Managing Edema and Pain in Advanced Pancreatic Cancer Patients

Pancreatic cancer metastasized to the liver, with bilateral lower extremity edema up to the knees?

Last November, a family member (female) was diagnosed with stage II pancreatic cancer and underwent a Whipple resection.
Post-surgery, she did not receive adjuvant chemotherapy.
Four months after the surgery, an MRI revealed several tumors in the liver measuring 2-3 cm, while no abnormalities were found in other areas.
She decided to undergo chemotherapy (Gemcitabine + Abraxane), but the treatment was not smooth due to frequent low white blood cell counts, which hindered her ability to continue therapy.
During the chemotherapy period, a CT scan showed an increase in liver tumor size, with no other abnormalities noted.
After the most recent chemotherapy session, her immune system was severely compromised, with a white blood cell count dropping to 380, leading to septic shock.
She was barely resuscitated and has since ceased chemotherapy, opting for regular follow-ups to monitor biochemical markers, cancer markers, and liver and kidney function.
Currently, the issues include bilateral lower limb edema (swelling extending from the feet to the knees and thighs), which has persisted for over three weeks.
She has recently complained of lower abdominal pain and discomfort in the perineal area, possibly due to an infection from wearing diapers during her last hospitalization.
Given these conditions, she returned to the oncology department for follow-up.
After blood tests, the doctor assessed her as malnourished, with low albumin levels, but there were no signs of infection or inflammation (WBC 6100, Albumin 3.1, eGFR 133.3, AST 27, ALT 21, T-BIL 0.26, Na 138, K 4.3, Hb 10.2).
Despite daily protein supplementation of 50g (the patient's weight is 33 kg), there has been no reduction in edema; in fact, it has worsened, with one leg becoming very painful over the past two days, requiring pain relief and muscle relaxants for comfort.
What do you think should be done in this situation? Should she consult other specialties for further examination, or is this a common occurrence in terminal cancer patients that does not require special intervention?

Yu Yu, 20~29 year old female. Ask Date: 2022/09/07

Dr. Chen Sirong reply Oncology

Yuyu / 28 years old / Female
1.
What does the doctor think should be done in this situation?
A: 1.1 The cancer itself may cause cachexia, leading to poor nutrient absorption, resulting in a severe weight loss down to 33 kg.
Even with supplementation, it may not be sufficient.
This is primarily due to the secretion of certain chemicals by cancer cells, which triggers this response.
If the cancer cells cannot be eradicated, this vicious cycle cannot be broken.
1.2 The cause of edema may be due to dysfunction of the heart, kidneys, or liver, leading to low albumin levels.
As for the triggering factors in your family member, it cannot be determined solely through online consultation.
However, even if the cause is known, it may not be manageable.
2.
Is it necessary to consult other specialties?
A: You can see a palliative care specialist to address symptom management.
3.
Should further examinations be conducted?
A: It is unlikely to be helpful.
4.
Is this a common situation for terminal cancer patients that does not require special intervention?
A: Perhaps palliative care can assist in making some symptoms more comfortable, but it does not resolve these symptoms.
When it truly cannot be managed, allowing the patient to rest more may alleviate suffering.
Wishing for a peaceful passing.
Taoyuan Hospital, Dr.
Chen Sih-Rong

Reply Date: 2022/09/07

More Info

Managing edema and pain in advanced pancreatic cancer patients can be quite challenging, especially when the patient has a complex medical history and is experiencing multiple symptoms. In the case you described, your family member has undergone significant treatment for pancreatic cancer, including a Whipple resection and subsequent chemotherapy, which unfortunately did not proceed as planned due to low white blood cell counts. The development of edema in the lower extremities and abdominal pain raises several important considerations.

Understanding Edema in Cancer Patients
Edema, or swelling due to fluid accumulation, can occur for various reasons in cancer patients. In this case, the edema in your family member's legs could be attributed to several factors:
1. Nutritional Deficiencies: The blood test results indicate low albumin levels (3.1 g/dL), which suggests that the patient may be experiencing protein malnutrition. Albumin is a protein that helps maintain oncotic pressure in the blood vessels; low levels can lead to fluid leaking into surrounding tissues, causing edema.

2. Liver Function: Given the presence of tumors in the liver, it is essential to consider whether liver function is compromised. Although the liver function tests (AST, ALT, and bilirubin) appear normal, the presence of tumors can still affect overall liver function and contribute to fluid retention.

3. Venous Insufficiency: Cancer and its treatments can lead to changes in blood flow and circulation, potentially causing venous insufficiency, which can result in swelling in the legs.

4. Lymphatic Obstruction: If the cancer has spread to lymph nodes or if there has been surgical intervention, lymphatic drainage may be impaired, leading to lymphedema.

Managing Pain
The abdominal pain and discomfort in the perineal area could be related to several factors, including:
- Tumor Growth: The growth of liver tumors or potential metastasis could be causing pain.

- Infection: Although the blood tests do not indicate an active infection, the history of urinary catheter use raises the possibility of a urinary tract infection or other localized infections.

- Muscle Spasms: Pain relief through muscle relaxants suggests that muscle spasms may be contributing to discomfort.

Recommended Actions
1. Consultation with Specialists: Given the complexity of the symptoms, it may be beneficial to consult with specialists such as a palliative care team, who can provide comprehensive symptom management. They can help address pain, edema, and nutritional issues holistically.

2. Nutritional Support: Since the patient is experiencing nutritional deficiencies, working with a dietitian specialized in oncology could help optimize protein intake and overall nutrition. This may involve adjusting the diet to include high-protein foods or considering enteral nutrition if oral intake is insufficient.

3. Diuretics: If the edema is significant and causing discomfort, a physician may consider prescribing diuretics to help reduce fluid retention. However, this should be done cautiously, especially in patients with compromised kidney function.

4. Pain Management: Continue to manage pain with appropriate medications. If the current pain management strategy is insufficient, discussing alternative pain relief options, including stronger analgesics or palliative care interventions, may be necessary.

5. Regular Monitoring: Regular follow-ups with the oncology team are crucial to monitor the progression of the disease and adjust treatment plans as necessary. This includes monitoring blood counts, liver function, and overall health status.

Conclusion
In summary, the symptoms your family member is experiencing are not uncommon in advanced cancer patients, but they warrant careful evaluation and management. Engaging with a multidisciplinary team can provide a more comprehensive approach to managing edema, pain, and nutritional needs, ultimately improving the quality of life for your family member. It is essential to communicate openly with healthcare providers about any new or worsening symptoms to ensure timely interventions.

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