[A case of a metastatic spine tumor treated using a multidisciplinary approach].

A 5 0-year-old man who was a hepatitis B carrier was admitted with back pain due to bone metastasis of the 12 th thoracic vertebra(Th12)in November 2011. He had been diagnosed with liver cancer in January 2010 and underwent liver resection following hepatic arterial chemoembolization. He presented with performance status(PS)2 and a numeric rating scale(NRS) pain score of 8 out of 10 at the time of admission. We started the patient on radiation and drug therapy, but lower limb muscle weakness(manual muscle test[MMT]grade 4 out of 5, Frankel D classification)occurred on day 12 after admission. Therefore, we immediately consulted the orthopedician, and the patient underwent posterior decompression fixation on day 15, followed by radiation therapy and rehabilitation. Even after discontinuation of all analgesics, his pain level on the NRS was 0, and he had no progressive muscle weakness. We ensured long-term care as well as nursing home visits. The patient was discharged on day 61. We have a variety of criteria for the selection of surgery for spinal metastasis, including Tokuhashi, Tomita, and Katagiri scores. The patient's general condition and prognosis are important factors to consider when selecting surgical therapy. In the present case, because of selection of the appropriate treatment and timely cooperation with specialists, it was possible to effectively relieve symptoms and discharge the patient to home care.

[Three cases of lung cancer presenting with spinal cord paralysis as the initial manifestation-symptom control, nursing care, and coordination of home medical care].

Bone metastasis from lung cancer accounts for approximately 30% of all metastatic bone tumors. The median survival time of patients with stage IV lung cancer with bone metastases is 5.5 months and that of patients without bone metastases is 7.5 months. Here, we report 3 cases of spinal cord paralysis. All cases were assessed according to the Tokuhashi score. As the predicted survival time of these patients was < or = 6 months, we opted for conservative treatment. We administered chemotherapy and radiation therapy, ensured symptom control, provided nursing care (prevention of decubitus, position changing, defecation control, rehabilitation, and mental health care), and coordinated home medical care. Patient management was mediated by a multidisciplinary medical team. However, all 3 patients were unable to return home and died in the hospital within 1-2 months after the onset of spinal cord paralysis. Spinal metastases can be expected not only in patients with lung cancer but also in patients with other types of carcinomas. Early diagnosis and treatment and accurate prognosis prediction are essential. Rapid responses and cooperation from experts are required, and increased awareness regarding spinal metastases among health professionals is essential.

[Difficulty in home care management of a young patient with terminal stage carcinoma--a case report].

A 48-year-old man with no remarkable medical history presented with upper abdominal pain for approximately 1 month. He was diagnosed as having pancreatic carcinoma with liver and lung metastasis and complicating carcinomatous peritonitis. Despite chemotherapy, his performance status worsened, his appetite deteriorated, and his pain became intolerable. The patient opted to return home for palliative care, and his parents, aged over 70 years, supported this decision. Although corticosteroid and opiate administration was attempted to improve appetite loss and pain, oral administration became difficult over a short span of time. Thus, treatment was switched from oxycodone to a fentanyl patch for opioid rotation. We also prescribed risperidone for the treatment of delirium. The patient once opted for "respite hospitalization" at a general hospital to relieve his aged parents' fatigue, and thereafter, he finally died at home. When rapid disease progression is expected, not only should a fully equipped environment for patients be ensured but concern for their caregivers should also be considered. For this purpose, cooperation and communication among multidisciplinary medical staff is indispensable.

[Survey of Prophylactic Administration of Naldemedine for Opioid-induced Constipation].

