Archive for October, 2007.
The cancer pain guidelines are very similar. Now the chronic pain guidelines are being developed and in many aspects the chronic non-malignant pain guidelines are going to be little different from the cancer pain guidelines. In the pharmacologic use of the drugs there’s practically no differences. But look at the similarities. All mild to moderate pain therapies(soma) should include an NSAID or Tylenol unless it’s contraindicated. Use these as chronic pain guidelines. You add an opioid if pain persists or increases. If the patient is already on an opioid change from a weak one to a strong one, or change from a strong one to more of a strong one. And I never cease to never to just totally not understand the tremendous fear that we seem to have towards opiates. One of my colleagues on the faculty came to me two weeks ago. His wife had developed shingles. Fortunately they are in their 30’s because if they are in their 50’s this would be a horrible problem. She developed ocular shingles and at first they thought the problem she was having was related to her history of Bell’s palsy. But it turns out to be shingles. The shingles were resolved but now she has incredible pain. And this is severe pain. She went to a physician who gave her an NSAID. And NSAID’s don’t work for severe pain. Shingles pain is severe pain. Went back to the physician. The physician gave her Lortab 10. That’s hydrocodone and acetaminophen, 10 milligrams of hydrocodone. And after a week she said it took the edge off a little bit so the physician prescribed her Lortab 5, take two at a time, which is basically the same thing. I told him what the contemporary therapy of shingles is. It’s strong opiate, antidepressant because it’s a neuropathic pain. Went back to the physician. The physician gave them OxyContin which is what I suggested they talk to the physician about. Ten milligram tablets. It probably isn’t enough, but start at this. Ten milligram tablets once a day. They work for 12 hours. The pain is now successfully being treated. Now this is a patient who is never going to be addicted, she’s going to be physically dependent when she finishes the treatment for her herpes, or the secondary pain from the herpes infection that she had. But physical withdrawal from opiates is not a problem. It just is not. Even if we didn’t have Clonidine to block all the symptoms, most patients don’t want to be on opiates anyway.
Chronic pain guidelines say that opioid tolerance and physical dependence do not equate with addiction. They are expected. But they are very easily dealt with in 95% of the people, and why should we brutalize the 95% because of our fear of the 5%? The oral route is preferred. It’s the most convenient. It’s the most cost effective. Rectal and transdermal should be reserved for patients who fail the oral route. This is an unbiased panel. And fail the oral route means that you’ve given them really adequate doses and they can’t absorb it or they can’t remember to take it often enough and it just doesn’t work.
Motrin
Pain is really deadly. Pain can cause a number of horrible problems for our patients. Poor wound healing, muscle weakness, tissue breakdown. In acute painful conditions patients won’t do deep breathing exercises. They won’t move around in bed so they are going to be at increased risk of thromboembolic events. They won’t do deep breathing exercises, they splint, they breathe shallowly so they are at greater risk for atelectasis and pneumonia. A number of other physiologic events occur and there are immunological factors. It decreases NK killer cells activity, causes negative motions, anxiety, depression, sleep deprivation, and over time then pain, especially chronic pain, can lead to tremendous suffering. If you don’t think we should get actively involved in physician-assisted suicide, you are totally in control of that. Now I was a hospice pharmacist for 13 years. And I know that no one wants to live more than people who know that the end is approaching if we can make them comfortable. And you have the resources. Ninety to 95% of painful conditions can be treated by tools that you commonly employ and have available to you. I’m not talking about intrathecal therapy, I’m not talking about epidural therapy, I’m talking about oral drugs that you are capable of prescribing; 90% to 95% of painful conditions.
With drugs there’s only three things we can do to treat pain: we can modify mechanisms at the source of the pain – and that’s what we do when we use Tylenol, NSAID’s – we can alter transmission to the central nervous system with a local nerve block, a local anesthetic. In the case of neuropathic pain, that’s what we do with we give antidepressants or anticonvulsants, or we can alter central perception. That’s what opiates do. They don’t block pain, they alter it. I learned that years ago talking to a cancer patient who I’d gotten very close to. She told me that she still felt something where she used to feel pain but it just wasn’t pain anymore. It wasn’t that there was no sensation but it just isn’t pain anymore. In complex pain states we can do all three. A polypharmacy for the treatment of complex pain is good if you do it intelligently. Having a patient on amitriptyline, Motrin and morphine is very sensible. Having a patient on Tylenol with codeine, Tylenol with Vicodin, fentanyl patch and MS Contin is kind of silly. It indicates to the whole world that you don’t have a clue what you are doing and the patient should try to figure it out for themselves.
