Time to Incurable Recurrence for Patients Treated With Pulmonary Metastasectomy for Colorectal Cancer.

BACKGROUND: Probability of cure is important for patients with lung metastasis who must decide whether to undergo metastasectomy. Although progression-free survival (PFS) is thought to reflect this, it does not include curative effects by repeat metastasectomy. Thus, the authors developed a new indicator, time to incurable recurrence (TTIR), in which only incurable recurrence was set as an event that included death, with incurable recurrence defined as recurrence not treated by definitive local therapy (DLT), recurrence treated by DLT but with PFS maintained less than 2 years, or recurrence followed by re-recurrence. METHODS: This multi-institutional study included 339 patients who underwent lung metastasectomy for colorectal cancer between 1990 and 2008. RESULTS: Among the 339 patients, 191 experienced recurrence, 77 received DLT for recurrence, 38 had a PFS of 2 years or longer after the treatment, and 33 had maintained a PFS at the last follow-up date. The patients had PFS ranging from 39 to 212 months (median, 101 months). The 5-year OS, PFS, and TTIR rates were respectively 63.4%, 42.2%, and 51.9%. The TTIR curve was similar to the OS curve 7 years after the initial metastasectomy. The difference between TTIR and PFS at 7 years was 9.7%, indicating probability of cure by repeat DLT. Multivariable analysis showed different prognostic factors among OS, PFS, and TTIR. CONCLUSION: At the initial metastasectomy, TTIR may reflect probability of a cure, including cure by repeat DLT, and can be used to analyze prognostic factors associated with cure.

Phase I/II study of nedaplatin and nab-paclitaxel for patients with previously untreated advanced squamous cell lung cancer: Kanto Respiratory Disease Study Group (KRSG) 1302.

BACKGROUND: Nedaplatin and nab-paclitaxel are each efficacious in the treatment of squamous cell lung cancer. PATIENTS AND METHODS: Eligibility criteria were: no prior chemotherapy, advanced squamous cell lung cancer; performance status 0-1, age > 20 years but < 75 years, and adequate hematologic, hepatic and renal function. Patients received escalating doses of nab-paclitaxel under a fixed dose of nedaplatin (100 mg/m2, day 1) every 3 weeks in phase I. The initial nab-paclitaxel dose was 100 mg/m2 on days 1 and 8 (level 1), and the next dose was 100 mg/m2 on days 1, 8, and 15 (level 2). In phase II, patients received the recommended doses. The primary endpoint was tumor response rate. RESULTS: In phase I, three patients at level 1 experienced no dose-limiting toxicities (DLTs) and two patients at level 2 experienced DLTs. Level 1 was thus determined as the recommended dose. Twenty-three patients were enrolled in phase II. The 3 patients in level 1 and 23 patients in phase II were included together for analyses. Three of these 26 patients were excluded from response analysis due to pneumonia and patient refusal. Response rate was 91.3% (95% confidence interval, 72.0-98.9%). Toxicities observed during all cycles were tolerable. CONCLUSIONS: The recommended dose for this combination was nedaplatin at 100 mg/m2 on day 1 and nab-paclitaxel at 100 mg/m2 on days 1 and 8 every 3 weeks. The combination of nedaplatin and nab-paclitaxel appears safe and efficacious in patients with untreated advanced squamous cell lung cancer.

Postoperative Vitamin Profile after Receiving a Novel Peripheral Parenteral Nutrition Solution: Multicenter Randomized Controlled Phase III Trial.

INTRODUCTION: We assessed the efficacy and safety of OPF-105, a novel all-in-one peripheral parenteral nutrition (PPN) solution containing multivitamins by the U.S. Food and Drug Administration in 2000 (FDA2000 recommendation). METHODS: We conducted a phase III trial administering OPF-105 or BFL (combination of a commercially available PPN solution and fat emulsion) to patients after gastrointestinal (GI) tract surgery from postoperative day (POD) 1 up to POD14. Until POD7, nutrients were provided only with OPF-105 or BFL. After blood sampling on POD8, oral food intake was permitted. PPN was administered according to the amount of food intake. RESULTS: Efficacy endpoints were assessed in 99 subjects (OPF group: 52; BFL group: 47). The levels of blood proteins and fatty acids in the two groups were similar on POD8. The transition of these mean levels was similar in both groups from POD1 or 2 to POD9 to 15. The mean preoperative blood vitamin levels were within reference intervals (RIs). On POD1 (before administration), the mean levels of most blood vitamins decreased compared to those of the preoperative levels. In the BFL group, the mean blood levels of vitamin B2, B6, pantothenic acid (PA), folic acid (FA), biotin, and C decreased below or near the lower limit of RIs on POD8, and the mean blood levels of vitamin B6 and C remained low from POD9 to 15. In the OPF group, the mean blood levels of vitamins, excluding vitamin K, were within RIs on POD8 and POD9 to 15. The mean levels of blood vitamin K increased over the upper limit of RIs on POD8 but within RIs from POD9 to 15. There was no obvious difference in the incidence of adverse events between the two groups, which is common after GI tract surgeries. CONCLUSION: Blood vitamin levels decreased when patients were administered PPN without vitamin supplementation during the first week after surgery. The novel PPN formula containing multivitamins recommended by FDA2000 can be safely administered to postoperative patients to maintain blood vitamin levels.

