Case Study: Mr. Qiu, Liposarcoma Treated With TCM (Treatment Failure)
This is one of my own failed TCM cases. The late Shanghai master Cheng Menxue once resolved to publish his own failed cases for the instruction of later learners, but unfortunately, for various reasons, the book was never completed.
Every physician treating disease has both successful and unsuccessful cases. In treating tumors—so-called world medical puzzles—failures outnumber successes.
Successful experience is of course worth consulting, but failed lessons are also worth learning. For each physician, reflecting on failure, drawing lessons from it, and constantly improving oneself is very necessary.
Yet because of self-interest and personal reputation, very few throughout history have been willing to publish their failed cases. I often regret being unable to read failed cases and learn from them to avoid detours.
Therefore, beginning with this piece, I will, for the rest of my days, gradually set down some typical failed cases for the reference of others learning TCM cancer treatment.
Mr. Qiu
Male, born June 1979, a native of Wenzhou, Zhejiang. On February 23, 2017, invited by Mr. Qiu, I went to Hangzhou to see patients, and first examined him at the Zhejiang Hotel in Hangzhou.
In November 2013, because of occasional lower-back soreness and distension, the patient was diagnosed at Zhejiang Provincial First Hospital with liposarcoma (right retroperitoneum). On November 20, 2013 he underwent right retroperitoneal tumor resection plus right adrenalectomy. Postoperative pathology: retroperitoneal liposarcoma (some areas dedifferentiated into high-grade sarcoma). On May 12, 2015, follow-up retroperitoneal MRI at Hangzhou First People's Hospital showed multiple nodular abnormal signals at the junction of the left and right liver and in the right posterior peritoneum; a cystic lesion in the right kidney with mild dilation of the renal pelvis.
In July 2015 the patient underwent one session of retroperitoneal radiofrequency ablation at Renji Hospital affiliated to Jiaotong University. On May 11, 2016, follow-up retroperitoneal MRI showed, after retroperitoneal liposarcoma surgery, perineural and adjacent perihepatic and paravertebral abnormal signals roughly unchanged from the film of March 9, 2016.
On September 3, 2016, follow-up lumbar MRI at Tianjin Cancer Hospital showed multiple space-occupying lesions in the right kidney, considered recurrence, involving the right psoas major and L1 accessory processes; L4–S1 disc herniation. On September 11 and 19, 2016 he underwent argon-helium cryoablation at Tianjin Cancer Hospital.
On December 26, 2016, MRI at Shanghai Proton and Heavy Ion Hospital showed: after retroperitoneal liposarcoma surgery, multiple masses around the right kidney and beside the L1 vertebral body, consistent with clinical recurrence given the history; multiple hepatic nodules of indeterminate nature—complex cysts? post-metastatic-treatment change?—clinical correlation advised; postoperative changes around the right kidney, tiny right renal cysts. General condition fair; appetite and diet fair; defecation and urination normal; no significant weight loss.
From January 19 to February 10, 2017, the patient underwent carbon-ion radiotherapy at Shanghai Proton and Heavy Ion Hospital. The course was smooth; white blood cells and neutrophils dropped, possibly related to the carbon-ion therapy; after oral leucogen they did not worsen. Pigmentation appeared in the treatment field without redness or ulceration, considered a grade-1 skin reaction. There may still be residual lesions near the spinal cord.
The patient's history includes H. pylori, low bone density (normalized after more sun exposure), gallbladder polyps (later resolving on their own as cholesterol dropped), high uric acid in 2012 (later self-resolved), persistent hepatic hemangioma, mild tricuspid regurgitation, and mild prostatic hyperplasia.
Appetite currently fair; diet leans light; recently has bad breath, and a dry nose when talking a lot; urination and defecation normal, stool formed but the patient feels it is sticky and damp. Nocturia is frequent. On rainy days he feels more tired, and sleep does not restore him.
Left pulse fine, faint, deep, small and rapid, soft and weak; the chi pulse rather restless, the cun and guan weak.
Right pulse fine, faint, deep, soft and weak, with a slight slippery quality; the right chi pulse deep and hidden, not emerging.
