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Case history

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Image not available. A 76-year-old man presented to a follow-up oncology clinic with symptoms of weight loss and severe reflux. He had previously received neoadjuvant epirubicin, cisplatin and capecitabine, and a subtotal gastrectomy for a T3N1M0 (4/4 lymph nodes) adenocarcinoma of the lower oesophagus. Asymptomatic mediastinal lymph node relapse occurred 3 years previously. He was currently under surveillance having received no palliative chemotherapy or radiotherapy. A CT scan following this appointment showed no progression of disease, and he was referred to palliative care for symptom control.

Symptoms of reflux had developed following surgery and were associated with anorexia. Although present during the day, they were worse at night. Anxiety regarding symptoms and the impact on quality of life (QOL) resulted in the patient stating he did not see the point of carrying on. At his palliative care appointment, the following medication changes were made:

  • Continue esomeprazole 20 mg OD.

  • Increase ranitidine to 150 mg BD.

  • Start mebeverine 150 mg TDS.

  • Start mirtazapine 7.5 mg ON.

A discussion with the gastroenterology team was undertaken regarding his symptoms. Gastric outlet obstruction was queried, resulting in the following changes in medication:

  • Stop mebeverine.

  • Start domperidone 10 mg TDS.

His imaging and history were reviewed at the gastroenterology multidisciplinary team meeting, at which mild gastric outlet obstruction secondary to coeliac axis lymphadenopathy was diagnosed. He was suitable for radiotherapy and received 20 Gy in five fractions of radiotherapy to that area.

Reflux persisted for 1 month after radiotherapy but improved when esomeprazole was increased to 40 mg/day.

Three months later he presented to his GP with persistent vomiting, breathlessness and weight loss. His GP requested a chest X-ray (Figure 3.1), which was initially interpreted as cardiomegaly, through failure to consider his surgical history. At his oncology appointment a CT scan was requested, which demonstrated gastric outlet obstruction with significant distension of the gastric conduit (Figure 3.2). His case was discussed at the weekly radiology meeting and deemed suitable for stenting of the obstruction. The risks and benefits of immediate nasogastric tube placement versus planned stenting were discussed. The patient opted for planned inpatient stenting. He was discharged after a 3 day stay and stent insertion. Three months later he was well and required no further intervention.

What was the goal of cancer treatment for this patient? What is the evidence base for further chemotherapeutic interventions for this patient?

Why is it important to take medical/surgical history into account when requesting imaging?

What is the evidence for the change of treatment enacted by palliative care and why was it changed following a potential diagnosis of gastric outlet obstruction?

What were the risks of delayed nasogastric tube placement? And when is radiotherapy preferred over stent placement for gastric outlet obstruction?

How can admissions for cancer patients in the last year of life be reduced?

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