The correct answer is 4 because if the patient has bone metastases and may suffer fractures we can control inflammatory pain with ibuprofen and it will also help us to use the antalgic synergy. We should change the treatment to a major opioid and treat the disrruptive pain vigorously since she is at almost the maximum pain she can bear.

[HIDDEN] if the patient has bone metastases and may suffer fractures we can control inflammatory pain with ibuprofen and it will also help us to use the antalgic synergy. We should change the treatment to a major opioid and treat the disrruptive pain vigorously since she is at almost the maximum pain she can bear.

A 45-year-old woman diagnosed with stage IV breast cancer with multiple bone metastases on hormonal treatment and iv bisphosphonates. She comes to your office referring intense bone pain (VAS=7), in several locations without associated neurological symptoms and exarcerbations of pain (VAS=9) several times a day that force her to remain at rest. In the treatment with ibuprofen (600 mg every 8 h) and tramadol (150 mg per day), what treatment would you consider most appropriate in this patient to improve the pain?

Suspend ibuprofen and tramadol and start a major opioid such as morphine or oxycodone.

Suspend tramadol, maintain ibuprofen and initiate a major opioid such as morphine and oxycodone.

Discontinue ibuprofen and tramadol and start a major opioid such as morphine or oxycodone and at the same time start treatment of breakthrough pain with sublingual fentanyl.

Suspend tramadol, maintain ibuprofen and initiate a major opioid such as morphine and oxycodone and at the same time treatment for breakthrough pain with sublingual fentanyl.

Pain ladder

The WHO guidelines recommend prompt oral administration of drugs ("by the mouth") when pain occurs, starting, if the patient is not in severe pain, with non-opioid drugs such as paracetamol (acetaminophen) or aspirin, with or without "adjuvants" such as non-steroidal anti-inflammatory drugs (NSAIDs) including COX-2 inhibitors. Then, if complete pain relief is not achieved or disease progression necessitates more aggressive treatment, a weak opioid such as codeine, dihydrocodeine or tramadol is added to the existing non-opioid regime. If this is or becomes insufficient, a weak opioid is replaced by a strong opioid, such as morphine, diamorphine, fentanyl, buprenorphine, oxymorphone, oxycodone, or hydromorphone, while continuing the non-opioid therapy, escalating opioid dose until the patient is pain free or at the maximum possible relief without intolerable side effects. If the initial presentation is severe pain, this stepping process should be skipped and a strong opioid should be

The Effect of Ibuprofen on Postoperative Opioid Consumption Following Total Hip Replacement Surgery.

Postoperative pain following hip surgery can be severe. Non-steroidal anti-inflammatory drugs are used in the treatment of postoperative pain to reduce opioid consumption. Our aim was to investigate the effect of ibuprofen on postoperative opioid consumption following total hip replacement surgery. Patients undergoing elective total hip replacement under general anaesthesia were included into this randomised, prospective and double-blind study. Forty patients classified according to the American Society of Anesthesiologists as Class I and II were randomised to receive 800 mg ibuprofen intravenously (IV) every 6 hours, or placebo. At the end of surgery, all patients were also administered tramadol 100 mg IV and paracetamol 1 gm IV. In the postoperative period, all patients were provided with a morphine PCA device. The PCA device was set to deliver 1 mg bolus dose and had 8 minutes of lockout period and 6 mg 1-hour limit. VAS scores were recorded at 1, 6, 12 and 24 h postoperatively. The incidence of nausea and vomiting, total morphine consumption during the 24 h postoperative period was recorded. The Mann-Whitney U and chi-squared tests were used for statistical analysis. The VAS score at postoperative 24 h was lower in the ibuprofen group (p=0.006). Morphine consumption at 24 hours was significantly lower at the ibuprofen group compared to the control group (p=0.026) (the mean doses were 16 mg and 24 mg, respectively). Five patients in the control group and 3 patients in the ibuprofen group reported vomiting. No other side effects or complications were observed. Following total hip replacement surgery, the administration of ibuprofen IV significantly reduced morphine consumption.

Morphine/naltrexone

Embeda became available again some years later. See also Hydrocodone/paracetamol Hydrocodone/ibuprofen Oxycodone/paracetamol Oxycodone/aspirin Oxycodone/naloxone Fentanyl/fluanisone References Opiates Semisynthetic opioids Kappa-opioid receptor antagonists Mu-opioid receptor antagonists Pfizer brands Combination analgesics

Oral versus intravenous opioid dosing for the initial treatment of acute musculoskeletal pain in the emergency department.

The objective was to compare the time to medication administration, the side effects, and the analgesic effect at sequential time points after medication administration of an oral treatment strategy using oxycodone solution with an intravenous (IV) treatment strategy using morphine sulfate for the initial treatment of musculoskeletal pain in emergency department (ED) patients. This was a prospective randomized clinical trial of patients >6 years old who were going to receive IV morphine sulfate for the treatment of musculoskeletal pain but did not yet have an IV. Consenting patients were randomized to have the treating physician order either 0.1 mg/kg morphine sulfate IV or 0.125 mg/kg oxycodone orally in a 5 mg/5 mL suspension as their initial treatment for pain. The time from the placement of the order to the administration of the medication was recorded. Pain was measured using a 100-mm visual analog scale (VAS) and recorded at 0, 10, 20, 30 and 40 minutes after drug administration. A total of 405 eligible patients were identified during the study period; 328 (81.0%) patients consented to be in the study. A total of 158 patients were randomized to the IV morphine sulfate treatment group, and 162 were randomized to the oral oxycodone treatment group. Of the patients who were randomized to IV therapy, 34 were withdrawn from the study prior to drug administration; leaving 125 patients in the IV group for analysis. Of the patients who randomized to oral therapy, 22 were withdrawn from the study prior to drug administration, leaving 140 patients for analysis. No serious adverse events were detected. There was a 12-minute difference between the median time of the order and the administration of oral oxycodone (8.5 minutes) and IV morphine (20.5 minutes). The mean percent change in VAS score was larger for patients in the IV therapy group than those in the oral therapy group at 10 and 20 minutes. At 30 and 40 minutes, the authors could no longer detect a difference. The satisfaction scale score was higher after treatment for the morphine group (median = 4; interquartile range [IQR] = 4 to 5) than for the oxycodone group (median = 4; IQR = 2 to 5; p = 0.008). The oral loading strategy was associated with delayed onset of analgesia and decreased patient satisfaction, but a shorter time to administration. The oral loading strategy using an oxycodone solution provided similar pain relief to the IV strategy using morphine 30 minutes after administration of the drug. Oral 0.125 mg/kg oxycodone represents a feasible alternative to 0.1 mg/kg IV morphine in the treatment of severe acute musculoskeletal pain when difficult or delayed IV placement greater than 30 minutes presents a barrier to treatment.

Cancer pain

The WHO guidelines recommend prompt oral administration of drugs when pain occurs, starting, if the person is not in severe pain, with non-opioid drugs such as paracetamol, dipyrone, non-steroidal anti-inflammatory drugs or COX-2 inhibitors. Then, if complete pain relief is not achieved or disease progression necessitates more aggressive treatment, mild opioids such as codeine, dextropropoxyphene, dihydrocodeine or tramadol are added to the existing non-opioid regime. If this is or becomes insufficient, mild opioids are replaced by stronger opioids such as morphine, while continuing the non-opioid therapy, escalating opioid dose until the person is painless or the maximum possible relief without intolerable side effects has been achieved. If the initial presentation is severe cancer pain, this stepping process should be skipped and a strong opioid should be started immediately in combination with a non-opioid analgesic. However, a 2017 Cochrane Review found that there is no

Oxycodone/ibuprofen

Oxycodone/ibuprofen (INNs, trade name Combunox) is an oral combination drug formulation of the opioid analgesic oxycodone and the nonsteroidal anti-inflammatory drug (NSAID) ibuprofen that is used in the treatment of chronic and acute pain. This particular drug is supplied in a fixed dose combination tablet which contains Oxycodone Hydrochloride, USP 5 mg with Ibuprofen, USP 400 mg. Adverse effects See also Oxycodone/paracetamol Oxycodone/aspirin Hydrocodone/ibuprofen References External links Combination analgesics

Oral analgesia in fixed-time interval administration versus spinal morphine for post-Cesarean pain: a randomised controlled trial.

To compare the efficacy of fixed-time-interval oral analgesia and spinal-morphine for management of post-Cesarean pain. In this open-label, parallel-group, randomized, controlled trial, 200 women due to undergo elective Caesarean section with spinal anaesthesia were enrolled between July 2015 and April 2016. Patients were randomly assigned to receive either spinal fentanyl followed by oral doses of tramadol, paracetamol, and diclofenac at predetermined regular intervals of 6 h for the first 48 h, and rescue treatment with percocet (oxycodone and paracetamol; oral analgesia group), or spinal morphine and rescue treatment with oral tramadol, paracetamol, and diclofenac (spinal-morphine group). The primary outcomes were pain intensity during the postoperative 48 h, measured on a 10-point numeric rating scale (NRS) and expressed as area under the curve (AUC), and the number of breakthrough events of moderate to severe pain (defined as NRS score ≥ 4). The oral analgesia group compared to the spinal-morphine group had similar mean pain intensity (AUC (120 ± 35 versus 121 ± 31, respectively; p = 0.8) but more events of moderate-to-severe breakthrough pain (4.8 ± 2 versus 3.8 ± 1.7, respectively; p = 0.0002). Higher rates and longer durations of pruritus, nausea, and vomiting were reported among patients receiving spinal morphine, as compared with oral analgesia. Satisfaction scores were high in both groups (8.2 ± 2.4 versus 8.7 ± 1.8 in the oral analgesia and spinal morphine, respectively; p = 0.23). Both oral analgesia at fixed time intervals and spinal morphine are satisfactory methods for treating post-Caesarean pain. ClinicalTrials.gov Identifier: NCT02440399, date of registration: 07/05/ 2015. URL: https://clinicaltrials.gov/ct2/show/NCT02440399?term=enav+yefet&rank=7 .

How low can you go: Achieving postoperative outpatient pain control without opioids.