We have a couple of guidelines that are really interesting. These guidelines are health policy statements developed by Health Care and Human Services but unlike most things that the Federal Government does, these were developed by clinicians. These were developed by clinicians, most of them physicians and the acute pain guidelines and the chronic pain guidelines have some interesting similarities. The acute pain guidelines say that NSAID’s should be used around the clock for all moderate pain unless it’s contraindicated. Now I know, unless you are really unusual, you use NSAID’s p.r.n. Because that’s how you write them. But think about that for a minute. When you are treating an acute painful condition and the patient comes to you and you make the decision to use an NSAID, that process is as bad as it’s likely to get right then. These drugs work by slowing down a biochemical cascade and it doesn’t make a lot of sense to slow that cascade down every now and then. Especially since most of your patients are afraid of medicine. They really are. They aren’t hot drug takers. They are scared to death of medicine. So what you should do is tell them to take it around the clock – every four hours, every six hours, every 12 hours depending on what you’re taking – for x number of days. And you determine what x is. That’s the time when you think this condition should start resolving. When you do that they’ll get the benefit of the analgesia and the antiinflammatory effect of that drug and they’ll do much better. Then, after x number of days have passed, they can start taking it p.r.n. The acute guideline said that strong opiates such as morphine is what we should use for severe pain. Not Vicodin. Morphine or other strong opiates. They said that Dilaudid is the best morphine alternative. They may not say that now. I think that OxyContin would have replaced that now. But meperidine use is to be avoided except for brief courses – one or two days – in young otherwise healthy patients. It really irritated me when I figured out that they thought young was 40 and under.
Posted on October 29th, 2007 by Canadian Health in
Cancer A. Intravesical Chemotherapy: Immuno- or chemotherapeutic agents can be delivered directly into the bladder by a urethral catheter. They can be used to eradicate existing disease or to reduce the likelihood of recurrence in those who have undergone complete transurethral resection. Such therapy is more effective in the latter situation. Most agents are administered weekly for 6–12 weeks. The use of maintenance therapy after the initial induction regimen may be beneficial. Efficacy may be increased by prolonging contact time to 2 hours. Common agents include thiotepa, mitomycin, doxorubicin, and BCG, the latter being the most effective agent when compared with the others. Side effects of intravesical chemotherapy include irritative voiding symptoms and hemorrhagic cystitis. Systemic effects are rare. Patients who develop symptoms from BCG may require antituberculous therapy.
B. Surgical Treatment: Although transurethral resection is the initial form of treatment for all bladder cancers as it is diagnostic, allows for proper staging, and will control superficial cancers, muscle infiltrating cancers will require more aggressive treatment. Partial cystectomy may be indicated in patients with solitary lesions and those with cancers in a bladder diverticulum. Radical cystectomy entails removal of the bladder, prostate, seminal vesicles, and surrounding fat and peritoneal attachments in men and in women also the uterus, cervix, urethra, anterior vaginal vault, and usually the ovaries. Bilateral pelvic lymph node dissection is performed simultaneously.
Urinary diversion can be performed using a conduit of small or large bowel. However, continent forms of diversion have been developed that avoid the necessity of an external appliance.
C. Radiotherapy: External beam radiotherapy delivered in fractions over a 6- to 8-week period is generally well tolerated, but approximately 10–15% of patients will develop bladder, bowel, or rectal complications. Unfortunately, local recurrence is common after radiotherapy (30–70%). Increasingly, radiotherapy is being combined with systemic chemotherapy in an effort to improve local and distant relapse rates.
D. Chemotherapy: Fifteen percent of patients with newly diagnosed bladder cancer will present with metastatic disease, and 40% of those thought to have localized disease at the time of cystectomy or definitive radiotherapy will develop metastases usually within 2 years after the start of treatment. Cisplatin-based combination chemotherapy will result in partial or complete responses in 15–35% and 15–45% of patients, respectively.
Combination chemotherapy has been integrated into trials of surgery and radiotherapy. It has been used before each in an attempt to preserve the bladder and decrease recurrence rates. Alternatively, it has been employed postoperatively in patients who have undergone cystectomy and have been found to be at high risk of recurrence. In current practice, adjuvant chemotherapy when indicated—ie, when the primary tumor invades perivesical fat or adjacent organs or when lymph nodes are found to have metastatic disease—is being offered mainly to patients being treated with radical cystectomy. It is used less often for patients with unresectable disease (extension to pelvic side wall).
