The albumin–bilirubin (ALBI) score is calculated using only serum albumin and bilirubin levels, and was developed as a simple method to assess hepatic function. In this study, a total of 409 patients with primary biliary cholangitis (PBC) were enrolled between March 1990 and October 2018. The predictive performances of the ALBI score and other well-established prognostic scores were compared using time-dependent receiver operating characteristic (ROC) analysis. During the follow-up period, 60 patients died, 45 due to liver-related diseases and 15 due to non-liver-related diseases, and 16 patients underwent liver transplantation. Time-dependent ROC analysis showed that the ALBI score has higher the areas under the ROC curves (AUROCs) than the Child–Pugh (C–P) score at each time point; AUROCs at 3, 5, and 10 years after the start of follow-up were 0.94, 0.91, and 0.90 for the ALBI score, and 0.89, 0.88, and 0.82 for the C–P score, respectively. The ALBI score showed the highest AUROCs within 2 years after the start of observation; beyond 2 years, however, the Mayo score had better prognostic ability for mortality and liver transplantation. The ALBI score/grade, derived from objective blood tests, and the Mayo score were superior prognostic tools in PBC patients.

Background and Aim The fibrosis stage of non-alcoholic fatty liver disease (NAFLD) is closely associated with long-term prognosis, including liver-related mortality. However, it is not yet clear whether noninvasive fibrosis markers can predict the incidence of non-liver-related complications in Japanese NAFLD. In this study, we clarified the prognosis of NAFLD patients, including non-liver-related diseases, based on hepatic pathology and noninvasive fibrosis markers. Methods A total of 246 Japanese patients with NAFLD diagnosed by liver biopsy were enrolled. We investigated their prognosis based on hepatic pathology and noninvasive fibrosis markers. Results When these patients were categorized based on the severity of liver fibrosis as F0-2 (n = 196) and F3-4 (n = 50), the patients with F3-4 had significantly poorer prognosis in overall survival rates and all complications (P < 0.05). The fibrosis-4 (FIB-4) index was useful to predict overall survival and the incidence of hepatocellular carcinoma and liver cirrhosis (LC)-related complications but not extrahepatic malignancies. Multiple logistic regression analyses revealed the following risk factors: total bilirubin >= 1.2 (hazard ratio [HR] 6.362, 95% confidence interval [CI] 1.393-29.052) and severe liver fibrosis (HR 6.512, 95% CI 1.433-29.592) for overall survival; liver fibrosis (F3-4) (HR 13.370, 95% CI 2.775-64.427) for hepatocellular carcinoma; FIB-4 index (HR 26.560, 95% CI 3.320-212.494) for LC-related complications, and liver inflammation (A2-3) (HR 4.214, 95% CI 1.354-13.116) for extrahepatic malignancies. Conclusions Severe liver fibrosis was associated not only with the hepatocarcinogenesis and LC-related complications but also with extrahepatic malignancies. The FIB-4 index was useful for predicting liver-related diseases but had limitations in predicting extrahepatic malignancies.

【緒言】オキシコドン徐放錠（SRO）増量後に嘔吐・嚥下困難が増悪し食道アカラシア（EA）の関与が疑われた肺がん症例を報告する．【症例】66歳女性，50歳時EAに対しバルーン拡張術（EPD）を受けた．65歳時に右肺腺がんと診断され化学療法を受けたが1年後に緩和医療へ移行した．複合要因による腰背部痛に対しSROを開始しプロクロルペラジンを併用したが嘔吐が持続し入院となった．制吐薬を追加したが嘔吐は軽減せず，CT（食道拡張）・内視鏡（esophageal rosette陽性）・食道造影（食道胃接合部狭窄）により，直線型EA拡張度II度と診断した．EPDは症状の改善に有効であった．【考察】高解像度食道内圧測定によるオピオイドやドパミンD2受容体拮抗薬誘発食道運動異常の報告より，本例の消化器症状はEAの潜在的な進行に加え，SRO自体による嘔吐や，SROや制吐薬がEAに影響を与えた可能性も類推された．

