Predicting the survival of patients with bone metastases treated with radiation therapy: a validation study of the Katagiri scoring system.

BACKGROUND: The selection of radiation therapy dose fractionation schedules for bone metastases is often based on the estimation of life expectancy. Therefore, accurate prognosis prediction is an important issue. It is reported that the Katagiri scoring system can be used to predict the survival of patients with bone metastases. We aimed to assess prognostic factors and validate the Katagiri scoring system in patients who were treated with radiation therapy for bone metastases. MATERIALS/METHODS: We retrospectively reviewed data of all patients who were treated with radiation therapy for bone metastases between 2004 and 2013. Age, sex, Karnofsky performance status (KPS), Eastern Cooperative Oncology Group performance status (ECOG PS), primary site (lesions and characteristics), visceral metastases, laboratory data, previous chemotherapy, and multiple bone metastases were analyzed for associations with overall survival (OS). Katagiri scores were calculated for each patient and were used to compare OS. RESULTS: Out of the 616 patients included in this analysis, 574 had died and 42 remained alive. The median follow-up time for survivors was 42 months. Univariate analysis revealed that age (P = 0.604) and multiple bone metastases (P = 0.691) were not significantly associated with OS. Multivariate analysis revealed that sex, ECOG PS, KPS, primary characteristics, visceral metastases, laboratory data, and previous chemotherapy were significantly associated with OS. The survival rates at 3, 6, 12, and 24 months, categorized by Katagiri score, were as follows: score 0-3, 94.4, 77.8, and 61.1%, respectively; score 4-6, 67.7, 48.7, and 31.2%, respectively; and score 7-10, 39.1, 22.1, and 9.0%, respectively (P < 0.001). CONCLUSION: Sex, ECOG PS, KPS, primary characteristics, visceral metastases, laboratory data, and previous chemotherapy were significant predictors of survival in patients with bone metastases. The Katagiri scoring system was significantly correlated with OS and can help us select the optimal dose-fractionation.

Guidelines for parenteral fluid management for terminal cancer patients.

BACKGROUND: Japan's first guidelines for parenteral fluid management for terminal cancer patients were issued in 2006. These guidelines focused on the fluid levels to administer to patients with a remaining life expectancy of 1-2 months. However, recent refinement of the concept of cachexia is prompting caregivers worldwide to rethink parenteral fluid management for terminal cancer patients. OBJECTIVE: Our objective was to develop guidelines for parenteral fluid management for terminal cancer patients with a remaining life expectancy of 1 month, a point when cachexia generally begins to severely adversely affect the body. METHODS: The Japanese Society for Palliative Medicine appointed a Guidelines Working Practitioner Group consisting of a multidisciplinary team of specialists. In response to 26 clinical questions on parenteral fluid management for terminal cancer patients, the Working Group used the Delphi method to reach consensus on the recommendability and evidence level of 89 relevant manuscripts identified through a systematic literature review. The Working Group then had an outside committee reviews the draft guidelines validity before authoring the final version. RESULTS: The resulting clinically aligned guidelines contain specific recommendations (25 recommendations on physical suffering/remaining life expectancy, 10 nursing-related recommendations and 4 ethical recommendations) assessed using the Delphi method and by an outside committee. CONCLUSIONS: Japanese Society for Palliative Medicine released a revised edition of the Guidelines for Parenteral Fluid Management for Terminal Cancer Patients, which are based on medical evidence and consider the pathologic features of cachexia. We recommend that caregivers carefully evaluate the clinical usefulness of the guidelines.

[Palliative Care for Non-cancer Patients].

Although palliative care has been developed and implemented as care for cancer pain, it is holistic care for suffering that includes physical, psychosocial and spiritual pain of life-threatening illness. It turned out that non-cancer patients in the end-stage are also suffering from various pain that should be treated as cancer patients. Trajectories of illness in non-cancer patients are with more gradual decline than those of cancer patients with steady progression and it is often difficult to make decision about end-of-life. The purpose of advance care planning was originally to help describe legal documents. This process is proved to contribute to improving QOL of patients and their families to discuss preference, hope, economic problems, spiritual question as well as medical treatment In Japan guideline of decision making process in end-of-life stage has been established. A program of communication training in end-of-life discussion has been made. Under current situation some comments on the role of anesthesiologists are also mentioned.

[Successful Subarachnoid Phenol Block Therapy in a Patient with Pelvic Tumor-related Rectal Tenesmus].