Postoperative outpatient narcotic overprescription plays a significant role in the opioid epidemic. Outpatient opioid prescription ranges from 150 to 350 oral morphine equivalent (OME) for a laparoscopic cholecystectomy or appendectomy, with 75 OME (10 pills of 5 mg of oxycodone) being the lowest recommendation (National Institute on Drug Abuse, 2018). We hypothesized that the addition of nonopioid medications to the outpatient pain control regimen would decrease the need for narcotics. In this prospective, observational pilot study, we prescribed a 3-day regimen of ibuprofen and acetaminophen to patients after uncomplicated laparoscopic cholecystectomies and appendectomies. An additional opioid prescription for 5 pills of 5 mg of oxycodone (37.5 OME) was written for breakthrough pain. During their postoperative visit, we evaluated patients' adherence to the pain control regime, their postdischarge opioid use, and the adequacy of their pain control. Sixty-five patients were included in the study (52% male). The majority (80%) of surgeries were performed urgently or emergently. The visual analog scale pain score at home was significantly better than upon discharge (3.7 vs. 5.5, p = 0.001). The average number of oxycodone pills taken postdischarge was 1.8 pills. Half (51%) of the patients did not take any opioids. All but four patients reported that their pain was adequately controlled. No patient required additional opioid prescriptions or visited the emergency department. This study demonstrated that opioids can be eliminated in at least half of the patients and that five pills of 5 mg of oxycodone (37.5 OME) is sufficient for outpatient pain control when a 3-day course of ibuprofen and acetaminophen is prescribed. Therapeutic study, level V.

Oxycodone

Oxycodone is available as a controlled-release tablet, intended to be taken every 12 hours. A July 1996 study independent of Purdue Pharma, the drug's originator, found the controlled-release formulation had a variable duration of action ranging from 10 to 12 hours. A 2006 review found that controlled-release oxycodone is comparable to immediate-release oxycodone, morphine, and hydromorphone in management of moderate to severe cancer pain, with fewer side effects than morphine. The author concluded that the controlled-release form is a valid alternative to morphine and a first-line treatment for cancer pain. In 2014, the European Association for Palliative Care recommended oxycodone by mouth as a second-line alternative to morphine by mouth for cancer pain.

Pain management

The list below consists of commonly used opioid analgesics which have long-acting formulations. Common brand names for the extended release formulation are in parentheses. Oxycodone (OxyContin) Hydromorphone (Exalgo, Hydromorph Contin) Morphine (M-Eslon, MS Contin) Oxymorphone (Opana ER) Fentanyl, transdermal (Duragesic) Buprenorphine*, transdermal (Butrans) Tramadol (Ultram ER) Tapentadol (Nucynta ER) Methadone* (Metadol, Methadose) Hydrocodone bitartrate (Hysingla ER) and bicarbonate (Zohydro ER) *Methadone and buprenorphine are each used both for the treatment of opioid addiction and as analgesics

Oxycodone

Oxycodone, sold under the brand names Roxicodone and OxyContin (which is the extended release form) among others, is an opioid medication used for treatment of moderate to severe pain. It is highly addictive and a common drug of abuse. It is usually taken by mouth, and is available in immediate-release and controlled-release formulations. Onset of pain relief typically begins within fifteen minutes and lasts for up to six hours with the immediate-release formulation. In the United Kingdom, it is available by injection. Combination products are also available with paracetamol (acetaminophen), ibuprofen, naloxone, naltrexone, and aspirin.

Pain management in children

After treatment Post-procedural treatment in children is primarily prescription opioids. Morphine is effective and relatively safe, and is often used with moderate to severe pain. Codeine and tramadol should be avoided especially in children younger than 12 years old since metabolism varies due to genetic differences between individuals, and, in the case of tramadol, this medication has not been well studied in children. However, other interventions include medications classified as non-opioid analgesics, which are useful in post surgical treatment. For example, acetaminophen or ibuprofen can be used as a non-opioid analgesics. Unlike acetaminophen, ibuprofen has anti-inflammatory property which can be useful for pain in inflammatory conditions. Aspirin is not used in pediatric population due to its association with Reye's syndrome. Management

Efficacy of oxycodone/paracetamol for patients with bone-cancer pain: a multicenter, randomized, double-blinded, placebo-controlled trial.

Bone-cancer pain is a common and refractory cancer pain. Opioids, on their own, do not control this type of pain well enough, and co-analgesics are necessary. Patients with bone metastasis-related pain at Numeric Rating Scale ≥4 were enrolled to this randomized placebo-controlled trial. They had also received morphine or transdermal fentanyl patches for at least 1 week. During the 3-day efficacy phase, patients received placebo or 1-3 tablets of oxycodone/paracetamol (5/325 mg), four times daily for 3 days. All patients kept a daily pain diary. The primary endpoint was the Pain Intensity Difference (PID). Secondary endpoints were cases of breakthrough pain and rescue morphine consumption. Additional analyses included the Short Form-6 Dimensions (SF-6D) quality-of-life scale and a general impression (GI) of patient satisfaction with treatment at the end of the phase. Of the 246 patients in the intent-to-treat set, 89·4% completed the 3-day efficacy phase. PIDs were 0·9 and 0·3 in the oxycodone/paracetamol and placebo groups respectively, on day 1 (P < 0·001), and 1·5 and 0·3 respectively on day 3 (P < 0·001). Thirty-eight patients in the treatment group, and 58 in the placebo group, suffered breakthrough pain on day 3 (P < 0·001). The SF-6D score decreased to 21·2 ± 2·5 in the oxycodone/paracetamol group at the end of the phase (P = 0·001). In the oxycodone/paracetamol group, 67% rated GI as good, very good, or excellent. Patients with bone-cancer pain, already on opioids, obtain clinically important, additional pain-control, with regular oxycodone/paracetamol dosing.

Hydrocodone/ibuprofen

Society and culture Cost The average wholesale price (AWP) of generic Vicoprofen varies based on the strength of the preparation. Pricing data gathered from Lexicomp in October 2017 indicates the AWP for a 100 count bottle of 7.5 mg/200 mg strength to be $114.62, a 100 count of 5 mg/200 mg strength to be $356.62 and a 100 count of 10 mg/200 mg strength to be $470.35. These prices are all for generic equivalents of Vicoprofen. Utilization In 2003, at the time of the approval announcement for the first generic equivalent, it was reported that annual sales of brand name Vicoprofen totaled $104 million. According to IMS, the hydrocodone/ibuprofen tablets 7.5 mg/200 mg, had an estimated market size of $15.7 million for the 12 months preceding May 2016. See also Fentanyl/fluanisone Hydrocodone/aspirin Hydrocodone/paracetamol Morphine/naltrexone Oxycodone/aspirin Oxycodone/ibuprofen Oxycodone/naloxone Oxycodone/paracetamol References External links

InternalMed_Harrison

For continuous pain, opioids should be administered on a regular, around-the-clock basis consistent with their duration of analgesia. They should not be provided only when the patient experiences pain; the goal is to prevent patients from experiencing pain. Patients also should be provided rescue medication, such as liquid morphine, for breakthrough pain, generally at 20% of the baseline dose. Patients should be informed that using the rescue medication does not obviate the need to take the next standard dose of pain medication. If after 24 h the patient’s pain remains uncontrolled and recurs before the next dose, requiring the patient to use the rescue medication, the daily opioid dose can be increased by the total dose of rescue medications used by the patient, or by 50% for moderate pain and 100% for severe pain of the standing opioid daily dose.

InternalMed_Harrison

Generic Name Dose, mg Interval Comments Nonnarcotic analgesics: usual doses and intervals Codeine 30–60 q4h 30–60 q4h Nausea common Oxycodone — 5–10 q4–6h Usually available with acetaminophen or aspirin Morphine 5 q4h 30 q4h Morphine sustained — 15–60 bid to tid Oral slow-release preparation release Hydromorphone 1–2 q4h 2–4 q4h Shorter acting than morphine sulfate Levorphanol 2 q6–8h 4 q6–8h Longer acting than morphine sulfate; absorbed well PO Methadone 5–10 q6–8h 5–20 q6–8h Delayed sedation due to long half-life; therapy should not be initiated with >40 mg/d, and dose escalation should be made no more frequently than every 3 days Meperidine 50–100 q3–4h 300 q4h Poorly absorbed PO; normeperidine is a toxic metabolite; routine use of this agent is 7-day transdermal patch Buprenorphine 0.3 q6–8h CHAPTER 18 Pain: Pathophysiology and Management Anticholinergic Orthostatic Cardiac Ave. Dose, Generic Name 5-HT NE Sedative Potency Potency Hypotension Arrhythmia mg/d Range, mg/d

Are strong opioids equally effective and safe in the treatment of chronic cancer pain? A multicenter randomized phase IV 'real life' trial on the variability of response to opioids.

Guidelines tend to consider morphine and morphine-like opioids comparable and interchangeable in the treatment of chronic cancer pain, but individual responses can vary. This study compared the analgesic efficacy, changes of therapy and safety profile over time of four strong opioids given for cancer pain. In this four-arm multicenter, randomized, comparative, of superiority, phase IV trial, oncological patients with moderate to severe pain requiring WHO step III opioids were randomly assigned to receive oral morphine or oxycodone or transdermal fentanyl or buprenorphine for 28 days. At each visit, pain intensity, modifications of therapy and adverse drug reactions (ADRs) were recorded. The primary efficacy end point was the proportion of nonresponders, meaning patients with worse or unchanged average pain intensity (API) between the first and last visit, measured on a 0-10 numerical rating scale. (NCT01809106). Forty-four centers participated in the trial and recruited 520 patients. Worst pain intensity and API decreased over 4 weeks with no significant differences between drugs. Nonresponders ranged from 11.5% (morphine) to 14.4% (buprenorphine). Appreciable changes were made in the treatment schedules over time. Each group required increases in the daily dose, from 32.7% (morphine) to 121.2% (transdermal fentanyl). Patients requiring adjuvant analgesics ranged from 68.9% (morphine) to 81.6% (oxycodone), switches varied from 22.1% (morphine) to 12% (oxycodone), discontinuation of treatment from 27% ( morphine) to 14.5% (fentanyl). ADRs were similar except for effects on the nervous system, which significantly prevailed with morphine. The main findings were the similarity in pain control, response rates and main adverse reactions among opioids. Changes in therapy schedules were notable over time. A considerable proportion of patients were nonresponders or poor responders. NCT01809106 (https://clinicaltrials.gov/ct2/show/NCT01809106?term=cerp&rank=2).

Oxycodone/naloxone

Adverse effects If the drug is used off-label by crushing the tablet and dissolving it for injection, it may precipitate severe opiate withdrawal symptoms due to the much higher bioavailability of intravenous naloxone compared to oral naloxone. In simpler terms, the normal injection dose of naloxone is far smaller than the oral dose due to more of an intravenous dose being absorbed and active in the body. See also Hydrocodone/paracetamol Hydrocodone/ibuprofen Oxycodone/paracetamol Oxycodone/aspirin Morphine/naltrexone Fentanyl/fluanisone References External links Combination analgesics Semisynthetic opioids

Analgesic efficacy of morphine sulfate immediate release vs. oxycodone/acetaminophen for acute pain in the emergency department.