Reactivation of hepatitis B virus (HBV) in HBV surface antigen (HBsAg)-positive patients treated with cytotoxic chemotherapy is well known. HBV reactivation in patients with HBV and hepatitis C virus (HCV) coinfection caused by direct-acting antiviral (DAA) therapy has also recently been reported. We report a case of acute hepatitis B in a patient with HCV infection after DAA therapy. An 83-year-old woman was referred for chronic hepatitis C. She was infected with HCV genotype 1b and negative for HBsAg at baseline. She received daclatasvir and asunaprevir therapy, and HCV became negative at 4 weeks and remained negative until 6 months after the end of DAA therapy. Acute hepatitis B developed 5 months after ending DAA therapy. Genome sequencing revealed the subgenotype as B1, and the serological subtype as adr. T118 K mutation at the S region as an immune escape mutant was identified. These virologic features led to HBV reactivation. The presence of hepatitis B core antibody or HBs antibody was not determined before DAA therapy, so prior HBV infection status was unclear. This case is speculated to represent HBV reactivation in a patient with previously resolved HBV induced by DAA therapy, based on virologic analysis and clinical status. The risk might be very low, but DAA therapy can cause HBV reactivation in chronic hepatitis C patients with prior HBV infection. When acute hepatitis emerges in patients who have received DAA therapy for HCV, HBV reactivation should be considered to allow early initiation of anti-HBV therapy.

For symptom alleviation, subcutaneous continuous injection of octreotide was administered to a patient with pancreatic neuroendocrine tumor (NET) accompanied by multiple hepatic metastases and ascites. The level of the tumor marker neuron-specific enolase decreased to the normal range and cystic necrosis of the tumors was confirmed. There have been some reports on the antineoplastic effects of octreotide on pancreatic NET; therefore, octreotide appears to be a valid option as a therapeutic agent in patients with highly advanced pancreatic NET, in whom administration of molecular targeted or anticancer agents is difficult because of a poor general status.

〔目的〕看取り期の患者における皮膚湿潤 (冷たくじっとりとした皮膚所見) の出現と関連因子を明らかにする。 〔方法〕緩和ケア病棟で, 看取りのクリニカルパス (Liverpool Care Pathway[LCP]日本語版) を用い, 看護師により皮膚湿潤を前向きに観察した。 〔結果〕LCP適用患者213例中, 皮膚湿潤は48例 (22.5%) にみられ, 夏・日中午前に多く, 出現後死亡まで平均45.8時間であった。多変量解析では非ステロイド系消炎鎮痛剤 (NSAIDs) 投与が独立した関連因子であった。結語: 皮膚湿潤は, 以前われわれが報告した後ろ向き研究 (頻度10.9%, 出現後死亡まで平均10時間) に比べ, 高頻度かつ早期からみられ, NSAIDs投与が独立した関連因子であった。

A 70-year-old man presented with septic shock and abdominal pain during treatment of pain caused by stage IV lung adenocarcinoma. CT revealed air collection from the retroperitoneum to the muscle around the thigh. Septic shock due to retroperitoneal penetration from the digestive tract was suspected. Despite treatment attempts, the patient died. The autopsy diagnosis was penetration of a sigmoid colon diverticulum under the serosa. When a diverticulum is located near the mesenterium and the size of penetration is small, the air collection rather than fecal matter is likely to extend retroperitoneally. Abdominal pain is little manifest in the penetration in contrast to perforation into abdominal cavity, and the attention is needed.

