Palliative Care, Signs and Symptoms of Primary Peritoneal Carcinoma - Case Study Example

Palliative Care Author’s Name: Instructor’s Name: Course Details: Institutional Affiliation: Date of Submission Introduction Primary peritoneal carcinoma is a form of malignancy which impinges on the peritoneum. Peritoneal carcinoma originates from the peritoneal cells. The peritoneum is the inner most layer that is found within the abdomen. It offers protection to various organs for instance the liver, stomach among others. In addition, the peritoneum enables the internal organs that are found within the abdomen to move about freely within the abdomen without undergoing wear and tear due to friction. The peritoneal tissues are majorly composed of the epithelial cells. The epithelial cells are also found in other parts of the body such as the ovaries (Álvarez1 et al, 2007). The condition affects the peritoneum of both the male a female populations. The exact cause of Primary peritoneal carcinoma is not known though it is associated with various risk factors which make the exposed groups to have increased chances of having the Primary peritoneal carcinoma. However, the female population is the most affected by primary peritoneal carcinoma. The diagnosis of Primary peritoneal carcinoma is based on the clinical features as well as the various imaging and laboratory tests. Its diagnosis is made the terminal stages of the illness (Gómez et al, 2007). The management of Primary peritoneal carcinoma is based on the staging of the disease. Patients who are in the later stages of the disease have limited chances of benefiting from the treatment. This is attributed to the rapid progression of Primary peritoneal carcinoma. Palliative care thus offers the best management model in addressing Angeline’s concerns and that of the family. Palliative care is the most frequently used in managing the cancer. Palliative care is aimed at alleviating Angeline’s symptoms that result from the cancer such as pain, and coping with the condition. Various services are offered in palliative care and they range from medical, psychosocial, surgical and spiritual services (Ordóñez, 2007). Signs and Symptoms of Primary Peritoneal Carcinoma The clinical features of the patients with the cancer include: The loss of appetite Distension of the abdomen and the build up of fluids within the abdomen (ascitis) Lower abdominal pains Changes in the bladder as well as the bowel habits which includes constipation, diarhoea and increased urgency. Increased abdominal girth (Park et al, 2008). Pathogenesis Aetiology The aetiology of primary peritoneal carcinoma is not well known. However, the occurrence of primary peritoneal carcinoma is associated with various risk factors which include: Genetic Predisposition Primary peritoneal carcinoma has for a very long time been associated with the gene that causes breast cancer. It is believed that the faulty gene linked to breast cancer is passed on within the families that have histories of breast cancers. The mutations of the genes BRCA1 or BRCA2 leads to the cancer (Pentheroudakis and Pavlidis, 2009). Advancement in Age Individuals with ages above 60 years are more prone to developing primary peritoneal carcinoma (Pentheroudakis and Pavlidis, 2009). Sex In primary peritoneal carcinoma, women are more predisposed when compared to the male population. The female population accounts for the highest number of incidences of the population reported to be having primary peritoneal carcinoma (Pentheroudakis and Pavlidis, 2009). Social Habits The social habits of an individual predispose one to the risk of having primary peritoneal carcinoma. The most notable social habits associated with primary peritoneal carcinoma include smoking and drinking (Pentheroudakis and Pavlidis, 2009). Pathophysiology The pathophysiology of primary peritoneal carcinoma highlights the progression of the disease. The peritoneum of composed of a thin layer of mesothelial cells. It is also composed of lymphatics and blood vessels. Primary peritoneal carcinoma originates from the peritoneal cells. The tumor brings about the differentiation of the cells within the peritoneum. The cells undergo numerous changes in terms of their shape and size. The differentiation occurs gradually as the tumor spreads to other areas (Álvarez1 et al, 2007). The pathophysiology of the tumor occurs in various stages. The first step entails the cancer cells exfoliating from the tumors which directly communicate with the peritoneal cavity. The cancer cells can also be delivered directly to the submesothelial spaces as well as the peritoneal cavity through the lymphatics. Mucin brings about the implementation of the cancerous cells on to the peritoneal surfaces. Therefore, mucin enables the tumor cells to readily invade the peritoneal cavity since they provide a conducive environment for implementation to take place. This is attributed to the fact that mucin is impregnated with growth factors and angogenic factors that aid in the implementation of the cancerous cells on the surfaces of the peritoneum. Implementation commences from the areas that are have the lymphatic stomata. Areas that are rich with the lymphatic stomata include the pelvic region, greater omentum as well as the diaphragm. The cancerous cells bring about the differentiation of the cells within the peritoneum. The cancerous