Previous research demonstrated that administration of Morphine Sulfate Immediate Release (MSIR) results in similar analgesic efficacy to Oxycodone but with significantly lesser degrees of euphoria and reward. The purpose of this study sit to investigate if MSIR combined with Acetaminophen can serve as an opioid analgesic alternative to Oxycodone combined with acetaminophen (Percocet) for acute pain in the Emergency Department (ED). A prospective, randomized, double-blind trial of ED patients aged 18 to 64 years presenting with moderate to severe acute pain as defined by an 11-point numeric rating scale (NRS) with an initial score of ≥5 (0 = no pain and 10 = very severe pain). Patients were randomized to receive either 15 mg MSIR combined with 650 mg of Acetaminophen or 10 mg Oxycodone combined with 650 mg Acetaminophen. Patients were assessed at baseline, 30, 45 and 60 min. The primary outcome was reduction in pain at 60 min. Secondary outcomes include drug likeability and adverse events. 80 patients were enrolled in the study (40 per group). Demographic characteristics were similar between the groups (P > 0.05). Mean NRS pain scores at baseline were 8.44 for the MSIR group and 8.53 for the Percocet group (P = 0.788). Mean pain scores decreased over time but remained similar between the groups: 30 min (6.03 vs. 6.43; P = 0.453), 45 min (5.31 vs. 5.48; P = 0.779), and 60 min (4.22 vs. 4.87; P = 0.346). Reduction in mean NRS pain scores were statistically significant from baseline to 30, 45 and 60 min within each group (P < 0.0001 at each time point for both groups). The largest NRS mean difference was from baseline to 60 min: 4.2 (95% CI: 3.43 to 5.01) for MSIR group and 3.61 (95% CI: 2.79 to 4.43) for Percocet group. No clinically significant changes or any serious adverse events were observed in either group. MSIR provides similar analgesic efficacy as Percocet for short-term pain relief in the ED, similar rates of nausea/vomiting, and lower rates of likeability of the drug.

Oxycodone

In the U.S., extended-release oxycodone is approved for use in children as young as eleven years old. The approved uses are for the relief of cancer pain, trauma pain, or pain due to major surgery, in children already treated with opioids, who can tolerate at least 20 mg per day of oxycodone; this provides an alternative to Duragesic (fentanyl), the only other extended-release opioid analgesic approved for children. Available forms Oxycodone is available in a variety of formulations for by mouth or under the tongue:

ATC code N02

N02AJ Opioids in combination with non-opioid analgesics N02AJ01 Dihydrocodeine and paracetamol N02AJ02 Dihydrocodeine and acetylsalicylic acid N02AJ03 Dihydrocodeine and other non-opioid analgesics N02AJ06 Codeine and paracetamol N02AJ07 Codeine and acetylsalicylic acid N02AJ08 Codeine and ibuprofen N02AJ09 Codeine and other non-opioid analgesics N02AJ13 Tramadol and paracetamol N02AJ14 Tramadol and dexketoprofen N02AJ15 Tramadol and other non-opioid analgesics N02AJ16 Tramadol and celecoxib N02AJ17 Oxycodone and paracetamol N02AJ18 Oxycodone and acetylsalicylic acid N02AJ19 Oxycodone and ibuprofen N02AX Other opioids N02AX01 Tilidine N02AX02 Tramadol N02AX03 Dezocine N02AX05 Meptazinol N02AX06 Tapentadol N02AX07 Oliceridine N02AX51 Tilidine and naloxone N02B Other analgesics and antipyretics

Opioids for cancer pain - an overview of Cochrane reviews.

Pain is a common symptom with cancer, and 30% to 50% of all people with cancer will experience moderate to severe pain that can have a major negative impact on their quality of life. Opioid (morphine-like) drugs are commonly used to treat moderate or severe cancer pain, and are recommended for this purpose in the World Health Organization (WHO) pain treatment ladder. The most commonly-used opioid drugs are buprenorphine, codeine, fentanyl, hydrocodone, hydromorphone, methadone, morphine, oxycodone, tramadol, and tapentadol. To provide an overview of the analgesic efficacy of opioids in cancer pain, and to report on adverse events associated with their use. We identified systematic reviews examining any opioid for cancer pain published to 4 May 2017 in the Cochrane Database of Systematic Reviews in the Cochrane Library. The primary outcomes were no or mild pain within 14 days of starting treatment, withdrawals due to adverse events, and serious adverse events. We included nine reviews with 152 included studies and 13,524 participants, but because some studies appeared in more than one review the number of unique studies and participants was smaller than this. Most participants had moderate or severe pain associated with a range of different types of cancer. Studies in the reviews typically compared one type of opioid or formulation with either a different formulation of the same opioid, or a different opioid; few included a placebo control. Typically the reviews titrated dose to effect, a balance between pain relief and adverse events. Various routes of administration of opioids were considered in the reviews; oral with most opioids, but transdermal administration with fentanyl, and buprenorphine. No review included studies of subcutaneous opioid administration. Pain outcomes reported were varied and inconsistent. The average size of included studies varied considerably between reviews: studies of older opioids, such as codeine, morphine, and methadone, had low average study sizes while those involving newer drugs tended to have larger study sizes.Six reviews reported a GRADE assessment (buprenorphine, codeine, hydromorphone, methadone, oxycodone, and tramadol), but not necessarily for all comparisons or outcomes. No comparative analyses were possible because there was no consistent placebo or active control. Cohort outcomes for opioids are therefore reported, as absolute numbers or percentages, or both.Reviews on buprenorphine, codeine with or without paracetamol, hydromorphone, methadone, tramadol with or without paracetamol, tapentadol, and oxycodone did not have information about the primary outcome of mild or no pain at 14 days, although that on oxycodone indicated that average pain scores were within that range. Two reviews, on oral morphine and transdermal fentanyl, reported that 96% of 850 participants achieved that goal.Adverse event withdrawal was reported by five reviews, at rates of between 6% and 19%. Participants with at least one adverse event were reported by three reviews, at rates of between 11% and 77%.Our GRADE assessment of evidence quality was very low for all outcomes, because many studies in the reviews were at high risk of bias from several sources, including small study size. The amount and quality of evidence around the use of opioids for treating cancer pain is disappointingly low, although the evidence we have indicates that around 19 out of 20 people with moderate or severe pain who are given opioids and can tolerate them should have that pain reduced to mild or no pain within 14 days. This accords with the clinical experience in treating many people with cancer pain, but overstates to some extent the effectiveness found for the WHO pain ladder. Most people will experience adverse events, and help may be needed to manage the more common undesirable adverse effects such as constipation and nausea. Perhaps between 1 in 10 and 2 in 10 people treated with opioids will find these adverse events intolerable, leading to a change in treatment.

[Best practice of pain management with opioids].

Opioids are main drugs in pain management for terminal cancer patients. In these days, we have to choice suitable opioids for the terminal cancer patients with severe pain by opioids rotation. Morphine is a basic drug in opioids. To know about character of morphine make us easy for using other opioids. In this article, character and some points in using opioids were described in detail. For example, timing for administrating opioids, titration, rescue dose, and side effects were included in this article. We don't have to remember the aim of pain management. Pain control is not a purpose, but a way for keeping QOL of the terminal cancer patients.

Grünenthal

To date, the PMCPA website lists 16 completed cases involving Grünenthal. Further drug development The company has focused on the treatment of pain and is doing its own research and development in this field. Grünenthal developed the drug Tramadol, which is marketed under the brand name Tramal, one of the best-selling opioid painkillers. Other business units are gynecology, dermatology, and anti-infectives. Current products include the birth control pill Belara and the matrix pain patch Transtec. Unlike Tramadol, which is a Schedule IV(C-IV) medication, the drug Tapentadol HCl, as licensed by Grünenthal, is Schedule II(C-II) in the U.S. (meaning it is a potent agonist, therefore subject to abuse similar to other C-II opioids, such as oxycodone and morphine).

[Effect of ondansetron in lower extremity bone surgery on morphine and tramadol consumption using patient controlled analgesia].

In this study, we aimed to assess the effect of administration of ondansetron on morphine and tramadol consumptions. After approval by the ethics committee, 120 patients with ASA status I or II, who will undergo elective lower extremity surgery, were included in the study. Patients were randomly divided into 4 groups following the anesthesia induction. Group I received tramadol as PCA with an infusion of 0.3 mg/kg following a loading dose of 1.5 mg/kg administered 1 hour before the end of the surgery. Group II received ondansetron 0.1 mg/kg following induction of anesthesia, additionally. Group III received morphine as PCA with an infusion following a loading dose of 0.15 mg/kg administered 30 minutes before the end of surgery. Group IV received ondansetron 0.1 mg/kg following induction of anesthesia, additionally. Pain scores(VAS), nausea, vomitting and sedation scores, analgesic consumptions and adverse effects were recorded at 5th, 15th, 30th, 45th minutes and 4th, 8th, 12th and 24th hours postoperatively. Postoperative VAS, nausea, vomitting and sedation scores were similar among the groups. The analgesic consumption was found significantly higher at 4th, 8th, 12th and 24th hours in group II. No statistically significant difference was found in analgesic consumption between group III and IV at all times. We concluded that, ondansetron, when administered as nausea prophylaxis in patients receiving tramadol and morphine as PCA, did not effect morphine consumption whereas did increased tramadol consumption.

Prescription drug addiction

Commonly abused drug categories Opioid analgesics Opioid painkillers exert CNS depressant effects by binding to opioid receptors. Its psychoactive properties potentially cause euphoria. Changes in the pain management including more liberal opioids prescription for chronic pain conditions, prescription of higher doses and the development of more potent opioid drugs play an important role contributing to the current epidemic of prescription opioid addiction. Examples of opioid drugs include morphine, codeine, oxycodone, hydrocodone, fentanyl, tramadol and methadone. Stimulants

A comparison of regularly dosed oral morphine and on-demand intramuscular morphine in the treatment of postsurgical pain.

A randomized, placebo-controlled, double-blind clinical trial was conducted to compare the use of regularly dosed po morphine and on-demand in morphine in 47 patients undergoing total hip arthroplasty. Patients were randomized to receive either 20 mg (initial dose) of regularly dosed morphine (every four hours po) plus breakthrough pain medication on-demand consisting of both 10 mg morphine po and placebo im, or an equivalent regularly dosed oral placebo (every four hours) with breakthrough pain medication consisting of oral placebo and 5-10 mg morphine im. Subsequent to each request for breakthrough pain medication, the next regularly dosed oral solution was increased by 5 mg (or equivalent volume of placebo) to a maximum of 40 mg po Q4H. Time-averaged pain scores were lower on both postoperative day 1 and 2 in the group receiving regularly dosed morphine po (P < 0.05). Fewer patients requested breakthrough pain medication on both days in the oral morphine group. The incidence of nausea and vomiting, and of decreased respiratory rates were similar in both groups. Regularly dosed oral morphine is inexpensive and should be compared to other methods of opioid delivery.

