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Background Myofascial pain syndrome (MPS) is a condition that involves skeletal muscles. It is caused by overload or disuse of muscles and is characterized by extreme tenderness in the muscles with taut bands. Treatment for MPS is different from that for cancer-related pain. Cancer patients have many factors that cause restriction of body movement and posture. Although cancer patients appear to demonstrate risk factors for MPS, its prevalence has not been reported in patients with incurable cancer. This study was conducted to investigate the prevalence of MPS in patients with incurable cancer. Methods A retrospective chart review. The data for patients with incurable cancer who received palliative care at our department between September 2015 and March 2016 were investigated. We examined the prevalence of MPS, which was diagnosed on the basis of the Rivers criteria (RC) and Simons criteria (SC). We also examined the following factors associated with MPS: performance status (PS), use of medical devices, and primary cancer sites. The primary outcome was the prevalence of MPS based on RC. Secondary outcomes included the prevalence of MPS based on SC and the relationship between MPS and either PS or medical devices. Results Thirty-four patients with incurable cancer were identified. MPS based on RC or SC was detected in 10 (29%) and 20 (59%) patients, respectively. Twenty-two of 34 patients who complained of pain, 10 (45%) had MPS based on RC and 20 (90%) had MPS based on SC. Age and central venous port were risk factors for MPS by multivariate analysis. Conclusion A very high prevalence of MPS was detected in our study population. MPS should be considered when patients with incurable cancer complain of pain.

Pleurocentesis and pleurodesis are the common treatments for pleural effusion. However, most home-visit physicians usually hesitate to perform these treatments for patients confined at home.A 51-year-old woman developed breast cancer(ER+, HER2-)at the age of 39 years. She underwent a partial mastectomy of the right breast. Nine years later, metastatictumors in the lungs, and hilar and mediastinal lymph nodes were found. The patient was admitted to our hospital because of the progression of pleural effusion and dyspnea. On the day of admission, the aspiration catheter was placed in the left lung with continuous suction, but pleurodesis could not be performed as the left lung did not re-expand enough. As the patient requested to go home as soon as possible, she was discharged with the catheter in place. Three days after the discharge, the home-visit physician drained 340 mL of fluid through the catheter. Six days after the discharge, the patient was readmitted to the hospital with malaise and dyspnea, but no signs of complications associated with the indwelling catheter use were observed. The patient died 4 days after the readmission.This case suggests that draining fluid using an indwelling pleural catheter as a home-based healthcare measure is one of the simplest and safest options.

Breast carcinoma and precancer are thought to start in the lining of the milk duct or lobule. Ductography and fiberoptic ductoscopy have beenadvocated as the mainprocedures inpatien ts with nipple discharge.We investigated the usefulness of microdochectomy(MD)by using indocyanine green(ICG)fluorescence imaging. ICG and indigo carmine were injected into the mammary duct. A periareolar incision was made, and a fluorescence image of the demarcated mammary duct segment was obtained.MD using indocyanine green fluorescence imaging is a useful procedure in guiding subsequent breast surgery in the treatment of nipple discharge.

In case an operation is necessary after an ST-VAB for microcalcification, a wide excision needs to be performed because of the loss of marking. The HydroMARK®breast biopsy marker can be visualized using an ultrasound or mammography and facilitates a small excision. Six months after the deployment, all markers were visualized using an ultrasound. Thus, Hydro MARK®can decrease the sample size(11 g)in open biopsies and correctly diagnose ADH. However, no HydroMARK®cases were diagnosed with ADH in large samples(44 g, 32 g). Five malignant histology cases underwent mastectomy, and the distance between the HydroMARK®and tumor was 300 mm. HydroMARK®appears to be a safe and effective marker after a stereotactic biopsy for calcification, which facilitates an exact small excision of lesion surgically.

A69 -year-old woman was diagnosed as having local advanced breast cancer. She was treated with neoadjuvant chemotherapy( AC followed by paclitaxel)and followed up with left total mastectomy with axillary lymphadenectomy for breast cancer(pT3N1aM0, Stage ⅢA, ER positive, PgR positive, and HER2 negative). She received adjuvant therapy with chest wall irradiation and an aromatase inhibitor. Two years after the mastectomy, mediastinal lymph node and rib metastases and dissemination appeared. We changed the regimen to capecitabine. She continued the capecitabine therapy for 7 years and was found to have multiple lung metastasis. Therefore, we chose eribulin mesylate therapy. Ten days after eribulin mesylate (1.0mg/body)was first administered, she suddenly had difficulty breathing, and chest CT revealed left low lobe atelectasis. The superior mediastinal lymph node had grown rapidly and compressed the left main bronchus and superior vena cava. To reduce the lymph node size, we started radiotherapy(50 Gy/25 Fr)for the superior mediastinal area in addition to the eribulin mesylate therapy. After the radiotherapy, chest CT revealed a remarkable reduction of lymph node size and full pulmonary reexpansion. One year after the radiotherapy, she is continuing treatment without systemic progression.

