ESMO SUMMIT LATIN AMERICA 2019 Palliative Care - Clinical Cases Presentation Joao Luiz Chicchi Thomé Oncologist and Palliative doctor
CONFLICT OF INTEREST DISCLOSURE No conflict of Interest disclosure
ESMO SUMMIT LATIN AMERICA 2019 Case 1
CASE 1 • V.L.A.R., male, 77 years old, married, 2 sons and 2 grandsons, natural from São Paulo, Brazil. Entrepreneur. • Smoker from 17 yo to 32 yo, more than 80 cigarettes per day • Without comorbidity • 2011: X-Ray with suspected pulmonary nodule ◆ Without follow-up or more investigation • 2017: ◆ August: Started with thoracic pain ◆ Oct: X-Ray with heterogeneous nodule and parenchymal densification adjacent to the left pulmonary hilum at lingular topography.
CASE 1 • Nov: • Thoracic CT and PET CT: ◆ Enlargement lymph node at left pulmonary hilum (1.7 x 1.6cm) with SUV max 3.9. ◆ Expansive pulmonary lesion in the left upper lobe (7.8cm) , affecting the anterior segment of lingular, associated with adjacent atelectasic opacities, with SUV max 12.4. ◆ Osteolytic lesion in the 3rd right costal arch (4.7cm) , with large soft parts component bulging the pleural region, infiltrating the intercostal muscle, with SUV max 7.1
CASE 1 Treatment proposed: First line: Carboplatin + Pemetrexede (Nov.2017) 2011 2017 Pulmonary Adenocarcinoma T3N1M1 with bone metastasis
CASE 1 Question 1 ◆ After first line therapy with carboplatin and pemetrexed, patient had myelotoxicity and progression disease with decreased Karnofsky scale from 90 to 60. What should we do? Schag CC, Heinrich RL, Ganz PA. Karnofsky performance status revisited: Reliability, validity, and guidelines. J Clin Oncology. 1984; 2:187- 193
CASE 1 Treatment proposed: First line: Carboplatin + Pemetrexede (Nov.2017) Progression Disease 2011 2017 Adverse Effects Pulmonary Second Line: Adenocarcinoma Nivolumab T3N1M1 (Jan-Mar.2018) with bone metastasis Progression Disease KPS
CASE 1 Question 2 ◆ After second line with nivolumab, patient had another progression disease with more decreased Karnofsky Scale from 60 to 40. When should we stop the oncology therapeutic? Question 3 ◆ This kind of thinking shrink the expectative of life?
ESMO SUMMIT LATIN AMERICA 2019 Case 2
CASE 2 Same patient of case 1: ◆ After stopped the specific treatment he had an improvement of performance, getting back to his quite normal activities like walking through his neighborhood, travel with his family. ◆ After 2 months, started with strong pain at his 3rd costal arch. And became more anxious. ◆ At this time, he was using patch of buprenorphine, totalizing 15mg/week, dipyrone 1g every 6h ◆ But without a correct use
CASE 2 Tried to improved the analgesic medications ◆ Gabapentin 400mg every 8h and maintenance other medications. ◆ Pain got worse Question 1 • What to do? ◆ Add more medications? ◆ Try other options like radiotherapy, psychotherapy, acupuncture?
CASE 2 Was decided for a combined treatment ◆ Psychotherapy ◆ Radiotherapy: 5 fx of 400cGy at 3rd costal arch and left shoulder (new progression of disease) on May 2018 Pain was controlled by for 4 months. Started getting worse and really difficult to control on September 2018 ◆ Patient resistance of high doses of opioids Question 2: • What to do to control his pain?
