ESMO SUMMIT LATIN AMERICA 2019 - Palliative Care - Clinical Cases Presentation Joao Luiz Chicchi Thomé Oncologist and Palliative doctor - OncologyPRO

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-

CASE 1
                               Treatment proposed:

                                    First line:
                                  Carboplatin +
                                  Pemetrexede
                                   (Nov.2017)

        2011            2017   Progression Disease
                                 Adverse Effects
    Pulmonary
  Adenocarcinoma                  Second Line:
     T3N1M1                        Nivolumab
                                 (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