Two Case Reports: TCM for Postoperative Diarrhea in Cancer Patients (Lymphoma and Liposarcoma)

Case 1: Mr. Gong, a lymphoma patient from Hubei

Mr. Gong is from Zigui County, Yichang, Hubei Province. On April 1, 2021, he first consulted me via online video to resolve his postoperative diarrhea and to prevent tumor recurrence.

The patient reported that his diet was normal but his bowel movements were irregular, with about 8–12 stools a day, which caused him great distress. The stool was sometimes dry and sometimes unformed; he suspected it was related to his recent rectal tumor surgery. Over the past year, he had been getting up to urinate 2–5 times at night, affecting his sleep. His urine was clear; his lower back did not hurt. He drank relatively much water and liked hot drinks; drinking cold water caused immediate diarrhea. His mouth was not bitter; he felt a slight aversion to cold.

For many years he had not sweated no matter how much he exercised, and could not even sweat in summer. His shoulders and back did not hurt and his neck was not tight. Early-stage lymphoma of the gastric fundus was discovered in 2015; after surgical treatment, he could sweat when exercising.

In March 2021, a 5 cm mass was again found in the pelvis; on March 7, 2021, he underwent a second surgery at the Zigui County People's Hospital. Postoperative pathology (pathology no. B202100903) showed non-Hodgkin B-cell small lymphocytic lymphoma. After surgery he was anemic, easily fatigued, with poor sleep quality, easy waking and night sweats. Although the pelvic mass had been removed, there were still scattered, multiple enlarged lymph nodes in the pelvis; in 2017, peripheral nerve injury medication caused symmetrical, continuous pain in the skin of both knees.

Height 165 cm, weight 69 kg; blood pressure and blood glucose were normal, with no obvious change from before illness. Overview of the various treatments the patient had received and their efficacy: from April to November 2015, 6 chemotherapy sessions and 28 radiotherapy sessions controlled the early lymphoma of the gastric fundus; in March 2021 a 5 cm pelvic mass was found and surgically removed, and the medical record showed non-Hodgkin B-cell small lymphocytic lymphoma.

Allergy history: allergic to Xuesaitong (a Panax notoginseng injection powder) and fat emulsion. The patient's paternal uncle died of esophageal cancer; his nephew died of lung cancer; his parents, grandparents, siblings and other immediate relatives were all healthy.

I considered this a Guizhi Jia Gegen Tang (Cinnamon Twig plus Kudzu Decoction) pattern, and treated it with modified Guizhi Jia Gegen Tang combined with Yupingfeng San (Jade Windscreen Powder).

Guizhi (Cinnamon twig) 15 g, Baishao (white peony) 15 g, Gegen (Kudzu) 30 g, Zhi Gancao (honey-fried licorice) 10 g, Sheng Huangqi (raw Astragalus) 30 g, Danggui 6 g, Jiao Baizhu (charred Atractylodes) 10 g, Fangfeng (Saposhnikovia) 10 g, Pao Fuzi (prepared aconite) 15 g (decoct first for 30 minutes), Zhi Biejia (honey-fried turtle shell) 24 g (decoct first for 30 minutes), Da Xueteng (Sargentodoxa) 30 g, Jixueteng (Spatholobus) 30 g, Baijiangcao (Patrinia) 15 g, Baitouweng (Pulsatilla) 15 g, Buguzhi (Psoralea) 10 g, Roudoukou (nutmeg) 10 g, Wuweizi (schisandra) 10 g, Wuzhuyu (Evodia) 3 g, Shengjiang (fresh ginger) 7 slices, Dazao (jujube) 7 pieces.

Decoct in water; one packet a day, divided into 2–3 doses, taken after meals.

Decoction method: For the first decoction, first boil Fuzi and Zhi Biejia for half an hour, then add the other herbs; soak all together for 10 minutes, bring to a boil over high heat, then simmer over low heat for 20 minutes. For the second decoction, no order is needed; bring directly to a boil over high heat, then simmer over low heat for 20 minutes. Each time add water to 1–2 cm above the herb surface. Combine the two decoctions, divide into 2–3 portions, and take one after each meal.

Continue this formula until the frequency of bowel and urinary movements is basically normal, then change the formula.

Patent medicine: Fufang Banmao Jiaonang (Compound Blister Beetle Capsules, Guizhou Yibai Pharmaceutical), taken according to the package insert.

Follow-up video on April 6, 2021.

The patient reported that he started the first formula on April 2; while taking it, bowel movements were difficult. On the 3rd he passed stool more than ten times within two hours; on the 4th and 5th he continued taking it, and the diarrhea stopped, while nighttime urination decreased to once or twice.

The prescription was adjusted, using modified Herong Sanjian Tang (Harmonizing-Nourishing Hard-Dispersing Decoction) for the enlarged lymph nodes: Taizishen (pseudostellaria) 10 g, Baizhu 10 g, Fuling 10 g, Zhi Gancao 6 g, Chuanxiong (Ligusticum) 6 g, Baishao 6 g, Danggui 6 g, Shudi (rehmannia) 6 g, Chenpi (tangerine peel) 6 g, Jiegeng (platycodon) 6 g, Kunbu (Ecklonia) 15 g, Duan Muli (calcined oyster shell) 30 g, Xuanshen 12 g, Zhe Beimu 12 g, Shengma (Cimicifuga) 6 g, Honghua (safflower) 6 g, Fengmi (honey) 60 g (stirred into the decoction), Pian Jianghuang 6 g, Chan Yi 6 g, Chao Jiangchan 10 g, Sanleng (Sparganium) 6 g, Ezhu 6 g, Banzhilian 20 g, Baihuasheshecao 20 g, Xianhecao 50 g, Baijiangcao 20 g, Yiyiren 30 g.

