Ronald Kanner

Cerebral granular cell tumor: immunohistochemical and electron microscopic study

A rare intracerebral granular cell tumor (GCT) was studied by immunocytochemical and ultrastructural methods. The tumor was composed of two cell types—filament-rich and granular cells. Granular cells contained PAS-positive, diastase-resistant granules that ultrastructurally corresponded to autophagic cytosegresomes. Glial fibrillary acidic protein, the intermediate filament protein specific for astrocytes, was demonstrated in the filament-rich and, to a lesser extent, in the granular cells. Unlike noncerebral GCT, neither S-100 protein nor vimentin was detected in the tumor cells. On the other hand, both cerebral and noncerebral GCT were labeled immunocytochemically with peanut lectin (Arachis hypogaea). The results suggest that cerebral GCT share some features with noncerebral GCT, but differ in other respects. They further suggest that GCT may be derived from different cell types depending on the tissue of origin, and that cerebral GCT may be derived from astrocytes.

Unavailability of narcotic analgesics for ambulatory cancer patients in New York city

Abstract This two-part study was designed to determine the availability of narcotic analgesics for ambulatory patients with cancer pain. In the first part, 50 randomly selected pharmacies in the Bronx, New York were called and asked which narcotic analgesics they routinely stocked. Thirty-four pharmacies responded. Seventeen (52%) stocked no Class II narcotic analgesics and 12 (36%) stocked nothing stronger than one of the oxycodone combinations. Four had levorphanol; three had hydromorphone; two had oral morphine and one had methadone. In the second part, 110 pharmacies throughout New York City were called. Ninety-four responded. Twenty-seven (29%) carried no Class II narcotics, and 24 (25%) carried nothing stronger than one of the oxycodone combinations. Nineteen (20%) had levorphanol; 14 (15%) had hydromorphone; three had oral morphine, and two had methadone. These data indicate that the potent analgesics most useful for the treatment of severe pain due to cancer are not readily available for cancer patients in New York City.

Diagnosis and management of neuropathic pain in patients with cancer.

Pain is a very common concomitant of cancer, affecting 30–50% of patients in active treatment and up to 90% of patients with advanced or near terminal illness (1). Although effective guidelines for cancer pain management are established (2,3), they are inconsistently followed. Barriers to adequate pain management arise from patients’ reluctance to report pain (4), nurses’ and physicians’ practices of pain management (5), societal and governmental views on opioid medications (6), and syndrome-related problems. Of the common cancer pain syndromes, neuropathic pain (pain initiated or caused by a primary lesion or dysfunction in the nervous system) (7) is one of the most difficult to diagnose and treat. This article reviews the normal neurological pathways for the transmission of pain, the presumed neurophysiological changes that subserve neuropathic pain, the common neuropathic pain syndromes seen in cancer, and recommended treatments for neuropathic pain. There are insufficient data to discuss these issues in the pediatric population, and comments are limited to the adult population.

Cocaine and morphine interaction in acute and chronic cancer pain

&NA; An evaluation of the analgesic, mood and side effects of the combination of intramuscular morphine and oral cocaine was conducted in 17 patients with postoperative pain and 19 others with chronic malignant pain for the purpose of assessing the therapeutic merits of so‐called ‘euphoriant’ elixirs in the management of pain in cancer patients. The study was designed as a randomized and double‐blind single dose but complete cross‐over comparison of the combination of 10 mg intramuscular morphine and 10 mg oral cocaine with morphine alone, cocaine alone, and placebo. While patients clearly discriminated between the analgesic effects of morphine and placebo, there were no differences in the analgesic responses to cocaine and placebo, or in responses to morphine and the combination of morphine and cocaine in either patient group. Side effects were predominantly morphine‐like and occurred in 59% of patients after the combination, 43% after morphine, 34% after cocaine and 25% after placebo. Interaction effects between cocaine and morphine were observed in terms of positive changes toward selected aspects of mood (e.g., cheerful, friendly) in postoperative patients but toward negative aspects of mood (e.g., sad, serious) in patients with chronic pain.

