Palliative and end of life care issues of carcinoma thyroid patient.

Malignancies of the thyroid gland has steadily increased over the last few decades, out of which mostly are differentiated carcinomas of the papillary or of follicular type, have a good prognosis and highest cure rate if treatment commences early. Here, we report a case of an 18-years-old boy with a huge multinodular goiter, which compromised the airway and lung metastasis, presented at advance stage of disease in tertiary care center. Factors prevent early diagnosis and treatment, distressing symptoms patient can develop, palliation of those symptoms, and effort to be made to prevent the delay are highlighted.

INTRODUCTION

Malignancies of the thyroid gland are relatively rare worldwide, but incidence has steadily increased[1] over the last few decades. The majority of thyroid cancers are differentiated carcinomas of the papillary or of follicular type, which typically have a good prognosis and highest cure rate.[2] Here, we report a case of an 18-year-old boy with a huge multinodular goiter, noted swelling first at 5 years of age, which compromised the airway with retro-sternal extension and tracheal compression. He was operated twice and found to be irresectable, further line of management from palliative care point highlighted in this text.

This case also draws our attention towards those factors which prevent the early diagnosis and treatment of these types of malignancies in which early diagnosis and treatment implications can change the whole prognostic scenario of the patient.

CASE REPORT

An 18-year-old male presented with multiple swellings [first swelling appeared at the age of 5 years] involving the entire neck [Figure 1] with history of dyspnea, change in voice, and 4 episodes of hemoptysis. The amount of blood was around 10 - 15 ml, and color was bright red. From the past 1 year, he had the complain of dyspnea on moderate exertion, which aggravated on neck flexion and also developed change in the voice. No other significant history was present.

Figure 1

Patient with a large goiter in propped up position

On examination, he looked well, not in distress or sweating. His body weight 35 kg, heart rate was 92 beats/ min, and blood pressure 100/70 mmHg. Local neck examination showed multiple nodular swellings with enlarged thyroid more on the right side moving with swallowing, firm in consistency, nodular surface, not tender with normal overlying skin, swelling seen extending from 1 cm above thyroid notch up to suprasternal notch, lower margin of the swelling could not be make out, swelling on right side extends 2 cm beyond posterior border of sternocleidomastoid muscle [Figure 2]. Larynx and trachea displaced towards left side, right carotid vessel displaced anteriorly, bruit heard and thrill felt, left carotid thrill also felt; engorged right external jugular vein was seen.

Figure 2

Patient with a large goiter in sitting position with neck extended

Cardiovascular and abdominal system examination was normal. Chest examination revealed bilateral decreased air entry more at basal region. Chest x-ray showed thin miliary nodules in both lung fields with basal predominance, suggestive of metastasis [Figure 3].

Figure 3

Chest x-ray shows multiple miliary mottling

X-ray soft tissue neck-AP and lateral view [Figure 4] showed calcified mass lesion in neck compressing trachea with retrosternal extension into superior mediastinum. Trachea was shifted to left side.

Figure 4

Lateral neck x-ray shows goiter extension to pretracheal and paratracheal area

Laboratory investigations were within normal range.

Fine needle biopsy showed papillary carcinoma thyroid. The patient was scheduled to undergo total thyroidectomy under general anesthesia. During surgery, it was found that tumor was unresectable due to an extensive involvement of major blood vessels of the neck, therefore, case was closed. We shifted the patient to ICU, ventilated him overnight and successfully extubated him on next day.

DISCUSSION

Thyroid cancer which involves the laryngotracheal airway is an uncommon[3] but serious clinical problem, its incidence has been reported to be 0.5 to 2.2%[4] among all thyroid cancers. From the anesthetic point of view, intubation and extubation could be quite challenging. However in this case, we did not face any problem during intubation and extubation but since the tumor was non-resectable, the main concern was to extend the life and to palliate the distressing symptoms due to progressive disease. Various distressing symptoms patient can develop due to local structure invasion such as pain, hoarseness of voice, dyspnea, dysphonia, hemoptysis, and dysphagia.[5] The most commonly invaded organs in WDTC [well-differentiated thyroid cancer] are the larynx and trachea,[6] and their involvement causes death from asphyxia. Thyroid cancer metastasizes to distant sites such as lung, bone, and liver can cause pain and other dysfunction. Psychological disturbances include depression, anxiety, insomnia, and delirium.[78] These symptoms are often a source of great discomfort and distress for the patient and for his family and raise a challenge for the treating doctor.

