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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 5  |  Issue : 3  |  Page : 112-115

Role of Ayurveda in symptomatic management of pancreatic neuro endocrine tumor - An experience


1 Department of Rachana Sharir, National Institute of Ayurveda, (De-Novo), Jaipur, Rajasthan, India
2 Central Ayurveda Research Institute, Patiala, Punjab, India

Date of Submission28-Dec-2021
Date of Acceptance02-Sep-2022
Date of Web Publication03-Oct-2022

Correspondence Address:
Dr. E M Thrijil Krishnan
Department of Rachana Sharir, National Institute of Ayurveda (De-Novo), Jaipur, Jorawar Singh Gate, Amer Road, Jaipur - 302 002, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jacr.jacr_114_21

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  Abstract 


The incidental diagnosis of neoplasms has greatly increased due to the widespread use of advanced imaging techniques. Pancreatic neuroendocrinal tumors (pNET) comprise 7% of the neuroendocrine tumors (NETs) that can be functional or nonfunctional. Nonfunctional pNETs are more common, which may further extend to the liver and produce symptoms such as loss of appetite, weight loss, and abdominal pain. A 47-year-old male, presented with loss of appetite, anorexia, weakness, and weight loss for the past three months. The patient was diagnosed with pNET and underwent precut sphincterotomy, common bile duct stenting, and Whipple surgery. Recurrent fever with previous complaints persisted even after surgery. The patient was advised to go for further operative procedures but he denied and decided to take Ayurveda treatment. Punarnavashtaka kwatha, Syrup Livomyn, Rohitakarishta, Avipattikara churna, Kutaki churna, and polyherbal decoction prepared with Bhumyamalaki (Phyllanthus niruri Linn.), Patolapatra (Trichosanthes dioica Roxb.), Guduchi (Tinospora cordifolia [Willd.] Miers.), Punarnava (Boerhavia diffusa Linn.), Rakta chandana (Pterocarpus santalinus Linn.), Parpataka (Fumaria parviflora Lam.), and Kiratatikta (Swertia chirata Buch.-Ham. ex Wall.) were prescribed after a thorough examination of the patient. After five months of treatment, the patient got relief from weakness, anorexia, and recurrent fever. Liver functions showed a significant improvement after the treatment. The patient had gained a body weight of four kg and he is able to do his day-to-day activities without lethargy.

Keywords: Amapachana, Pancreatic neuroendocrine tumor, Punarnavashtaka kwatha, Srothodushti


How to cite this article:
Kumar S, Krishnan E M, Kesavan N, Thiyagaraj K, Neelam K. Role of Ayurveda in symptomatic management of pancreatic neuro endocrine tumor - An experience. J Ayurveda Case Rep 2022;5:112-5

How to cite this URL:
Kumar S, Krishnan E M, Kesavan N, Thiyagaraj K, Neelam K. Role of Ayurveda in symptomatic management of pancreatic neuro endocrine tumor - An experience. J Ayurveda Case Rep [serial online] 2022 [cited 2022 Dec 9];5:112-5. Available from: http://www.ayucare.org/text.asp?2022/5/3/112/357785




  Introduction Top


A neuroendocrine tumor (NET) is a neoplasm that arises from the neuroendocrinal cells of the body, especially in the lungs, digestive tract, and pancreas.[1] These cells have traits of both hormone-producing endocrine cells and nerve cells. Pancreatic neuroendocrine tumors (pNETs), which were first described in 1869,[2] are a subgroup of neuroendocrinal neoplasms that have distinct biological behavior arising from the pancreas. Approximately 7% of NETs develop in the pancreas.[3] pNETs are otherwise called islet cell tumors. Although the incidence of pNETs is ≤1 case/100,000 individuals/year, their incidence is gradually increasing in recent years.[4] PNETs are clinically classified as functioning or nonfunctioning, depending on whether they release hormones that produce symptoms. About 60%–90% of pNETs are nonfunctioning and largely asymptomatic.[5] In contrast, functioning pNETs are much more uncommon and associated with symptoms due to hormonal hypersecretion. Nonfunctioning pNETs cause nonspecific symptoms such as vague abdominal pain and can be an incidental finding when imaging tests such as Computed Tomography (CT) or magnetic resonance imaging scans are done for other reasons.[6]

There are no clear differences in the epidemiology of pNETs based on race, sex, geographic area, or socioeconomic status.[7] Studies reported that the crude annual incidence of pancreatic NETs/1,000,000 is 1.8 in females and 2.6 in males.[8] If untreated, most pNETs grow and eventually metastasize to the liver; extensive liver metastasis is the most common cause of death for patients with pNETs. The biological behavior of an individual pNET is unpredictable. Surgical resection is still the only curative therapeutic option for localized pNETs.