WHO Analgesic Ladder -- Definition/Introduction

First Step - Mild pain: non-opioid analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen with or without adjuvants Second Step - Moderate pain: weak opioids (hydrocodone, codeine, tramadol) with or without non-opioid analgesics and with or without adjuvants Third Step - Severe and persistent pain: potent opioids (morphine, methadone, fentanyl, oxycodone, buprenorphine, tapentadol, hydromorphone, oxymorphone) with or without non-opioid analgesics, and with or without adjuvants [4]

Opioid Equivalency -- Enhancing Healthcare Team Outcomes -- Case Example 3: Change Opioid and Route

Develop pain prescription: Fentanyl patch is placed on the skin for 72 hours, after which the old patch is removed and replaced with a new one. For patients who are prescribed a long-acting opioid, it is preferable to add a short-acting opioid. The short-acting opioid helps to address breakthrough pain, which is not addressed by the long-acting opioid alone. The dose of the short-acting opioid is determined as follows: Calculate 24-hour OME from the long-acting opioid dose. In the example above it is: (24-hour OME = fentanyl patch dose X 2 = 50 mg) Dose of short-acting opioid is 10% of OME: Morphine 5 mg PO. A short-acting medication is usually dosed every 3 to 4 hours, which the patient takes on an as-needed basis. Equivalent doses of different short-acting formulations of hydromorphone and oxycodone are calculated using the same principles of equianalgesia as outlined above.

Intractable pain

Intrathecal Pain Pump - delivers a very small amount of the chosen medication directly to the thecal space (next to the spinal cord, even closer than an epidural) Epidural, nerve root, and/or trigger point corticosteroid injections mu-Opioids - Depending on the specific drug, opioids can be oral, transdermal, IV, intramuscular, subcutaneous, transmucosal, sublingual, intranasal, epidural, or intrathecal. Examples include morphine, hydromorphone, oxymorphone, hydrocodone, oxycodone, codeine, buprenorphine methadone - methadone is a mu-opioid, kappa-opioid, and NMDA receptor antagonist. It is used for neuropathic pain, however it is also useful for other types of pain, such as bone pain, and musculoskeletal pain.

Peripheral neuropathy

A 2009 Cochrane review states that there is no evidence from randomised trials on any form of treatment for neuralgic amyotrophy Medications A range of medications that act on the central nervous system have been used to symptomatically treat neuropathic pain. Commonly used medications include tricyclic antidepressants (such as nortriptyline, amitriptyline. imapramine, and desipramine,) serotonin-norepinephrine reuptake inhibitor (SNRI) medications (duloxetine, venlafaxine, and milnacipran) and antiepileptic medications (gabapentin, pregabalin, oxcarbazepine zonisamide levetiracetam, lamotrigine, topiramate, clonazepam, phenytoin, lacosamide, sodium valproate and carbamazepine). Opioid and opiate medications (such as buprenorphine, morphine, methadone, fentanyl, hydromorphone, tramadol and oxycodone) are also often used to treat neuropathic pain.

[Opioids in chronic noncancer pain-are opioids different? A systematic review and meta-analysis of efficacy, tolerability and safety in randomized head-to-head comparisons of opioids of at least four week's duration].

We updated a systematic review on the comparative efficacy, tolerability and safety of opioids and of their routes of application in chronic noncancer pain (CNCP). We screened MEDLINE, Scopus and the Cochrane Central Register of Controlled Trials (CENTRAL) up until October 2013, as well as the reference sections of original studies and systematic reviews of randomized controlled trials (RCTs) of opioids in CNCP. We included randomized head-to-head comparisons of opioids (opioid of the sponsor of the study versus standard opioid) of at least 4 week's duration. Using a random effects model, absolute risk differences (RD) were calculated for categorical data and standardized mean differences (SMD) for continuous variables. The quality of evidence was rated by the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. We included 13 RCTs with 6748 participants. Median study duration was 15 weeks (range 4-56 weeks). Hydromorphone, morphine, oxymorphone and tapentadol were compared to oxycodone; fentanyl to morphine and buprenorphine to tramadol. In pooled analysis, there were no significant differences between the two groups of opioids in terms of mean pain reduction (low-quality evidence), the patient global impression to be much or very much improved outcome (low-quality evidence), physical function (very low-quality evidence), serious adverse events (moderate-quality evidence) or mortality (moderate-quality evidence). There was no significant difference between transdermal and oral application of opioids in terms of mean pain reduction, physical function, serious adverse events, mortality (all low-quality evidence) or dropout due to adverse events (very low-quality). Pooled head-to-head comparisons of opioids (opioid of the sponsor of the study versus standard opioid) provide no rational for preferring one opioid and/or administration route over another in the therapy of patients with CNCP. The English full-text version of this article is freely available at SpringerLink (under "Supplemental").


1 and 5: These are diagnostic tests, they are meaningless since you have already made the diagnosis. 2: Age should not be a limiting factor, especially considering that it is only 71 years old, but especially because the patient's "quality of life" is good (and I put "quality of life" because it is a term used erroneously, it is supposed to mean that he maintains a good functional level). 3: Presents a very mild respiratory limitation, does not require such a test. 4: Is the correct one.

1 and 5: These are diagnostic tests, they are meaningless since you have already made the diagnosis. 2: Age should not be a limiting factor, especially considering that it is only 71 years old, but especially because the patient's "quality of life" is good (and I put "quality of life" because it is a term used erroneously, it is supposed to mean that he maintains a good functional level). 3: Presents a very mild respiratory limitation, does not require such a test. 4: Is [HIDDEN].

A 71-year-old patient, smoker of 2 packs of cigarettes/day for 50 years, with good quality of life and no other pathologic history of interest, consults for cough and hemoptotic expectoration. Physical examination revealed no significant pathological findings. Chest X-ray showed a mass of 4x3.4 cm lower right, a finding that was confirmed in the thoracoabdominal CT scan, which located the lesion in the lower lobe and found no adenopathy or metastasis. Bronchoscopy showed an infiltrating lesion in the right basal pyramid, biopsied as a well-differentiated squamous cell carcinoma. As for respiratory function tests, the FVC is 3,300 cc (84%) and the FEV 1 is 2,240 cc (80%). What should be the next step to follow in this patient?

Surgical intervention with curative intent should be contraindicated due to the advanced age of the patient.

An oxygen consumption test should be performed, given the respiratory limitation he presents.

Surgical resection (lobectomy of the lower lobe of the right lung) should be indicated directly.

A trantoracic puncture should be performed.

Total thoracoscopic high-position sleeve lobectomy of the right upper lobe of the lung.

This video demonstrates a total thoracoscopic high-position sleeve lobectomy of the right upper lobe in patients with central lung cancer. A 50-year-old male was admitted to the hospital due to a two-month history of coughing. His previous medical history was unremarkable. On admission, physical examination revealed reduced breath sounds in the right upper lung, but no significant rales were present. Chest CT scan revealed a mass in the right upper lung near the lung hilum, atelectasis of the right upper lobe, and enlarged right hilar lymph nodes. No significantly enlarged mediastinal lymph node was noted. Bronchoscopy revealed occlusion of the right upper lobe bronchus by the tumor. Pathological examination of the obtained biopsy reveled squamous cell carcinoma. The required preoperative examinations were completed, and no distant metastasis was evident. Total thoracoscopic sleeve resection of the right upper lobe was performed via the "three-port approach" in which the anterior port was the main operating port. First, the inferior pulmonary ligament was dissected to remove the lymph nodes of station 9. Next, the lymph nodes of stations 7 and 8 were removed. Third, the lymph nodes in the region between the intermediate bronchus and the right upper lobe were dissected. Then, the dissection continued superiorly to remove mediastinal lymph nodes of stations 2 and 4 followed by successful anatomic right upper lobectomy, which briefly included division of the superior pulmonary arteries and veins, skeletonization of the upper right lobular bronchus, localization via incision by a sharp blade, division of the bronchus with scissors, and anastomosis with 3-0 prolene continuous suture. The surgery was successful. The postoperative pathological stage was T4N1M0 (stage IIIA).

[21-year-old man with squamous cell carcinoma of the lung].

Lung cancer among people in their twenties is rare and accounts for only 0.1-0.4% of all cases. We describe a case of squamous cell carcinoma of the lung in a 21-year-old man. The otherwise healthy patient presented with a 1 month history of cough. Chest radiography showed a well-defined round mass 5 cm in size in the right lower lobe. Computed tomography also showed a 3 cm hilar lymph node. Bronchoscopy revealed a white polypoid mass obstructing the right basal bronchus. Transbronchial biopsy revealed poorly differentiated squamous cell carcinoma of the lung. Clinical diagnosis was T2N1M0, stage IIB lung cancer. Right lower lobectomy with mediastinal lymph node dissection was performed. Lymph node metastases were proven histologically in the pretracheal, subcarinal, hilar, and intrapulmonary regions. Pathological diagnosis was T2N2M0, stage IIIA lung cancer. Endobronchial and mediastinal lymph node metastases were found 2 months after surgery. He received 3 rounds of chemotherapy with cisplatin and docetaxel and irradiation to the right hilum and mediastinum at a total dose of 60 Gy in 30 fractions. He is alive 6 months after surgery.

[Three cases of small intrapulmonary lymph nodes coincidental with primary lung cancer].

We report three cases of intrapulmonary lymph nodes coincidental with primary lung cancers. In the first case, a 56-year-old man had a small subpleural nodule in the right lower lobe associated with adenocarcinoma of the right upper lobe. The small nodule was 10 mm in diameter and was difficult to differentiate radiologically from intrapulmonary metastasis. Wedge resection of this small nodule was performed. Histologic examination of the nodule revealed an intrapulmonary lymph node with anthracotic pigmentation. A right upper lobectomy for adenocarcinoma was performed, and was completely curative. The second patient, a 77-year-old woman, had adenocarcinoma in the right lower lobe diagnosed by transbronchial biopsy. Computed tomography (CT) revealed a small nodule 5 mm in diameter in the right upper lobe. Histologic examination of the small wedge-resected nodule revealed a lymph node. Lower lobectomy was performed with completely curative results. In the third case, a 63-year-old man was admitted for investigation of a mass shadow in the right upper lobe. CT showed a small nodular shadow in the right middle lobe, confirmed histologically to be lymphoid tissue, in addition to the original mass, which was diagnosed by transbronchial biopsy as squamous cell carcinoma. Upper lobectomy was performed and proved to be curative. Small intrapulmonary lymph nodes are very difficult to diagnose by methods other than surgical resection. When a small intrapulmonary nodule is detected in a patient with primary lung cancer, the presence of an intrapulmonary lymph node must be considered. If radiological characters compatible with an intrapulmonary lymph node are found and there is no other metastasis indicating poor prognosis, it should be considered as a possible indication for surgical resection.

[The operated case of 89 year-old patient with pleomorphic carcinoma of the lung].