Influence of Glucose Dosage in Parenteral Nutrition on Body Thiamine Levels in Rats.

The objective of this study was to determine the relationship between glucose dosage in parenteral nutrition and reductions in levels of body thiamine in rats. Vitamin-free infusions with differing amounts of glucose were administered to normal or thiamine-deficient rats for 5 days, after which urinary thiamine excretion and the amounts of thiamine in the blood, liver, brain, and skeletal muscles were measured. The total energy dosage was set at three levels (98, 140, and 196 kcal/kg), and the dose of amino acids was constant among all groups. Urinary thiamine excretions on Day 5 decreased with increasing glucose dosage in the infusions. In normal rats, the amount of thiamine in the blood and all organs decreased compared with the diet group; however, no significant differences were found among the infusion groups. In thiamine-deficient rats, on the other hand, the amount of thiamine in the liver and skeletal muscles did not differ significantly among infusion groups; however, the amount of thiamine in the brain and blood decreased with increasing glucose dosage. An organ-specific correlation was found between glucose dosage in infusions and reductions in levels of thiamine. To prevent thiamine deficiencies from affecting the central nervous system, greater caution must be exercised during high-caloric parenteral nutrition. However, a constant supply of thiamine seemed to be essential, irrespective of the amount of energy supplied via parenteral nutrition, to maintain a sufficient level of thiamine in the body.

Optimizing Vitamin and Trace Element Profiles in Blood after Gastrointestinal Tract Surgery by a New Parenteral Nutrition Formula.

INTRODUCTION: Though micronutrient formulations for parenteral nutrition (PN) have been revised, the impacts of these changes on nutritional parameters, blood micronutrient levels, and safety have yet to be clarified. We examined the efficacy and safety of a new PN formulation with a micronutrient composition based on the Food and Drug Administration 2000 recommendation in surgical patients. METHODS: This phase III clinical trial (JapicCTI-No. 142610) was a prospective, randomized, controlled, parallel-group, open-label, multicenter study. Two types of PN, OPF-108 (revised formula, n = 51) and ELN (previous formula mainly based on American Medical Association 1975 guidelines, n = 59), were given to patients from POD1 or 2 to POD7 after surgery. OPF-108 contains more vitamin B1, B6, C, and folic acid, a much lower dose of vitamin K, and less iron than ELN. Nutritional parameters and micronutrient profiles in blood and safety were evaluated. RESULTS: Nutritional parameters on POD5 and 8 were similar between the 2 groups. Blood vitamin B1, B6, and folic acid levels on POD 5 and 8 were higher in the OPF-108 group than in the ELN group. Only OPF-108 restored vitamin C levels to within the normal range on POD5 and 8. Vitamin K levels far exceeded the upper limit of the standard range on POD5 and 8 in the ELN group, whereas OPF-108 essentially maintained these levels within the standard ranges. Serum iron levels on POD8 were nearly normal in both the OPF-108 and ELN groups. CONCLUSION: Beneficial effects of the new micronutrient formulation were demonstrated in surgical patients.

Hatched "egg" of thymoma with sarcoidosis.

