Hesham Mahmoud Hamza

Effect of Topical Morphine on Acute and Chronic Postmastectomy Pain: What Is the Optimum Dose?

Background and Objectives Poorly controlled postoperative pain is strongly associated with the development of chronic pain. We aimed to investigate the effect of topical morphine (in 1 of 3 doses: 5, 10, or 15 mg) on acute and chronic neuropathic pain after modified radical mastectomy for cancer breast. Methods In this registered clinical trial (ClinicalTrials.gov identifier: NCT02462577), 90 patients were allocated to receive 10 mL plain bupivacaine 0.5% plus either 5, 10, or 15 mg morphine (designated by the group names Morphine5, Morphine10, and Morphine15, respectively). The combination was diluted by saline 0.9% to 20 mL and irrigated in the wound before skin closure. Groups were compared for the following: time to first postoperative analgesia; intravenous patient-controlled analgesia (PCA) morphine consumption; pain scores; hemodynamics; sedation; adverse events in first postoperative 48 hours; and Leeds Assessment of Neuropathic Symptoms and Signs scores in first and third postoperative months. Results No patient in the Morphine15 group requested postoperative PCA morphine versus 19 and 8 in the Morphine5 and Morphine10 groups, respectively (P < 0.002). Time to first analgesic request and total consumption of PCA morphine analgesia were 7.31 ± 3.12 hours versus 14.00 ± 3.54 hours (P < 0.000) and 1.42 ± 0.50 mg versus 1.00 ± 0.00 mg (P = 0.371) in the Morphine5 and Morphine10 groups, respectively. Lowest scores on visual analog pain scale at rest (P < 0.001) and visual analog pain scale during movement (P < 0.01) were recorded in the Morphine15 group, followed by Morphine10 then Morphine5 group. Lowest Leeds Assessment of Neuropathic Symptoms and Signs scores were recorded in the Morphine15 group in the first month (1.10 ± 0.37 vs 5.76 ± 3.26 and 4.73 ± 2.87, P < 0.0001) and third postoperative month (4.40 ± 1.77 vs 6.33 ± 3.21 and 5.43 ± 2.67, P < 0.006) compared with Morphine5 and Morphine10 groups, respectively. No patient in the Morphine15 group developed chronic pain versus 4 and 2 in Morphine5 and Morphine10 groups, respectively. Conclusions Topical morphine controlled acute postmastectomy pain in a dose-dependent manner and reduced the incidence and severity of chronic postmastectomy pain syndrome.

Role of Surgery in Stages II and III Pediatric Abdominal Non-Hodgkin Lymphoma: A 5-Years Experience

Abdominal Non-Hodgkin lymphomas (NHL) are the most common extra nodal presentation of pediatric NHL. Our aim is to assess the role of surgery as a risk factor and to evaluate the impact of risk-adjusted systemic chemotherapy on survival of patients with stages II and III disease. This study included 35 pediatric patients with abdominal NHL treated over five years at South Egypt Cancer Institute (SECI), Assiut University, between January 2005 and January 2010. The data of every patient included: Age, sex, and presentation, staging work up to determine extent of the disease and the type of resection performed, histopathological examination, details of chemotherapy, disease free survival and overall survival. The study included 25 boys and 10 girls with a median age of six years (range: 2.5:15). Thirty patients (86%) presented with abdominal pain, 23 patients (66%) presented with abdominal mass and distention, 13 patients (34%) presented with weight loss, and intestinal obstruction occurred in six patients (17%). The ileo-cecal region and abdominal lymph nodes were the commonest sites (48.5%, 21% respectively). Burkitts lymphoma was the most common histological type in 29 patients (83%). Ten (28.5%) stage II (group A) and 25 (71.5%) stage III (group B). Complete resections were performed in 10 (28.5%), debulking in 6 (17%) and imaging guided biopsy in 19 (54%). A11 patients received systemic chemotherapy. The median follow up duration was 63 months (range 51-78 months). The parameters that significantly affect the overall survival were stage at presentation complete resection for localized disease. In conclusion, the extent of disease at presentation is the most important prognostic factor in pediatric abdominal NHL. Surgery is restricted to defined situations such as; abdominal emergencies, diagnostic biopsy and total tumor extirpation in localized disease. Chemotherapy is the cornerstone in the management of pediatric abdominal NHL.

Sacrococcygeal tumors: clinical characteristics and outcome of pediatric patients treated at South Egypt Cancer Institute. A retrospective analysis.

BACKGROUND Sacrococcygeal tumors (SCT) are relatively uncommon tumors affecting neonates, infants and children. The aim of this article is to clarify any special characterizations in natural history, clinical presentation and outcome of such tumors treated at South Egypt Cancer Institute, the only research center located in South Egypt. METHODS A retrospective analysis of children with SCT treated at the Pediatric Oncology department South Egypt Cancer Institute, Assiut University between 2004 and 2010. RESULTS Nineteen children were included in the study. Age ranged between 10 days and 5 years. All but three had sacral mass at presentation. AFP levels ranged between normal age-related levels and 217,200 ng/ml. Initial resection was possible in 11, while eight patients with clinical suggestion of advanced malignant disease were inoperable. They received initial chemotherapy followed by delayed surgery. Yolk sac tumor (YST) was reported in 52.9% of patients. Recurrence was reported in 5 patients (3 mature teratomas and 2 YST). Five-year OS and RFS rates of patients who had malignant disease were 81.8% and 77.8% respectively. CONCLUSIONS Older age and delay in presentation that resulted in predominance of extensive disease and malignant transformation at presentation were the main challenges we faced in managing patients with SCT in our locality.

Long-term Follow-up of Infantile Wilms Tumor Treated According to International Society of Pediatric Oncology Protocol: Seven Years' Follow-up

OBJECTIVES To report the long-term follow-up of patients with infantile Wilms tumor treated according to the International Society of Pediatric Oncology study 9 protocol. METHODS We retrospectively reviewed our medical reports for diagnosed WT in patients aged 6-12 months from January 2001 to January 2009. The clinical presentation, stage, operative details, pathologic findings, and outcomes for these infants were analyzed. We reviewed the charts of these patients throughout the whole disease course through long-term follow-up, paying particular attention to the details of the clinical presentation, stage at presentation versus postoperative stage, intraoperative findings, pathologic findings, and outcomes. RESULTS The records revealed 16 patients with a median age of 7.5 months. All patients had presented with an abdominal mass, and 25% had presented with abdominal pain and hematuria. Associated congenital anomalies were observed in 16.7% of the patients. A favorable histologic type was found in 91.7% of the patients and 8.3% had an unfavorable histologic type. The median follow-up period was 57 months. Postoperative complete remission was achieved in all patients who underwent surgery. Relapse developed in 1 patient. The 7-year disease-free survival rate was 93.8%, and the 7-year overall survival rate was 75%. CONCLUSIONS The long-term follow-up data using the International Society of Pediatric Oncology study 9 protocol revealed good outcomes. The protocol was a safe and an effective line of therapy, associated with decreased morbidity and improved survival. Also, the reduction in tumor volume resulted in easier surgical procedures, with no intraoperative complications.