Patient case study on

Small Cell Gastric Cancer

Done by: Amira Naji

3/20/2017

Infections:

Helicobacter pylori infection is an essential risk factor in 65–80% of gastric cancers, but only 2% of people with Helicobacter infections develop stomach cancer. It was estimated that Epstein–Barr virus is responsible for 84,000 cases per year. Other factors associated with increased risk are AIDS.

Smoking:

Smoking increases the risk of developing gastric cancer significantly, from 40% increased risk for current smokers to 82% increase for heavy smokers. Gastric cancers due to smoking mostly occur in the upper part of the stomach near the esophagus. Some studies show increased risk with alcohol consumption as well.

Genetics:

About 10% of cases run in families and between 1% and 3% of cases are due to genetic syndromes inherited from a person's parents such as hereditary diffuse gastric cancer.

Risk Factors

Stomach cancer is often asymptomatic or cause only nonspecific symptoms in its early stage. By the time symptoms occur, cancer is generally metastasized to other part of the body and can cause the following signs and symptoms:

Abdominal pain or discomfort

Nausea and vomiting

Diarrhea or constipation

Bleeding (vomit or blood in stool)

dysphygia

Weight loss and fatigue

Clinical Manifestations

Personal Background of the Patient

Social history: Patient lives in Kayseri with his wife and 3 children. Patient able to carry on normal activities with minor signs and symptoms of the dieses. Patient use tobacco since 14 years one pack per day and occasionally alcohol drinker since 13 years.

Past medical history: He complains of hypertension and myocardial infarction, Patient underwent hernia surgery. No known allergies to food or drug.

Medications: Aspirin, antiemetic, oral chemotherapy (Etoposide)

Family history:

Patient brother diagnosed with gastric cancer.

Chief complain:

Anemia, swelling of abdomen associated with epigastric pain.

History of present illness:

N.K 61 years old male, known case of HTN and CHF. On October 2016

patient admitted to hospital with complain of anemia, abdominal swelling

and epigastric pain. Several diagnostic test done like microscopy and

C.difficle, the result shows blood in stool.

o Vital signs

Temperature: 36.7 c

Blood pressure: 150/60 mmHg

Pulse: 90 b/min

Respiration: 25 b/min

o Mouth and Oropharynx:

Outer lips is pale, no dryness

Tongue in central position,

moves freely

No signs of dysphagia

o Thorax and lungs:

Chest symmetric

Skin intact, uniform temperature

Chest wall intact, no tenderness, no masses

Clear breath sounds, not on respiratory distress

o Abdomen:

Uniform in color

Abdomen soft with moderate tenderness, no masses

No bowel obstruction

Radiology Examinations

o Endoscopy and biopsy on 8 November 2016:

Findings:Bulbus wall and mucosa normal, Active ulcer and deformity and Post bulber duodenum normal. Stomach malign tumoral lesion.

o PET scan on 21 November 2016:

Findings:Liver metastasis stage 4.

AFP: 1565 Normal < 5.4 ng per mL, primary tumor: Hepatocellular carcinoma, nonseminomatous germ cell tumors

CEA: 842.5 Normal < 2.5 ng per mL in nonsmokers and < 5 ng per mL in smokers

CA19.9: 66.1 Normal < 37 units per mL, primary tumor: Pancreatic cancer, biliary tract cancers

NSE: 199.6 Normal < 9 ug/L, primary tumor: Small cell cancer, neuroblastoma

Blood tumor marker October 2016

Diagnosis

Neuroedocrine tumor, Small cell gastric cancer metastasizes to liver.

Blood Chemistry:

13/3/2017 Result Normal values Interpretation

WBC 5000 5000-10.000 Within normal rage

Neutrophils 2000 1500 - 8000 Within normal range

Platelet 388 150-450 × 10 Within normal range

Hemoglobin 10 13.5 - 18 Decrease, various

anemia or prolonged hemorrhage

Preventive Management and Treatment

Vaccine against helicobacter Pylori still in progress, the following may help to reduce the risk of gastric cancer:

Don’t smoke

Eat health balanced diet rich in fruits and vegetable

Taking medication to treat reflux disease if present

Decrease intake of preserved food.

Screening Program

Cisplatin and Etoposide

Started on 28 November 2016, patient receives total of 6 cycles. Day 1 Cisplatin and etoposide via a drip over approx 6 hours Days 2 & 3 Etoposide via a drip over 90 minutes Day 21 (cycle 2) Restart with the next cycle day 1 This treatment is repeated every 3 weeks for 6 cycles and the patient will have a routine blood test before the start of each 2 cycle of treatment.

Chemotherapy treatment

Possible Side Effects

Common side effects (more than 1 in 10)

Nephrotoxicity:

Platinum conctration are higher in the kidney than in plasma or other tissue. Hypomagnesmia develop in about 75% of patients beginning 3 to 12 weeks after therapy and presenting for months to years.

Nusea and Vomiting:

Acute or delayed Highly emetogenic if use dose ≥ than 50 mg/m Moderatrly emetogenic if use doses ≤ 50mg/m

Hair loss

Hair loss is usually total. The hair falls out gradually 10 to 14 days following first course of treatment.

