Last Day at Hem/Onc by Heidi Pang

Wk 2 Day 4-5 Hem/Onc w/ Dr Chen by Heidi Pang

Time flies by quickly and I am at the end of my hem/onc rotation.

Case 1: NSCLC, adenocarcinoma with brain metastasis. Initial presentation of the patient was persistent headache and vomiting. Brain MRI was ordered at the ER and showed multiple brain metastases. Patient started on radiation therapy at another hospital (radiation treatment is not available at this hospital) and a brain shunt is placed by another surgeon. However, he came into the clinic complaining of consistent discharge and tenderness at his umbilicus. It is relatively common to drain the fluid into the abdominal cavity but for some odd reason, the tube seems to be draining through the umbilicus instead. Patient is also due for his chemo medications soon. The inconvenience of being under the National Insurance is that the patient will have to be arranged for a Brain CT first to determine the effectiveness of the drug before even getting the next approval for renewing the prescription.

Case 2: 20 y/o male dx with Desmoplastic Small Cell Cancer in Feb 2014 with peritoneal metastasis and liver tumor. He initially presented with easy dizziness, abdominal distention and poor appetite. Abdominal echo showed massive ascites (common finding for DSRCT). Patient had no prior h/o systemic disease. Dr Chen explained that this is an extremely rare type of cancer which involves t(11;22). Initial chemotherapy caused the tumor to gradually enlarge after 1 month so patient was switched to a newer drug Pazopanib (a multi-target receptor TK inhibitor). Unfortunately, this drug is not covered by the National Insurance, costing ~NT 70K per month. DSRCT are often missed during initial screening as it is so rare that physicians often thought of it as rhabdomyosarcoma, neuroblastoma, lymphoma or peritoneal mesothelioma. The patient’s abdominal area is not as bloated as before but the tumor is still palpable. Dr Chen said that the goal of the therapy is to hopefully shrink the tumor enough eventually, and hopefully be able to surgically remove the tumor then.

Other things I have learnt in the last 2 days:

-          PPI needed for patient on chemo with signs of GERD. Dr Chen will usually suggest pantoscopy to confirm GERD but most patients here in Taiwan refuse the procedure. He said that there aren’t any significant side effects so patients on chemo will usually be put on PPI concurrently if they have signs of GERD.

-          National Insurance may sound very promising but it also has a lot of limitations especially when it comes to treatment options. Many cancer patients often need the most updated drugs available and regular imagining studies done but due to the insurance restrictions, they have to either self-pay the newest drugs or have to go with traditional standard therapies.

Dr Chen, student doctor Jonathan Go, and I also had a discussion on cancer cachexia. This condition occurs in terminal cancer patients and if patients present with such symptoms, their prognosis is often very poor. Currently there are a lot of hypothesis on pathophysiology of cancer cachexia, but no one has really pinpoint the actual etiology of it. From what I have researched, it has been suspected that cancer cachexia is caused by systemic inflammatory response (mediators such as IL-6, TNF-α) and altered metabolism in the body. It is different from malnutrition in the sense that malnutrition can be “fixed” simply by replenishing the nutrients (a poor energy intake condition), while cachexia is due to increase in resting energy expenditure (to maintain the function of the brain for example). There isn’t a “cure” for cachexia. According to Dr Chen, general practice in Taiwan is to give patient anabolic steroids to prevent cachexia, but only for those at terminal stage or it may lead to diabetes or infection. Oncologists also routinely use drugs to improve the appetite of the patients but it’s mainly for making the patient feel better.

We ended the week with a smile with Dr Chen.