A-89-year-old male patient who complained dry cough was detected lung mass of 3 cm size in diameter at the right upper lobe by CT. FDG-PET seemed to show hilar and mediastinum lymph nodes metastasis. After three weeks, the mass showed rapid growth with 5 cm diameter in size at CT. Therefore the original tumor was supposed to be undifferentiated carcinoma, above all, pleomorphic carcinoma. He had been done pulmonary resection after short period. The right upper lobectomy with combined resection of the partial middle lobe was performed. Hilar and mediastinum lymph nodes dissection was added. In pathological examination, the tumor was proved pleomorphic carcinoma, however, no lymph node metastasis was recognized. He did not refer any complications and discharged back home at the post-operative 11th day. Pleomorphic carcinoma of the lung is known to be difficult to obtain definite diagnosis in early stage because of rapid growth. Therefore many cases are detected in advanced stage. In addition, chemotherapy is generally not effective, so only operative resection seems to be useful. Our patient was 89-year-old, he tolerated the operation and was alive with no trouble during 6 months after resection. When complete resection seems to be possible, operation should be regarded as an initial treatment.

[Synchronous primary lung cancers: due to the four cases].

If two primary lung cancers are present in the same time, it diagnosed as synchronous lung cancer. It constitutes 0.1-1.6% of all lung cancers. In this report, we described four cases diagnosed synchronous multiple primary lung cancers (MPLC) in between June 1999 and May 2002. Mean age was 63, and all of those were male. All patients were heavy smoker (mean 58 packet/year). Histology of lung cancers was squamous-adeno in two cases, squamous-small cell lung cancer in one case, and squamous-squamous in two cases. All patients had bilateral mass lesions and no mediastinal and systemic spread. Lesion of second primary lung cancer was unable to seen in two patient's chest X-ray. Their lesions were seen by computerized tomography in one case, and by bronchoscope only in the other case. Lesion site was left lower lobe, right lower lobe, right middle lobe, and left upper lobe (25% for each). Diagnosis of lung cancer was made by transthoracic needle biopsy in three lesion, and made by bronchoscopic biopsy in other lesions. While it is recommended that, all of MPLC lesions were staged separately and treated surgically, due to the advanced age, presence of small cell lung cancer, and inadequate post-operative respiratory reserve, surgical treatment could not apply to these patients and they received chemotherapy. Three of them was died (mean survival was 11 months). Due to the this report, we emphasized that diagnostic procedures should be done separately for each lesions in patients who had more than one lesion, and treatment should plane according to these results.

[Pulmonary nodule. The surgeon's approach].

Malignancy must be suspected with any pulmonary nodule detected on radiologic examination of the chest until its benign origin has been proven. This requires further evaluation of the patient. The non invasive diagnostic steps include patient's history, clinical examination, lung function testing, and standard radiographs and a computed tomography (CT) of the chest. Based on these findings the presumed diagnosis claims the next appropriate diagnostic steps. If lung cancer is the most likely diagnosis and lung function testing revealed that the patient is a candidate for lung resection than surgery may be the next step. Preoperative proof of the histologic diagnosis is not mandatory. It is the less required the more surgery may be curative. If curative resectability is indoubt or the patient is not candidate for lung resection than histologic diagnosis should be confirmed prior to introduction of radiotherapy or chemotherapy by the least invasive procedure (bronchoscopy < lymph node biopsy < needle biopsy < mediastinoscopy/-tomy < VATS). If metastatic disease must be suspected, staging should be completed as required for the primary malignancy. With local recurrence and other metastases excluded the number of pulmonary nodules detected on CT scan points to the appropriate surgical approach. In case of a solitary nodule or multiple but resectable nodules, complete (wedge) resection with lymph node dissection through a lateral thoracotomy will be the procedure of choice. With multiple and unresectable nodules, surgery allows definitive diagnosis and videothoracoscopy affords the opportunity to accomplish wedge resection of the lung along with low morbidity. When lesions are deemed indeterminate, definitive diagnosis should nevertheless be attempted. If there is no history of malignancy routine evaluation for such in asymptomatic patients is not indicated. With small nodules (less than 3 cm in diameter) located in the periphery of the lung, videothoracoscopic wedge resection is indicated without preoperative sputum cytology, bronchoscopy or transthoracic needle biopsy. The histologic diagnosis obtained by intraoperative frozen sections than determines the further surgical approach. Benign lesion: completion of surgery; lung cancer: proceed to thoracotomy with anatomic lung resection and mediastinal lymph node resection; metastatic disease: completion of surgery and further search for primary malignancy.

[Pulmonary pleomorphic carcinoma].

Pleomorphic carcinoma is a rare primary pulmonary malignancy. We report 2 surgical cases of pulmonary pleomorphic carcinoma. The first case was a 71-year-old male. Chest computed tomography (CT) showed a rapidly growing tumor with irregular density. Transbronchial lung biopsy revealed the tumor to be malignant. Left lower lobectomy was performed. Pathological diagnosis was pleomorphic carcinoma (pT2N2M0, stage IIIA). He died 8 months after surgery due to brain metastasis and mediastinal lymph node metastasis. The second case was a 74-year-old male who complained of bloody sputum. Chest CT showed a tumor with cavity in the right middle lobe. Brushing cytology under bronchofiberscopy revealed atypical cell. Right middle lobectomy and partial resection of the right lower lobe were performed. Pathological diagnosis was also pleomorphic carcinoma (pT2N0M0, stage IB). He has no findings of recurrence nor metastasis 15 months after the operation.

Report of a lung carcinoma extended to the left atrium through pulmonary vein.

Lung cancers may extend along or grow through the pulmonary veins to invade or lie within the left atrium (LA). A 62-year-old man, previously healthy, presented with 1-month ventilatory-independent right hemithorax back pain, dry cough and large effort dyspnea. He also referred weight loss of 12 kg in 10 months and denied hemoptysis. As antecedents, he smoked for 40 years and moderate daily alcoholism. On physical examination, the patient was in good general condition, hydrated and regular respiration at rest [blood pressure (BP) =120/80 mmHg; heart rate (HR) =90 bpm; respiratory rate (RR) =16 rpm]. Cardiac auscultation revealed two standard rhythmic sounds without murmurs. Pulmonary auscultation revealed a slightly diminished vesicular murmur in the lower 1/3 of the right hemithorax without adventitious noises. Chest radiography showed a mass over the right lower lung. A CT scan confirmed the radiography image with the mass extending along the right inferior pulmonary vein and a tumor in the LA. Transthoracic and transesophageal echocardiography revealed large mass within the LA (occupying almost the entire cavity), measuring about 10 cm × 3 cm at its largest diameter, prolapsing into the left ventricle. Bronchoscopy, head CT scan, and whole-body bone scintigraphy investigation did not show any distant metastasis. The patient was successfully operated removing the intracardiac and inferior pulmonary vein tumor with the aid of cardiopulmonary bypass, followed by a right inferior lobectomy carried out after 25 days. After 30 days from surgery presented seizures associated a brain metastasis evidenced by CT when adjuvant radio and chemotherapy was started. During the next 90 days, the clinical conditions worsened, and the patient died 4 months after the surgical treatment. The case report has two primary justifications, even considering the poor outcome: (I) rarity and (II) the possibility of the surgical treatment.

Surgical treatment of non-small cell lung cancer in octogenarians - safety and prognosis.

Reluctance to recommend surgery for the elderly is partly based on the expectation that the rate of complications and mortality is higher in this group of patients and on the impression that the life expectancy of an octogenarian with lung cancer is limited by death from natural causes. Between 2007-2011, we operated on 57 patients over 80 years who underwent thoracotomy with curative intent for lung cancer. Mean age was 82.2 years, 17 were female and 40 male. The presence of preoperative comorbidities in this group of patients was significant: chronic lung disease - 22.8%, cardiovascular disease - 38.6% and a history of other malignancy - 17.5%. However, their respiratory function was very acceptable with an average FVC of 93.6% and an average FEV1 of 83.2%. The predominant location of tumor (mean size of 3.0±1.7 cm) was upper lobes (63.2%) and cytological diagnosis was established preoperatively in 61.4% of cases. Preoperative staging was complemented by positron emission tomography in 42.1% of cases and in 12.2% with mediastinoscopy. We performed 35 lobectomies (61.4%), 4 bilobectomies (7.0%), 9 wedge resections (15.8%) and 5 pneumonectomies (8.8%). All surgeries were performed through lateral thoracotomy. In 4 patients (7.0%), anatomic resection was aborted intraoperative due to unexpected metastatic disease and/or unresectable mass discovered during exploratory thoracotomy. Lymph node dissection was complete in 57.8%. Final pathology analysis showed: adenocarcinoma in 50.9% of cases, squamous cell carcinoma in 14.0% and carcinoid tumour in 14.0%. Final staging was T1 (24.4%), T2 (26.7%), T3-4 (11.1%), N0 (35.5%), N1-2 (4.4%), G1 (8.9%), G2 (28.9%), G3 (8.9%). Mean hospital stay was 10.7±8.1 days. Main surgical complications recorded were: prolonged air leak (15.8%), atelectasis requiring bronchoscopy (7.0%) and persistent air chamber on chest roentgenography (10.5%). We observed an overall operative mortality of one case - 1.8%, which was an 80 year-old patient submitted to a pneumonectomy. In conclusion, octogenarians should not be denied surgery exclusively due to age. Surgeons should base their decision first on the stage of the disease, and then on an accurate assessment of the general clinical conditions. Pneumonectomy and extended operations should generally be avoided.

Tongue carcinoma with endobronchial metastasis: a rare case.

Endobronchial metastases of extrapulmonary malignant tumors are quite rare. We present a patient with endobronchial metastasis previously operated for tongue carcinoma. A 71-year-old female patient presented with the complaint of cough. She had a history of tongue carcinoma operation 2 years before. Chest x-ray revealed an air-fluid level in the lower zone of the right hemithorax. There was a big cavitary lesion in the right lower lobe and bilateral multiple nodular lesions, some of which had cavity formation on computed tomography. Bronchoscopy re- vealed a polypoid lesion with necrotic appearance and pathologic examination showed squamous cell carcinoma. The lesion was accepted as a metastasis of tongue carcinoma after evaluation of the materials taken from the tongue on previous operation. There was no finding suggestive of local recurrence; however, the patient died from hemoptysis and respiratory insufficiency. In conclusion, endobronchial metastasis should be considered in patients with extrapulmonary malignancies and bronchoscopic examination should be performed in such cases, even in the presence of atypical radiological findings.

[Choice of examination methods in bronchial cancer].

