to Vincent et al. [5], the rapid dissemination of malignant cells via hematogenous and lymphatic pathways is facilitated by being close to major blood vessels and organs [5]. According to Ryan et al. [4], this patient’s bile duct obstruction and jaundice-typically the first clinical signs that prompt further investigation—were caused by the tumor’s origin in the head of the pancreas, a common site for PDAC [4]. The patient’s long-term smoking, alcohol use, and habit of chewing tobacco probably played a significant role in the development of his pancreatic cancer. Smoking is a deeply grounded risk factor, with smokers having a 2-3 times higher gamble contrasted with non-smokers [3].

Chronic pancreatitis, a known risk factor for pancreatic cancer, is linked to heavy alcohol consumption [7]. Additionally, the carcinogenic nitrosamines in smokeless tobacco have been linked to an increased risk of pancreatic cancer [8]. According to Ryan et al. [4], approximately 50% of patients diagnosed with pancreatic cancer have liver metastases. Due to the liver’s abundant blood supply via the portal vein, metastatic spread frequently occurs there. Liver metastasis is a crucial factor in staging and has a significant impact on prognosis, frequently preventing surgical resection from being an option for treatment. The prognosis and treatment options were severely limited by the presence of liver metastasis in this instance. Palliative care is typically the only treatment option for advanced pancreatic cancer with liver metastases [4]. According to Conroy et al. [9], chemotherapy, such as FOLFIRINOX or gemcitabine-based therapy, is the standard treatment, but it frequently results in only modest improvements in survival and is linked to significant toxicity. This patient’s chemotherapy reaction was restricted, mirroring the general unfortunate responsiveness of PDAC to these medicines [9]. In the treatment of pancreatic cancer, the roles of targeted therapies and immunotherapy are still under investigation. In subsets of patients with particular genetic mutations, such as BRCA1/2, some promising outcomes have been observed [10].

Targeted therapies are limited because this patient’s genetic testing did not reveal any mutations that could be taken into account. As a result, the treatment plan focused on reducing symptoms and improving quality of life, a common strategy for patients with advanced pancreatic cancer. Patients with liver metastasis and pancreatic cancer typically have a poor prognosis, with median survival ranging from three to six months [8]. The disease’s aggressive nature and limited efficacy make it clear that new therapeutic approaches are needed right away [11]. There is ongoing research into new treatment strategies like PARP inhibitors, immune checkpoint inhibitors, and personalized medicine. Additionally, this case demonstrates the significance of a multidisciplinary approach to care. In managing this complicated and difficult disease, it is essential to involve oncologists, gastroenterologists, surgeons, radiologists, and specialists in palliative care. Improving patient outcomes necessitates comprehensive care that addresses both physical and psychological needs.

Recommendations

With liver metastasis and advanced pancreatic cancer, the prognosis is still poor. Along these lines, early identification is significant for further developing results. General wellbeing drives ought to zero in on expanding familiarity with risk factors, for example, smoking discontinuance programs and advancing a sound way of life. According to Lowenfels & Maisonneuve [3], individuals who have a family history of either chronic pancreatitis or pancreatic cancer should receive genetic counselling and should be closely monitored. Creating viable evaluating apparatuses for pancreatic disease is direly required. Investigation into biomarkers, imaging procedures, and fluid biopsies for early identification is continuous. Endoscopic ultrasound (EUS) or magnetic resonance imaging (MRI) surveillance strategies may be beneficial for high-risk groups, despite the lack of a reliable screening test for the general population [2]. This case shows how the disease stage at diagnosis is affected by the absence of early symptoms and effective screening, highlighting the need for advancements in these areas. The use of targeted therapies and molecular profiling of tumors to identify actionable mutations is recommended as part of an individualized treatment plan. For instance, patients with BRCA1/2 transformations might profit from PARP inhibitors, which have shown guarantee in clinical preliminaries [7].

For patients with advanced pancreatic cancer, clinical trials should be considered in order to gain access to novel therapies that are not yet available in standard practice. The role of immunotherapy in pancreatic cancer is still being developed. Recent research suggests that combination therapies, such as immune checkpoint inhibitors and other modalities like radiation or chemotherapy, may enhance the immune response against tumors, despite the fact that immunotherapy has historically been resistant [3]. For potential breakthroughs in managing this disease, ongoing research in this field is essential. For patients with advanced pancreatic cancer, palliative care should be incorporated into the treatment plan from the time of diagnosis. Overseeing side effects like torment, jaundice, and stomach related issues is urgent for keeping up with personal satisfaction. A crucial aspect of care is also meeting the mental and emotional requirements of patients and their families. In this instance, support and symptom relief were provided by palliative care throughout the course of the disease. To discover new therapeutic targets, additional research into the biology of pancreatic cancer is required. To develop more effective treatments, it will be essential to comprehend the molecular mechanisms that drive metastasis, treatment resistance, and progression of pancreatic cancer. To put these findings into practice in the clinic, researchers, clinicians, and pharmaceutical companies must work together.

Conclusion

Advanced pancreatic cancer usually has a poor prognosis and is a significant challenge, particularly when there is liver metastasis. Due of the significant limitations of late-stage diagnosis on both treatment options and survival rates, this example emphasizes the vital need for early detection. Technological developments in biomarkers and imaging are critical for early detection of pancreatic cancer, which could lead to better prognosis and treatment outcomes. Compared to conventional medicines, personalized treatment plans, such as targeted therapies based on genetic analysis, show promise for improved management and fewer adverse effects. In cases where there are few therapeutic options, comprehensive palliative care is nevertheless essential for controlling symptoms and improving quality of life for patients with advanced disease. This instance emphasizes how crucial it is to use a multidisciplinary approach when providing holistic and supportive care, incorporating nurses, oncologists, and other medical specialists. To improve outcomes, more research is needed into customized medicine, early detection techniques, and innovative medicines. Despite the limitations of present treatments, continued efforts provide optimism for future improvements in patient care and more efficient management.

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