Patent medicine: Fufang Banmao Jiaonang, taken according to the package insert.

After half a month on the second prescription, everything was going well with no adverse reactions, so the medicine was changed to pills.

Case 2: Mr. Wang, a dedifferentiated liposarcoma patient

Video consultation on April 26, 2021.

In February 2020, the patient went to the hospital for abdominal distension and was found to have liposarcoma; he underwent surgery at the Third Hospital of Xi'an, Shaanxi. The pathology report of that hospital, dated February 10, 2020, no. 202000773: (tumor below the pancreas, tumor anterior to the left kidney, tumor anterior to the right kidney) mesenchymal tissue tumor; based on histomorphology and immunohistochemistry, considered of adipose origin, consistent with dedifferentiated liposarcoma.

Afterward the patient had a second recurrence; by the time of consultation he had already undergone three surgeries. Each postoperative pathology was retroperitoneal dedifferentiated liposarcoma. The first surgery removed five sarcomas, located respectively below the pancreas, behind the duodenum, anterior to the left kidney, anterior to the right kidney, and anterior to the abdominal aorta; no organs were removed. A CT on the eighth postoperative day showed multiple nodules around the left kidney. After discharge, chemotherapy began in March—five sessions—but the left-kidney nodules kept growing and chemotherapy was ineffective. In mid-August 2020, a second surgery removed the tumor anterior to the left kidney; the tumor had invaded the left kidney, so the left kidney and spleen were removed along with it, and part of the psoas major muscle was resected. After surgery he had continuous diarrhea, with thigh muscle soreness, indigestion, a thick greasy tongue coating and aversion to cold, and anemia. Eight months after the second surgery, examination again showed recurrence in the pelvis; the pelvic mass was large, pressing on the bladder, and he could not eat. On April 18, 2021, a third surgery removed the pelvic mass and the mass of the left psoas major. This surgery was less traumatic, but because the mass was large the wound was fairly big and he was still recovering. At present he still felt cold, with diarrhea three or four times in the morning, obvious soreness of the left thigh muscle (possibly caused by surgery, since the main operative area was on the left), poor appetite, a thick greasy tongue coating, fatigue and weakness, calcified pulmonary nodules, cough, weak immunity and frequent colds.

The patient had had continuous diarrhea, watery stools, ever since the second surgery, and repeated use of all kinds of Chinese and Western medicines had been ineffective. Reviewing the previous doctors' prescriptions, they were basically formulas to fortify the spleen and stop diarrhea.

The consultation revealed: severe diarrhea with watery stools. Diarrhea three or four times in the morning; after the first surgery he had had more than ten diarrheal stools a day, now stable at five or six. His appetite was worse than before, with a thick greasy tongue coating, no appetite, and not even wanting to drink water. Long-term aversion to cold had been marked since the year before diagnosis (2018). After diagnosis of liposarcoma, he often had red, painless rashes on the skin. Weak immunity: a slight chill brought on a cold, with headache and fever, frequent headaches, and no runny nose. Urine was clear with much foam. The mouth was not bitter. Tongue was enlarged with teeth marks and a yellow greasy coating. After meals he had paroxysmal sweating, sometimes so profuse that the pillow grew damp; ordinarily he did not sweat, he feared wind and cold, and felt cold after eating.

Sleep quality was fair. His build had long been overweight; height 172 cm, over 180 jin before diagnosis, now over 140 jin. His limbs were relatively thin and weak while his abdomen was large. The left thigh muscle was sore after surgery but did not twitch. Lung function was poor, with pulmonary nodules partly calcified; he often coughed with an itchy throat. Heart rate and blood pressure were normal. He had type 2 diabetes, long controlled with metformin. After surgery, urination was weak; during diarrhea he often went to the toilet with no stool, sometimes watery, with long-term borborygmus.

Seeing that previous doctors had used many warming-tonifying herbs without effect, I decided to treat him with the original Baitouweng Tang (Pulsatilla Decoction): Baitouweng 30 g, Huanglian 6 g, Huangbo 12 g, Qinpi (ash bark) 12 g.

Three days later, the family reported that the first stool had begun to form, though the daily stool count was still five or six; his appetite had improved markedly. I therefore added a few herbs to the original formula: Baitouweng 30 g, Huanglian 6 g, Huangbo 12 g, Qinpi 12 g, Machixian (purslane) 30 g, Baizhu 10 g, Fuling 10 g, Zhi Gancao 10 g.

Three days after taking the second prescription, the patient's stools were reduced to three a day, each formed and no longer watery. But later he ate some wild vegetables and the diarrhea returned.

Considering that the patient had just had surgery and needed nourishment, I added some qi-boosting, spleen-fortifying herbs to the original formula: Dangshen (Codonopsis) 30 g, Huangjing (Polygonatum) 30 g, Baitouweng 30 g, Huanglian 6 g, Huangbo 12 g, Qinpi 12 g, Machixian 30 g, Baizhu 10 g, Fuling 10 g, Zhi Gancao 10 g. I told him to stop once the stools normalized, and to start anti-tumor medicines after the perioperative period.

Diarrhea is a common aftereffect of surgery in cancer patients; its cause is complex, the postoperative diarrhea of many patients is intractable and hard to treat, and it affects the patients' quality of life. TCM pattern differentiation and treatment has certain advantages in treating diarrhea. The treatment of these two patients was symptomatic supportive care guided by TCM pattern differentiation.