cells can also metastasize to various parts of the body. The common modes of spreading include local infiltration, hametogenous route and through lymphatics (Ordóñez, 2007). Diagnosis The diagnosis of primary peritoneal carcinoma is made based on the clinical features as well as imaging and laboratory examination. The diagnosis of Angeline’s illness is made at the late stages of the disease. The late diagnosis means that Angeline has slim chances of attaining recovery from the various management models that address primary peritoneal carcinoma. The diagnosis is made after ruling out other forms of malignancies such as ovarian cancer (Takano et al., 2009). Clinical Presentation The clinical symptoms in Primary peritoneal carcinoma normally appear in the advanced stages of primary peritoneal carcinoma. The clinical presentation of patients with Primary peritoneal carcinoma is characterized by the presence of abdominal and back pains that is associated with abdominal distension. Most of primary peritoneal carcinoma patients will have ascitis present. Female patients will tend to present with histories of deperunia and irregular monthly periods. In addition, primary peritoneal carcinoma patients have increased abdominal girth. Angeline in the case study had signs and symptoms which are associated with Primary peritoneal carcinoma (Álvarez1 et al, 2007). Angeline had a history of having a bloated abdomen, intestinal obstruction of the small intestines, vomiting as well as lower abdominal pains. In addition, Angeline also presented with clinical features of primary peritoneal carcinoma that had already metastasized to other organs in the body. For instance Angeline is reported to have had severe dyspnea and had bilateral edema of the lower limbs which is characteristic of the involvement of the primary peritoneal carcinoma in the respiratory cardiovascular systems. The surgical history also shows that the primary peritoneal carcinoma had metastasized to other regions of the body, for instance Angeline is said to have undergone total hysterectomy, bilateral oophorectomy, infragastrectomy and appendisectomy (Álvarez1 et al, 2007). Diagnosis Based On Imaging Techniques The most significant imaging technique in picking primary peritoneal carcinoma is the Computed tomography scan. The abdominal computed tomography scan is able to pick up the cancerous mass and even shows extend of cancerous involvement. Other imaging techniques used in the identification of primary peritoneal carcinoma include the use of the ultrasound, magnetic resonance imaging as well as the x-ray. The ultrasound and magnetic resonance imaging is essential in highlighting extend of tissue involvement of the tumor. The x-ray on the other hand is vital in ruling out the metastasis of primary peritoneal carcinoma to other organs such as the lungs. The diagnosis of Angeline’s condition based on the imaging techniques was done using the computed tomography scan. The Computed tomography scan showed the presence of ascitis as well as the metastasis of primary peritoneal carcinoma (Gómez et al, 2007). Blood Tests Blood tests will also be effective in making the diagnosis of primary peritoneal carcinoma. The blood tests will enable the establishment of the titer levels of the protein maker CA 125 which is characteristic of primary peritoneal carcinoma. High titer levels of CA 125 than the normal will be indicative of Angeline having primary peritoneal carcinoma. In the case study, the blood test was key in making the diagnosis of primary peritoneal carcinoma. Angeline had elevated levels of the tumor marker CA 125 which is normally associated with primary peritoneal carcinoma. The titers of CA 125 were elevated when compared to the normal values. The elevated levels of the tumor marker established the presence of primary peritoneal carcinoma (Ordóñez, 2007). Laparoscopic Biopsy The peritoneum is made up of the mesothelial cells. The mesothelial cells are elongated, flat and slender. The mesothelial cells have a centrally located nucleus and abundant cytoplasm. The mesothelial cells also contain surface microvillus. Based on histology, it is very hard to differentiate primary peritoneal carcinoma with the ovarian carcinomas. This is based on the fact that the two have the same embryonic origin. However, the diagnosis is made after the exclusion of ovarian malignancies. Biopsy enables the identification of the cancerous cells since it will be vital in identifying the cell changes that are associated with Primary peritoneal carcinoma (Ordóñez, 2007). Paracentesis Paracentesis is conducted in patients with ascitis. The fluid is examined under the microscope to identify the cancerous cells (Gómez et al, 2007). Staging of Primary Peritoneal Carcinoma The staging of the tumor is done at laparatomy. The staging of the tumor is based on the size of the tumors, how differentiated the tumors are from the normal cells within the peritoneum and how far it has metastasized. The staging is similar manner to that of the ovarian cancers since they have the same embryonic origin. The staging of peritoneal tumors is significant in making the choice of the treatment mode as well as the prognosis. The staging of peritoneal cancers is based on the gilly staging method and the peritoneal cancer index scoring. The peritoneal index scoring system is based on the level of metastasis of the