BACKGROUND: While calcification of thymoma is common, "eggshell" calcification is rare. We report a case of an eggshell calcified thymoma that "hatched" after 4 years of follow-up. Pathologically, it revealed that sarcoidosis accompanied this case of thymoma, which might cause in calcification. CASE PRESENTATION: The patient was a 68-year-old female. A 20-mm anterior mediastinal nodule completely covered with calcification was noted in an annual health check-up. However, as the nodule did not change during 6 months of follow-up, she discontinued regular examinations. Four years later, an abnormality in her chest X-ray was noted again. The tumor grew outside the calcification to reach 63 mm. She underwent resection of this anterior mediastinal tumor. Pathologically, the tumor was diagnosed as thymoma of type B1 in the WHO classification. The histology of the tumor inside and outside of the calcification was not different, suggesting that the tumor grew from the inside of the calcification. The calcification was located within the fibrotic capsule of thymoma. Sarcoidosis also presented in her lung and mediastinal lymph nodes. CONCLUSIONS: Although the mechanism of calcification of the capsule was not clear, sarcoidosis might be related to this case because macrophage accumulation and altered lipid metabolism in sarcoidosis present with similar dystrophic calcification.

[Benefit of Adjuvant Chemotherapy after Curative Resection of Liver and Lung Metastases in Colorectal Cancer].

The survival benefit of adjuvant chemotherapy after resection of liver and pulmonary metastases in colorectal cancer(CRC) remains controversial. We enrolled9 0 CRC patients who underwent hepatic metastasectomy and2 5 CRC patients who underwent pulmonary metastasectomy between April 2005 and March 2017 to clarify the efficacy of adjuvant chemotherapy after hepatic andpulmonary metastasectomy. Forty-two patients receivedad juvant chemotherapy after hepatic metastasectomy, and1 0 patients receivedad juvant chemotherapy after pulmonary metastasectomy. Patients who underwent hepatic metastasectomy andreceivedad juvant chemotherapy hadlonger overall survival(OS)(p=0.043)andrelapse -free survival (RFS)(p=0.043)than those who underwent surgery alone. There were no significant differences in OS(p=0.84)andRFS (p=0.87)between patients receiving adjuvant chemotherapy after pulmonary metastasectomy and those receiving surgery alone. On multivariate analysis, adjuvant chemotherapy was independently associated with favorable OS in patients who underwent hepatic metastasectomy(hazardratio: 0.473, 95% confidence interval: 0.23-0.97, p=0.04). No prognostic factor associatedwith OS andRFS was identifiedin patients undergoing pulmonary metastasectomy. These results suggest that patients who undergo hepatic metastasectomy couldhave an OS andRFS benefit from adjuvant chemotherapy, but those who undergo pulmonary metastasectomy would not.

Supplementation of parenteral nutrition with fish oil attenuates acute lung injury in a rat model.

Fish oil rich in n-3 polyunsaturated fatty acids has diverse immunomodulatory properties and attenuates acute lung injury when administered in enternal nutrition. However, enteral nutrition is not always feasible. Therefore, we investigated the ability of parenteral nutrition supplemented with fish oil to ameliorate acute lung injury. Rats were infused with parenteral nutrition solutions (without lipids, with soybean oil, or with soybean oil and fish oil) for three days. Lipopolysaccharide (15 mg/kg) was then administered intratracheally to induce acute lung injury, characterized by impaired lung function, polymorphonuclear leukocyte recruitment, parenchymal tissue damage, and upregulation of mRNAs for inflammatory mediators. Administration of parenteral nutrition supplemented with fish oil prior to lung insult improved gas exchange and inhibited neutrophil recruitment and upregulation of mRNAs for inflammatory mediators. Parenteral nutrition supplemented with fish oil also prolonged survival. To investigate the underlying mechanisms, leukotriene B4 and leukotriene B5 secretion was measured in neutrophils from the peritoneal cavity. The neutrophils from rats treated with fish oil-rich parenteral nutrition released significantly more leukotriene B5, an anti-inflammatory eicosanoid, than neutrophils isolated from rats given standard parenteral nutrition. Parenteral nutrition with fish oil significantly reduced lipopolysaccharide-induced lung injury in rats in part by promoting the synthesis of anti-inflammatory eicosanoids.

Risk-adjusted hazard analysis of survival after pulmonary metastasectomy for uterine malignancies in 319 cases.

