Montague Lane

Recent clinical experience with dronabinol

Dronabinol, delta-9-tetrahydrocannabinol in sesame oil, has been used for several years as an antiemetic for patients receiving cancer chemotherapy. In combination studies with prochlorperazine, enhancement of efficacy, as measured by duration of episodes of nausea and vomiting and by severity of nausea, has been found. The incidence of psychotropic effects from dronabinol appears to be decreased by concomitant administration of prochlorperazine. In open pilot studies, dronabinol caused weight gain in seven of ten patients with symptomatic HIV infection. In both HIV and cancer patients, dronabinol improved appetite at a dose which was well tolerated for chronic administration.

Combination chemotherapy for multiple myeloma

Response rate, remission duration, and survival time were compared in 236 patients with multiple myeloma receiving a melphalan‐prednisone‐procarbazine combination and in 156 patients receiving only melphalan‐prednisone. Response was confirmed when myeloma protein production had been reduced to less than 25% of the pretreatment value. Of the evaluable trials, 59% of patients responded to the procarbazine combination, and 48% to melphalan and prednisone. In both treatment groups, the survival time of all patients (22 months) and the remission duration of responding patients (21 months) were similar. Maximum degrees of myeloma protein reduction were associated with longer remissions and survival. Previously reported resistance to treatment of patients with only lambda Bence Jones protein was not apparent with these superior treatment regimens. Results support the value of combination chemotherapy with melphalan‐prednisone‐procarbazine for remission induction in patients with multiple myeloma.

The relationship of dispositional optimism, daily life stress, and domestic environment to coping methods used by cancer patients

The relationship of dispositional optimism, daily life stress, and domestic environment to two types of coping methods was examined in a group of 94 cancer patients. As expected, dispositional optimism and domestic environment made significant contributions to the prediction of avoidance coping. Dispositional optimism contributed significantly to the prediction of active-behavioral coping. Specifically, a significant positive relationship was obtained between active-behavioral coping and optimism. A significant positive relationship also was found between avoidance coping and both daily stress and domestic environment. Avoidance coping was negatively related to dispositional optimism. In multivariate analyses, gender and disease-related variables did not make significant contributions to the prediction of coping method. Suggestions for future research were made.

Women with breast cancer: perception of family functioning and adjustment to illness

&NA; Fifty‐seven women with breast cancer completed measures of family adaptability and cohesion, marital adjustment, and psychosocial adjustment to illness. Using a circumplex model of family systems, we examined whether subjects who perceived their families at moderate levels of cohesion and adaptability reported better psychosocial adjustment than subjects from families with extreme levels of cohesion and adaptability. The results indicated that the patients who reported the best adjustment to breast cancer and in their marriages, also reported the highest levels of family cohesion. There was not a significant relationship between adjustment to illness and adaptability. The implications for the treatment of women with breast cancer and for the families of these patients were discussed.

Conservative management of malignant pericardial effusion

The traditional approach to treatment of malignant pericardial effusion has been surgical, with establishment of a pericardial window. Conservative management with local instillation of chemotherapeutic agents and/or focal radiotherapy has received less attention, particularly when solid tumors have been causative. This series of 5 patients with antemortem diagnoses of malignant pericardial disease had predominant pericardial effusion rather than tumor encasement as the basis for tamponade. These 5 patients received initial therapy with local instillation of a chemotherapeutic agent ± radiotherapy. Four of the 5 made complete responses with total disappearance of cardiac symptoms and signs. Two of the responders are dead, 4 and 12 months, respectively, after initial treatment, neither showing significant pericardial fluid at postmortem examination. Two patients are alive and asymptomatic, 40 months and 8 months, respectively, after initial therapy. A literature review of treatment of malignant pericardial effusions discloses longer symptom‐free intervals in patients treated by conservative measures compared to surgical programs utilizing pericardial window accompanied by any combination of other treatment modalities.