Strut adjusted volume implant(SAVI)was approved by the Food and Drug Administration(FDA)for the treatment of breast cancer in 2006.The phase II study was conducted to investigate the activity and safety of SAVI in breast cancer patients. Criteria for SAVI treatments were N0, T2 cm, and age≥40. After patients underwent breast-conserving surgery, they received SAVI twice a day×5 days(34 Gy). The primary endpoint are feasibility and safety. Second endpoint are local recurrence rate and cosmesis.Three patients were enrolled and the median duration of administration is 18.7 days(17-20). Further, the most common treatment-related adverse events were thickening and redness of skin(grade 1/2), while there was no deformity of breast in each case.The current study demonstrated that SAVI is well tolerated treatment in breast cancer patients and may be convenient for use in patient treatment.

The patient was a 71-year-old woman with ER(+), PgR(-), HER2(3+), and Ki-674 2% breast cancer. After surgery for left breast cancer(Bt+Ax), epirubicin, cyclophosphamide therapy was administered as postoperative adjuvant chemotherapy, and nabPTX plus trastuzumab therapy was started sequentially. The patient was hospitalized due to severe neutrope- nia(neutrophils 0/mm3)from nabPTX, but her condition stabilized after admission. However, the patient suddenly went into shock after 3 days and was thus transferred to the ICU. Her general condition was rapidly improved through cytokine adsorption therapy in the ICU. After 5 days, she was extubated and wheeled back to a general ward. She was discharged without problems in the succeeding months. In this case, FN or cardiovascular diseases was ruled out, and engraftment syndrome was considered given that cytokine adsorption therapy significantly improved the patient's condition. Considering the risk for severe neutropenia in nabPTX administration, clinicians should exercise caution when administering the drug.

Background: Emergency admissions and emergency department visits (EAs/EDVs) have been used as quality indicators of home care in terminally ill cancer patients. We established a cancer transitional care (CTC) program to monitor and manage terminally ill cancer patients receiving care at home. The purpose of this study was to evaluate the effectiveness of CTC by the frequency of EAs/EDVs. Methods: In a retrospective chart review, we identified 133 patients with cancer admitted to our department, of whom 56 met study eligibility criteria. The CTC consisted of at least 1 or more following components: (1) a 24-hour hotline for general physicians or home care nurses to reach hospital-based physicians, (2) periodic phone calls from an expert hospital-based oncology nurse to home care medical staff, and (3) reports sent to our department from home care medical staff. The primary outcome variable was the frequency of EAs/EDVs. Results: There were 32 EAs/EDVs and 69 planned admissions during the observation period. In the last 30 days of life, 16 patients (28.6%) had 1 EA/EDV and none had multiple EAs/EDVs. Compared with previous studies, our study found a similar or lower frequency of EAs/EDVs. Conclusion: Our findings suggest that the implementation of CTC reduces the number of EAs/EDVs by replacing them with planned admissions. Further prospective studies to evaluate CTC are warranted.