Objective: There is little evidence of the outcome of pulmonary metastasectomy for uterine tumors when comparing different histologies. This study aimed to delineate the primary histology that leads to more favorable outcomes after pulmonary metastasectomy. Methods: The database of the Metastatic Lung Tumor Study Group of Japan for 1984 to 2016 was used to analyze the outcomes of patients with gynecologic malignancies who underwent pulmonary metastasectomy. Prognostic factors and long-term outcomes were compared according to the histology of the primary uterine tumors, specifically adenocarcinoma, squamous cell carcinoma, and sarcoma. The adjusted hazard risks according to disease-free intervals (DFIs) and the number and maximum size of resected tumors were also analyzed to delineate the pattern of risk trends. Results: A total of 319 patients were included in the analysis (122 with adenocarcinomas, 113 with squamous cell carcinomas, 46 with sarcomas, and 38 with other types). The 5-year survival rate was 66.5% for the entire cohort, 71.6% for the patients with adenocarcinoma, 61.3% for those with squamous cell carcinoma, and 55.4% for those with sarcoma. Multivariate analyses identified the positive prognostic factors as DFI ≥12 months in adenocarcinoma and sarcoma and the primary site (corpus) of uterine tumors in adenocarcinoma. The nonlinear adjusted hazard risks indicated that a shorter DFI was associated with an elevated risk of death in patients with adenocarcinoma and sarcoma. Conclusions: The survival outcome after pulmonary metastasectomy varies according to primary tumor histology, and the prognostic factors differ among histologic subtypes. Surgical indications should be determined based on the prognostic factors for each histology.

Imaging of ventilation with dual-energy CT during breath hold after single vital-capacity inspiration of stable xenon.

PURPOSE: To assess single-breath-hold technique for ventilation mapping by using dual-energy computed tomography (CT) in phantom experiments and volunteers. MATERIALS AND METHODS: Institutional review board approved this study, and written informed consent was obtained from all volunteers. A rubber bag filled with a mixture of xenon (0%-35.4%) and oxygen was scanned with dual-source dual-energy CT (80 kV and 140 kV with tin [Sn] filter [Sn/140 kV] and 100 kV and Sn/140 kV). A cylinder containing six tubes of identical sizes with different apertures was ventilated once with a mixture of 35% xenon and 65% oxygen and was scanned in dual-energy mode (80 kV and Sn/140 kV). Xenon-enhanced images were derived by using three-material decomposition technique. Four volunteers were scanned twice in dual-energy mode (80 kV and Sn/140 kV) during breath hold after a single vital-capacity inspiration of air (nonenhanced) and of 35% xenon. Xenon-enhanced images were obtained by using two methods: three-material decomposition and subtraction of nonenhanced from xenon-enhanced images. Regression analysis with t and F tests was applied to the data of the rubber bag scans, with the significance level set at .05. RESULTS: Mean pixel values of gas in the bag were linearly related to xenon concentration for all x-ray tube voltages (r(2) = 1.00, P < .00001). Pixel values of the xenon-enhanced images of the tubes were related to their aperture size. Nearly homogeneous (coefficient of variation: 0.22, 0.23, and 0.34) pixel values were found in the lungs of healthy volunteers, with higher pixel values in the trachea and lower pixel values in the bullae. Xenon-enhanced images calculated by using three-material decomposition had better image quality on visual comparison than those calculated by using subtraction. CONCLUSION: Xenon-enhanced dual-energy CT with the single-breath-hold technique could depict ventilation in phantoms and in four volunteers.

Effect of an omega-3 lipid emulsion in reducing oxidative stress in a rat model of intestinal ischemia-reperfusion injury.

OBJECTIVES: The usefulness of omega-3 lipid emulsions has been extensively studied. The objectives of the present study were to examine the effect of an omega-3 lipid emulsion in reducing oxidative stress in a rat model of intestinal ischemia-reperfusion injury and the underlying mechanism. METHODS: A total of 66 rats were divided into three dietary groups (lipid-free, soybean oil, and fish oil groups). Each animal was administered total parenteral nutrition for 3 days, followed by induction of intestinal ischemia for 100 min. Animals subjected to sham surgery served as the controls. Intestinal tissue and blood were harvested 6 and 12 h after the surgery, then, assessment of the histological damage score, plasma-related parameters, and statistical evaluation were performed. RESULTS: The histological damage score in the intestinal tissues was significantly lower in the fish oil group than in the soybean oil group (P = 0.0121). The late-phase urinary level of 8-hydroxy-2-deoxyguanosine was also significantly lower in the fish oil group as compared with that in the other groups (P = 0.0267). Furthermore, the plasma level of high-mobility group box 1 protein was also significantly lower in the fish oil group as compared with that in the lipid-free group (P = 0.0398). CONCLUSION: It appeared that intravenous administration of an omega-3 lipid emulsion prior to ischemia-reperfusion injury reduced the oxidative stress and severity of tissue damage. Modification of membrane fatty acids may serve as the mechanism underlying this reduction of tissue damage.

Surgical resection of a thymoma developed in a case with isolated persistent left superior vena cava.