The techniques used for the investigation of a patient with lung carcinoma are determined by the mode of presentation of the disease. The first step is based on the clinical examination and the chest X-ray (frontal and lateral view). The pathological examination of the tumor represents the second step. Depending on the operability of the patient at this stage of the investigation, further evaluation will (or will not) be performed to determine the extension of the tumor, using TNM staging system. Any candidate for surgery has to be bronchoscoped in order to evaluate the endobronchial spread of the tumor and to look for additional lesions. Transverse tomography of the thorax is the central part of any staging procedure. The choice among the other methods of investigation depends on the site of the tumor in the thorax. Mediastinoscopy is only needed in case of a lesion of unknown nature located in the anterior mediastinum or in addition to CT scan when there is a suspicion of mediastinal involvement. Transthoracic needle aspiration is best performed on peripheral lesions. In small cell lung carcinoma, the preoperative work-up should be very systematic even in the absence of clinical or laboratory abnormality. Whereas in certain cases the investigation of a patient with lung carcinoma can be limited to a clinical examination and a chest X-ray, any candidate for surgery has to be submitted to a detailed TNM staging.

Three metachronous primary lung cancers in a chronic smoker: A case report and review of the literature.

Lung cancer is a leading cause of cancer-related deaths. Smoking is major risk factor for initial and subsequent lung cancer especially in active smokers. Treatment of subsequent lung cancer depends on whether it is synchronous or metachronous. We report a rare case of triple metachronous lung cancer and review of literature of patients with triple metachronous cancers. This will be the second case reported of triple metachronous lung cancer. A 60-year-old male, active smoker with diabetes mellitus, chronic obstructive pulmonary disease (COPD) and peripheral arterial disease presented with cough and hemoptysis. Initial computed tomography (CT) scan showed right upper lobe spiculated mass. He underwent transthoracic needle biopsy for right upper lobe mass, showing primary lung adenocarcinoma (ADC)-Stage-IIIA. He continued to smoke and 9-years later had new left upper lobe spiculated nodule, which on surgical resection showed squamous cell carcinoma (SCC)-Stage-IA1. Despite counselling on smoking cessation, he was unable to quit. Six months later, he presented with shortness of breath and CT chest showing right hilar adenopathy in right upper and lower lobes. He underwent transbronchial biopsies of lesion which showed small cell lung carcinoma (SCLC). His initial lung ADC-Stage-IIIA, was treated with chemotherapy, weekly thoracic radiation and additional chemotherapy cycles. Nine years later, his left upper lobe mass showing SCC-Stage-IA1 was deemed curative after apical resection and he was kept on surveillance. Six months later, after diagnosis of SCLC in right upper and lower lobe, patient was not a candidate for systemic chemotherapy due to poor performance status and opted for hospice care. His initial lung ADC-Stage-IIIA showed complete radiological response with chemotherapy and radiation. Subsequent SCC-Stage-IA1 was deemed curative after resection. Due to his poor performance status, he was not a candidate for chemotherapy for SCLC and patient opted for hospice care. Smoking is a major risk factor for developing lung cancer and with continued smoking, patients are at higher risk for developing subsequent primary lung cancers. We recommend, patients with lung cancer must quit smoking, and those who do not, should remain on long-term surveillance.

[Indications for surgical intervention in patients with pulmonary cancer. Observations on 714 cases].

Selection modes for surgery were studied in a group of lung cancer patients. Selection is based: on the certain diagnosis of the disease, its histological classification and stage respiratory function tests and the assessment of any surgical indications. A total of 714 lung cancer cases were examined. Of these, 28.4% were at stage 1, 19.8% at stage 2 and 51.8% at stage 3. Only 141 patients or 19.8% of all cases examined were judged fit for radical exeresis. In the absence of metastasis all three stages of epidermoid carcinomas and adenocarcinomas were judged operable. In the case of microcytomas indication to surgery was limited to very few cases and only those in the first two stages. In the presence of metastasis to the hilar lymph nodes, surgery was only indicated where the metastasis was small. Exeresis was also indicated in the presence of single metastases to mediastinal lymph nodes on the same side as the neoplasia especially if these were considered intranodal. The difficulty of precise assessment of metastases to the hilar and mediastinal lymph nodes even with the aid of modern techniques like CAT scanning and mediastinoscopy was also noted. In 87 of 141 patients operated it was possible to check the result which was radical in 84 cases. In all, 19 pneumonectomies, 49 lobectomies and 16 bilobectomies were performed. The operative mortality rate was 3.4%. The various surgical indications were also examined in relation to the diverse clinical situations presented by lung cancers. In conclusion the modalities to be followed in order to enhance the value of radical resections in lung cancer are outlined. Above all diagnostic means must be refined to a point where the disease can be staged with maximum precision, patients for surgery must be selected with the utmost care and diagnosis must be as early as possible.

[Yield of bronchofibroscopy in patients with hemoptysis and normal thorax radiography].

The clinical histories of all the patients with hemoptysis who underwent bronchofibroscopy (FB) during a period of 5 years (1981-1986) are revised. 25.6% (108 out of 702) of the endoscopic explorations were performed in patients without radiographic pleuropulmonary abnormalities with a definite pathology. In these patients, an early FB results in one of the diagnostic methods with greatest sensibility to diagnose subglottic bleeding. Its efficacy decreases when it is performed more than 24 hours after the bleeding apparently ceased. As a whole, the side of the bleeding was determined in 50% of cases with the localization of the segment involved in 53 occasions (29.4%). In 8 (4.4%) patients, hemoptysis was secondary to bronchial neoplasia and in 6 of them FB contributed with the diagnostic material. In 5 cases hemoptysis lasted for more than seven days. Seven patients suffering bronchial carcinoma were males over 40 years old and smokers of more than 40 years/packet. There was a 77 year old female, with a carcinoid tumor who was a non smoker. In other 3 patients (2 suffering endobronchial angiomas and one case of tracheal bronchus ) the cause of bleeding could be determined with FB. We conclude that in patients presenting hemoptysis and normal chest x ray, FB is a useful procedure to localize the origin of bleeding and in a significant percentage of cases permits the etiological diagnosis.

Sister Mary Joseph's nodule as a presenting sign of internal malignancy.

CASE 1: A 64-year-old, otherwise healthy woman was referred to the surgery clinic for a presumed umbilical hernia. On physical examination, a cutaneous nodule was noted on the umbilical region and the patient was referred to the dermatology clinic. The patient was reexamined and an erythematous nodule was observed in the umbilicus measuring 2.5 cm in diameter. The patient denied pain, change in bowel habits, or weight loss. There were no other abdominal masses, no sign of ascites, and no regional lymphadenopathy. A skin biopsy from the nodule showed mucinous adenocarcinoma. Immunohistochemical staining was positive for carcinoembryonic antigen, and negative for cytokeratin (CK)7 and CK20. These results were consistent with a Sister Mary Joseph's nodule and led to the diagnosis of an occult colon carcinoma. The patient had no risk factors for colorectal carcinoma. The patient underwent surgery in another hospital, and died 3 months after the initial diagnosis of Sister Mary Joseph's nodule. CASE 2: A 73-year-old woman was referred to the dermatology clinic for evaluation of a painful, ulcerated, 3-cm lesion in the umbilicus (Figure 1). She was otherwise asymptomatic. A skin biopsy showed neoplastic glandular cells infiltrating among collagen bundles (Figure 2). Stainings for mucin and for CK7 were positive, while staining for CK20 was negative. An abdominopelvic CT scan demonstrated a 3.5-cm space-occupying lesion in the liver. Results of gastroscopy, colonoscopy, chest computed tomographic (CT) scan, and mammography were normal. Serum levels of the tumor-associated protein CA125 were elevated to 164 units, while those of CA 19-9 and carcinoembryonic antigen were within normal range. A gynecologic examination and a transvaginal ultrasound were normal. The patient had no personal or family history of any malignancy or any risk factors for developing a carcinoma. The patient was scheduled for a palliative resection of the umbilical nodule, combined with a laparoscopic inspection in search of the undetected primary tumor. She refused surgery and was lost to follow-up. She died 4 months after the initial diagnosis of umbilical metastasis. CASE 3: A 51-year-old man was aware of a silent mass in his umbilicus for 2 years without seeking medical advice. Following 2 weeks of increasing pain in this area, he was referred to the emergency room for a suspected incarcerated umbilical hernia. Surgery revealed a mass attached to the fascia and peritoneal fat. The mass was removed and diagnosed as a poorly differentiated adenocarcinoma, staining positively for carcinoembryonic antigen, and negatively for CK20, CK7, prostate-specific antigen, and prostatic acid phosphatase. Both gastroscopy and colonoscopy failed to detect the primary tumor. An abdominopelvic CT scan was normal, but a CT scan of the chest disclosed a nodule measuring 2.5 x 1.5 cm in the lower lobe of the right lung. On bronchoscopy, it was found to be an invasive adenocarcinoma, consistent with a primary tumor of the lung. The patient was a heavy smoker (45 pack-years). The patient received 4 cycles of combined chemotherapy with carboplatine and gemcitabine, with no improvement. A month later, the patient complained of abdominal pain. Following demonstration of intra-abdominal spread of disease by CT scan, a second line chemotherapy was instituted with paclitaxel. A month later the patient's condition deteriorated and he complained of cough, sweating, and pain along the right leg. A bone scan revealed bone metastases in the right femur and left tibia. Two weeks later he was admitted to the hospital with intestinal obstruction and underwent laparotomy. He had massive intra-abdominal spread of cancer and ascites. Only a palliative colostomy was performed. The patient died 3 weeks later, 9 months after the diagnosis of adenocarcinoma of the lung. The clinical data on the three patients are summarized in Table I.

[Early diagnosis of lung cancer].

268 patients with suspected lung cancer were examined over the period 1 January 1972 to 31 May 1974. On the basis of the 735 investigations performed, a 6-8 h workup program has been established including physical and functional examination, standard X-rays and hilar tomography, endoscopy and biopsy for cytologic or histologic study. Several biopsy technics are described and their indications tabulated according to their efficiency in relation to the radiologic aspect of the lesion. The number of cases and the yield for each technic are summarized in Table 2.

First case of lung cancer with pneumoconiosis and endobronchial leiomyoma complicating the diagnosis.

In the treatment of lung cancer, the presence or absence of mediastinal lymph node involvement has a significant bearing on the indication for surgery. In addition, if a tumor is found in the trachea during preoperative scrutiny of lung cancer, the possibility of intratracheal metastasis should be considered, since this kind of metastasis is a contraindication for surgery. In the present study, we experienced a case of lung cancer associated with pneumoconiosis and a rare intratracheal leiomyoma. In this case, preoperative staging was difficult, but endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and intratracheal tumor biopsy were helpful in determining the treatment strategy. A 65-year-old man was referred to our hospital for evaluation of abnormal chest X-ray shadows. Sputum cytology indicated squamous cell carcinoma. PET-CT scan showed fluorodeoxyglucose uptake in a right upper lobe mass and the hilar, mediastinal and right supraclavicular lymph nodes, and bronchoscopy revealed a protuberant lesion in the left bronchus. Hence, EBUS-TBNA for the mediastinal lymph nodes and simultaneous evaluation of the protuberant lesion in the left bronchus were performed. The bronchial tumor was histopathologically diagnosed as leiomyoma. Since mediastinal lymph node biopsy showed no malignant cells, a right upper lobectomy and a right S6 segmentectomy were performed. Postoperative pathological evaluation of the dissected lymph nodes revealed pneumoconiosis but no metastasis. He was, thus, diagnosed with squamous cell lung carcinoma (pT2bN0M0, pStage IIA). We report a patient with lung cancer and coexistence of a rare endobronchial leiomyoma and pneumoconiosis, who underwent surgery after preoperative evaluation using EBUS-TBNA.

