Exploring Ayurvedic Treatment Options for Periampullary Cancer with Lung Metastasis: A Comprehensive Case Study
- DR Dinesh Vats
- Dec 31, 2024
- 5 min read
Updated: Feb 7
Periampullary Cancer Overview
Periampullary cancers are aggressive cancers that typically arise within 2 cm of the major papilla, where the common bile duct (CBD) opens into the second part of the duodenum.
Ampullary: Cancer arising on the ampulla of Vater.
Biliary: Intrapancreatic distal bile duct, also called Pancreatic ductal adenocarcinoma.
Pancreatic: Arises in the head of the pancreas.
Duodenal: Arises in the second part of the duodenum.
Signs and Symptoms of Periampullary Cancer
Signs and symptoms of periampullary cancer Are:
Jaundice caused by compression or blockage of the common bile duct, leading to extrahepatic biliary obstruction (EHBO) and could be painless
Yellowish discoloration of skin/sclera (due to jaundice)
Itching
Generalized weakness
Nausea/vomiting
Bloating
Weight loss
Anemia
Diagnosis
Ultrasonography (USG): Ultrasonography (USG): Useful for detecting extrahepatic biliary obstruction but not definitive for diagnosis.
Triphasic CT: Useful for diagnosing periampullary carcinoma and assessing the status of periampullary lymph nodes, liver metastasis, pancreatic metastasis, and lung metastasis. It also help to further decide the treatment plan.
Magnetic Resonance Cholangiopancreatography (MRCP): Provides accurate anatomical position and size of the cancer.
Positron Emission Tomography - Computed Tomography (PET-CT): Ideal for diagnosing and staging periampullary carcinoma.
Endoscopic Ultrasonography (EUS): Useful for measuring and determining the extension of periampullary masses. A gastroenterologist can take a biopsy of the masses and periampullary lymph nodes for confirmatory diagnosis and TNM staging.
Endoscopic Retrograde Cholangiopancreatography (ERCP): Helpful in diagnosis and management, allowing for biopsy from the tumor and placement of CBD stents in case of biliary obstruction to decongest the hepatobiliary system.
Keywords
Cancer, Periampullary cancer, Whipple Procedure, Chemotherapy, Radiotherapy, Ayurvedic Treatment.
Management
Whipple Procedure (Pancreatoduodenectomy): The preferred treatment for patients with localized disease.
Chemotherapy: Used for patients with metastasis, along with CBD stents to decompress the hepatobiliary system.
Case Presentation
In this case presentation we will discuss cancer with lung metastasis Ayurvedic management.
A 64-year-old male with Type 2 Diabetes Mellitus (T2DM) and quadriparesis (secondary to cervical laminectomy for OPLL in February 2023, complicated by cord edema) developed altered bowel habits in February 2024, along with generalized weakness, yellowish skin discoloration, and brownish urine.
Evaluation Timeline:
23-Feb-2024: Mild increase in serum bilirubin, SGOT, SGPT, and alkaline phosphatase levels; moderate anemia; normal kidney function test and viral markers.
29-Feb-2024: Mild increase in bilirubin level and reduction in SGOT and SGPT levels.
14-Mar-2024: Significant increase in bilirubin and alkaline phosphatase levels.
16-Mar-2024: Abdominal ultrasonography shows dilated CBD with abrupt cut-off at the distal part, suspicious soft tissue, and upstream mild CHD, IHBR dilatation.
17-Mar-2024: MRCP shows mass lesion in distal common bile ducts in the periampullary region with severe dilatation of proximal CBD, CHD, and central and peripheral intrahepatic duct dilatation, suggestive of malignant stricture - extrahepatic cholangiocarcinoma.
18-Mar-2024: Tumor marker CA19-9 was normal (6.83 U/mL).
Subsequent Consultations and Treatments:
19-Mar-2024: Consulted at a tertiary center for Whipple surgery but required further evaluation. Planned for CBD stenting with ERCP, but it was not possible due to blockage by the periampullary mass. Managed with PTBD on 21-Mar-2024 and advised for Triphasic CECT Abdomen and Chest for staging.
28-Mar-2024: Biopsy report showed adenomatous polyp with high-grade dysplasia.