The patient denies dizziness or blurred vision, denies sore and weak loins and legs; shoulders and back are rather hard and tight; the right lower back is tender on pressure; slight bitter mouth on waking; bowel sounds; the area around the navel rather hard; hands and feet cold. The right leg once had shingles.
Before illness the patient was a technical backbone at a well-known state-owned enterprise, with intense workload and high pressure; he had studied in the UK.
On comprehensive analysis, I judged the patient to have spleen-kidney yang deficiency with untransformed phlegm-dampness, an yin pattern, and decided to treat primarily with a modified Yanghe Tang combined with Jiangjiang San, plus Xihuang Wan.
Decoction:
Lujiaojiao (Cervi Cornus Colla) 12g (melt separately), Shudi 40g, Baijiezi (Sinapis Semen) 12g, Rougui 12g (add later), Sheng Mahuang 3g, Paojiang (blast-fried ginger) 6g, Sheng Gancao 6g, Pian Jianghuang 6g, Chao Jiangcan 10g, Chanyi 6g, Huangjing 12g, Baihe (Lilii Bulbus) 12g, Maidong 12g, Sheng Huangqi 30g, Danggui 12g, Nüzhenzi 10g, Baishao 10g, Tongcao (Tetrapanacis Medulla) 3g, Gegen 20g.
Taken all at once in the morning.
Guipi Wan (Jiuzhitang), twice a day, 8 pills each time.
Xiaoyao Wan (stop once the bitter taste disappears).
Xihuang Wan (Beijing Tongrentang), once a day, 3-6-9-12-12-12-12g, at bedtime (reduce or pause if the stomach is too irritated).
Fufang Banmao Jiaonang (Guizhou Yibai) (pause if urination increases or decreases; resume when normal).
Take all medicines for one week, then stop one week.
Stop medicines during colds.
Avoid all raw-cold, greasy, grilled, pickled, salted-vegetable and seafood foods.
March 7, 2017: after I emergency-treated a patient in Yiwu and passed through Hangzhou, the patient returned for follow-up.
Pulse deep and slippery; interior cold-phlegm; icy limbs. Palms sweat easily. After the first prescription, blisters appeared at the corners of the mouth and the hands peeled; stool moist. The patient reported his limbs were not warm and numb. The decoction was changed to a modified Guizhi Wuwu Tang:
Sheng Huangqi 15g, Guizhi 12g, Baishao 12g, Shengjiang 24g, Dazao 4 pieces, Baijiezi 12g, Cangzhu 12g, Ezhu 6g, Sanleng 6g, Xianhecao 30g, Pian Jianghuang 6g, Chanyi 6g, Chao Jiangcan 10g.
Patent medicines unchanged.
April 12, 2017: the patient came to Beijing and, fasting in the morning, followed up in my study.
Since the last Hangzhou follow-up, on top of the decoction he added Neixiao San (along with norcantharidin tablets), Xihuang Wan, Pingxiao Pian, and Shenqi Shiyiwei Keli.
The patient felt an aching, faint heaviness at the back lesion, especially when tired. After adding Neixiao San, he had two bowel movements a day, the second unformed. Hands and feet gradually felt warmer.
Left pulse soft, fine and slightly rapid, with a slight wiry quality in the chi; overall a faint (wei) pulse.
Tongue coating basically normal.
Right cun and chi deep, faint and slightly rapid; guan pulse fine, slippery and rapid.
Appetite good; stool sticky; nocturia frequent; sleep quality rather poor; legs aching.
Sheng Huangqi 15g, Guizhi 12g, Baishao 12g, Danggui 12g, Shengjiang 24g, Dazao 4 pieces, Baijiezi 12g, Cangzhu 12g, Ezhu 6g, Sanleng 6g, Xianhecao 30g, Pian Jianghuang 6g, Chanyi 6g, Chao Jiangcan 10g, Huai Xiaomai (whole wheat) 30g, Sheng Gancao 6g, Bajitian 15g, Yinyanghuo 15g, Tusizi 10g, Shayuanzi 10g, Fa Banxia 10g, Jiao Sanxian each 10g, Yuanhu 20g, Wuyao 10g, Jinyingzi (Rosa Laevigatae Fructus) 15g.
Take one dose of Guipi Wan at bedtime.
May 29, 2017.
Right pulse slippery and rapid.
Left pulse deep, fine and rapid.