In Ayurveda, all types of growths can be categorized under Arbuda (~tumor). According to the manifested symptoms, Arbuda can be classified based on involved Dosha (~regulatory functional factors of the body). On considering the site of disease, it comes in Pittasthana, i.e., “Hritnabhiyomadhya” (~in between Hridaya and Nabhi).[9] Thus, treatment should be done by targeting the predominant Dosha. In the present case study, the patient was diagnosed with a nonfunctional pancreatic neuroendocrinal tumor with altered liver functions even after the surgery, and the condition was managed with Ayurveda herbal preparations.


  Patient Information Top


A 47-year-old man, nonalcoholic and nonsmoker, medium built with a body weight of 53 kg, having Kapha pitta prakruti (~Kapha-pitta psychosomatic constitution), presented to the outpatient department with complaints of recurrent fever, loss of appetite, indigestion, weakness, and weight loss for the past three months. There was no family history of similar complaints. The patient had been experiencing difficulty to carry out the daily chores due to severe fatigue and weakness.


  Clinical findings Top


In May 2020, the patient experienced severe chest pain and was found with the symptoms of myocardial infarction and underwent percutaneous transluminal coronary angioplasty. After one month, he started experiencing severe abdominal pain and backache with recurrent fever and was admitted to an allopathic hospital. After examination and investigation, the condition was diagnosed as pancreatitis. Contrast-enhanced CT (CECT) scan showed atrophy of liver segments IV, V, and VIII with mild caudate hypertrophy and a small suspicious intraluminal lesion in the second part of the duodenum. Upper gastrointestinal endoscopy showed Grade-B esophagitis, erosive gastritis with an ampullary mass. Histopathological features were suggestive of pNETs Grade I. Endoscopic retrograde cholangiopancreatography report showed large periampullary diverticula. A mass was seen with ulceration arising from the inferior aspect of ampulla/duodenum and it was difficult to cannulation of the Common Bile Duct (CBD) diagnosed with NET of the ampulla of Vater. Thereafter patient underwent precut sphincterotomy and CBD stented with 10 FR (French sized catheter) Double Pigtail stent (DPT) plastic stent in June 2020.

The symptoms were not reduced and after two months, the patient again suffered from high-grade fever, abdominal pain, and jaundice with severe fatigueness. CECT whole abdomen was done and the report showed altered attenuation of islet cells tumor lesion measuring approximately 19 mm × 18 mm × 20 mm in pancreatic head/periampullary region that indicates progression of the tumor. Then, the patient had undergone Whipple procedure in August 2020.

After the surgery, the patient was discharged from the hospital on September 4, 2020. After 1 month, on October 8, 2020, the patient started experiencing severe weakness, fever, anorexia, loss of appetite, and noticeable weight loss. Blood investigations showed elevated serum glutamic oxaloacetic transaminase (SGOT) (278.1 U/L), serum glutamic pyruvic transaminase (SGPT) (243.3 U/L), and serum alkaline phosphatase values (258.9 U/L). In March 2021, the patient again visited the gastroenterology department and was suggested for percutaneous transhepatic biliary drainage with stenting but he denied it and decided for Ayurveda consultation.


  Timeline Top


The timeline of the present case is depicted in [Table 1].
Table 1: Timelines of therapeutic interventions

Click here to view



  Diagnostic assessment Top


The patent underwent upper GI Endoscopy on June 5, 2020, and found esophagitis, erosive gastritis, and ampullary mass. Histopathological analysis of ampullary mass showed features suggestive of NET. The diagnosis was confirmed by tumor marker studies. Tumor marker studies on July 16, 2020, showed diffusely positive for synaptophysin and chromogranin-A and Mitochondrial Calcium Uniporter 1 (MCU-1). Endocrine testing, imaging, and histopathological evidence were considered diagnostic criteria of pNETs.


  Therapeutic interventions Top


After a thorough examination, the patient was prescribed with polyherbal formulations [Table 1]. The patient was advised to visit at frequent intervals for evaluation and assessment.