Neurotoxicity

Most common symptoms peripheral neuropathy and hearing loss if cumulative dose more than 300mg/m

Anaemia

The number of red blood cells in the blood reduced. These cells carry oxygen around the body. If the number of red blood cells is low, the patient may be tired and breathless.

Rare side effects (less than 1 in 100)

Tinnitus & high frequency hearing loss

You may develop tinnitus (ringing in the ears), this sensation usually subsides when your treatment finishes.

Eyesight disturbances

Extravasation

Is when chemotherapy leaks outside the vein. If you develop redness, soreness or pain at the injection site at any time please let us know straightaway.

Oral Etoposide

On 15 March 2017, patient shifted to oral Etoposide , to receives total of 2 cycles. Total dose patient take at home 50mg/day for 14 days, Day 21 (cycle 2) Restart with the next cycle day 1 This treatment is repeated every 3 weeks and the patient will have a routine blood test before the start of cycle of treatment.

Chemotherapy Treatment

The capsule should be swallowed whole, on an empty stomach (1 hour before or 2 hours after eating breakfast) and

taking anti-emetic half hour before food.

Do not chew, open, break or crush the capsules.

Capsules swallow with water only, grapefruit, and carrot juice decrease the medication bioavailability

Medication should be stored in the refrigerator this medication should not be stored in a pillbox. Keep containers out

of reach of children and pets.

If a caregiver prepares the dose for you, they should consider wearing gloves or pour the pills directly from their

container into the cap, a small cup.

Avoid touching the pills and should always wash their hands before and after taking the medication.

Return any unused medication for disposal. Do not flush down the toilet or throw in the trash.

Nursing recommendations for taking oral Etoposide at home

Side Effect Related to

Oral Etoposide

Low white blood cell count. (This can increase risk for infection).

Low platelet count (This can increase risk of bleeding).

Hair loss

Loss of fertility.

Nausea and vomiting (especially at high-doses)

The following side effects are common (occurring in greater than 30%)

for patients taking etoposide:

o Mouth sores (especially at high doses)

o Diarrhea (especially at high doses)

o Poor appetite

Other side effects:

o Metallic taste during infusion of drug

o Peripheral neuropathy (numbness in your fingers and toes) may occur with repeated doses.

These side effects are less common, meaning they occur in 10-29 percent of patients

receiving etoposide:

Self-Care Recommendations

Complications Health Education

Nephrotoxicity

Maintain adequate hydration by taking 3-4 ml/day of water, unless contraindicated by doctor

Avoid other nephrotoxic medications

Taking magnesium and potassium supplementation.

Routine labs to check electrolyte imbalance

Nausea and Vomiting

Take antiemetic drugs as prescribed

Avoid things that may worsen the symptoms, such as heavy or greasy/fatty, spicy or acidic

foods (lemons, tomatoes, oranges).

Try antacids, (e.g. milk of magnesia, calcium tablets such as Tums).

Eat small, frequent meals.

Call your doctor or nurse if you are unable to keep fluids down for more than 12 hours or if you

feel lightheaded or dizzy at any time.

Hair loss

The use of scarves, wigs, hats and hairpieces may help.

Hair generally starts to regrow soon after treatment is completed.

Hat is particularly important in cold weather or to protect you from the sun.

Complications Health Education

Neutropenia

Washıng hands, both yours and your visitors, is the best way to prevent the spread of infection.

Avoid large crowds and people who are sick (those who have a cold fever or cough or live with

someone with these symptoms).

Keep all cuts or scratches clean.

Shower or bath daily and perform frequent mouth care

Do not cut cuticles or ingrown nails.

Thrombocytopenia

Do not use a razor (an electric razor is fine).

Avoid contact sports and activities that can result in injury or bleeding.

Do not take aspirin (salicylic acid), non-steroidal, anti-inflammatory medications (NSAIDs)

increase the risk of bleeding. Unless the healthcare team tells you.

Do not floss or use toothpicks and use a soft-bristle toothbrush to brush your teeth.

Mouth sore

Brush with a soft-bristle toothbrush or cotton swab twice a day.

Avoid mouthwashes that contain alcohol. A baking soda and/or salt warm water mouth rinse (2

level teaspoons of baking soda or 1 level teaspoon salt in an eight ounce glass of warm water) is

recommended 4 times daily.

If your mouth becomes dry, eat moist foods, drink plenty of fluids (6-8 glasses), and suck on

sugarless hard candy.

Avoid smoking and chewing tobacco, drinking alcoholic beverages and citrus juices.

Complications Health Education

Taste change

Maintain good oral hygiene - brush your teeth before and after each meal.

Choose and prepare foods that look and smell good to you.

Eat small, frequent meals.

Do not eat 1-2 hours before chemotherapy and up to 3 hours after therapy.

Eat mints (or sugar-free mints), chew gum (or sugar-free gum) or chew ice to mask the bitter or

metallic taste.

Flavor foods with herbs, spices, sugar, lemon, and tasty sauces.

Chilled or frozen food may be more acceptable than warm or hot food.

Try tart foods such as oranges or lemonade (this may be painful if mouth sores are present).

Avoid cigarette smoking.

Eliminate bad odors.

Eat in pleasant surroundings to better manage taste changes.

Increase your fluid intake.

In patient case the tumor has spread outside the stomach,cure not possible and treatment is directed toward improvement of symptoms.

Evolution

THANK YOU