Challenging issues are[9]:

Physical problems faced by patient, which carry a poor prognosis.

End of life care and psychosocial issues.

Physical problems

Pain[910] - It is quite disappointing for the patient and should be treated as early as possible. Find out the cause and prescription of appropriate analgesics [opoids or non-opoids] and adjuvant drugs, with addition of drug to control the intolerant adverse effects of analgesic, is the mainstay of treatment. Sometimes patient may respond with palliative chemotherapy, radiotherapy, or specific intervention [nerve block, neurolysis, trigger point injection etc.].

Excess oral secretion and salivary drooling[911] - Treat with pharmacologic inhibition [hyoscine hydrobromine transdermal patch or 150 – 300 μg SL or Glycopyrronium 200 – 400 μg SC or 400 – 1200 μg by continues SC infusion or hyoscine butyl bromide 20 mg orally or SC and 40 – 180 mg by CSCI] or radiation, or surgery.

Breathlessness[912] – Due to tracheal invasion or compression, patient may develop breathlessness. This should be managed by explaining the cause and the treatment plan to patient with involvement of physiotherapist to teach breathing techniques and use of relaxation and cognitive behavioral therapy techniques. Oxygen, heliox, inhaled furesemide, anti-depressant, facial cooling by fan, opoids for reduction of sensation of breathlessness and benzodiazepines for panic and anxiety attack and sometimes non-invasive ventilation can be used.

Dry cough[13] – If there is no underlying reversible cause, it can be suppressed by oral antitusive or use inhaled or nebulized steroids or inhaled cromolyn sodium or lidocaine, nebulized morphine, paroxetine, benzodiazepines, etc.

Fear and panic- Occurs due to compressive symptoms and impending death, should find out the underlying cause and seek help with clinical psychologist for patients with complex problem or start benzodiazepine.

Management of bleeding[14] – Identify and treat underlying cause, if appropriate consider hemostatic agents and dressings, anti-fibrinolytic agent, vit. K, vasopressin / desmopressin, octreotide / somatostatin, blood product transfusion, radiotherapy, endoscopic ligation and coagulation, and transcutaneous arterial embolization and for patient at risk of major bleed in the terminal phase, use of sedative medications[9] like midazolam buccal /IV/IM/SC or diazepam per rectum and green towels or surgical clothes to minimize the visual impact of blood loss. If major bleed occurs, stay with and reassure the patient and family.

Lymphedema[15] – Manage with good skin care, regular exercise of effected limb, manual lymph drainage, massage therapy, compressive therapy or some patients require radiotherapy or chemotherapy or dexamethasone 16 mg daily for 1 week for acute lymphatic obstruction.

The majorities of thyroid cancers[9] are slow growing and have an excellent prognosis after surgical and medical therapy, therefore, the early diagnosis and institution of treatment is necessary. The major challenges for early diagnosis and treatment are

Negligence or lack of knowledge[16-19] - Unawareness, lack of education, social and domestic[20] responsibilities are the causes attributes delay from patient side.

Paucity of approach[19] - Lack of approach or accessibility to health care services causes delay.

Financial constraints[21] – In our country, one of the very important factors leading to delay in seeking medical advice.

Quacks and alternative treatment modalities – An improper guidance may lead to aggravation of disease and delay in the diagnosis and hence for treatment.

Non-uniformity of medical advice – Due to unconsensus opinion regarding the treatment modalities, patient gets confused and leads to delay in seeking the proper treatment.

Fear of surgery – Many patients have various fears regarding surgery; therefore, the proper counseling is necessary.

Palliative care should not only include physical symptoms management but also cover psychological, spiritual, and social aspect of care. Integrated care pathway should be opted, especially for the patients who are at the last stage.

CONCLUSION

A patient of advance thyroid malignancy should receive palliative support in the form of disease management, symptom control, and psychosocial care.

In the above-discussed case, patient has reached a point of no return due to delayed diagnosis, therefore, for the prevention of such type of incidences in future, the government, health care professionals and NGO'S should work at the grass root level to develop health care awareness in uneducated, poor, rural-based peoples, and there should be an easy accessibility and proper guidance by primary health service centers. Involvement of the local self governments [Panchayat] in the provision of care in the locality will be essential for ensuring sustainability of the projects at the primary health care system level. Legislation introduced and funds allotted by the government are important for establishing a stable system that can achieve a meaningful coverage, should reach to all and provide continued care of patients discharged from referral or specialist centres.