  Follow-Up and Outcome Top


The patient was assessed at regular intervals for the response to the treatment based on changes in physical symptoms and laboratory parameters. After five months of treatment, the patient got relief from weakness, anorexia, and recurrent fever. Liver functions showed a significant improvement after the treatment [Graph 1]. The patient had gained a body weight of 4 kg and he is able to do his day-to-day activities without lethargy.




  Discussion Top


As per the fundamentals of Ayurveda, harmony among the Dosha, Dhatu, and Mala (~waste products) are essential for the maintenance of health.[10] Agni (~digestive factors) has an important role in the physiological functioning of the body. Here, in this case, Jatharagni (~metabolic factors located in the digestive tract) and Dhatwagni (~metabolic factors located in Dhatu) were altered. Agnimandya (~diminution of Agni), Arochaka (~tastelessness), and Dourbalya (~weakness) were the main symptoms seen in the patient which shows the involvement of Ama.[11] Raising SGOT, SGPT, and ALP levels in the blood can be considered Amavisha. The symptoms of Amavisha such as Srotorodha (~obstructive pathology occurring in channels), Balabhramsa (~diminution of physical strength), and Gaurava (~heaviness in the body) were manifested. In the stage of Ama, proper Paka (~digestion or transformation) of Rasa dhatu (~primary product of digested food) is not produced from the Ahara rasa and leads to Rasavaha sroto dushti (~deformity in the body channels).[12] This further triggered manifestation of recurrent fever. Rasa (~primary product of digested food) attained Amlatva (~sourness) that lead to Dushti (~vitiation) of Pachakapitta (~Pitta that is situated in between the Amasaya and Pakvasaya which divides the food into Sara [~nutritive] and Kitta [~waste] portions) in Koshta (~bowel). As Rasa dhatu gets vitiated, Dhatwagni (~metabolic factors located in dhatu) got affected and it hampered the proper Paka (~digestion) of Utharothara dhatu, which leads to weight loss. Since Rakta (~blood tissue), Mamsa (~muscle tissue), and Medodhatu (~fat tissue) got vitiated, Kittaroopamala (~waste product) accumulated, and Dosha dushya sammurchana occurred in the Agnyasaya (~pancreas) where there is Khavaigunya (~vacant space) and it manifested as a pancreatic tumor.

Agnideepana (~enhancing digestive fire), Amapachana (~digestion), Pitta shamana (~pacification of Pitta), Dhatu poshana (~nourishment of Dhatu), and Yakrit samrakshana (~hepato protective) are the treatment principles adopted here. Pitta dosha (~Dosha responsible for regulating body temperature and metabolic activities) and Raktadhatu are Anyonyashrita and both are involved here. Pitta and Rakta dushti are treated with Sodhana chikitsa (~purification therapy) and Yakrit vikara shamana chikitsa. Most of the drugs prescribed here are Tikta rasa pradhana (~bitter taste predominant) that are Pitta shamana. Punarnavashtaka kwatha is indicated in Sarvanga sopha (~swelling all over the body) and its contents have the property of Agni deepana and Pitta shamana, Jwara shamana (~pacification of fever), especially for Amapachana (~digestion), which helped in the initial stage of the treatment.[13] Avipattikara churna removes Mala mootravibandha (~obstruction to the passage of feces and urine) and Agnimandhya hara (~increases the power of digestion, assimilation, and metabolism).[14] Katuki has Bhedana swabhava (~purgative in nature) and helped to attain Anulomata (~evacuation of the flatus) of Vata.[15] In the later phase, Punarnavashtaka kwatha was replaced by Kwatha prepared with a combination of Bhumyamalaki (Phyllanthus niruri Linn.), Patolapatra (Trichosanthes dioica Roxb.), Guduchi (Tinospora cordifolia [Wild.] Miers.), Punarnava (Boerhavia diffusa Linn.), Rakta chandana (Pterocarpus santalinus Linn.), Parpataka (Fumaria parviflora Lam.), Kiratatikta (Swertia chirata Buch.-Ham. Ex. Wall.) for Pitta shamana (~pacification of Pitta), Rakta shodhana (~purification of blood), and Yakrit samrakshana. The overall therapy helps the patient to get symptomatic relief.


  Conclusion Top


The present case report shows that Ayurveda management has given a symptomatic result in the symptoms of patients with pNET. On the second visit, the patient had no weakness, improved appetite and there was no recurrence of fever. On the third visit, the effect of the treatment was sustained and there was weight gain and he was well able to perform day-to-day activities. It encourages the physicians that the name of the disease is not important, moreover, it is the Yukti (~logical management) of the physician to treat the patient with the most suitable medicines by assessing the Agni, predominant Dosha and Dhathu involved, and Avastha of Roga (~stage of disease).

