A Case of Three Tumors
Presenters:
Timothy Joseph Abad, Oliver Chan, Leslie Co Kehyeng, Mitsuharu Enatsu, Cristina Garcia, Harvy Joy
Liwanag
Objectives
To present a case of a patient with three separate primary tumors
To discuss the approach to and management of a patient presenting with multiple tumors
Identifying Data
I.F., 54-year old male from Cainta, Rizal
Informant: Patient and his wife
Chief Complaint
Routine Check-up
History of Present Illness
Several years prior to consult, the patient had already begun experiencing early satiety. Patient
experienced nausea every time he was eating solid foods. The patient instead of taking 3 meals a day, he
took frequent small meals per day.
1 month prior to consult, the patient underwent a routine check-up ultrasound of the lower GR
which showed a 3.1 x 3.8 cm mass from the 3rd Gastric Wall. Patient then underwent a CT scan which
showed a pancreatic nodule 2.4 x 2.4 cm in size and a hepatic nodule 2.5 x 1.9 in size.
Patient was then advised admission and surgery
3rd admission:
The patient is a diagnosed case of hepatocellular carcinoma since May 2011, thru tissue biopsy,
hence patient was advised to undergo surgery.
There is no history of abdominal pain, chest pain, jaundice, dyspnea, or urinary symptoms.
Past Medical History
Illnesses: Diabetes (2006), Subclinical Hyperthyroidism, Multinodular goiter, Hypertension (20 years)
Surgery: Subcoronary Angina 2008; R arm surgery; Cholecystectomy; GIST s/p partial gastrectomy (Dec
2010)
No known allergy to food or medications
Other Maintenance Medications: Diovan 80 mg/tab OD, Carvediol 6.25 mg/tab BID, Plavix 75 mg OD (on
hold for 2 weeks already) Insulin injection (Novomix) 16 units in AM and 16 units in PM
Personal/Social History
Married with children, works as a Manager for San Miguel, 20 pack year smoker and occasional alcoholic
beverage drinker, no history of illicit drug use
Family History
(+) Diabetes, Hypertension, Cancer (Esophageal)
Review of Systems
No fever,
Weight loss of 9 kg in 3 months
No tinnitus, no colds
No cough
No orthopnea, no PND
No nausea, no vomiting, no change in bowel movements
No heat or cold intolerance, no excessive sweating, no excessive thirst
Physical Examination
Stable vital signs
HEENT:
Anicteric sclerae, pink palpebral conjunctivae, no nasal congestion, flat neck veins, no tonsillopharyngeal
congestion, no cervical lymphadenopathy, palpable thyroid mass 5x7cm (right), 4x5cm (left), firm, smooth
Cardiovascular:
Adynaminc precordium, apex beat at 5th ICS LMCL, normal rate, regular rhythm, distinct S1 and S2, no
murmurs
Pulmonary:
Symmetric chest expansion, clear breath sounds
Abdomen:
Flabby, soft abdomen, normoactive bowel sounds, no tenderness
Skin and Extremities:
Full and equal pulses, no edema, no cyanosis, good skin color and turgor, with dermatoses/trophic skin
changes, no pallor, no jaundice, Normal hair, scalp, and nails,
Admitting Diagnosis
Hepatocellular carcinoma
Hypertension
DM
Subclinical Hyperthyroidism
Pancreatic and Kidney cyst
Course in the Wards
Patient was admitted for Nephrectomy and Hepatectomy on 6/22/11. Patient's medications
Valsartan (Diovan), Carvedilol, Novomix, and Methimazole 5 mg/tab OD were continued and CBG
monotoring was done 3 times a day, premeals and at bedtime, Baseline laboratory testing included the
following: BUN, Crea, ALT, AST, Alkaline phosphatase, GGT, Total Bilirubin, Indirect and Direct
Bilirubin, protime, albumin, Na, K, and CBC. A 12-led ECG and Chest X-ray were also done. Vitamin K
was given at 10 mg IV OD. Five units of packed RBCs, properly typed and cross-matched, were prepared
for surgery. Four units of fresh frozen plasma were also reserved. Patient was cleared for surgery
(Exploratory laparotomy with biopsy of left kidney with Frozen section; Hepatectomy and possible distal
pancreatectomy). The patient was put on NPO in preparation for surgery and D5NR 1 L x 8 hours was
given. Medications in preparation for surgery were given: Pantoprazole (Pantoloc) 40 mg TIV, Cefuroxime
(Zegen) 1.5g TIV 1 hr prior to operation. CBG monitoring was increased to every 4 hours while on NPO.
Surgery was done on 6/23/11. The following procedures were performed: exploratory laparotomy, partial
nephrectomy, left, with frozen section, partial hepatectomy, segment 6 and 7, resection of liver nodule,
segment 6 and excision biopsy of gastric mass. Results of frozen section revealed renal cell carcinoma, left.
Surgery tolerated by the patient. After surgery, Cefuroxime was continued at 750 mg IV every 8
hours and Pantoprazole 40 mg IV OD while on NPO. Incentive spirometry was started 15 minutes at a time
3x daily. Thoracic epidural was provided for continuous post-op analgesia. The patient was given Parcoxib
40 mg IV BID x 2 doses, Paracetamol 300 mg IV QID, and was given PCA (morphine 0.125% + Fentanyl
2meq/ml). Patient has adequate input and output. JP drain (right and left) also patent and secure (right JP
drain: 423 ml/24 hrs; left JP drain: 391 ml/24 hrs). Patient was in moderate high bed rest and deep
breathing was encouraged. At 6/26/11, medications were being shifted from oral to IV, such as Carvedilol
to Metoprolol and Amiodarone IV to Amiodarone oral. Patient pain scale is 0/10 at rest with slight
discomfort (VAS 1-3/10) with movement. At 6/27/11, pain medication continued shifting to oral –
Tramadol+Paracetamol (Dolcet) Patient able to tolerate liquid diet. At 6/28/11, patient given soft diet,
tolerated, with good appetite. Patient was with no subjective complaints and allowed to go home on
6/30/2011. Patient monitored for 8 days before discharge. Follow-up with respective consultants scheduled.
Discharge Diagnosis
Hepatocellular Carcinoma, right lobe
Renal Cell Carcinoma, left kidney
GIST, stomach, recurrent
Paroxysmal Atrial Fibrillation
Mild non-obstructive coronary artery disease
Hypertension
DM, type 2