Posted on October 29th, 2007 by Canadian Health in
Cancer Pathology & Selection of Treatment
Ninety-eight percent of primary bladder cancers are epithelial malignancies, with the majority being transitional cell carcinomas (90%). These latter cancers most often appear as papillary growths, but higher-grade lesions are often sessile and ulcerated. Grading is based on histologic architecture: size, pleomorphism, mitotic rate, and hyperchromatism. The frequency of recurrence and progression is strongly correlated with grade. Whereas progression may be noted in few grade I cancers (19–37%), it is common with poorly differentiated lesions (33–67%). Carcinoma in situ is recognizable as a flat, nonpapillary, anaplastic epithelium and may occur focally or diffusely, but it is most often found in association with papillary bladder cancers. Its presence identifies a patient at increased risk of recurrence and progression.
Adenocarcinomas and squamous cell cancers account for approximately 2% and 7% (respectively) of all bladder cancers detected in the USA. The latter is often associated with schistosomiasis, vesical calculi, or chronic catheter use.
Bladder cancer staging is based on the extent of bladder wall penetration and the presence of either regional or distant metastases. The TNM classification of the American Joint Cancer Committee for bladder cancer is shown in Table 23–11.
Table 23–11. TNM staging system for bladder cancer.
T: Primary tumor
Tx Cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ (CIS)
Ta Noninvasive papillary carcinoma
T1 Invasion into lamina propria
T2 Invasion into superficial layer of muscularis propria
T3a Invasion into deep layer of muscularis propria
T3b Invasion through serosa into perivesical fat
T4a Invasion into adjacent organs
T4b Invasion into pelvic sidewall
N: Regional lymph nodes
Nx Cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in a single lymph node £ 2 cm
N2 Metastasis in a single lymph node > 2 cm and < 5 cm or multiple
nodes none > 5 cm
N3 Metastasis in lymph node > 5 cm
M: Distant metastasis
Mx Cannot be assessed
M0 No distant metastasis
M1 Distant metastasis present
The natural history of bladder cancer is based on two separate but related processes: tumor recurrence and progression to higher stage disease. Both are related to tumor grade and stage. At initial presentation, approximately 50–80% of bladder cancers will be superficial: Ta, Tis, T1. Lymph node metastases and progression are uncommon in such patients when they are properly treated, and survival is excellent at 81%. Patients with superficial cancers (Ta, T1) are treated with complete transurethral resection and the selective use of intravesical chemotherapy. The latter is used to prevent or delay recurrence. Patients who present with large, high-grade, recurrent Ta lesions, T1 cancers, and those with carcinoma in situ are good candidates for intravesical chemotherapy. Patients with more invasive (T2, T3) but still localized cancers are at risk of both nodal metastases and progression, and they require more aggressive surgery, irradiation, or the combination of chemotherapy and selective surgery or irradiation due to the much higher risk of progression compared to patients with lower-stage lesions. Patients with evidence of lymph node or distant metastases should undergo systemic chemotherapy initially.
Posted on October 29th, 2007 by Canadian Health in
Cancer Bladder cancer is the second most common urologic cancer. Bladder cancer occurs more commonly in men than women (2.7:1), and the mean age at diagnosis is 65 years. Cigarette smoking and exposure to industrial dyes or solvents are risk factors for the disease and account for approximately 60% and 15% of new cases, respectively.
Clinical Findings
A. Symptoms and Signs: Hematuria—gross or microscopic, chronic or intermittent—is the presenting symptom in 85–90% of patients with bladder cancer. Irritative voiding symptoms (urinary frequency and urgency) will occur in a small percentage of patients as a result of the location or size of the cancer. Most patients with bladder cancer will fail to have signs of the disease because of its superficial nature. Masses detected on bimanual examination may be present in patients with large-volume or deeply infiltrating cancers. Hepatomegaly or supraclavicular lymphadenopathy may be present in patients with metastatic disease, and lymphedema of the lower extremities may be present as a result of locally advanced cancers or metastases to pelvic lymph nodes.
B. Laboratory Findings: Urinalysis will reveal hematuria in the majority of cases. On occasion, it may be accompanied by pyuria. Azotemia may be present in a small number of cases associated with ureteral obstruction. Anemia may occasionally be due to chronic blood loss or to bone marrow metastases. Exfoliated cells from normal and abnormal urothelium can be readily detected in voided urine specimens. Cytology may be useful in detecting the disease at the time of initial presentation or to detect recurrence. Cytology is very sensitive in detecting cancers of higher grade and stage (80–90%) but less so in detecting superficial or well-differentiated lesions (50%). Sensitivity of detection using exfoliated cells may be enhanced by flow cytometry.