Dronabinol and prochlorperazine in combination for treatment of cancer chemotherapy-induced nausea and vomiting

Dronabinol (Marinol, Roxane Laboratories, Columbus, OH) and prochlorperazine were tested alone and in combination in a randomized, double-blind, parallel group, multicenter study. Patients were randomized to receive either 1) dronabinol 10 mg every 6 hr plus placebo; 2) placebo plus prochlorperazine 10 mg every 6 hr; or 3) dronabinol and prochlorperazine, each 10 mg every 6 hr. Antiemetic treatment was begun 24 hr prior to and continued for 24 hr after the last dose of chemotherapy; all was given orally. Only 29% of patients in group 3 versus 47% in group 1 and 60% in group 2 experienced nausea after chemotherapy. In addition, the median duration per episode and severity of nausea were significantly less with combination therapy. Vomiting occurred after chemotherapy in 41%, 55%, and 35% of patients in groups 1, 2, and 3, respectively. The median duration per episode of vomiting was 1 min in group 3 versus two in group 1 and four in group 2. Side effects, primarily CNS, were more common in group 1 than in group 2; addition of prochlorperazine to dronabinol appeared to decrease the frequency of dysphoric effects seen with the latter agent. The combination was significantly more effective than was either single agent in controlling chemotherapy-induced nausea and vomiting.

Endodermal sinus tumor of the mediastinum: A report of seven cases and review of the literature

Primary mediastinal endodermal sinus tumor is rare, and to date only 49 cases have been described in the English‐language literature. Seven new cases are reported. Light microscopic examination showed characteristic features including papillary, reticular, tubular and solid growth patterns, complete or incomplete Schiller‐Duval bodies and intracellular or extra cellular periodic acid‐Schiff‐positive material. Immunohistochemical studies showed alpha‐1‐antitrypsin in seven, alpha‐fetoprotein in seven, keratin in six, and carcinoembryonic antigen in four cases. The beta summit of human chorionic gonadotropin, albumin, fibronectin, and transferrin were not found in any case. Electron microscopic studies performed in four cases showed intracellular and extracellular basement membrane‐like material, multiple large multivesicular bodies, desmosomes and microvilli. Mediastinal endodermal sinus tumor can and must be differentiated from poorly differentiated adenocarcinoma metastatic or extending to the mediastinum because of the distinctly different prognoses and therapies. In spite of modern chemotherapy, the prognosis of mediastinal endodermal sinus tumor remains poor. The single most important prognostic indicator is whether the tumor mass can be completely excised before or after chemotherapy. Cancer 58:730‐739, 1986.

ACTH‐secreting carcinoma of the breast

We report a case of ACTH‐secreting carcinoma of the breast. Membrane‐bound secretory granules were seen within the cancer cells electron microscopically. Cytoplasmic granules reacting immunochemically to anti‐ACTH antisera were seen on light microscopy. Breast cancers have been shown to secrete calcitonin, parathyroid hormone, human chorionic gonadotropin, and norepinephrine in addition to ACTH. This suggests either the presence of neuroendocrine cells in the breast as a source of such neoplasms, as in the lung, or genomic derepression during neoplastic transformation.

Attitudes to cancer: Psychometric properties of fighting spirit and denial

Higher rates of recurrence-free survival at 5- and 10-year follow-up have been reported for breat cancer patients who initially responded to cancer with attitudes of “fighting spirit” or denial. We report here a factor analytic attempt, utilizing questionnaire data, to objectify these attitudes. A reliable factor structure replicated in breast and mixed cancer samples, yielding three factors: (1) Fighting Spirit or belief in the ability to fight back, conquer, and recover from cancer; (2) Information-Seeking behavior; and (3) Denial. Adequate 1-month test-retest correlations were obtained for Fighting Spirit and Information Seeking factor scores. A pattern of differential correlations with other measures (affect, coping, and optimism) distinguished Fighting Spirit and Information Seeking. The Denial factor appeared to be less stable and did not correlate significantly with other measures.

Hepatoma presenting as a retro-orbital metastasis.

Patients with hepatomas who present primarily with symptoms of metastatic disease are rare. A case is described of a patient whose initial manifestation of disease was related to a retro‐orbital mass. The literature concerning orbital metastases is reviewed.