Declaration of patient consent

Authors certify that they have obtained patient consent form, where the patient has given his consent for reporting the case along with the images and other clinical information in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dasari A, Shen C, Halperin D, Zhao B, Zhou S, Xu Y, et al. Trends in the incidence, prevalence, and survival outcomes in patients with neuroendocrine tumors in the United States. JAMA Oncol 2017;3:1335-42.  Back to cited text no. 1
    
2.
Ma ZY, Gong YF, Zhuang HK, Zhou ZX, Huang SZ, Zou YP, et al. Pancreatic neuroendocrine tumors: A review of serum biomarkers, staging, and management. World J Gastroenterol 2020;26:2305-22.  Back to cited text no. 2
    
3.
Available from: http://www.cancer.net/cancer-types/neuroendocrine-tumor-pancreas/introduction/. [Last accessed on 2021 Jan 09].  Back to cited text no. 3
    
4.
Hallet J, Law CH, Cukier M, Saskin R, Liu N, Singh S. Exploring the rising incidence of neuroendocrine tumors: A population-based analysis of epidemiology, metastatic presentation, and outcomes. Cancer 2015;121:589-97.  Back to cited text no. 4
    
5.
Metz DC, Jensen RT. Gastrointestinal neuroendocrine tumors: Pancreatic endocrine tumors. Gastroenterology 2008;135:1469-92.  Back to cited text no. 5
    
6.
American Joint Committee on Cancer. Neuroendocrine Tumors of the Pancreas. AJCC Cancer Staging Manual. 8th ed. New York, NY: Springer; 2017.  Back to cited text no. 6
    
7.
Yao JC, Hassan M, Phan A, Dagohoy C, Leary C, Mares JE, et al. One hundred years after “carcinoid”: Epidemiology of and prognostic factors for neuroendocrine tumors in 35,825 cases in the United States. J Clin Oncol 2008;26:3063-72.  Back to cited text no. 7
    
8.
Halfdanarson TR, Rabe KG, Rubin J, Petersen GM. Pancreatic neuroendocrine tumors (PNETs): Incidence, prognosis and recent trend toward improved survival. Ann Oncol 2008;19:1727-33.  Back to cited text no. 8
    
9.
Paradakara HS, editor. Ashtanga Hridayam with Sarvanga Sundaram of Arunadatta and Ayurveda Rasayana of Hemadri, Sutra Sthana. Ayushkameeya Adhyaya. 10th ed., Ch. 1, Ver. 7. Varanasi: Chaukumbha Sanskrit Orientalia; 2005. p. 32.  Back to cited text no. 9
    
10.
Paradakara HS, editor. Ashtanga Hridayam with Sarvanga Sundaram of Arunadatta and Ayurveda Rasayana of Hemadri, Sutra Sthana. Doshadivijnaneeya Adhyaya. 10thed., Ch. 11, Ver. 1. Varanasi: Chaukumbha Sanskrit Orientalia; 2005. p. 182.  Back to cited text no. 10
    
11.
Kunte AM, Sastri KR, editors. Ashtanga Hridayam, Sutra Sthana. Doshopakramaniya Adhyaya. Ch. 13, Ver. 23-4. Varanasi: Chaukambha Orientalia; 2013. p. 216.  Back to cited text no. 11
    
12.
Kunte AM, Sastri KR, editors. Ashtanga Hridayam, Sutra Sthana. Doshopakramaniya Adhyaya. Ch. 13, Ver. 27, Varanasi: Chaukambha Orientalia; 2013. p. 216.  Back to cited text no. 12
    
13.
Annonyms. Sahasrayogam; Kashaya Prakarana. Ver. 46. Varanasi: Chaukambha Sanskrit Series Office; 2008. p. 35.  Back to cited text no. 13
    
14.
Mishra SN, editor. Bhaisajya Ratnavali of Govind Das Sen, Amlapitta Rogadhigara. Ch. 6, Ver. 24-8. Varanasi: Chaukambha Surbharati Prakashan; 2005. p. 903.  Back to cited text no. 14
    
15.
Sastri PR, editor. Sarngadhara Samhita, Purva Khanda; Deepanapachana Vidhi. Ch. 4, Ver. 06. New Delhi: Chaukambha Publications; 2013. p. 36.  Back to cited text no. 15
    



 
 
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