We report a successful case of subarachnoid phenol block therapy in a patient with refractory rectal tenesmus caused by metastatic breast cancer. A 50-year-old woman with pelvic metastasis of breast cancer had the constant desire for defecation and anal discomfort, although analgesics including opioids relieved her from low abdominal and anal pain. Computed tomography revealed rectal invasion of metastatic breast cancer and the diagnosis of tumor-related rectal tenesmus was made. Symptoms of rectal tenesmus were severe and drug-resistant. Subarachnoid phenol block in the sitting position, which was neurolytic saddle block and expected to inhibit rectal reflex, was performed and her symptom was dramatically relieved. The effect of the block continued until she died 19 days after. To our knowledge, we first report subarachnoid phenol block therapy for a patient with pelvic-tumor related rectal tenesmus.

Methadone for Patients with Malignant Psoas Syndrome: Case Series of Three Patients.

BACKGROUND: Malignant psoas syndrome (MPS) is a relatively rare syndrome that accompanies malignancy; the pain associated with MPS is often difficult to control. Methadone is known to be effective in relieving both nociceptive and neuropathic pain. OBJECTIVE: Herein we describe treatment strategies for three patients with MPS, diagnosed by imaging and clinical findings, who responded to methadone treatment. METHODS: Patient diagnoses, pain characteristics, and treatment were analyzed retrospectively. Subjects were three patients with MPS who presented to Hyogo Cancer Center with pain. A numeric rating scale (NRS; 0-10) was used to assess patients' pain levels. RESULTS: All three patients were diagnosed with malignancies (prostate, cervical, and urachal) and had impaired gait and thigh extension. All had tumor invasion to the iliopsoas muscle, as determined by imaging, and were diagnosed with MPS. After starting methadone, symptoms improved in all patients and they were able to extend the thigh and walk normally. The NRS scores improved by an average of -7.3 points (95% confidence interval [CI] -4.97, -9.69) on Day 14; and the average time until symptom improvement after starting methadone was 2.3 days (95% CI 1.86, 2.80). CONCLUSIONS: Methadone may be considered a treatment choice for MPS patients in whom pain is difficult to control.

[A case of dexmedetomidine administration for slight end-stage sedation in a patient with sudden continuous bleeding].

We report a case of sudden fatal bleeding during the treatment of pancreatic cancer. The patient underwent palliative treatment for his symptoms with hydroxyethyl starch (HES) and continuous dexmedetomidine. He suffered from advanced pancreatic cancer, underwent gastrojejunostomy, and was scheduled to undergo chemotherapy. He suddenly vomited large amounts of blood and his blood pressure fell. Computed tomography revealed a hole in the branch of the arteria mesenterica superior that supplies the duodenum; best supportive care was selected. The patient suffered from pain associated with low blood pressure throughout his body. Infusion of 6% HES and continuous dopamine alleviated the pain and normalized his blood pressure. Continuous dexmedetomidine reduced his fatigue. He was able to talk comfortably with his family for 72 hours during treatment. Subsequently, his level of consciousness deteriorated and we administered haloperidol and midazolam for continuous sedation. He died painlessly 120 hours later after dexmedetomidine initiation.

[Efficacy of CT-guided splanchnic nerve block for persistent pain after fluoroscopy-guided nerve block in a patient with advanced pancreatic cancer].

We report a successful case of CT-guided splanchnic nerve block in a patient with advanced pancreatic cancer. A 76-year-old woman with epigastric distress was diagnosed with pancreatic cancer with multiple metastases. She underwent chemotherapy, but decided on best supportive care when her performance status worsened. Computed tomography revealed a 6 x 8 cm tumor mass in the pancreatic head. Oral oxycodone 20 mg x day(1) was ineffective and her Numerical Rating Scale (NRS) score was 9. Fluoroscopy-guided splanchnic nerve block with alcohol from L1-2 significantly reduced her pain, but she still required a fentanyl patch 2.1 mg x 3 days(-1) and loxoprofen (NRS 3). Four days later, we performed CT-guided splanchnic nerve block with alcohol 10 ml from T11-12. This significantly alleviated her pain and she was discharged uneventfully. She died 3 weeks after discharge. CT-guided splanchnic nerve block may be useful in cases of insufficient pain relief after fluoroscopy-guided splanchnic nerve block.

[Three successful cases of continuous dexmedetomidine infusion for the treatment of intractable delirium associated with cancer pain].

