CASE REPORT

Diagnosis: Pancreas cancer + bone metastases - SO

A forty-year-old woman's medical condition deteriorated within a week in September 1997. She first experienced non-specific pain in her abdomen, indigestion, and bloating. Then urea color turned yellow. When her skin color turned pale, she was admitted on 11 September 1997 to Bursa High Specialization Hospital (Bursa Yuksek Ihtisas Hastanesi) ( Appendix SO1 ). Laboratory tests demonstrated that conjugated bilirubin and alkaline phosphatase levels were 18 mg/dL and 1008 U/L respectively. Ultrasound examination of the abdomen showed that the gall bladder was hydropic and that the choledoch had enlarged to about three centimeters. Laparotomy was performed on 18 September. A 7x8 cm tumor that was attached to vena porta was located in the pancreatic head. Latero-lateral choledochoduodenostomy and cholecystectomy were performed. Since the stomach passage was normal, application of gastroenterostomy was found to be unnecessary ( Appendix SO2 ). The patient was discharged on 24 September 1997.

While recovering at home, the patient started to experience pain in her abdomen and in other locations of her body. She presented to Bursa Ali Osman Sonmez Oncology Hospital on 23 October 1997. Bone scintigraphy performed on 24 October demonstrated increased activity in the right 6^th and 7^th costae's posterior sites, lumbar 5^th vertebra's right side, as well as in the right parietal bone in the form of a focal point. Activity accumulation was noted to be irregular in the vertebral column. All these scintigraphic lesions were interpreted as being bone metastases ( Appendix SO3 ).

An abdominal computed tomography (CT) scan was performed on 28 October 1997 with and without contrast ( Appendix SO4 ). It demonstrated in the right posterior liver lobe a hypodense lesion that measured 4.5x3.5 cm, and that applied pressure to the surrounding structures. The scan revealed at the head of the pancreas site a tumoral mass that showed a remarkable lobulation towards the front. It infiltrated the second part of the duodenum in lateral, and the mesenteric vein in front and medial. This was found to be consistent with inoperable head of pancreas tumor. A thorax CT scan performed on the same day revealed no pathological finding ( Appendix SO5 ).

Chemotherapy was recommended, but the patient declined.

The patient was taken to Dr. Ozel on 29 October 1997. She had wide spread sharp pain in the chest and abdomen. No jaundice was present. On physical examination, there was fullness in epigastrium and right hypochondrium; the muscles thereof were stiff, and even slight pressure upon them caused pain. The patient was previously diagnosed as having head of pancreas carcinoma with bone metastases. A test dose of 0.4 cc caused a fever of 37.8^o C. The patient was placed on a daily regimen of 0.4 cc dose of N.O.I. for six days per week, and 1 cc of N.O.O. to be administered three times daily after the meals. It was advised to adjust NOI dosage according to the maximum fever.

The patient presented to Dr. Ozel on 18 December 1997 for a follow up. She had with her a thorax CT examination performed on 11 December ( Appendix SO6 ) and an abdominal CT examination performed on 15 December ( Appendix SO7 ). Thorax computed tomography demonstrated no significant pathological findings. Abdominal CT showed: 1) a small lobule image at the head of the pancreas site, but no other tumor image was seen, 2) sequelae alike images in the hepatic right posterior lobe. The liver lesion of 4.5x3.5 cm demonstrated on the CT scan of 28 October had disappeared. On physical examination, all systems were found to be normal. She was free of any pain. 0.4cc dose of NOI was still causing a fever of about 37.7^o C, and the patient was recommended to continue N.O. treatment according to the regimen previously described.

The patient came for another follow up on 20 March 1998 with lumbar vertebrae radiograms taken on 12 February ( Appendix SO8A ) and lumbar MR images obtained on 17 February ( Appendix SO8B ). Except for a suspicious focus nearby the left sacroiliac joint, there was no pathological finding. The patient was recommended to continue the same N.O. treatment scheme.

She presented to Dr. Ozel for follow up on 5 May 1998. On physical examination, there was a thrombosed hemorrhoids sac located 1 cm far from the anal ring in 9 o'clock position. There were no other findings, and the patient had no complaint. She stated that since recently she had been experiencing no fever after N.O. injections. The patient was then placed on a maintenance regimen with 0.4cc of N.O.I. to be given every two days, and 1 cc of N.O.O. to be administered daily three times.

She came for follow up on 10 February 1999 with an abdominal ultrasonogram obtained on 3 February that demonstrated no pathological finding ( Appendix SO9 ). The patient had been pregnant for 10 weeks, and the obstetrician who was following her was worried about her pregnancy. He had told her that her baby might born with defects since she had been receiving treatment for cancer. Dr. Ozel advised her to stop the maintenance treatment and continue the pregnancy. In September 1999, she gave birth to a healthy baby boy.

The patient visited Dr. Ozel in May 2002 with her 2.5-year-old son. Both of them were in excellent health.

In March 2007, the patient and her 8 years old son were living normal daily life in Bursa.