The patient is a 79-year-old woman admitted to our hospital in mid-August 2022 for "distension and pain in the upper and middle abdomen for 1 week and pancreatic occupancy for 6 days." In fact, the patient could maintain a normal life and take care of herself except for distension and pain in the upper and middle abdomen without any cause, accompanied by nausea and a small amount of vomiting, which were mostly gastric contents. The KPS score of the patient was approximately 80. The aforementioned condition could evidently be aggravated by hunger and was relieved by eating small amounts of food. There was no fever, chills, diarrhea, or black stool. At first, she went to the local hospital to find elevated CA 19-9 levels (details unknown), and abdominal ultrasonography suggested an occupancy in the head of the pancreas. For further diagnosis and treatment, the patient came to our hospital with a diagnosis of pancreatic mass. The patient denied a past history of hypertension, diabetes mellitus, hepatitis, tuberculosis, etc. and denied any history of surgical trauma. The hospital conducted a physical examination as follows: T 36.9 C, R 19 bpm, HR 85 bpm, BP 159/72 mmHg, and pain score 1. The patient was conscious and mentally competent. The skin and sclera were not yellowish and without enlarged superficial lymph nodes, with clear breath sounds in both lungs and uniform heart rhythm without cardiac murmur. The abdomen was flat with normal bowel sounds and negative shifting dullness. The whole abdomen was soft without abnormal masses and pressure pain or rebound pain. There was no edema in both lower extremities, and the pathological features were negative.
The supplementary examination included the blood count: WBC, 6.0*10^9/L; Neo, 3.32*10^9/L; HB, 128 g/L; and Plt, 254*10^9/L.
Blood biochemistry was reported as follows: K, 3.78 mmol/L; ALT, 19 U/L; AST, 17 U/L; AKP, 123 U/L; gammaGGT, 45 U/L; ALB, 42.9 g/L; TBIL, 6.3 mumol/L; and DBIL, 1.0 mumol/L. Blood glucose was 11.4 mmol/L. Tumor markers included CA 19-9, 69.8 IU/mL; CEA, 1.39 ng/mL; CA 15-3, 10.60 U/mL; CA 125, 14.30 U/mL; and AFP, 1.77 ng/mL. CT scan images of admission (Figure 1) showed occupancy in the pancreas head, which was considered to be cancer, with an involvement of the gastroduodenal artery and the superior mesenteric vein, and a soft tissue mass shadow was observed in the pancreas head, approximately 57*32 mm.
Ultrasound endoscopy showed a well-defined and irregular hypoechoic mass in the pancreatic head with a vascular invasion of approximately 43*29 mm. The preliminary diagnosis was considered pancreatic malignancy (cT3N0M0, stage IIA), which indicated the clinical diagnosis stage. Due to excessive SMV involvement and evaluation of posterior venous unresectable reconstruction, the disease was diagnosed as locally progressive unresectable pancreatic cancer. The current standard first-line treatment for advanced unresectable pancreatic cancer is based on a gemcitabine regimen. However, the patient insistently refused chemotherapy after repeated communication and explanation, and based on its immune regulation mechanism, combining our previous medication experience with the icaritin soft capsule, we tried to recommend lenvatinib and icaritin soft capsule for treatment. To the best of our knowledge, no case study was found to be reported to treat pancreatic cancer until now.
The patient underwent a CT review after 1 month of medication, and although the huge mass did not shrink and significant cystic necrosis was visible inside, in the meantime, the significant spillage of the contrast agent could be observed, suggesting the possibility of bleeding inside a tumor. It was inferred that the disease has been controlled (Figure 2). Since the tumor envelope was still intact, it was considered that the risk of progressive bleeding could be avoided by self-compression to stop the bleeding. Generally speaking, short-term and small amounts of bleeding have limited harm, but it could lead to death with a large amount of bleeding. The patient was discharged after conservative treatment in the hospital.
The patient came to our hospital for the second time due to sudden abdominal pain. The routine blood tests showed WBC, 12.0*109/L; Neo, 9.82*109/L; CRP, 188.5 mg/L; blood amylase, 239 IU/L; and lipase, 231.10 IU/L; all of the aforementioned indicators were elevated. The tumor biomarker of CA 19-9 showed a decrease from 70 IU/mL to 30 IU/mL, and the imaging showed a 52% reduction in tumor size (35*28 mm), a reduction in superior mesenteric vein (SMV) involvement, and significant relief of vascular stenosis. The efficacy of lenvatinib and icaritin soft capsules was evaluated comprehensively and reached PR with significant tumor remission after 2 months (Figure 3). Anti-infective and amylase-lowering symptomatic treatment was given for acute pancreatitis after her admission into the hospital.
On 15 October 2022, the patient was readmitted to the hospital again with sudden onset of abdominal pain for 1 day, and routine blood showed WBC, 14.7*109/L; Neo, 11.98*109/L; CRP, 156.3 mg/L; blood amylase, 211.6 IU/L; and lipase, 224.0 IU/L. CT of the abdomen showed a diffuse inflammatory exudate below the pancreas, suggesting secondary acute pancreatitis (Figure 4). Also, the tumor lesion was approximately 20% smaller than last time and 57.5% smaller overall than before treatment. The vascular involvement was also reduced and the proximal stenosis of SMV was also relieved with a better contour. The patient's condition was regarded to be locally advanced pancreatic cancer as before, and the surgical assessment met the criteria for SMV resection and reconstruction (Figure 4). Therefore, its TNM stage was downgraded from T3N0M0 (stage IIA) before the treatment to T2N0M0 (stage IB) after the treatment, and surgery was recommended as an effective treatment choice. Meanwhile, the patient requested the surgery after another two cycles of medication due to the results being beyond her expectation. The patient was admitted to the hospital only for an anti-infective symptomatic treatment of secondary acute pancreatitis.
Unfortunately, the patient stopped taking these two drugs for financial reasons and was re-examined 1 month later, which showed an increase of 1 cm in the active component of the primary pancreatic lesion (original necrotic part), an increment of 2 cm in the tumor located in the pancreatic hook, and multiple metastases in the hepatoduodenal ligament and the hepatogastric ligament based on the results of abdominal CT imaging. Also, increased tumor biomarkers, such as CA 19-9 (241.1 U/mL) and ferritin (686.0 ng/mL), on November 3 suggested tumor progression. Later, the patient took Tegio as treatment, and CA 19-9 increased to 501.6 U/mL in December without a CT review (Figure 5). Also, the patient is still alive today.