We report three cases of successful treatment of intractable delirium associated with cancer pain with continuous dexmedetomidine (DEX) infusion. Case 1 : An 83-year-old man receiving oral oxycodone for lung cancer pain developed delirium. He was resistant to haloperidol infusion, oral quetiapine, and opioid rotation. DEX infusion was administered at 0.4 microg kg-1 hr-1, and his delirium resolved. Case 2: A 50-year-old woman with cervical cancer of the uterus suffered from sepsis but could not take oral oxycodone. After continuous morphine infusion, she developed delirium. She was resistant to haloperidol infusion or injections of oxycodone for opioid rotation, but DEX infusion at 0.4 microg kg-1hr-1 led to disappearance of delirium symptoms. Case 3: A 71-year-old woman with advanced renal cancer was treated with epidural analgesia to alleviate cancer pain. She subsequently developed delirium but was resistant to haloperidol or chlorpromazine infusion. DEX infusion at 0.3 microg kg-1 hr-1 led to disappearance of delirium symptoms and orientation recovery. DEX infusion may be effective for the treatment of intractable delirium associated with cancer pain.

[Three successful cases of relieved abdominal fullness by thoracic epidural analgesia].

We report three successful cases of treating intractable abdominal fullness associated with cancer by continuous thoracic epidural analgesia. Case 1 was a 31-year-old woman with sarcoma of the uterus suffering from back and epigastric pain; abdominal fullness was treated by continuous epidural analgesia with ropivacaine and morphine. After epidural analgesia, symptoms disappeared and removal of ascites was unnecessary. Case 2 was an 18-year-old woman with Ewing's sarcoma suffering from abdominal fullness and fentanyl patch-resistant cancer pain. After continuous epidural analgesia, symptoms disappeared and she was discharged for home care. Case 3 was a 63-year-old woman with advanced liver cancer who was treated with epidural analgesia for cancer pain. She also suffered from abdominal fullness due to meteorism caused by intestinal hypomotility by cancer invasion to the spine. Thoracic epidural analgesia effectively treated cancer pain and reduced abdominal fullness, allowing her to continue hospital visits. Our findings suggest that epidural analgesia may effectively treat opioid-resistant intractable abdominal fullness.

[Intrathecal segmental analgesia with a single dose of bupivacaine for cancer pain in the abdominal wall].

A 48-year-old woman, diagnosed as colon cancer with metastases in the liver, lung, bone and left rectus abdominis, developed refractory left abdominal pain in spite of escalating administration of opioids and nerve block therapy, and intrathecal analgesia was applied. The tip of the catheter was intrathecally placed at the level of the T8 vertebra and pain relief was obtained with a daily dose of bupivacaine 36 mg producing segmental analgesia of the area between the 7th and 10th thoracic segments and preserving sensory and motor functions of the lower limbs. Face scale scores decreased from 5/6 to almost 0 after induction of the intrathecal analgesia. Side effects related to systemic opioids, such as nausea, vomiting and sleepiness, significantly improved and she was able to walk to the toilet. It is suggested that when the site of pain is limited to the truncus, intrathecal analgesia only with local anesthetics can be applied without affecting functions of the lower limbs.

A novel video-assisted anatomic segmentectomy technique: selective segmental inflation via bronchofiberoptic jet followed by cautery cutting.

OBJECTIVE: Segmentectomy is an anatomic parenchyma-sparing resection that is recently being performed for small-sized lung carcinoma and constitutes a useful procedure in a thoracic surgeon's armamentarium. We have generated a new technique that improves the identification of the intersegmental border and whose clinical utility we evaluate in this study. METHODS: Under bronchofiberscopy, jet ventilation is selectively applied to the burdened bronchus to develop an anatomic plane between the inflated segment to be resected and the deflated area to be preserved. From April 2004 to June 2006, 52 consecutive patients with a clinical T1 N0 M0 peripheral cancer 2 cm or smaller underwent video-assisted segmental resection called hybrid VATS segmentectomy in which electrocautery with no stapler was used to divide the intersegmental plane detected by selective jet ventilation. RESULTS: Complete resection was achieved in all patients. The median operative time and bleeding during the operation were 155 minutes (range 85-225 minutes) and 60 mL (range 10-210 mL), respectively. The complication rate was 13.5% (7/52), and the most common was concerning air leak. The median duration of postoperative air leak and chest tube drainage was 1 day and 3 days, respectively. There were no in-hospital deaths. There was one case of mediastinal lymph node recurrence and another of metastasis to the brain although there was no case of local recurrence in the surgical margin area. CONCLUSIONS: A novel video-assisted segmentectomy technique for lung cancer is clinically useful. Selective segmental inflation provides an obvious intersegmental plane quickly and easily, allowing a real margin distance in the ventilated segment. Despite the minimally invasive approach, since only the segment to be resected and not the entire lobe is expanded, an appropriate surgical view is possible.