〔目的〕緩和ケアチームスタッフの自己貢献度と患者への効果を明らかにする。 〔対象と方法〕介入した患者への自己貢献度とSTAS-J症状版の介入前後の改善度を前向きに検討した。 〔結果〕自己貢献度では医師・看護師・臨床心理士・薬剤師は概ね高いが栄養士はやや低く, 年齢・性別・原発部位別・介入期間に関連がみられた。STAS-Jでは疼痛・嘔気嘔吐・食欲不振・不眠は改善, せん妄・抑うつは増悪した。自己貢献度とSTAS-J改善度では, 薬剤師は7項目に関連がみられたが他の職種は1項目のみであった。 〔考察〕自己貢献度には差があり, 介入しても必ずしも自己貢献度は高くなかった。個人の要素も大きいとは思われるが, 薬剤師は客観的な立場での評価や薬剤提案が可能であることが, 関連項目数の多い一因と考えられる。 〔結語〕各職種・個人の特性に基づいた活動を今後行なうことが望ましい。

BACKGROUND:Previous research has reported that mirtazapine, a 5-HT3 antagonist, is effective for alleviation of digestive symptoms.PURPOSE:To elucidate the effect of low-dose mirtazapine on digestive symptoms.PATIENTS AND METHODS:Mirtazapine was administered to 50 cancer patients with digestive symptoms in palliative care, and the data were retrospectively examined. The initial doses ranged from 1.875 to 7.5 mg, and were increased to a maintenance dose according to its effects and the degree of somnolence.RESULTS:The cases were divided into 2 groups based on the cause of the digestive symptoms, including unknown causes(27 cases)and chemotherapy and/or opioid treatment(23 cases). At the initial dose, the efficacy rate was 74.4%, and the effectiveness was significantly higher in patients whose symptoms were due to chemotherapy and/ or opioid use than in those with symptoms of unknown cause(p=0.008). The rate of somnolence was 29.5%. Discontinuation of treatment within 1 week occurred in 10 cases. In 40 cases that continued administration of the maintenance dose, the efficacy rate was 82.5%, and the increased doses provided relief in the patient group with digestive symptoms of unknown cause.CONCLUSIONS:Low-dose mirtazapine showed different effects depending on the cause of digestive symptoms; therefore, the dose should be increased in patients whose symptoms are of unknown cause. Somnolence often appeared even at a low-dose, and this should be taken into consideration in the palliative care setting.

The patient was a woman in her 70s, who had been diagnosed as having a malignant fibrous histiocytoma in the right axilla with invasion to the intrathoracic space at a local hospital. The growth of cytokine-producing tumor was suspected, and thrombocytopenia caused by bleed-ing and jaundice by blood transfusion were disclosed. When she was admitted to our palliative care unit, the platelet count was 19,000/ µ l and total bilirubin was 6.4mg/dl. Furthermore, sev-eral predictive fools showed the prognosis for survival was poor. After transferal to our hospital, the patient was treated mainly with medication. No blood transfusion was given. In the clinical course, the platelet count and total bilirubin level were restored to normalcy. The patient lived on for another five months or over. The contributing factors, in prolonging her life longer than predicted were probably as follows ; (1) spontaneous recovery of thrombocytopenia without bleeding, (2) improvement of jaundice caused by the blood transfusion, and (3) foods taken orally even in small amounts. There are patients whose prognosis varies substantially in the fields of the palliative care. It is important to work out proper medical treatment and care plans according to symptoms and the status of patients.

【緒言】フェンタニル貼付剤による色素沈着の報告は現在までにみられない. 【症例】43歳, 男性. 直腸がん術後再発に対して, セツキシマブ+イリノテカン療法後, パニツムマブ+FOLFIRI療法を施行した. がん疼痛に対して, フェンタニル貼付剤(フェントス®)投与し, 再発部位に後方からの放射線療法を行った. 経過中, 胸部と腹部のフェンタニル貼付剤の貼付部位に色素沈着がみられた. 貼付中止後, 4カ月でほぼ消失した. 【考察】色素沈着の機序として, フェンタニル貼付剤による接触皮膚炎後の炎症後色素沈着である可能性が高い. 正確な機序の解明のためには, パッチテスト・皮膚生検が望ましい. 【結論】フェンタニル貼付剤投与時には, 色素沈着に留意する必要がある.