Opioid-induced constipation (OIC), an adverse event that occurs due to opioid analgesics, reportedly causes poor quality of life and adherence to opioid analgesics in patients. Therefore, this issue must be addressed appropriately. Naldemedine (NAL), a peripherally-acting µ-opioid receptor antagonist, is currently recommended for treating OIC when other laxatives are ineffective, but there have been no clinical reports of NAL being used prophylactically for OIC. Therefore, we conducted a retrospective survey of hospitalized patients who received NAL as prophylaxis for OIC with strong opioid analgesics to clarify the reality of this situation and to consider points to be taken into account in its clinical implementation. In this study, 61.7% of the subjects had an Eastern Cooperative Oncology Group performance status score of 3 or higher. The rate of addition of new laxatives and increased laxatives during seven days of NAL prophylaxis was 46.8%, and the rate of diarrhea was 6.1%. This study suggests that patients initiated with strong opioid analgesics during hospitalization often presented with poor performance status, and it is important to pay attention to constipation even under NAL prophylaxis. However, the incidence of diarrhea was low, and the safety of NAL prophylaxis was considered to be good.

[Early diagnosis of metastatic spinal tumor is a key for effective palliative radiotherapy in patients with lung cancer].

Patients with metastatic spinal tumor are the largest in number among the patients with bone tumor. It causes a severe bone pain, pathological fracture and spinal cord compression. Thus it harshly hampers patient's quality of life. We report 3 patients with lung cancer whose initial manifestation was metastatic spinal tumor. We treated the 3 patients with palliative radiotherapy and medication. Although the severe pain has improved on a numerical rating scale(NRS), but performance status(PS)and activity of daily living(ADL)of the 3 patients got worse because the disease was progressed and complicated. Generally, PS of cancer patients found by bone matastasis is low. However, it is difficult to take an effective treatment, which leads to ADL improvement. There are many choices for treating metastatic bone tumors including pain control, bisphosphonate administration, radiation therapy, strontium radiotherapy, bone cement, palliative surgery and orthotics. In addition, a development of molecular target drugs, such as Denosmab, is expected as future modality of palliative care. In conclusion, we should detect a bone metastasis in the patient with lung cancer as early as possible, and select an appropriate treatment in collaboration with each specialist for achieving the ADL and PS improvement.

[A case with an ovarian cancer patient who could receive anti-cancer therapy and palliative care simultaneously at home through seamless collaboration in healthcare linkage].

A palliative care team provides palliative care in the hospital setting.However, palliative care might be discontinued when a patient was switched to an outpatient from an inpatient or when a patient was being transferred to another hospital.In the present work, we report a case who could receive anti-cancer therapy and palliative care simultaneously at home.The case is a 46-year-old woman.She was diagnosed as left ovary cancer in 1990's and underwent an operation followed by chemotherapy. The tumor relapsed and invaded the sigmoid colon in 2000's.She then developed an intestinal obstruction and was hospitalized.After her conditions were stabilized, she was discharged but still needed a high degree of medical interventions. She was introduced to another hospital providing a home palliative care as well as emergency admission.She could fulfill her desire to receive a palliative care and chemotherapy simultaneously at home through this seamless healthcare linkage.It should be insisted that hospital oncologists and home doctors need to acquire the knowledge of palliative care and close cooperation between them is required.It is also important to establish a comprehensive healthcare linkage system in the society.

Pulmonary inflammatory pseudotumor observed by bronchoscopy and resected using video-assisted thoracic surgery.

Pulmonary inflammatory pseudotumor is rare. A 34-year-old woman visited our hospital due to an abnormal chest shadow. Computed tomograhy showed a nodule in the right upper lobe. Bronchoscopy showed a polypoid endobronchial nodule obstructing most of the orifice of B2a. The nodule was white, glossy, and smooth, and it seemed to be covered with bronchial mucosa. However, transbronchial biopsy could not facilitate a diagnosis. To obtain a definitive diagnosis, we performed lobectomy of the right upper lobe using video-assisted thoracic surgery and removed the nodule completely. The pathologic diagnosis made during surgery was inflammatory pseudotumor. Immunohistochemical examination showed proliferating spindle cells were positive for vimentin and smooth muscle actin, but negative for epithelial markers. These findings were consistent with the staining pattern of inflammatory pseudotumor previously reported. Careful follow-up is necessary to detect any sign of local recurrence and distant metastases.