of a randomized phase III trial of the AIO Quality of Life Working Group. This trial compared the effect of Mapisal (a new ointment; Medac, Hamburg, Germany) and urea cream on the primary end point of reduction of the incidence of hand-foot syndrome (HFS) within 6 weeks. Secondary end points were time to development of HFS of any grade and of HFS greater than grade 1 as well as quality of life analyses. A total of 152 patients were evaluable. Of these, 47 patients (30.9%) experienced HFS, with 39.5% in the Mapisal arm and 22.4% in the urea arm (stratified odds ratio, 2.37; P 5 .02). Time to any-grade HFS was significantly longer in the urea group than in the Mapisal-treated group (P 5 .03), and skin-related quality of life was significantly worse in the group treated with Mapisal. The trial by Hofheinz et al 1 showed the superiority of urea cream over Mapisal; however, there are a few controversial points regarding the interpretation of the results. We believe the following three points require clarification from the authors: First, regarding the rationale of the study, the authors concluded that this trial demonstrated, contrary to their hypothesis, that urea cream is superior to Mapisal in preventing HFS in patients with cancer who were treated with capecitabine. In addition, it was revealed that the new ointment was more likely to increase adverse events. Although this trial was conducted as a phase III study, a phase II study or an exploratory study does not seem to have been performed—a rationale for a phase III trial is absolutely required before conducting it. Furthermore, in calculating the sample size of their study, Hofheinz et al 1 did not describe how the incidence of HFS was estimated at 10% in the Mapisal group. Hence, the sample size of this trial was set without an appropriate rationale, and we doubt that this sample size has enough statistical power to prove their clinical hypothesis. The sample setting in this trial was based on only the data for the effectiveness of Mapisal for pegylated liposomal doxorubicin, and the evidence for capecitabine was not shown. Second, regarding the selection of patients in the control arm, to our knowledge, there is no evidence that uric acid–based creams offer effective prophylaxis for capecitabine-associated HFS. To review, uric acid–based creams were shown to be ineffective in the prevention of capecitabine-induced HFS. 2 A randomized phase II study demonstrated the effect of a urea-based cream on sorafenibassociated hand-foot skin reactions. 3 In the trial by Hofheinz et al, 1 urea cream treatment was selected as the treatment for the best supportive care control arm; however, best supportive care as a control arm in this trial was poorly defined. A study with a poorly defined control arm is in danger of either creating excessiveness in or of underestimating the comparator arms. 4 Third, we believe that the results of this trial would have no impact on clinical practice even if Mapisal were found to be significantly more effective than urea, because urea cream is not recognized as the standard treatment. Because a phase III trial requires many resources and considerable effort, including that by the patients, it should be conducted after careful planning, and any harm caused to patients by the experimental treatment should, of course, be avoided. We insist that a phase III trial without established evidence of safety, tolerability, and efficacy should not be performed. We doubt that any arguments of ethical adequacy were offered during the approval process of this trial.

We report a case of consciousness disorder following the fourth course of chemotherapy with cisplatin (CDDP) and 5- fluorouracil (5-FU) in a patient with esophageal cancer. A 74-year-old man was admitted to our hospital to receive chemotherapy for esophageal cancer. Six days after chemotherapy, the patient showed impaired consciousness and his serum sodium concentration was found to be 125 mEq/L, but no edema or dehydration was noted. This hyponatremic state was diagnosed as CDDP-induced syndrome of inappropriate secretion of antidiuretic hormone (SIADH) on the basis of serum and urine hypo-osmolality. Accordingly, fluid intake was restricted and sodium supplements were administered, resulting in an appropriate increase in the serum sodium concentration to 132 mEq/L in 4 days.

97 Background: Myofascial pain syndrome (MPS) is a condition that involves skeletal muscles. It is caused by overload or disuse of muscles and is characterized by extreme tenderness in the muscles with taut bands. Treatment for MSP is different from that for cancer-related pain. Cancer patients have many factors that cause restriction of body movement and posture. Although cancer patients appear to demonstrate risk factors for MPS, its prevalence has not been reported in patients with incurable cancer. This study was conducted to investigate the prevalence of MPS in patients with incurable cancer. Methods: The data for patients with incurable cancer who received palliative care by our department between September 2015 and March 2016 were retrospectively investigated. We examined the prevalence of MPS. MPS was diagnosed on the basis of the Rivers criteria (RC) and Simons criteria (SC). We also examined the following factors associated with MPS: performance status (PS), use of medical devices (MD), and primary cancer sites. The primary outcome was the prevalence of MPS using the RC. Secondary outcomes included the prevalence of MPS using the SC, and the relationship between MPS and either PS or MD. Results: Thirty-four patients with incurable cancer were identified. The clinical characteristics are as follows: age (median, range): 65 (39-89) years; male/female ratio: 16/18; primary sites: pancreas (n = 8), breast (n = 8), lung (n = 4), colorectal (n = 4), head and neck (n = 2), and other primary sites (n = 8). Seventeen of 34 patients (50%) had a PS 3 or 4. Twenty-two patients (64.7%) complained of pain. MPS using the RC was detected in 10 patients (29%). MPS using the SC was detected in 20 patients (59%). Of 22 patients who complained of pain, MPS using the RC was detected in 10 (45%) patients and MPS using the SC was detected in 20 (90%) of patients. Patients with central venous port (CVP) devices had a significantly higher number of MPS lesions than patients without CVP devices (p = 0.029). Conclusions: A very high prevalence of MPS was detected in our study population. MPS should be considered when patients with incurable cancer complain of pain. A multi-center prospective study will be conducted to confirm our findings.