【緒言】従来の一般的な内服や外用薬に対して治療抵抗性の皮膚掻痒感をもつがん患者では, 症状緩和に難渋する. 【症例】72歳, 女性. 肺がん膵転移に伴うがん性疼痛に対してオキシコドン徐放剤を投与し, また閉塞性黄疸に対して内視鏡的胆道ドレナージを行った. 皮膚掻痒感がみられたため, 外用薬・内服(ミルタザピンと漢方)の投与を行ったが改善しなかった. 難治性皮膚掻痒感と診断しプレガバリンを投与した. 低用量で開始後増量し, 投与3日目に改善効果がみられた. 最終的には皮膚掻痒感のNumerical Rating Scaleは投与前8/10から投与後0~1/10となり, 症状緩和が得られた. 【考察】プレガバリンが皮膚掻痒に有効であるという海外の先行研究がみられている. 自験例でも, プレガバリンにより難治性皮膚掻痒感の症状緩和を得ることができた. 【結論】プレガバリンは, 難治性皮膚掻痒感に対する有効な治療の選択肢の1つと考えられる.

This paper presents a woman in her 70's with G-CSF producing anaplastic carcinoma of the pancreas(Stage IVb)who underwent chemotherapy by S-1 alone. On FDG-PET after the first course, accumulation of FDG was impaired remarkably. After the second course, the patient died of carcinomatous pleuritis and peritonitis on the 88th day after initiation of treatment. G-CSF producing anaplastic carcinoma of the pancreas is extremely rare and there are no reports with regard to response evaluation by FDG-PET. Thus, this case has significant clinical value.

症例は56歳,女性。多発性骨転移がみられ,外科での乳房腫瘍針生検同一日に緩和ケア科を受診した。乳癌骨転移による疼痛が強く,オキシコドンの積極的な増量で疼痛緩和を図った。疼痛緩和を得た後に,緩和ケアと並行しEC療法とweekly PTX療法での化学療法を行なった。自験例では緩和ケア医と主治医とが密に連携を行ない,十分な鎮痛が得られた後に化学療法を行なうことが可能であった。がん治療を行なう主治医と症状緩和を行なう緩和ケア医が良好な信頼関係を築き,ともに患者中心の医療を行なうことが大切である。

症例1は50歳代男性。肺腺癌に対して,プロシュア®2本／日を投与し放射線療法とカルボプラチン＋ドセタキセルによる化学療法を行なった。体重は入院時62.4kgから退院前63.7kgと増加し,CRPは入院時3.08mg/dlから0.48mg/dlに低下,アルブミンは入院時3.6g/dlから退院前3.5g/dlに維持できた。症例2は60歳代男性。肺扁平上皮癌と診断し,プロシュア®2本／日と抗菌薬投与を行なった。1か月半後,カルボプラチン＋S-1による化学療法と放射線療法を施行した。体重は入院時47.0kgから退院前47.2kgと維持,CRPは入院時15.45mg/dlから3.26mg/dlまで低下し,アルブミンは入院時2.6g/dlから退院前2.7g/dlに維持できた。プロシュア®投与により,化学療法肺癌患者で栄養状態の改善と抗炎症効果がみられた。

This paper presents the case of a man in his 60's with advanced esophageal cancer after the first course of 5-FU/CDDP therapy during follow-up visit, who had pain and numbness from right scapula to upper arm. MRI revealed bone metastasis in the first thoracic vertebra and lymph node metastasis to be diagnosed as neuropathic pain by brachial plexus invasion. Radiation therapy and medical treatment with lornoxicam and controlled-release oxycodone started. However, breakthrough pain in the night was remarkably severe and numerical rating scale was 9-10/10. Pregabalin as analgesic adjuvant was administrated from dose of 75mg/day to 300mg/day and the breakthrough pain in the night disappeared completely. The patient underwent the second course of 5-FU/CDDP therapy without the pain. In the present case, the combined therapy of medical treatment and radiation therapy provided complete relief of the neuropathic pain. We conclude that it is an option to select pregabalin as effective agent for neuropathic pain in medical treatment.