Lung cancer combined with methotrexate-associated lymphoproliferative disorder: A case report.

Methotrexate (MTX)-associated lymphoproliferative disorder occurs in rheumatoid arthritis patients treated with MTX; however, patients with concomitant pulmonary lesions are rare. We present a case of lung cancer combined with MTX-associated lymphoproliferative disorder for which, for which it was necessary to differentiate these from possible pulmonary metastasis. A 72-year-old man was referred to our hospital for treatment of squamous cell carcinoma in the left upper bronchus. He was receiving oral MTX and prednisolone for rheumatoid arthritis for 15 years. However, chest computed tomography performed 1 week before surgery revealed a 1-cm-sized pulmonary nodule in the right lung. Surgical pulmonary resection of the right lung tumor revealed substantial B-cell lymphoma-type lymphoproliferative disorder. Left upper lobectomy for the squamous cell carcinoma in the left upper bronchus was performed 5 weeks after the first surgery. Chest CT performed 2 weeks after the first surgery revealed a new 1-cm-sized nodule in the lower left lung lobe. However, after discontinuing oral MTX therapy, the new lesion in the left lower lobe disappeared. In lung cancer patients treated with MTX for rheumatoid arthritis, MTX-associated lymphoproliferative disorder should be considered as a differential diagnosis.

[Analysis of symptoms and case history data in the set of 353 patients with lung cancer].

Lung cancer (LC) incidence in men in the Czech Republic has been declining since 1995, in women it grows up continually. To analyse the characteristics of recent set of patients (pts) and contribution of their symptoms for diagnostic, treatment and prognosis we carried on the retrospective study on patients from 1st Pulmonary department from 2004-2007. Men:women ratio in the set of 353 pts was 2:1. The frequency of symptoms at the time of diagnosis were: cough 69%, dyspnoe 54%, loss of weight 49%, expectoration 39%, pain on the chest 37%, haemoptysis 17.7%, fever 16%, vena cava superior syndrome 3.7%. Smokers fell in to the disease in significantly younger age than nonsmokers, 63 vs. 73 years. 40% of pts with LC suffer from COPD, more frequently have had squamous type of cancer. 78% of the set was morphologically verified, most frequent types of cancer were squamous type (22.1%) followed by adenocarcinoma, 21.2%. Surgical therapy underwent 18.1% of the whole set. We look consequently for correlation between symptoms and other data of the pts. The pts with abuse of alcohol beverage fell in to the disease in a younger age. The pts with central tumor suffer from stronger cough more frequently, at bronchoscopy had more often direct tumor changes. The pts with IV. TNM stage of LC more frequently suffer from fever and pain. Significantly fewer pts with dyspnoe, loss of weight and lower FEV1 underwent surgical resection, FEV1 was lower in pts with central than with peripheral type of tumor. In pts with direct bronchoscopical tumor changes were found more frequently haemoptysis, broader spectrum of symptoms, lower FVC and FEV1. Dyspnoe correlated with PaO2 but not with PaCO2. CRP was lower in pts with peripheral type of LC, higher in pts with small cell LC (SCLC). Occurrence of haemoptysis did not correlate with number of smoked cigarettes. Conclusions. In conclusion we proofed that proper taking of history case may accelerate and improve the diagnostic process.

Primary malignant melanoma of the lung: a case report of a rare tumor and review of the literature.

Primary malignant melanoma of the lung (PMML) is a rare malignancy that exhibits aggressive behavior and has a very poor prognosis. We are reporting on a case of PMML in an otherwise healthy 22-year-old Caucasian male with no significant past medical history and an unremarkable family history. The patient initially presented with a 2-month history of a cough and an unexplained 22-lb weight loss. His initial chest X-ray demonstrated opacification of the right lower lobe (RLL) of his lung and a subsequent computerized tomography scan (CT scan) of his lung revealed a large mass occupying most of his RLL (Figure 1). The patient subsequently underwent a bronchoscopy with endobronchial ultrasound. Biopsies revealed a poorly differentiated carcinoma. A positron emission tomography with low dose CT scan was performed per protocol and revealed an intensely hypermetabolic tumor with no evidence for lymphatic disease or extra-thoracic spread. The patient underwent a surgical exploration and a right lower lobectomy with a thoracic lymphadenectomy. The pathology including immunohistochemical stains demonstrated a malignant melanoma with no lymph node involvement. A physical examination including ophthalmic, mucosal, and skin examinations revealed no evidence for an extra-thoracic site of the disease. The patient had negative margins for resection and did not receive any adjuvant therapy and is alive and well with no evidence for recurrence 3 years after the resection.

[Evaluation of a broncho-pulmonary cancer patient].

A complete check-up is indispensable in patients suffering from broncho-pulmonary cancer, in order to establish a base-line for the lesions, and necessary in order to pose possible surgical indications. It must make use of the clinical examination and various instrumental exploratory methods which must be used with discrimination depending on the benefits which can be expected of them. Clinical examination is essential; it enables analysis of the symptoms and evaluation of the general condition. Investigation of the progressive potential of the cancer is based on the histological study, evaluation of the subject's state of immunity and the time for the tumor to double in size. Functional respiratory investigation is indispensable for any possible surgical discussion. Its importance equals the assessment of local extension of the tumor, of mediastinal glandular involvement and the result of vascular involvement checks. Finally, the identification of metastases remains essential, although deceptive, inspite of progress in the means of investigation which can be used.

Video-assisted thoracic surgery right sleeve lobectomy.

A 50-year-old active male with a smoking history of 30 years (20 cigarettes per day) was admitted to hospital because of more than one month's cough without sputum. No comorbidity was present. The preoperative examination showed: blood test normal, ECG normal, cardio-pulmonary function normal, chest computed tomography (CT) display right upper lobe (RUL) mass of 5 cm diameter. Bronchoscopy examination and biopsy indicated large cell neuroendocrine carcinoma (LCNEC) in the take-off of RUL bronchus. No metastatic focus was found after emission computed tomography (ECT) scan of whole body bone, abdominal US scanning and brain MR. After initial evaluation, the clinical stage before operation was cT2bN0M0 (IIA stage). A selective video-assisted thoracic surgery (VATS) operation was arranged after 9 days of smoking cessation. Lateral position, one 10 mm trocar for camera in the 7th intercostals space in the mid-auxiliary line, 4 cm trocar for operation in the 4th intercostal space in the anterior axillary line, 15 mm trocar for auxiliary operation in the 8th intercostal space in the scapula line, the patient received VATS RUL lobectomy, plus systemic mediastinal lymph nodes dissection. The procedure of 200 minutes operation was smooth with blood loss of about 150 mL. Chest tube was removed 6 days after operation, and the patient discharged 11 days after the operation; The post-operation pathological examination showed RUL LCNEC, and the pathological stage was pT2bN0M0R0 (IIA stage). The patient has received four cycles of EP adjuvant chemotherapy per 21 days and is still alive without disease recurrence and metastasis after re-examination.

[The discussion of the need of mediastinal lymph node dissection in the surgical treatment of lung cancer].

The need of lymph node dissection in the case of operative lung cancer with negative mediastinoscopy was discussed. As a preliminary study, the N-number obtained from the mediastinoscopy and that of postoperative examination was compared. The rate of agreement of N-number was as high as 96%. Secondary, 183 cases of lung cancer with squamous-or adenocarcinoma pathologically T-1 or 2. N-0 and P-0 or 1 were picked up and examined. In those cases, the result of 3 years survival rate was 80% in the cases of absolute curative operation and 60% in that of relative non-curative cases, and 5 years survival rate was 70% and 52% respectively, and the cases of absolute curative operation was statistically excellent than that of another group. However, the background of the two groups was different to some degree on account of the advancement of the cancer and the age of the patients. Therefore, the randomized study as for the lymph node dissection in the cases of negative mediastinoscopy was finally performed. In the 30 cases of squamous cell carcinoma where dissection was carried out in 13 cases and not done in 17 cases, the result of 3 years survival was 84% (dissecting group) and 89% (non-dissecting group), and 5 years survival was 73% and 63% respectively. In 23 cases of adenocarcinoma (13; dissecting, 10; non-dissecting), the result of 3 years survival was 100%, 63% and that of 5 years survival rate was 100%, 63% respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgery_Schwartz

involvementHoarsenessRecurrent laryngeal nerve involvementSwelling of head and armsBulky involved mediastinal lymph nodes Medially based right upper lobe tumorTable 19-6General principles governing appropriate selection of patients for pulmonary metastasectomy1. Primary tumor must already be controlled.2. Patient must be able to tolerate general anesthesia, potential single-lung ventilation, and the planned pulmonary resection.3. Metastases must be completely resectable based on computed tomographic imaging.4. There is no evidence of extrapulmonary tumor burden.5. Alternative superior therapy must not be available.identified any additional lesions, they were resected. The study concluded that the probability that a metastatic lesion will be missed by VATS excision is 56%. Patients in the Memorial study were evaluated before the advent of spiral CT scanning, however, and it remains controversial whether metastasis resec-tion should be performed via VATS. Proponents of VATS argue that

Primary synchronous colloid adenocarcinoma and squamous cell carcinoma in the same lung: A rare case report.

Double primary lung cancer (DPLC) is a relatively rare type of lung cancers. According to whether the diagnosis interval between lesions is more than 6 months, it can be divided into synchronous DPLC (sDPLC) and metachronous DPLC (mDPLC). Here, we describe a case of sDPLC in which one of the components is a rare colloid adenocarcinoma (CA). A 69-year-old male was admitted to the hospital due to chest distress and shortness of breath for 1 year, getting worse in the last 15 days. Both HE staining and IHC supported the diagnosis of CA in the right lower lobe and moderately differentiated squamous cell carcinoma in the right upper lobe. The patient was treated with 3 cycles of adjuvant chemotherapy with pemetrexed and lobaplatin after the right upper lobectomy, wedge resection of the right lower lobe and lymph node dissection under video-assisted thoracoscope. Our plan was to follow him up with general physical examination, chest-abdomen CT and serum tumor markers every 6 months for 2 years. The patient was still alive until the last follow-up in November 2020. CA of the lung is a rare primary lung adenocarcinoma. The diagnosis should be based on the patient's clinical characteristics, imaging examination and pathological characteristics, and also need to be differentiated from other mucinous adenocarcinomas. Interestingly, our patient developed not only a CA in the right lower lobe, but also a moderately differentiated squamous cell carcinoma in the right upper lobe.