202 Background: Cancer pain is the most important problem to overcome in terminally ill cancer patients (TICPs). Recently, the fentanyl patch (FP) has been widely used for the treatment of cancer pain. However, the FP requirement largely varies in patients. The purpose of this study was to identify the determinants of the FP requirement in TICPs and propose effective pain relief using a FP. Methods: In a retrospective chart review, we investigated cancer patients who were admitted in our hospital from April 2012 to July 2015 and used FP until their deaths. We examined the time course of FP use in TICPs until death. We used descriptive statistics and a mixed effect model. The primary endpoint of this study was the final dose of FP use (FDFP). Results: Eighty patients were included the analysis. The clinical characteristics were as follows: age (median, range): 64.5 (29-88) years; male/female ratio: 40/40; primary tumor sites: pancreas (n = 33), digestive tract (n = 12), liver and bile duct (n = 7), ovary and uterus (n = 6), hematologic (n = 5), lung (n = 4), head and neck (n = 4), breast (n = 3), and other (n = 6). FDFP was inversely correlated with age (R = -0.272, P < 0.05; Spearman test). The FDFP (mean ± SD) administered in the patients was 3.06 ± 3.20 mg/day (Male/Female: 3.83 ± 4.06/2.29 ± 1.81 mg/day). The FDFP was 4.36 ± 4.32/2.15 ± 1.64 mg/day in patients with/without pancreatic cancer. FDFP was significantly higher in male than in female patients (P < 0.05; student’s t test), and also significantly higher in patients with pancreatic cancer than in patients without pancreatic cancer (P < 0.005; student’s t test). In pancreatic cancer patients, the FP adjustments were more frequent in the last 60 days of life than in patients with other malignancies (P for interaction < 0.001; mixed effect model). Conclusions: We found that younger age, male sex, and pancreatic cancer were risk factors for higher requirement of FP in TICPs. TICPs with pancreatic cancer in particular required more frequent adjustment of FP near death. We should consider quick titration of fentanyl in patients with pancreatic cancer because the pain-relieving action of FP requires time.

We read the Article by Ricard Mesia and colleagues with great interest. The CONCERT-1 trial did not show a survival benefi t in patients with locally advanced squamous-cell carcinoma of the head and neck who were treated with panitumumab in addition to chemoradiotherapy. Patients receiving panitumumab plus chemoradiotherapy did not have any benefi t in terms of the primary endpoint, local-regional control at 2 years. Although the authors also compared overall survival and progression-free survival between patients matched by tumour p16 status, no survival benefi ts were seen in the panitumumab plus chemoradiotherapy group. A comparison of patients requiring cisplatin dose reduction (≤225 mg/m2) in the chemoradiotherapy group with all patients in the panitumumab plus chemoradiotherapy group showed that the panitumumab plus chemoradiotherapy group had a nonsignifi cant increase in local-regional control at 2 years, suggesting a possible benefi t of panitumumab. Patients requiring a cisplatin dose reduction are likely to have more comorbidities than patients who do not. Generally, cisplatin dose reduction is considered when a patient has a relatively poor performance status, poor organ (especially kidney) function, advanced age, or a history of severe adverse events during a previous treatment course. Accordingly, the population who received a reduced dose of cisplatin is more likely to have included older patients and patients who were more frail, compared with the overall patient population. In contrast, patients who completed the planned dose of panitumumab plus chemoradiotherapy are probably in better physical condition than patients in the chemoradiotherapy group who received a reduced dose of chemoradiotherapy. Frail patients are more likely to have a poorer prognosis. We think Mesia and colleagues should have taken into consideration that comparison of a frail group of patients with a more robust population is scientifi cally inaccurate. Although the authors reported that some outcomes favoured the panitumumab plus chemo radiotherapy group, there was no signifi cant diff erence. We would like to know the patient characteristics, the dose intensity for cisplatin, panitumumab, and radiotherapy, and the reason for the dose reductions to assess the benefi ts of combined panitumumab plus chemoradiotherapy. The CONCERT-1 trial was a phase 2 trial with a relatively small number of participants, and a decisive conclusion cannot be made on the basis of these results alone. Nevertheless, we are doubtful of the additional benefi t of panitumumab for the treatment of head and neck squamous-cell carcinoma. We are not sure why two similar anti-EGFR inhibitor antibodies, cetuximab and panitumumab, cause discrepant results. Cetuximab has shown promising results and is recommended in treatment guidelines for head and neck squamous cell carcinoma. The diff erence in immunoglobulin classes between cetuximab (IgG1) and panitumumab (IgG2) might aff ect their effi cacies. We would like to know why these diff erences arise.