INTRODUCTION: Persistent left superior vena cava (PLSVC) is one of the most common vascular abnormalities in the chest. In approximately 10 % of cases, the right superior vena cava is missing, which is called isolated persistent left superior vena cava (IPLSVC). PRESENTATION OF CASE: The case is an 85 years-old female. An anterior mediastinal tumor was accidentally revealed when the patient was admitted after a traffic accident. As the tumor became larger within four months, a thymectomy was planned. The anterior mediastinal tumor was in front of the ascending aorta, which was close to the confluence of the left and right brachiocephalic veins in normal anatomy. However, in this case, the right superior vena cava was missing, and the right brachiocephalic vein flowed into the left superior vena cava by the chest computed tomography. Preoperative examinations found no accompanying cardiac abnormality. Robot-assisted thymectomy was performed. No tumor infiltration was observed in the right brachiocephalic vein. No abnormality was found in either phrenic nerve. The tumor could be safely resected, and her postoperative course was uneventful. The pathological diagnosis was a thymoma. DISCUSSION: A case of thymectomy with IPLSVC is quite rare. A careful observation of the preoperative computed tomography images helps to diagnose IPLSVC. Technically, thymectomy was not much different from normal, other than the reversed location of the veins. However, it should be noted that IPLSVC cases may have cardiac malformations. CONCLUSION: Thymectomy for thymoma with IPLSVC can be safely performed when the left and right veins are reversed.

Randomized controlled phase I trial for a novel peripheral parenteral nutrition formula containing dextrose, amino acids, fat emulsion, electrolytes, and FDA2000 recommendation-based vitamins.

BACKGROUND & AIMS: We developed the world's first all-in-one type peripheral parenteral nutrition product containing dextrose, amino acids, fat emulsion, electrolytes and vitamins, according to the FDA 2000 recommendation. This phase I trial examined the safety and changes in nutritional parameters in healthy participants. METHODS: A single-center, randomized, open-label, active-controlled trial was performed in single ascending dose (SAD: Step 1-3) and multiple dose (Step 4) studies. Participants were administered a single dose of OPF-105 (test solution: 150 g of dextrose, 60 g of amino acids, 40 g of fat, 1240 kcal of total energy per 2200 mL, and 106 NPC/N ratio, with multivitamins, n = 17) or BFI (control solution: 150 g of dextrose, 60 g of amino acids, 840 kcal of total energy per 2000 mL, and 64 NPC/N ratio, with vitamin B1, n = 18) with three ascending doses (Step 1: 550 mL, Step 2: 1100 mL, and Step 3: 2200 mL) in the SAD study, or received multiple doses with Step 3 amount of OPF-105 (n = 5) or BFI (n = 6) for 3 days (Step 4) via peripherally inserted venous catheters. The safety and nutritional parameters were assessed. RESULTS: There were no serious adverse events or events requiring discontinuation of the solution administration in either group. Blood urea nitrogen (BUN) levels remained within the normal range in both groups (Step 1-4). However, they gradually increased during the time course of the study in the BFI group but not in the OPF group (Step 4), suggesting the prevention of body protein breakdown. Blood triglyceride (TG) levels increased after administration in the OPF group but promptly returned to the pre-administration level (Step 1-4). Blood total ketone body levels increased the day after administration in both groups, which may imply a lower degree of starvation (Step 1-3), but the increase in the OPF group was milder than that in the BFI group (Step 4). Blood vitamin B6 and folic acid levels were maintained within the normal ranges in the OPF group but were near the lower limit in the BFI group (Step 1-4). Blood vitamin C levels showed almost lower limit in the two groups (Step 1-3), but increased only in the OPF group (Step 4). Blood vitamin K levels in the BFI group remained near the lower limit of the normal range, but those in the OPF group were higher than the upper limit at the end of administration and quickly returned to the pre-administration level (Step 1-4). CONCLUSIONS: This trial suggests that the newly developed formula (OPF-105) improves fat metabolism, maintains vitamin profiles, and may prevent body protein and fat breakdown and can be safely administered to healthy participants. Registration number of Clinical Trial: UMIN000046915; https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000053479.

A case of cerebral infarction due to aplastic or twig-like middle cerebral artery after lung cancer surgery.

