Pancreatic Cancer
Description
● Introduction
With more than 430,000 fatalities recorded in 2018, pancreatic cancer ranks as the seventh most common cause of cancer-related deaths globally. Because of its subtle beginnings, late diagnosis, poor resectability, and inherent resistance to chemotherapy and radiation, its 5-year survival rate is still less than 10%. In order to enhance patient outcomes, new therapy combinations must be investigated for locally advanced pancreatic cancer (LAPC), which poses a therapeutic challenge.
A case of stage III pancreatic head adenocarcinoma is described in this report. The patient had chemo-radiotherapy and sequential chemotherapy as first treatments, followed by a first-line AG regimen and TS-1 plus anlotinib. The patient had a progression-free survival of 14 months with good tolerability.
● Case Description Patient Profile
➣Age/Sex: female, 58 years old
➣Height, Weight, and BSA: 1.4188 m², 46.5 kg, and 150 cm
➣Display: Jaundice for one week and generalised weakness for more than a month
● Physical Assessment
➣mild sclera and skin jaundice
➣No rebound soreness and mild epigastric tenderness
● Imagining
➣MRI/MRCP: Gallbladder alterations, biliary obstruction, tiny left liver cysts, and a mass in the pancreatic head.
➣CT scan: 3.6 × 3.5 cm mass, dilation of the pancreaticobiliary duct (also known as the "double-tube sign"), contact with the duodenum and superior mesenteric arteries, and no distant metastases indicate locally progressed illness.
●Surgical Findings (April 24, 2019)
➣Intraoperative mass: 3.5 × 3.5 × 2 cm, many enlarged lymph nodes (Groups 8 & 13), constricted mesentery root, invading superior mesenteric artery and vein.
➣Invasive/metastatic adenocarcinoma is a fast intraoperative pathology.
➣Adhesiolysis, lymph node biopsy, and palliative Roux-en-Y cholecystojejunostomy were the procedures carried out.
➣The final diagnosis was pT4N2M0, stage III, pancreatic head adenocarcinoma with metastases to the abdominal lymph nodes.
●First Treatment
➣ Chemo-Radiotherapy Concurrent (May 27, 2019)
•Chemotherapy: TS-1, d1-14, Q3W, 60 mg morning + 40 mg evening
•IMRT in 3D conformal radiotherapy; PGTV: 25f/50 Gy
•Result: Follow-up CT showed stable disease (SD) in August 2019.
•chemotherapy in stages (Gemcitabine + TS-1)
•Dosage: TS-1 40 mg po bid d1-14, Q3W + Gemcitabine 1300 mg IV d1, d8
•Six cycles, from August 2019 until January 2020
•Response: Lesion shrank from 3.9 × 3.3 cm to 1.1 × 0.9 cm; partial response (PR).
➣Failure of First-Line Therapy
•June of 2020 CT: A slightly larger tumour measuring 1.0 x 2.3 cm
•Gene testing: BRCA1/2 wild-type, pMMR → ineligibility for targeted treatment
•August–September 2020: First-Line AG regimen (Gemcitabine + Abraxane)
•Reaction: First-line failure due to rapid tumour progression (2.4 × 4.3 cm)
●Discussion
➣After first-line therapy fails, this case shows that TS-1 with anlotinib can stabilise the illness over the long term.
➣Gemcitabine resistance caused the first-line AG treatment to fail.
➣Chemotherapy (TS-1) combined with second-line treatment that targets the tumour microenvironment (via anlotinib) significantly increased progression-free survival (14 months), outperforming the usual results from conventional regimens.
➣Clinical significance: For locally advanced pancreatic cancer, oral combination treatment is practical, efficient, and acceptable.
Protocol
● Problem: Advanced, Unresectable Pancreatic Cancer
→ Management Interventions
•The patient was diagnosed with locally advanced pancreatic cancer (pT4N2M0, stage III) with abdominal lymph node metastasis, which could not be radically resected.
•Initial management included palliative surgery (Roux-en-Y cholecystojejunostomy, lymph node biopsy, and adhesiolysis) to address biliary obstruction and confirm diagnosis.