tumor into the peritoneal cavity. The scoring system fragments the abdomen and pelvis into thirteen regions and the nodules found in each of these regions are added up. The scoring ranges from a score of zero to the lower the peritoneal index score the higher the chances of a better prognosis. The peritoneal index in this patient is high due to the level of metastasis that the tumor has undergone since various parts of the body have been affected (Takano et al., 2009). The TNM staging is also essential in primary peritoneal carcinoma. The TNM staging entails the categorization of the tumor based on the tumor being present, the level of nodal involvement of the tumor and finally if the tumor has metastasized or is localized. In the case study, Angeline had a tumor present and it had already undergone metastasis (Takano et al., 2009). Despite the various methods available that are used in the staging of primary peritoneal carcinoma, diagnosis of the condition is normally made at the later stages of the disease due to its aggressiveness and rapid spread. The most common stages in primary peritoneal carcinoma are the third and the fourth stages. In the third stage, the tumor is still confined within the peritoneum. However, the fourth stage is characterized by the tumors which have undergone metastasis and have spread to other organs in the body such as the lungs, liver and there is diffuse lymph node involvement (Álvarez1 et al, 2007). The grading of primary peritoneal carcinoma by the medical practitioners is normally based on their metastatic capabilities. The grade one cancers spread slowly and have a normal cell appearance. The grade two cancers are characterized by relatively normal cells that spread slightly rapid when compared to grade one. Grade there tumors on the other hand are the abnormal cells that spread more rapidly and are totally differentiated from the normal cells. Based on the clinical status, Angeline in the case study has stage four of the tumor. Stage four is characterized by the metastasis of the tumor to other regions of the body. Angeline in the case study is reported to have undergone various forms of surgical procedures that are aimed at eliminating the cancer cells. These surgical procedures are indicative that the disease has metastasized to various body parts such as the ovaries, small intestines, liver and the lungs among others (Ordóñez, 2007). Management of Primary Peritoneal Carcinoma The management of the cancer is based on the staging, the size of the cancerous cells, age as well as the general health status of Angeline. Primary peritoneal carcinoma is mostly in the third and the fourth stages before a discovery is made. This means that at most times the advanced treatment modes are used. Some of the treatment options for patients with primary peritoneal carcinoma include surgery, chemotherapy and palliative care (Álvarez1 et al, 2007). In Chemotherapy, anticancer drugs are used to eliminate the cancerous cells. Other drugs mediate their anticancer effects by inhibition of the abnormal cells from undergoing multiplication or division (Gómez et al, 2007). Surgical management involves the use of surgical procedures in the management of cancer. Surgical procedures will aim at removal of the cells that have become cancerous (Park et al, 2008). Radiotherapy entails the use of high energy rays in the destruction of the cancer cells. In addition, radiotherapy can be used to decrease the size of the cancerous cells (Álvarez1 et al, 2007). Palliative Care in Primary Peritoneal Carcinoma Palliative care in patients with primary peritoneal carcinoma is mean to address Angeline’s needs, relievement of the symptoms associated with the cancer and giving the psychological as well as social support to Angeline’s family. The palliative care will encompass the delivery of medical, psychosocial as well as spiritual services. The diagnosis of primary peritoneal cancer normally occurs at the later stages of the disease in which the chances of getting cured are very minimal. Palliative care aims to address the various needs that Angeline’s and the family will have after the diagnosis of the condition has been made. Palliative care promotes the quality of Angeline’s life and enables Angeline and the family to cope with the challenges that cancer brings. Palliative care makes enhances the quality of life while at the same time influencing the course or progression of the illness. The quality of life that palliative care addresses involves Angeline, her family and the health care providers. The quality of life with regard to Angeline entails uplifting the psychological, physical and spiritual well being. Quality at the family level entails the uplifting the social, psychological and spiritual well being. At the health care providers’ level, the quality of life will entail uplifting the psychological and spiritual well being. Palliative care affirms life and at the same time enables the family members and Angeline to understand that dying is a normal process (World Health Organization, 2007). The delivery of palliative care requires adequate planning to be put in place. The first step in planning of palliative care for patients with primary peritoneal cancer entails the identification of the target patient. This will be followed by the identification of Angeline’s needs and the anticipation of future needs of