Right lower back pain.
One box of Guifu Dihuang Wan.
June 24, 2017: invited to Hangzhou by another patient's family, the patient again sought follow-up.
Pulse and tongue records are incomplete; only the prescription remains:
Shengdi 10, Shudi 10, Chuanxiong 10, Danggui 10, Guizhi 10, Baishao 10, Baizhu 10, Fuling 10, Fa Banxia 10, Dan Nanxing 10, Baijiezi 6, Taoren 10, Honghua 6, Chuanniuxi 10, Duzhong 10, Xuduan 10, Ezhu 10, Sanleng 10, Danpi 15, Pugongying 15, Rendongteng 15, Yejuhua 6, Tiankuizi 6, Diding 6, Xuanshen 12, Zhebei 12, Sheng Muli 30 (decoct first), Haifushi 30 (decoct first), Haizao 30, Kunbu 30, Dibiechong 15, Taoren 10, Shu Dahuang 6, Daji 15, Xiaoji 15, Mohan Lian 6, Nüzhenzi 6.
Patent medicines as before.
July 31, 2017
Records incomplete; likely the patient had a local TCM physician take his pulse, reported it to me, and asked for an adjustment. Recently the pulse was deep and fine, with lower-back pain.
Shudi 15g, Zhi Shouwu 15g, Huangjing 15g, Maidong 10g, Yuzhu (Polygonati Odorati Rhizoma) 10g, Tusizi 10g, Shayuanzi 10g, Bajitian 15g, Yinyanghuo 15g, Yuanhu 10g, Wuyao 6g, Xuduan 10g, Duzhong 10g, Cangzhu 10g, Houpo 10g, Baizhu 15g, Dangshen 15g, Fuling 10g, Zhi Gancao 10g, Rougui 10g, Mugua 10g, Huainiuxi 10g, Jinyingzi 15g, Pian Jianghuang 6g, Chao Jiangcan 10g, Chantui 6g, Xianhecao 30g, Ezhu 10g, Baihua Shejicao 15g, Tengligen 15g, Banzhilian 15g, Mohan Lian 10g, Nüzhenzi 10g, Sheng Huangqi 30g, Yiyiren 60g, Zexie 10g, Han Fangji 15g, Chao Baishao 20g, Dibiechong 10g, Chao Zhiqiao (stir-fried Aurantii Fructus) 6g.
Patent medicines:
1. Fufang Banmao Jiaonang
2. Xihuang Wan
3. Pingxiao Pian
4. Neixiao San
Below is the patient's own added account of his condition:
My lower back first began to hurt in 2007. I went to the hospital; after ruling out ankylosing spondylitis and lumbar disc herniation, the final diagnosis was fasciitis, treated with massage and relaxation, which later eased.
From 2007 until the tumor was found in 2013, the lower-back muscles were very stiff; when it ached I used massage to relieve it. In November 2013 the tumor was found and operated on; after surgery my lower back felt very relaxed.
Recurrence came in 2015, and in July 2015 I had radiofrequency intervention; the radiofrequency needle entered from the side of the waist between L3 and L2. After treatment a tender point remained at the puncture site, persisting until a few days ago, when floating-needle therapy made it disappear.
In mid-May 2016, lower-back and hip pain appeared; I had been practicing qigong a lot that month. At first I thought it was over-practice. After the pain appeared I did not treat it specifically; I saw a lumbar specialist, who diagnosed "L3 syndrome" and used acupuncture plus moxibustion on the L3 transverse process, about three sessions. Meanwhile, in mid-June, a TCM physician changed the formula to Guizhi Jia Xin Tang and Dayuan Yin; in early July the back pain suddenly eased and my lower back felt very comfortable.
In September 2016, in Tianjin, I had interventional cryotherapy on the tumor beside the spine. During the freezing I felt a cold current run down under the abdominal fascia to the groin; I thought the ureter was carrying the cold down, but the doctor said it was too far away and not the ureter. After the cryotherapy, the skin at the lower back and hip felt as though anesthetic were always on it; tactile sensation was badly damaged.
From October to December 2016 there was continuous lower-back and hip discomfort, worst when sitting; I often felt a cold-water flow in the right hip as if from an air conditioner. By December, with no treatment, the symptoms slowly vanished, and sensation in the right hip skin began to return a little.