➣ Nursing Interventions
•Postoperative care included close monitoring for complications such as infection, bleeding, and bile leakage.
•Supportive nursing focused on pain assessment, nutrition, hydration, and physical mobility to promote recovery.
● Problem: Chemotherapy and Radiotherapy Tolerance
→ Management Interventions
•Concurrent chemotherapy (TS-1 oral regimen) and three-dimensional conformal radiotherapy were used to target the primary tumor site.
•Sequential chemotherapy involved gemcitabine plus TS-1 for six cycles, followed by periodic evaluation using imaging (CT scans) and tumor markers.
➣ Nursing Interventions
•Nurses provided education on oral chemotherapy administration and side effect management (nausea, mucositis, myelosuppression).
•Skin care for radiotherapy sites was implemented to manage potential dermatitis.
•Routine lab monitoring was used for early detection of cytopenias; dietary and medication support to manage GI symptoms was offered.
● Problem: Drug Resistance and Disease Progression
→ Management Interventions
•Upon evidence of progression after first-line therapy (Gemcitabine + Abraxane), therapy switched to •TS-1 combined with anlotinib, an oral targeted agent with a broad spectrum of activity (VEGFR, PDGFR, FGFR, c-Kit).
•Dose adjustment for anlotinib was implemented based on disease response and tolerance (8 mg to 10 mg daily for 14 days in each 3-week cycle).
➣ Nursing Interventions
•Nurses closely monitored for side effects of targeted therapy, focusing on hypertension, hand-foot syndrome, and hyperlipidemia.
•Blood pressure monitoring was routine; antihypertensive therapy (nifedipine sustained-release tablets) was started for first-degree hypertension.
•Skin care regimens (moisturizing, emollients) were provided for hand-foot syndrome prevention and management.
•Dietary guidance was given—especially for potential lipid elevations, and patient education emphasized symptom reporting.
● Problem: Symptom Burden and Quality of Life
→ Management Interventions
•Regular evaluation of ECOG performance status and pain score (NRS) ensured ongoing attention to quality of life.
•Secondary radiotherapy was added when indicated for local control, balancing tumor stability with preservation of function.
•Adjustments in treatment schedules and supportive measures contributed to symptom minimization and prevention of complications.
➣ Nursing Interventions
•Pain assessment was systematic; analgesics were prescribed as needed although the patient's pain remained well-controlled.
•Gastrointestinal symptom management included antiemetics, proton pump inhibitors, and dietary consultation to maintain nutritional status.
•Psychosocial support and education promoted coping and treatment adherence.
● Problem: Adverse Drug Reactions
→ Management Interventions
•Adverse events monitoring was continuous. Grade I hand-foot syndrome and hypertension were recognized early and managed appropriately.
•There was vigilance regarding possible hematologic and non-hematologic toxicities, including triglyceride and cholesterol elevations.
•Regular follow-up assessments during oral therapy helped prevent severe complications.
➣ Nursing Interventions
•Blood pressure checks and skin assessment were routine prior to each chemotherapy cycle.
•Nurses educated the patient regarding early signs of hand-foot syndrome and hypertension, facilitating timely intervention.
•Skin care and hydration strategies were reinforced through education. Dietary modifications were suggested for metabolic changes.
● Problem: Psychosocial Impact and Long-Term Monitoring
→ Management Interventions
•Given the chronic nature of disease and therapy, the interdisciplinary team maintained frequent communication with the patient, adapting care plans in line with physical, emotional, and social needs.
•Continued oral therapy enabled the patient to reduce hospital visits, minimizing financial and logistical burdens.
➣ Nursing Interventions
•Ongoing emotional support and counseling services were offered.
•Education was provided regarding therapy goals, expected side effects, and self-care strategies.
•Nurses assessed for anxiety, depression, and distress, offering referrals to specialist support as necessary.
Notes
for more details visit https://pmc.ncbi.nlm.nih.gov/articles/PMC9283868/
