We report two cases of myoclonus following the administration of gabapentin for neuropathic pain in the end stage of malignancy. Patient 1: A septuagenarian woman with sarcoma of the uterus was admitted to our hospice. She complained of severe neuropathic pain in her left leg caused by an invasive lumbar tumor. To reduce the neuropathic pain, she was administered 200mg of gabapentin daily. Four months later, the gabapentin was increased to 400mg daily due to worsening pain in her left leg. Three days later, she felt muscle weakness in her left arm and frequent muscle twitches were observed even during sleeping. Myoclonus associated with gabapentin administration was suspected. The myoclonus disappeared after cessation of gabapentin for 2 days. Patient 2: An octogenarian man with renal cell carcinoma was admitted to our hospice. He was administered 200mg of gabapentin daily to reduce the neuropathic pain felt in his back and bilateral leg due to a metastatic tumor of a para-aortic lesion. On the next day, frequent muscle twitches were observed in his extremities and upper trunk while he was sleeping. Myoclonus associated with gabapentin administration was suspected, which disappeared within one day following cessation of the drug. Myoclonus is a rare side effect of gabapentin, but it may occur even with the low-doses given to patients with end-stage malignancy. Although the pathogenic mechanism of induction of myoclonus by gabapentin was suspected to be heterogeneous, discontinuation of gabapentin should lead to rapid resolution of symptoms. Palliat Care Res 2010; 5(1): 308-313

The assessment of suffering in cancer patients affected by dementia can be challenging. We report a patient with advanced skin cancer and dementia who was admitted to our hospital without appropriate diagnosis as having cerebral infarction at previous hospitals. Case:An 85-year-old woman presented with existing cognitive dysfunction from 2009 and progression of a left facial skin tumor existing from 2013. She was admitted to hospital A for facial skin tumor with dysphagia, and diagnosed as having advanced skin cancer with dementia in June 2014. After palliative therapy for the skin tumor, she was transferred to hospital B. The physicians at both hospitals explained the presenting symptoms as complications of her advanced skin cancer and dementia. She was admitted to our hospital at 36 days after symptom onset, and we diagnosed subacute cerebral infarction based on head CT and MRI examinations. In this case, the patient’s advanced cancer and dementia might have interfered with the recognition of her symptoms of cerebral infarction. A detailed interview on admission might have contributed to our decision for further examination. Although the diagnosis of cerebral infarction could not palliate her physical symptoms, it might assist the family to recognize her suffering or to provide care perceiving her poor prognosis. Additionally, the diagnosis might have an effect for emotional satisfaction of the family.

We describe two patients who underwent repeat off-pump coronary revascularization by axillocoronary artery bypass grafting. A 63-year-old man (case 1), who had undergone coronary artery bypass grafting (CABG) 13 years previously, was admitted to our hospital with exertional angina. The saphenous vein grafts (SVG) to the left anterior descending artery (LAD), circumflex artery (Cx), and right coronary artery (RCA) all were occluded. The left internal thoracic artery (LITA) also was occluded because it had been injured. Because the patient declined to undergo a redo CABG, percutaneous transluminal coronary angioplasty (PTCA) to the LAD was attempted. However, coronary dissection occurred, and an emergency operation was performed. A 66-year-old man (case 2), who had undergone CABG 12 years previously, was admitted with unstable angina. The LITA to the LAD and the SVG to the RCA were occluded. The SVG to the Cx had 99% stenosis in its mid-portion and was the cause of the angina. PTCA and stenting of this SVG were performed. Two weeks later, an operation was done. In both patients, the left axillary artery was selected as the site of the proximal anastomosis. Both patients underwent off-pump bypass grafting to the LAD from the left axillary artery using a SVG. Both grafts were patent postoperatively. This approach resulted in early symptomatic improvement.