C. Imaging: Bladder cancers may be detected using intravenous urography, ultrasound, CT, or MRI where filling defects within the bladder are noted. However, the presence of cancer is confirmed by cystoscopy and biopsy, so imaging is useful primarily for evaluating the upper urinary tract and in staging the more advanced lesions.
D. Cystourethroscopy and Biopsy: The diagnosis and staging of bladder cancers is made by cystoscopy and transurethral resection. If cystoscopy—performed usually under local anesthesia—confirms the presence of bladder cancer, the patient is scheduled for transurethral resection under general or regional anesthesia. A careful bimanual examination is performed initially and at the end of the procedure, noting the size, position, and degree of fixation of a mass, if present. Any suspicious lesions are resected using electrocautery. Resection is carried down to the muscular elements of the bladder wall so as to allow complete staging. Random bladder and, on occasion, prostatic urethral biopsies are performed to detect occult disease elsewhere in the bladder and, therefore, identify patients at high risk of recurrence and progression.
Posted on October 25th, 2007 by admin in
Cancer Treatment
Electrodesiccation and curettage.
This treatment is most beneficial for nodular BCCs less than 6 mm in diameter, regardless of anatomic site; selected larger BCCs, depending on their anatomic site; and superficial BCCs. It is not appropriate for morpheaform BCCs because margins cannot be clinically defined. Lesions on the nose and nasolabial folds may be treated if they are well defined and very small; otherwise these high-risk areas should be treated by Mohs’ micrographic surgery. However, the treatment is particularly useful for ear lesions, where mobilization of skin for closure after excision is difficult.
Curettage requires firm dermis on all sides and below the tumor to enable the curette to distinguish between dermis and soft tumor. If the tumor encroaches on the fat, the curette cannot distinguish between fat and soft tumor, and an alternate procedure must be used. Curettage should be avoided for lesions on the back and shoulders, where the dermis is thick, unless the BCCs are superficial and small. Proper technique requires vigorous curettage, usually two to three times; therefore, lesions on the eyelid or lip area are treated by other methods. It is especially useful for lower extremity tumors, where tissue mobilization for excision may be difficult. Wounds created by electrosurgery ooze serum and accumulate crust during a 2- to 6-week healing period.
Excision surgery.
Excision surgery is preferred for large tumors with well-defined borders on the cheeks, forehead, trunk, and legs. The cosmetic result is good and healing time is less than that required for electrosurgery. Excision with primary closure is technically difficult on the ears and nose. The advantage of feeling the tumor with a curette is lost and adequate margins must be taken. A 98% cure rate was achieved in one study when BCCs less than 2 cm were excised with excisional margins of 4 mm around the tumor. One large series revealed 5-year recurrence rates of BCCs excised from various anatomic sites: 0.7% on the neck, trunk, and extremities; 3.2% on the head if lesions were less than 6 mm in diameter; 5.2% on the head if lesions were 6 to 9 mm in diameter; and 9.0% on the head if lesions were 10 mm or more in diameter.
INCOMPLETELY RESECTED BCC.
Adequate excision, peripherally and in depth, is the key to surgical control, and the demonstration of tumor cells at the margins of excision is associated with recurrence rates of more than 30%. Data support the policy of immediate re-excision for all patients with incompletely excised basal cell carcinomas rather than a “wait-and-see” policy after incomplete excision. Re-excision may not be necessary if the patient’s life span is limited or if treatment of a possible recurrence would not be difficult.
Cryosurgery.
Cryosurgery with liquid nitrogen delivered with a spray apparatus or a cryoprobe is appropriate for small-to-large BCCs of the nodular and superficial types with clearly definable margins (laterally and in depth). It is not indicated for tumors deeper than 3 mm unless thermocouples are used to measure depth of freeze. A biopsy is performed as a separate operation before the cryosurgical procedure to determine cell type and extent of the tumor or just before the cryosurgery if there is no doubt about the diagnosis. Postoperative pain is moderate to severe. The appearance of a wound a few days after treatment is sometimes alarming to patients.
Mohs’ micrographic surgery.
Mohs’ surgery is a microscopically controlled technique that may be used for all types and sizes of BCCs. The procedure is unnecessarily destructive for smaller lesions or for lesions with well-defined clinical margins, such as nodular or superficial multicentric BCCs.
Mohs’ surgery is the treatment of choice for most sclerosing BCCs and other BCCs with poorly defined clinical margins; for tumors in areas of potentially high recurrence, such as the nose or eyelid; for very large primary tumors; and for large recurrent BCCs