Initiation of Ayurvedic Treatment
24-Mar-2024: Started personalized Ayurvedic treatment to prevent further progression of the disease until definitive treatment could begin.
Follow-up Imaging and Biopsies:
09-Apr-2024: CECT chest & abdomen showed EHBO with mild central and peripheral IHBRD, pneumobilia with biliary stent in situ, hypo-enhancing thickening involving the duodenal wall around the stent in distal CBD, significant locoregional lymphadenopathy, and random pulmonary nodule suggestive of metastasis.
27-Apr-2024: Whole body PET-CT showed hypermetabolic irregular soft tissue mass in the 2nd part of the duodenum involving distal CBD, faint FDG avid prominent precaval lymph node, and faint FDG avid subcentimeter soft tissue nodule in the lower lobe of the left lung, suggestive of metastasis.
01-May-2024: PET-CT guided lung nodule biopsy suggested adenocarcinoma (CK-positive).
02-May-2024: EUS guided periportal lymph node biopsy showed no malignant cells.
24-May-2024: Hepatobiliary surgery consultation refused surgery due to distant metastasis; referred to radiotherapy.
Staging: After going through PET-CT reports and biopsy reports Patient is diagnosed as T2N0M1 or can say CUP(Cancer of unknown primary origion) or Stahe 4 cancer.
25-May-2024: Radiotherapy consultation advised IHC of previous biopsy.
28-May-2024: Further radiotherapy consultation requested patient review.
04-Jun-2024: Re-consultation advised further biopsy for chemotherapy evidence.
06-Jun-2024: Consulted in a private hospital for PTBD stent removal due to recurrent cholangitis; PTBD stents removed and CBD stents placed. EUS guided biopsy taken from periampullary mass for surgical pathology and cytopathology.
12-Jun-2024: Surgical pathology report showed no evidence of dysplasia or malignancy.
19-Jun-2024: Further medical oncology consultation advised re-biopsy.
10-Oct-2024: Due to recurrent cholangitis, CBD stents changed and biopsy taken, reported on 19-Oct-2024 as CK 7: Negative, CK 20: Negative, CDX2: Focally Positive, Ki-67: High Index, CEA: Negative, CA 19.9: Negative, CK 19: Positive, synaptophysin: Negative. Diagnosis: IHC profile consistent with periampullary carcinoma.
18-Dec-2024: Medical oncology consultation advised whole body PET-CT for staging along with routine blood tests and CA 19.9.
20-Dec-2024: Whole body PET-CT showed metabolically active residual disease at the periampullary region along the CBD stent, few small paraduodenal lymph nodes without significant metabolism, and no other hypermetabolic malignant lesions elsewhere. Mild increase in the size of the periampullary lesion compared to the previous PET-CT dated 27-Apr-2024. CA 19.9 levels were still normal at 0.75.
Staging: After going through the latest PET-CT report patient is now in T2N0M0 or we can say in stage 2.
27-Dec-2024: Medical oncologist consultation refused chemotherapy due to resistance in the periampullary area. Suggested three options: radiotherapy consultation for RT of the tumor, surgical oncology consultation for pancreatoduodenectomy, and EUS guided radiofrequency ablation.
Conclusion: Periampullary cancers are very aggressive with poor prognosis if not treated promptly. In this case study, Ayurvedic treatment was initiated immediately after the diagnosis of Stage 4 Cancer (T2N0M1, or CUP) and continued throughout the treatment period. The supportive Ayurvedic treatment inhibited the metastasis of cancer and slowed the growth of the tumor Stage 2(T2N0M0). Unlike chemotherapy, Ayurvedic treatment was well tolerated by the patient and did not show specific or non-specific side effects. Weight loss, loss of appetite, and anorexia are common in cancer patients, but with this personalized Ayurvedic treatment, our patient was free from such side effects. This case study suggests that Ayurvedic treatment can be effective in managing cancer until biopsy-proven evidence allows for definitive treatments such as surgery, chemotherapy, radiotherapy, or immunotherapy.. These treatments are evidence-based, but sometimes obtaining evidence may take several weeks to several months. During this phase, personalized Ayurvedic treatment can be started to prevent further progression of the disease as in this case Patient improves from stage 4 to stage 2.
Well done drsab👍🏻