Aplastic/twig-like middle cerebral artery is a rare vascular abnormality. We report a case of postoperative cerebral infarction caused by this disease. The patient is a male in his 40s. A 9-cm tumour was revealed to have invaded the superior vena cava from his right lung. He underwent right upper and middle bilobectomy. Due to the vascular invasion, the intraoperative bleeding exceeded 2 litres. Mechanical ventilation was required for postoperative pneumonia. After extubation, he was unable to write and was found to have cerebral infiltration in the left middle cerebral artery region. The cause of the cerebral infarction was investigated, but no thrombus in the left atrium or arteriosclerosis was found. No atrial fibrillation was observed during or after the surgery. Magnetic resonance angiography of the brain revealed an aplastic/twig-like middle cerebral artery.

[Palliative Care Interactive Network in KAWAGOE: PINK for regional alliances].

The Cancer Control Act has come into effect in 2007. As an important idea of the act, a regional based hospital for cancer treatment and care should respect cancer patient's autonomy and improve his/her quality of life. We have organized PINK (Palliative Care Interactive Network in Kawagoe)in order to fulfill the idea in practical palliative care. Our activities are: Annual conference, Civic forum on Relay for Life in Kawagoe , Patients' association, and Case study examination using our mailing list. This network was built based on our activities to realize an important idea of the Cancer Control Act.

A desmoplastic fibroblastoma that developed in the anterior mediastinum: a case report.

BACKGROUND: Desmoplastic fibroblastoma (also known as collagenous fibroma) is a benign, slowly growing soft-tissue tumor. Most desmoplastic fibroblastomas develop in the limbs, neck, or trunk. A mediastinal origin is quite rare. CASE PRESENTATION: A 32-year-old Asian female was referred to us for the diagnosis and treatment of an anterior mediastinal tumor. The tumor was 80 mm in the largest diameter and was located on the pericardium. No invasion was evident. She underwent resection of the tumor via video-assisted thoracoscopic resection. The tumor was totally encapsulated, and its pedicle was on the pericardium. The resected specimen was very rigid, making it difficult to remove from the intercostal space. Histologically, the tumor was composed of a paucicellular dense collagenous tissue. Mitosis was rarely observed, and cellular atypia was not evident, suggesting that the tumor was benign. We diagnosed the tumor as a desmoplastic fibroblastoma by morphology and immunohistochemistry. CONCLUSIONS: Desmoplastic fibroblastoma of the mediastinum is an extremely rare disease. Preoperative diagnosis is difficult. Early surgical resection is suitable for diagnosis and treatment planning.

[Surgery for tuberculosis--a ten-year experience].

We reviewed our institutional experience of surgical cases of tuberculosis in the last decade. There were 42 surgical cases, including 26 cases of tuberculoma, 5 cases of tuberculous lymphadenitis, 4 cases of tracheobronchial tuberculosis, and 7 cases of tuberculous empyema. The most aim of the surgery for tuberculoma and lymphadenitis were to make differential diagnosis from malignant neoplasm. Sleeve resection was done in 3 cases of tracheobronchial tuberculosis and Montgomery T-tube placement was underwent for a case of tracheal stenosis. Radical surgery was indicated for 4 cases of empyema and open window thoracostomy for 3 cases. There was no major complication and operation-related death. The surgical indication for tuberculosis is very limited nowadays because of effective chemotherapy, however, surgery is still relevant in selected small groups of tuberculosis patients. Exchanging more information and alliance among physicians and thoracic surgeons will become more important for better tuberculosis treatment.

[Successful management of a patient with pain and dyspnea from bone metastasis and lymphangitis carcinomatosa after surgery for non-small cell lung cancer (NSCLC) in whom optimal dosages of transdermal fentanyl were determined by titration with fentanyl injection, and oxycodone hydrochloride].

With recent progress in disease-modifying treatments for cancer, patients who have recurrences during a period of several years before entering the terminal stage are encountered frequently. Despite improved life expectancy with cancer therapy, for patients this means prolongation of the period in which various symptoms such as cancer pain and adverse reactions are undergone. In these conditions, although the recognition is not yet sufficient, the importance of palliative care along with disease-modifying treatment is recognized in Japan. We treated a 50s female with pain and dyspnea from bone metastasis and lymphangitis carcinomatosa after surgery for NSCLC in whom the optimal dosages of transdermal fentanyl (Durotep Patch) were determined by titration with fentanyl injection, and oxycodone hydrochloride (OxyContin) in a short period. The dosages after titration were transdermal fentanyl 35 mg, oxycodone hydrochloride 60 mg, and betamethasone 4 mg. Before her death, she was able to stay at home with her family for 3 days without severe symptoms. In the present study we describe the clinical course of this case, the difference of characteristics in these opioids, and the titration method with fentanyl injection.