Angeline. Angeline’s requirements will be based on the burden that the disease has on Angeline, the stage of the disease, the urgency of the intervention to Angeline and the societal impact of the condition. Angeline needs include the nutritional requirements, relieving of the symptoms associated with the cancer among others. The goals and the objectives of palliative care will thus be formulated to guide the stakeholders in providing a comprehensive approach in the management of Angeline’s condition. The next step will entail the identification of the resources that are available to aid the dissemination of palliative care. The resources will range from human resource such as the health care providers and the family, financial resources since the care will require some expenditure being incurred. In addition, the various stakeholders that are required in the dissemination of palliative care will also have to be identified. In addition, the physical resources such as the infrastructure and essential dugs will be provided. This is followed by choosing and implementing of palliative care strategies. Implementing of palliative care strategy will be based on the effectiveness of the method, the financial implications and the sustainability of the strategy. Planning for palliative care will encompass evaluation process being done. The evaluation when conducting palliative care will enhance the identification of the strengths, weaknesses, opportunities as well as weaknesses. The feasibility of various interventions will be assed during the evaluation process and the management models will be adjusted to suit enables Angeline to have the best outcome of the condition (World Health organization, 2007). Ethical as well as legal issues have to be addressed while disseminating palliative care to Angeline with primary peritoneal carcinoma. The ethical and legal issues will involve Angeline in the treatment though only giving the services which have been consented by Angeline. Angeline’s decision is final with regard to the various treatment alternatives suggested to them (World Health Organization, 2007). Palliative care is an option that is used by most patients who are not able to undertake chemotherapy due to weakness or sickness. Palliative care is aimed at making Angeline more comfortable. Palliative care encompasses various procedures such as Paracentesis, pain management, nutritional therapy and social support from family members, friend as well as professionals (Park et al, 2008). In the case study, various methods were used in the management of Angeline’s condition. The first management option that was used was chemotherapy. Chemotherapy involved then patient being given anti cancer drugs to eliminate the cancerous cells. Angeline was put on chemotherapy sessions (Álvarez1 et al, 2007). The surgical option was also included in the management options for Angeline. The surgical management was aimed at removing the cancerous cells. The removal of the cancerous cells targeted the reducing the chances of the cancer spreading to other organs in the body (Ordóñez, 2007). The prognosis of primary peritoneal carcinoma is dependant upon the stage of the tumor. Primary peritoneal carcinoma is often diagnosed at later stages. Most patients will thus be diagnosed with primary peritoneal carcinoma in the 3rd and 4th stages of the disease. The diagnosis of primary peritoneal carcinoma in the late stages makes the prognosis to be often poor. In addition, Primary peritoneal carcinoma progresses in a more aggressive manner and this makes Angeline’s condition to detoriate rapidly since the cancer cells multiply at a faster rate. The late diagnosis and the aggressiveness of primary peritoneal carcinoma make the prognosis of patients to become poor. Most patients would not be able to benefit from other forms of management of primary peritoneal carcinoma at the later stages. Most patients would thus go for palliative form of management other than the other management models since they are too ill to with stand treatment. Palliative care in patients with primary peritoneal carcinoma is intended in relieving symptoms. Palliative care will thus address the symptoms of Angeline such ad pain, nutrition as well as social support (Ordóñez, 2007). The prognosis of Angeline in the case study is poor. The poor prognosis is attributed to the stage of primary peritoneal carcinoma. Angeline was not responding to the various modes of treatment due to the disease being in the advanced stages. In addition, the advancement of the cancer limited the management options used in the management of her condition. For instance, Angeline had to seize the use of chemotherapy as well as surgical management options as the disease advanced. The ceasing of the treatment models is attributed to the disease being in the late stage which makes Angeline to be ill (Pentheroudakis and Pavlidis, 2009). The terminal stages of primary peritoneal cancer limit the management options that are available to deal with the condition. It is due to Angeline being in the late stages of the disease that palliative care is used in Angeline. The palliative patient is mainly aimed at easening the symptoms associated with the disease. Palliative care in this patient was used in alleviate the pain, nutritional problems associated with the disease (Takano et al., 2009). Angeline’s condition is