[Follow-up of patients with non-small-cell pulmonary cancer undergoing complete resection. Should surgeons be in charge?].

To evaluate the effectiveness of patient follow-up after complete lung resection for non-small cell carcinoma in the same unit where the patients were treated. Retrospective review of outpatient clinic records of patients undergoing surgery for lung cancer between January 1994 and December 1996 who met the following conditions: histologically complete resection (segmentary and wedge resections were excluded) and survival at least three months after surgery. Follow-up was in accordance with preestablished guidelines that included taking the patient's medical history and performing physical examination, simple chest X-ray, hematocrit and biochemical parameters, chest and abdominal computerized tomography (CT) and periodic bronchoscopy. In 103 cases followed for between three to 34 months, 27 recurrences were detected (13 remote, 11 local and 3 local and remote). The clinical diagnosis of recurrence was made by case history adn physical examination in 18 cases, by simple chest film in 3, by biochemical blood parameters in 2, by fiber optic bronchoscopy in 2, and by CT findings in 2. One of the patients with local recurrence (bronchial stump) underwent a second operation 11 months after the first. Most recurrences are detected during simple checkups that can be performed without hospital admission. Only one patient underwent surgery for a local recurrence, suggesting that follow-up by thoracic surgery units does not appear to be worthwhile.

Lung nodule

A lung nodule or pulmonary nodule is a relatively small focal density in the lung. A solitary pulmonary nodule (SPN) or coin lesion, is a mass in the lung smaller than three centimeters in diameter. A pulmonary micronodule has a diameter of less than three millimetres. There may also be multiple nodules. One or more lung nodules can be an incidental finding found in up to 0.2% of chest X-rays and around 1% of CT scans. The nodule most commonly represents a benign tumor such as a granuloma or hamartoma, but in around 20% of cases it represents a malignant cancer, especially in older adults and smokers. Conversely, 10 to 20% of patients with lung cancer are diagnosed in this way. If the patient has a history of smoking or the nodule is growing, the possibility of cancer may need to be excluded through further radiological studies and interventions, possibly including surgical resection. The prognosis depends on the underlying condition.

Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia: Case series and a review of the literature.

Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) is a rare idiopathic disease with only about 100 cases reported in the literature. Here, we presented 4 cases of DIPNECH. Four patients included 2 females and 2 males, aged 54 to 64 years old; 3 had no smoking history and 1 had history of smoking for 30 years. Surgical resection was performed for every patient. Cases 1 and 3 did not receive postoperative chemotherapy or radiotherapy, and case 2 received 4 times of postoperative chemotherapy. Case 4 just finished the operation and after a period of time, he will receive postoperative chemotherapy. Case 1: A 57-year-old female had chest pain, and computer tomography (CT) examination prompted a mass shadow of left lung lower lobe. Case 2: A 64-year-old female had cough and expectoration for more than 1 month. CT examination showed: a lump with diameter of about 2.5 cm and irregular edge was in right lung upper lobe, being largely possibly lung cancer. Case 3: A 54-year-old male, CT examination accidentally found a long strip-shaped nodule in left lung oblique fissure when checkup's, and he had no fever, cough, expectoration, chest tightness, or chest pain. Case 4: A 61-year-old male, checkup's CT examination accidentally found a nodule, fibrosis, bronchiectasis, and secondary infection in the left lower lobe. Combined with pathological morphology and immunohistochemistry, cases 1 and 3 were diagnosed as DIPNECH with multiple carcinoid tumorlet formation and chronic inflammation and bronchiectasis, case 2 was diagnosed as an adenocarcinoma with DIPNECH and multiple carcinoid tumorlet formation, case 4 was diagnosed as an adenocarcinoma with DIPNECH and multiple carcinoid tumorlet formation and chronic inflammation and bronchiectasis. Surgical resection was performed for every patient. Cases 1 and 3 did not receive postoperative chemotherapy or radiotherapy, and case 2 received 4 times of postoperative chemotherapy. Case 4 just finished the operation and after a period of time, he will receive postoperative chemotherapy. Four patients have been followed up and have had good condition. DIPNECH is often found accidentally in a surgical specimen, is easily missed, and needs careful observation. Immunohistochemistry is necessary to make this diagnosis.

[Diagnosis and surgical treatment of pulmonary sclerosing hemangioma].

As a rare benign lung tumor, pulmonary sclerosing hemangioma (PSH) occurs predominantly in Asian women in their fifth and sixth decades of life. PSH is considered to be evolved from primitive undifferentiated respiratory epithelium. In this study, we summarized our experience in 89 cases of PSH. There were a total of 89 patients who received surgical resection and were histopathologically diagnosed as PSH during the period January 2001 to December 2010 in department of thoracic surgery, Cancer Institute and Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences. The clinical data of these patients including symptoms, disease courses, image characteristics and surgical procedures were collected and reviewed retrospectively. The PSHs were most frequently (50.6%) found in the patients aged 41 to 60 years with a median age of 51 years (range: 24 - 71), and the sex ratio (male/female) was approximately 1:7 in this series. In the 89 patients, 53 (59.6%) were asymptomatic while the other 36 (40.4%) had some non-special symptoms such as cough (30.3%), hemoptysis (24.7%). There were only 3 cases (3.4%) with multiple PSHs, 4 cases (4.5%) combined with synchronous primary lung cancer, and 13 cases (14.6%) with lesions located in the hilar region. The median diameter of the 92 lesions was 2.3 cm (range: 0.3 - 6.0 cm), of which 38% located in the right lower lobe and 26.1% in the right middle lobe, and only about 1/3 were assumed as PSHs preoperatively based on CT imaging. One of the five patients who underwent PET-CT scan had been misdiagnosed as malignant. Of the 92 lesions, 47 were resected by enucleation, 29 by wedge resection, 14 by lobectomy, and 2 by pneumonectomy. PSH frequently occurs in the middle-aged women. Most individuals with PSH are asymptomatic or have some non-specific symptoms. Their lesions are usually found accidentally by chest imaging. Although PSH often shows typical imaging characteristics of benign neoplasm of the lung, it is difficult to establish a defined pathological diagnosis preoperatively. The significant error or deferred rate of intraoperative frozen-section evaluation for PSH may result in some unnecessarily extensive surgical procedures. The complete surgical resection is considered the only effective treatment for PSH, and the normal pulmonary tissue should be reserved as possible.

[Clinical features of non-small cell lung cancer cases].

The aim of this study was to evaluate the clinical features of non-small cell lung cancer (NSCLC) cases that were diagnosed in our clinic. The patients who were diagnosed as NSCLC in our clinic between January 1988 and January 1999 were comprised the study group. The files and records of the study group were retrospectively reviewed to identify patients and all the data including demographic characteristics, history, physical examination findings, laboratory values, diagnostic procedures, radiologic findings and staging procedures. The study group included 564 patients (506 male, 58 female). The mean age was 60 years (28-97). 87% of the patients were current smokers or ex-smokers. The most frequent symptoms on admission were cough, sputum, and dyspnea. The most common radiologic finding was a central mass with a diameter of more than 4 cm with an irregular border. The diagnosis was established by histopathologic examination of biopsy specimens obtained by various means, in which bronchoscopy was the sole means of diagnosis in 83% of the patients. Histopathologic examination of the biopsy specimens resulted as follows: 85.8% squamous cell carcinoma, 10.3% adenocarcinoma, 1.4% large cell carcinoma, 0.45% adenosquamous carcinoma, and 2.1% undifferentiated NSCLC. Staging procedures that were done in all patients revealed that 85% of the patients were diagnosed at the stage IIIB and IV. Metastasis was most frequently to the bones followed by brain and liver. In our study squamous cell carcinoma was the most common histopathologic type with a higher percentage than the previous reports in the literature. The percentages of stage IIIB and IV were also higher in our study than previous papers in the literature.

A case of bilateral invasive mucinous adenocarcinoma of the lung with severe productive cough and dyspnea successfully treated with palliative lung lobectomy.

Invasive mucinous adenocarcinoma (IMA) of the lung is a chemo-refractory type of lung cancer with frequent intrapulmonary dissemination. Patients with IMA of the lung often suffer from a productive cough and rapid deterioration of performance status (PS). There is currently no standard therapeutic strategy against this unrelenting condition. Here we report a patient with bilateral IMA of the lung with severe productive cough and dyspnea successfully controlled by palliative lung lobectomy. A 67-year-old Japanese man presented with a 3-month history of productive cough. Chest computed tomography (CT) revealed a mass lesion in the left lower lobe and a small nodule and multiple thin-walled cystic lesions in the right lung. He was diagnosed with stage IIB IMA of the lung. Over the next two weeks, his productive cough and dyspnea drastically worsened and his PS declined from 0 to 4. Chest CT showed increases in size of both the nodule and cystic lesions in the right lung and the mass lesion in the left lower lobe. He was re-diagnosed as stage IVA. Given the extreme heterogeneity of the tumor distribution, we decided to perform palliative resection of the left lower lobe. After the surgery, he experienced complete relief of respiratory symptoms, and his PS improved dramatically, enabling chemotherapy. Thirty-one months after surgery, he maintains good PS. In conclusion, our report suggests that aggressive introduction of palliative lung lobectomy played a substantial role for in the excellent outcome of our patient with relatively well confined, advanced-stage IMA.

Staging: the key to rational management of lung cancer.

Staging is the quantitative assessment of malignant disease and allows logical groupings of patients with a similar extent of disease for prognostic, therapeutic, and analytic purposes. In bronchogenic carcinoma a stage is assigned based on size, location, and the extent of invasion of the primary tumor, as well as the presence of any regional or metastatic disease. Selecting the most appropriate treatment for a patient with bronchogenic carcinoma depends on precise staging. The extent of local invasion and presence of metastatic disease will determine the likelihood of complete resection and possible cure. Careful assessment of the history, blood chemistry, radiographic studies, bronchoscopy, mediastinoscopy, and exploration (thoracotomy) are all important staging tools. Routine radionuclide scans have no useful role when there is no clinical or laboratory evidence of metastases. The T status of a tumor is best judged by bronchoscopy and at thoracotomy. Thoracic surgeons must be familiar with the techniques available to determine T status intraoperatively and use this information when planning resection. Computed tomography of the chest has fallen short in predicting direct invasion of the mediastinum and chest wall. Cervical and anterior mediastinoscopy remain important tools in determining operability. Intraoperative assessment of node involvement determines the extent of resection and likelihood of cure.