Palliative care: not only for treating symptoms: a case report

Introduction

Palliative care (PC) is a medical discipline that was established to prevent or relieve the discomfort of patients with life-threatening diseases and to provide support for patients and their families from a psychosocial and spiritual point of view. It advocates comprehensive person-centered care to ultimately improve quality, if not quantity, of life. ¹ In a cancer setting, whereas PC was initially only hypothesized for use at end of life (EoL), it has now been proposed for use in the early phases of the disease (early PC [EPC]), thus representing a part of the cancer care continuum. ² It has been seen that patients with advanced cancer who receive EPC have a better quality of life and reduced symptom burden. They also actively participate in the decision-making process, with a consequent reduction in indicators of EoL treatment aggressiveness with respect to those who receive PC on demand (i.e. only when specifically requested). ³ Temel et al. ⁴ reported longer survival in patients with metastatic non-small cell lung cancer who underwent EPC. Over time, PC has begun to encompass patients independently of their diagnosis (cancer or chronic disease). The integration of medical oncologists and palliative care specialists in EPC is now strongly recommended. Simultaneous models are now considered a high priority to ensure the best quality and quantity of life for patients and their families. ⁵

PC is unique in that it considers the person independently of the disease, and the success of this approach depends on fundamental elements such as the personalization of treatment and symptom management, diagnostic and prognostic awareness, shared decision-making process, and attention to spiritual well-being and social aspects.^5,6

When symptoms arise, the PC specialist steps in to provide relief with symptomatic therapy, but a global vision of the individual also means looking for the etiopathogenesis of the problem. In considering the overall clinical condition of the patient, the physician can weigh the pros and cons of an in-depth analysis to reach a diagnosis and offer treatment that could perhaps control symptoms definitively.

We present a case report illustrating the successful integration of palliative care, oncology, and radiology in an EPC setting. This approach enabled the multidisciplinary group, headed by the PC clinician, to identify a metastasis of the trigeminal ganglion metastasis, a rare localization of breast cancer. ⁷

The study was carried out in accordance with the principles laid down in the Declaration of Helsinki. Informed consent was obtained from the patient.

Case description

A 79-year-old woman with advanced breast cancer and lung and bone metastases was undergoing chemotherapy with oral 5-fluorouracil at our institute. She had a history of varicella-zoster virus infection and was allergic to the contrast medium used in computed tomography (CT). The patient presented with a 2-week history of progressive asthenia, hyposthenia of the lower limbs and paresthesia around the mouth, convergent strabismus of the right eye, difficulty in chewing, and continuous pain in the right ear extending to the jaw, which responded partially to paracetamol. Upon physical examination, she was also noted to have nystagmus of the right eye.

Contrast-enhanced magnetic resonance imaging (MRI) of the brain was performed (16 November 2018), revealing a frontal lobe lesion attached to the base of the skull hypothesized as meningioma, and some smaller lesions with hyperintense signal identified as potential chronic vascular alterations. On 21 November, the patient was referred by the attending oncologist to our PC Unit. The PC specialist increased the dose of paracetamol, prescribed gabapentin for the referred pain, and repeated blood tests. She asked the referring radiologist to review the MRI again and scheduled a consultation with a neurologist, who hypothesized a differential diagnosis of Gradenigo syndrome or cavernous sinus syndrome because of a deficit in cranial nerves V and VI. He also advised a consultation with an ENT specialist and a review of the previous MRI to look for signs of thrombosis or inflammation of the left sinus. Review of the recent MRI and comparison with a positron emission tomography/CT scan performed in 2016 ruled out meningioma, inducing the group to repeat contrast-enhanced brain MRI, in particular to study the Merkel cave. The new specific MRI revealed an extrameningeal gasserian ganglion metastasis of cranial nerve V (Figures 1–3), causing a partial deviation of the right eyeball and explaining the other symptoms.

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Figure 1.

Contrast-enhanced T1-weighted magnetic resonance image shows oval mass in the left Meckel cave (arrow).

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Figure 2.

Coronal contrast-enhanced T1-weighted magnetic resonance image confirms the lesion in the left Meckel cave (arrow).

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Figure 3.

Sagittal contrast-enhanced T1-weighted magnetic resonance image shows the lesion on the trigeminal nerve, which appears thickened (arrow).

The following week the patient underwent stereotactic radiotherapy of the metastasis. After a month, she was no longer in pain and her performance status was good, but the strabismus and diplopia did not resolve. Chemotherapy was restarted.

Discussion

The present case report shows the advantages of involving other specialists (oncologist, radiologist, neurologist) in EPC and highlights the potential for the PC clinician to further personalize care from a diagnostic point of view. The primary aim of PC is to control symptoms and provide psychological and spiritual support, independently of the disease. Interventions are individual-centered, in contrast to the more disease-oriented focus of the oncologist. Both disciplines have become more complex and specialized over the years, and the integration of oncology and palliative care appears to be the key to improving the quantity and quality of life of cancer patients.^2,5,6,8

The personalization of diagnostic and therapeutic strategies differs on the basis of the discipline. Oncology tends to focus on precision medicine, genomics, and prevention programs, whereas PC, intervening in a specific phase of the disease, encompasses patients and their families as part of the overall care project, fostering diagnostic and prognostic awareness, inviting active participation in the therapeutic decision-making process, and offering support in terms of spiritual and social well-being.^2,5,9

Understanding the cause of the symptom or hypothesizing a cause is an important part of the PC clinician’s work. For example, when delirium occurs in a patient with advanced cancer, the PC specialist evaluates the overall clinical condition of the individual and plans diagnostic interventions on the basis of that situation. The clinician initially looks for reversible causes of delirium, also evaluating when an etiopathogenetic approach might be useful. ¹⁰ Such a strategy might also be useful for other symptoms, including pain.

Only 0.2% of lesions found in the cerebellopontine angle are metastases, and metastases of the gasserian ganglion and trigeminal nerve are even rarer. They may be solitary localizations from lymphoma or lung, breast, or colon cancer, but may also derive from melanoma or renal or thyroid tumors. ⁷ An accurate clinical examination to look for signs and symptoms of trigeminal nerve lesions and a specific study of the Meckel cave by MRI are key to diagnosis. However, as reported by Caraceni et al., ¹¹ it is also possible that MRI may be normal in early-stage lesions despite the presence of symptoms, requiring a repeat scan to be performed after a few weeks to confirm or refute the presence of disease. Meningioma and schwannoma should also be included in the primary differential diagnosis of gasserian ganglion metastasis, and radiotherapy, stereotactic radiosurgery, or surgical exploration are possible treatments. Prognosis has never been defined because of the few cases reported. ⁷

Conclusion

We present a case report that is an example of how the collaborative efforts of a PC clinician, oncologist, and radiologist aimed at understanding the cause of a series of specific symptoms culminated in the discovery of a rare metastasis.

Research into the causes of pain and other symptoms in advanced cancer serves to strengthen the concept of PC as a proper medical discipline, not simply a humanistic branch of medicine, and is especially important in EPC, which can be initiated at any stage of the disease. Simultaneous care resulting from the integration of PC and oncology represents the next step in the area of treatment personalization.