reported to have detoriated from time to time with advancement of peritoneal carcinoma towards the terminal stage. Angeline is reported to have sought various management options to reduce the progression rate of the disease. The palliative care given to Angeline included the medical, surgical, spiritual and psychosocial services (Park et al, 2008). Surgical services in palliative care for this patient were aimed at preventing the spread of the cancer to other parts of the body. The cancerous tissues were surgically removed to avoid the metastasis of the cancer. Surgical management was conducted at various intervals in this patient. Angeline is reported to have undergone various forms of surgical procedures such as peritoneal taps, exploratory laparatomy and palliative ileostomy, Total hysterectomy, bilateral oophorectomy, infragastricomentectomy and appendicectomy. However, the surgical management in this patient did not work very well since the disease advanced to the late stages. The advancement to the late stages meant that this patient had slim chances of recovery (Álvarez1 et al, 2007). Medical services offered in the palliative care to Angeline entailed the use of anti cancer agents as well as the traditional medicinal concoctions. Medical management was suppressing the spread of the tumor and alleviating the symptoms of the disease. Prevention of further spread of the disease was enhanced by the anti-cancer drugs. The anticancer drugs suppressed the cancer cells as well as eliminated the cancerous cells. The medical management was also geared towards easening symptoms of the disease such as the distress caused by the pain. The chemotherapy was also aimed at slowing the progression rate of the cancer. The slowing down of the progression of the cancer meant that the palliative care promoted the longevity Angeline’s life (Gómez et al, 2007). The psychosocial services are offered to Angeline as well as the family members. The psychosocial services are aimed at enabling the family and Angeline to cope with the condition. Angeline and the family in the case study did not receive psychosocial services. This is evidenced by the distress that the sister and the daughter had on discovering Angeline’s condition. Psychosocial services are supposed to prepare Angeline and the family in dealing with the condition. The lack of psychosocial counseling greatly affected the way the family perceived the information of Angeline having cancer without their knowledge. The sister for instance is greatly troubled for not being informed about Angeline’s condition (Pentheroudakis and Pavlidis, 2009). Spiritual services in palliative care enable Angeline to positively cope with the challenges that come with primary peritoneal cancer. The spiritual services make Angeline ready to face all the possible out comes of the condition which include death or recovery. In the eventuality of death, Angeline is also reassured that it is a normal process and this enables Angeline not be depressed about her health condition. At the last stages of the illness, Angeline is reported to have been very devoted to the matters pertaining to the spiritual matters. Angeline sought spiritual interventions to enable her cope with the condition. The spiritual intervention enabled Angeline to accept the reality of having the condition and to have hope that she can overcome the challenge and the tribulations which is associated with primary peritoneal cancer (World Health Organization, 2007). References Álvarez1, J., Gómez1, M., Prats1,M., Agorreta1, M., Cajal, J., López, J., Goyanes, J., (2007). Extraovarian primary peritoneal carcinoma. A case report, REV ESP PATOL 2007; Vol 40, n.º 1: 47-52. Retrieved on 18th May, 2012 from http://www.patologia.es/volumen40/vol40-num1/pdf%20patologia%2040-1/40-01-07.pdf Gómez, P., Cendoya, I., Muriel, J., Olabarria, I., Guede, N., Moraza, N., (2007). Malignant peritoneal mesothelioma. Our experienced with triple combined therapy: cytoreduction, intraperitoneal perioperative chemotherapy and hyperthermia. Cir Esp;81(2):82-6. Ordóñez, NG., (2007). Pathologic characterization and differential diagnosis of malignant peritoneal mesothelioma. Recent Results Cancer Res. 2007;169:123-36. Park, JY., Kim, KW., Kwon, HJ., Park, MS., Kwon, GY., Jun, SY., (2008). Peritoneal mesotheliomas: clinicopathologic features, CT findings, and differential diagnosis. AJR American Journal of Roentgenology;191(3):814-25. Pentheroudakis, G., Pavlidis, N. (2009). Serous papillary peritoneal carcinoma: Unknown primary tumour, ovarian cancer counterpart or a distinct entity? A systematic review. Critical Review of Oncological Hematology. Takano, M., Yoshokawa, T., Kato, M., Aida, S., Goto, T., Furuya, K., (2009). Primary clear cell carcinoma of the peritoneum: report of two cases and a review of the literature. European Journal of Gynaecological Oncology;30(5):575-8. World health organization, (2007). Palliative care. Cancer control : knowledge into action : WHO guide for effective programmes ; module 5. Reterived on 18th May, 2012 from http://www.who.int/cancer/media/FINAL-Palliative%20Care%20Module.pdf. Yan, TD., Deraco, M., Baratti, D., Kusamura, S., Elias, D., Glehen, O., (2009). Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for malignant peritoneal mesothelioma: multi-institutional experience. Journal of Clinical Oncology;27(36):6237-42. Read More