Pain management in palliative cancer patients: a prospective observational study on the use of high dosages of transdermal buprenorphine.

INTRODUCTION: Despite guidelines and recommendations, a large proportion of patients with cancer still have inadequate pain control. Transdermal opioid administration can overcome problems such as swallowing and compliance, because only one application every three days is needed. Transdermal buprenorphine was documented to provide effective pain relief in cancer and non-cancer patients. A ceiling effect was described in animals at supratherapeutic dose levels. OBJECTIVES: This prospective observational pilot study was designed to explore the need for doses of transdermal buprenorphine beyond the recommended maximum dose of 140 microg/h, in a cohort of palliative patients with cancer pain. METHODS: 36 consecutive palliative patients with uncontrolled cancer pain were prescribed transdermal buprenorphine after having received adequate information on the disease, its evolution, the pain and the drug. They gave written informed consent for participation in this observational study. Pain intensity and use of breakthrough medication were registered by the patient and the health care provider. RESULTS: Pain was judged to be satisfactory controlled, by the patient and the health care providers, in 21 of 28 evaluable patients at a dose lower than or equal to 140 microg/h. The success rate was higher in the hospitalized patient group. The observation of adequate pain control in two patients treated with doses up to 210 microg/h supports the hypothesis that buprenorphine dose titration above 140 microg/h can be clinically effective and well tolerated. This also refutes the assumption of a clinically relevant ceiling effect. CONCLUSIONS: Transdermal buprenorphine control cancer pain in the majority of palliative patients.

Cyclophosphamide, doxorubicin, and cisplatin in advanced salivary gland cancer.

OBJECTIVES: Advanced salivary gland cancer is a rare disease that comprises different histopathological tumour types; correspondingly, data on palliative systemic treatment are scarce. Combination chemotherapy with cyclophosphamide, doxorubicin, and cisplatin (CAP) has been reported to induce a reasonable response rate, although fewer than 100 cases have been described. We conducted a retrospective review of advanced salivary gland cancer patients treated with CAP. METHODOLOGY: Fifteen consecutive patients with recurrent, locally advanced, or metastatic progressive salivary gland cancer treated with CAP were identified over a five-year period. The mean age at start of treatment was 53.5 years, and the male/female ratio was 11/4. The most common histological subtypes were adenoid cystic carcinoma and adenocarcinoma not otherwise specified (NOS), with the parotid gland as the most frequently affected anatomical site. RESULTS: A response rate of 60% was achieved, with one complete and eight partial responses and six stable diseases according to RECIST criteria. No patient progressed under treatment. An average of 5.4 treatment cycles were administered; median time to progression after ending CAP was 6.6 months, and median overall survival was 15.1 months. Patients with adenocarcinoma NOS appeared to benefit more than patients with adenoid cystic carcinoma, but had a shorter time to progression. Except for neutropenia with neutropenic fever and alopecia, no NCI-CTC grade III or IV toxicity was observed. CONCLUSION: This retrospective study confirms the clinically meaningful efficacy of CAP in advanced adenocarcinomas NOS of the salivary gland in routine practice, with acceptable safety levels.

A case series of embryonal rhabdomyosarcoma of the head and neck in adults.

Embryonal rhabdomyosarcoma (RMS) is a rare malignant mesenchymal tumour that is believed to arise from cells committed to a skeletal muscle lineage. The head and neck region is among the most frequent locations for embryonal RMS in adults. We present a retrospective review of seven patients treated in our institution between 2000 and 2008. The age at diagnosis ranged from 19 to 41 years. One patient received primary surgery followed by adjuvant radiotherapy. Six inoperable patients were treated along a single chemotherapy protocol: the VIA-VIP regimen (a combination of vincristine, ifosfamide and doxorubicin (VIA) in alternation with etoposide, ifosfamide and cisplatin (VIP) administered in 3-weekly cycles), followed by local therapy, involving radiation therapy and/or surgery. An objective response to chemotherapy was observed in all six patients. Three out of seven patients remain disease-free with a median follow up of 4.5 years. Although the prognosis of head and neck embryonal RMS is worse in adults than in children, a multimodality treatment combining surgery, radiotherapy and intensive chemotherapy is feasible and effective in this population.