Received Date: June 26, 2014 Accepted Date: June 27, 2015 Published Date: June 29, 2015
Citation: Macleod N, Klepstad P, Fallon M, Laird B (2015) Mesothelioma Eroding through the Chest Wall. J Palliat Care Med 5:i102. doi: 10.4172/2165-7386.1000i102
Copyright: © 2015 Macleod N, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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A 68-year-old man presented to his local hospital with severe right-sided chest pain and breathlessness. He had worked as an apprentice carpenter in the shipbuilding industry many years ago. A chest X-ray was performed which showed a right-sided pleural effusion and pleural thickening. A Computerised Tomograph (CT) scan, including a CT guided biopsy, was done with pathology confirming MPM of sarcomatoid type. Treatment options were discussed with the patient. Chemotherapy was discussed but this was declined by the patient due to low likelihood of benefit. The patient agreed that treatment would be symptomatic only. The gentleman described his pain as “stabbing and shooting”, suggesting a neuropathic component. He also stated that it was severe in intensity.
Prior to admission, he had been taking tramadol (400 mg daily) and gabapentin (300 mg three times daily). During his admission, he was commenced on 40 mg of Morphine Sustained Release Tablets (every 12 hours), 15 mg of Immediate release Morphine Tablets when needed for pain, and a lidocaine patch applied over the chest wall. Tramadol was discontinued.
Pain continued to be problematic and when his morphine dose was escalated, he developed signs of opioid toxicity (muscle jerks and pseudo-hallucinations). He was therefore switched to Oxycodone Sustained Release Tablets (30 mg twice daily). With this, his opioid toxicity improved though was still present. His gabapentin was increased to 600 mg TDS and he remained on a lidocaine patch. Despite all this, his pain remained poorly controlled. At this point, he received radiotherapy with the aim of improving his pain. Twenty Gy in 5 fractions of radiotherapy were administered which brought about a temporary improvement in his pain but six weeks after treatment, his pain was as severe as it was prior to his radiotherapy. Following this, he was considered for cordotomy but unfortunately died before he was able to receive this.
This case illustrates some of the difficulties patients with MPM face in terms of pain management. Despite multiple analgesics and palliative radiotherapy, his pain remained poorly controlled. Not all cases of MPM are as challenging as this.
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