CASE 2 Indicated intrathecal catheterization by epidural catheter of morphine ◆ Pain better controlled ◆ 2 episodes of intoxication by opioids ◆ Dose reduced and demystified about opioids and adverse effects ◆ Pain controlled till his death on Dec.2018
ESMO SUMMIT LATIN AMERICA 2019 Case 3
CASE 3 • D.T.C, female, 85 years old, widow, 3 sons. Housekeeper, natural from São Paulo, Brazil. Lived alone, with caregiver. Without religion • Diagnoses: ◆ Neurological degenerative disease ◆ Advanced dementia - totally dependent, without neurological interaction ◆ Rheumatoid arthritis ◆ Non-investigated lung cancer because of her impossibility of treatment if confirmed • Hospitalized at December 15, 2018 with pulmonary sepsis from a bronchoaspiration ◆ At the emergency room: ◆ Received Ceftriaxone and Clindamicin ◆ Orotracheal intubation and sent to Intensive Care Unit
CASE 3 At a previous conversation, patient said that didn’t want to be machine’s dependent. Her family knew that too. Question 1 • What to do in this case?
CASE 3 • Patient admitted at the ICU at the same day • Parameters of ventilations was adjusted for her need and medications to prevent discomfort too • Talked to the family to understand what they were expecting. And a decision was made: avoid any kind of discomfort Question 2: Is the palliative extubation an option? How to do that?
CASE 3 • After 2 days, family was distressed with the orotracheal intubation. They were against this measure, because it was totally different from her wishes. And agreed with the extubation ◆ Ventilatory parameters at the day of extubation: Support pressure, PEEP 6, SP 12, FiO2 60%, RR 25, V 330 ◆ Extubation at 12:15h of Dec 18.2018. ◆ After, was putted a catheter of O2 2L/min • Patient was transferred to the ward and died on December 20.2018 at 8h, surrounded by her family as they wanted too
ESMO SUMMIT LATIN AMERICA 2019 Case 4
CASE 4 • W.A.S., 69 years old, female, married • 2015: ◆ March: submitted to screening tests and found a mass at the left ovarian, without sings or symptoms ◆ PET TC: Hypermetabolic activity at a large mass at the left ovarian and at retroperitoneal and external iliac lymph nodes (probable secondary processes) ◆ May: Cytoreduction surgery • High grade left ovarian adenocarcinoma, with 22.5cm, lymph node positive and infiltration at the anterior wall of the rectum.
CASE 4 ◆ 2015 ◆ Jun: Chemotherapy 6C Carboplatin + Paclitaxel + Bevacizumab and bevacizumab as maintenance for 1 year ◆ 2016 ◆ November: PD lymph node > Doxorrubicin + Carboplatin 6C till May 2017 ◆ 2017 ◆ December > PD peritoneum ◆ 2018 ◆ Jan - April: Carboplatin + Paclitaxel > PD ◆ April - June: Gencitabin > PD - First episode of Malignant Bowel Obstruction (MBO) ◆ June - July: Pemetrexed > PD and new MBO > Hospitalized
CASE 4 Upper tract Obstructed OBSTRUCTION POINT
CASE 4 • July-Oct ◆ Hospitalized to treat the MBO Question 1 • What are the measures to control the MBO?
CASE 4 • July-Oct ◆ Hospitalized to treat the MBO Question 1 • What are the measures to control the MBO? ◆ Tried clinical measures to revert the MBO, but without success Question 2 • Invasive measures are adequate? Any other kind of clinical measures can be done?
CASE 4 • July-Oct ◆ Hospitalized to treat the MBO Question 1 • What are the measures to control the MBO? ◆ Tried clinical measures to revert the MBO, but without success Question 2 • Invasive measures are adequate? Any other kind of clinical measures can be done? ◆ Made a decompressive gastrectomy on 10 Oct. 2018 Question 3 • Palliative sedation is an indication? When should be started?
CASE 4 • July-Oct ◆ Hospitalized to treat the MBO Question 1 • What are the measures to control the MBO? ◆ Tried clinical measures to revert the MBO, but without success Question 2 • Invasive measures are adequate? Any other kind of clinical measures can be done? ◆ Made a decompressive gastrectomy on 10 Oct. 2018 Question 3 • Palliative sedation is an indication? When should be started? ◆ Initiated sedation on Oct 26, 2018 and patient died 8h after
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