In February 2017 I had heavy-ion radiotherapy. After discharge there were no symptoms for three months, until mid-May when lower-back and hip discomfort returned: a cold flow in the right hip when sitting, and aching, worst when sitting.
Later I took Shenzhuo Tang (prescribed by me) for three days and Xiayuxue Tang (prescribed by me) for three days; by mid-June it gradually eased, though discomfort remained without affecting daily life.
Then, in early July, after a car trip to my father-in-law's home, I felt the lower back and hip tired after sitting long; a week later the discomfort returned. Now I use floating-needle therapy, which has made the post-radiofrequency tender point between L3 and L2 disappear.
In addition, sensation in the lower back and hip skin has basically returned; there is no cold-water flow when sitting, but the aching in the lower back and hip has worsened, and the entire lower-back muscles have been like dead wood, without elasticity, since the radiotherapy.
Follow-up August 9, 2017
After the above formula, the patient developed a rash on his face.
Lower-back pain recurred, unbearable; pulse as before.
Shudi 10g, Huangjing 10g, Maidong 10g, Yuzhu 10g, Tusizi 10g, Shayuanzi 10g, Bajitian 10g, Yinyanghuo 10g, Yuanhu 10g, Wuyao 6g, Xuduan 10g, Duzhong 10g, Cangzhu 10g, Houpo 10g, Baizhu 10g, Dangshen 10g, Fuling 10g, Zhi Gancao 6g, Rougui 10g, Mugua 10g, Huainiuxi 10g, Jinyingzi 15g, Pian Jianghuang 6g, Chao Jiangcan 10g, Chantui 6g, Xianhecao 30g, Ezhu 10g, Baihua Shejicao 15g, Tengligen 15g, Banzhilian 15g, Mohan Lian 10g, Nüzhenzi 10g, Sheng Huangqi 30g, Yiyiren 60g, Zexie 10g, Han Fangji 15g, Chao Baishao 20g, Dibiechong 10g, Chao Zhiqiao 6g, Chaihu 10g, Huangqin 10g, Chao Zhizi 10g.
Patent medicines:
1. Fufang Banmao Jiaonang
2. Xihuang Wan
3. Pingxiao Pian
4. Neixiao San
On September 5, 2017, follow-up MRI showed increased signal and disease progression. Over half a year of Chinese-Western treatment had failed.
Summarizing this patient's course, I believe the reasons for failure were as follows:
First, liposarcoma has no blood vessels inside; it is what TCM calls the "gaohuang" region, and the medicinals taken cannot reach the lesion, so treatment can hardly be effective.
Second, the approach was repeatedly adjusted during treatment. Over half a year, the broad prescribing strategy changed several times. Part of this was my own lack of confidence in my pattern differentiation, and part was the patient's own doing.
The patient studied TCM extensively in his spare time and consulted many other TCM physicians. Their opinions on his pattern disagreed, which influenced my treatment.
The late veteran TCM physician Yue Meizhong wrote an essay, "For Chronic Diseases, Have a Fixed Formula and Hold to It; For Acute Diseases, Have Courage and Insight," stressing that for chronic diseases one should hold to the prescribing strategy and not lightly change course.
For chronic diseases such as tumors, after pattern differentiation one should hold to a basic strategy, making only minor adjustments at each visit. Repeatedly changing the broad strategy is a cardinal error in treating chronic disease, not a blessing for the patient.
On this point, the late Shi Jinmo, one of Beijing's four great modern physicians, also especially emphasized holding to the formula. A patient who had failed a previous doctor after a long course came to Shi; Shi kept the previous doctor's original formula unchanged, only changing each herb's name to its alias, and had the patient take it, finally effecting a cure.
Treating major and chronic disease is not the work of a day. If opinions diverge and the strategy shifts morning to evening, it is hard to end well.
Third, during treatment I took the patient's condition too lightly. When I took him on, he was quite satisfied with the result of proton/heavy-ion therapy, and his Western doctor had told him it would not recur for a long time; so I used relatively mild medication, aiming only to prevent recurrence.
In fact, later follow-ups showed the heavy-ion therapy had not achieved much, and I missed the window for using aggressive medicinals to attack the tumor.