Our palliative care team intervened in a patient with sciatica resulting from metastasis to sacral bone after surgery for rectal cancer. Rapid pain control and a change in the route of rescue drug administration from the stoma were needed. Partial opioid rotation was performed. The dose of 25.2 mg in 72 hours in a transdermal fentanyl patch decreased to 16.8 mg in 72 hours, and the dose of 3.6mg in an hour by continuous intravenous injection of morphine was added. The change in the rescue root to intravenous administration by a patient-controlled analgesia pump gave the patient relief from his pain. He was able to attend his daughter’s wed-ding. His family were all pleased with the relief provided. The advantages of this partial opioid rotation are summed up in the following three points : (1) The required time is relatively short ; (2) It can be expedient for analgesia due to the addition of different opioids ; and (3) The partial opioid rotation produces fewer adverse effects than a full opioid rotation. Adjustment of the amount of drugs for pain relief in cancer patients is important with the situations of the patient and the family taken into consideration fully.

A 37-year-old man underwent lobectomy of the right liver for granulocyte colony-stimulating factor (G-CSF) producing hepatocellular carcinoma accompanying type B hepatitis. Within two months after the surgery, lung metastases were revealed and administration of sorafenib was begun, however, the lung metastases continued to enlarge. Changing the patient's medication to tegafur-uracil provided remarkable reduction of the lung metastases. The patient is alive two years after diagnosis and receives outpatient chemotherapy. We concluded that this case is valuable with regard to the extreme rarity of G-CSF producing hepatocellular carcinoma and its successful treatment in this case.

〔背景〕当院ではがんサロン開催時に，短時間の講演 (ミニレクチャー) ののちに交流会を行なっている。〔目的〕ミニレクチャーの位置づけを検討すること。〔方法〕参加者のアンケート調査結果を集計した。〔結果〕ミニレクチャーは多職種で行なったが，医師以外の職種によるミニレクチャーは，医師によるものに比べて，その後の交流会で参加者が「参考になった」と感じる割合が有意に高かった (χ2検定，p＝0.021)。〔考察〕ミニレクチャーは情報提供だけでなく，引き続き行なう交流会の導入として「場の雰囲気作り」に大切である。さらに，講演者が医師でも参加者の評価を得るには，参加者の気持ちを捉えながらレクチャーし，引き続き行なう交流会に自然な雰囲気で参加することが大切であろう。〔結論〕ミニレクチャーは，交流会への雰囲気づくりと，講演者がその場に溶け込むきっかけとなる。

This paper presents a man in his 80's with pancreatic cancer(cStage IV). He suffered from nausea duringS -1 therapy, and therefore, prochlorperazine maleate at a daily dose of 15 mgwas administered. However, refractory nausea was diagnosed because it did not improve, and mirtazapine at a daily dose of 7. 5 mgbefore bedtime was started. Nausea was improved in the next morning, and the patient ate almost all of his breakfast. After that, no nausea appeared, and his food intake was robust. Mirtazapine is a new antidepressant called noradrenergic and specific serotonergic antidepressant(NaSSA)and blocks 5-HT3 receptors to improve nausea. Mirtazapine is usually started at a daily dose of 15 mg, but this dose induces somnolence. Therefore, mirtazapine was administered at a low daily dose of 7. 5 mgin the present case. No somnolence or disturbance of daily life was seen, and administration was safely continued. We conclude that low-dose mirtazapine is one effective option for refractory nausea duringS -1 therapy.