Unavailability of narcotic analgesics for ambulatory cancer pain patients in New York city

Cancer Center, New York, NY 10021, USA Aim of Investigat.ion: This study was designed to evaluate possible interactions between cocaine and morphine in terms of analoesic, mood and side effects in cancer patients with moderate to severe chronic pain in a single-dose assay. Methods: Patients (36) received placebo, 10 mg IM morphine, 10 mg PO cocaineand the morphine-cocaine combination, each on separate days, within a randomized double-blind crossover design. Serial estimates of pain intensity, pain relief, side effects and selected aspects of mood were obtained for up to six hours or until pain returned to baseline. Resul ts : Cocaine was no different than placebo in terms of analgesia. Themorphine-cocaine combination provided significant analgesia, no different than morphine alone and greater than that provided by placebo or cocaine. In contrast, the combination was associated with one-third fewer reports of side effects (e.g., sleepiness, nausea) than morphine and with improvements in selected aspects of mood (e.g., cheerfulness) to a greater degree than other treatments. Conclusions: The combination of 10 mg PO cocaine with a standard IM morphine dose provides analgesia comparable to morphine alone but with fewer side effects and greater mood improvement in cancer patients with moderate to severe pain. Supported in part by USPHS NIH Grants DA-01707 and CA-32897 and NCI Core Grant CA-08748.

Neurological consultation in the management of patients with systemic cancer admitted to a community hospital.

To characterize the neurological complications of cancer patients admitted to a community hospital, the charts of all cancer patients evaluated by a neurologist during a single year were reviewed. Nine percent (N = 93) of cancer patients received neurological consultation compared to 3.6% of other patients. The neurologic problem preceded the diagnosis of cancer in 11% of patients. Complications were most common with known metastases. Neurologists frequently discovered signs not noted by the referring physician: 52 patients were paretic, with weakness reported in only 31; cranial nerve complaints were described in 3, but found in 20; sensory abnormalities were noted in 8, but found in 26. A change in mental status was confirmed in 33% and ataxia in 10%. After consultation, distant metastasis was diagnosed in 40% of patients, direct extension in 8%, metabolic encephalopathy in 14% and remote effects of cancer and side effects of cancer therapy in 4% each. Other patients had unrelated diagnoses. In most cases, the neurologic consultation let to a change in treatment, with radiotherapy directed to a symptomatic tumor mass the most common beneficial outcome.

Epidural Spinal Cord Compression

Epidural spinal cord compression (ESCC) is a medical emergency that can lead to paraplegia and loss of bowel and bladder function. It is characterized clinically by: 1. Back pain and tenderness 2. Radicular pain 3. Myelopathy Diagnosis is made by: 1. Clinical history and examination 2. Radiographic studies: a. Bone films b. Bone scan c. Myelopathy Emergency treatment is with: 1. Dexamethasone, 100 mg IV 2. Emergency radiation therapy 3. Possible surgical decompression

Cerebral Herniation Syndromes

Cerebral herniation syndromes are medical emergencies caused by displacement of the brain across hard structures in the skull. Acute and/or asymmetric increases in intracranial pressure, as seen with hemorrhage into a tumor or obstruction of cerebrospinal fluid (CSF) flow, are most likely to cause herniation. Ill-timed lumbar puncture may also cause brain shifts by producing a pressure gradient. The syndromes evolve rapidly, over hours, and are characterized clinically by the following symptoms: 1. Progressive obtundation 2. Pupillary and oculomotor signs 3. Motor signs Treatment is designed to reduce intracranial pressure through hyperventilation, steroids, osmotic agents, and surgery.

Cocaine and morphine in cancer patients with chronic pain

Cancer Center, New York, NY 10021, USA Aim of Investigat.ion: This study was designed to evaluate possible interactions between cocaine and morphine in terms of analoesic, mood and side effects in cancer patients with moderate to severe chronic pain in a single-dose assay. Methods: Patients (36) received placebo, 10 mg IM morphine, 10 mg PO cocaineand the morphine-cocaine combination, each on separate days, within a randomized double-blind crossover design. Serial estimates of pain intensity, pain relief, side effects and selected aspects of mood were obtained for up to six hours or until pain returned to baseline. Resul ts : Cocaine was no different than placebo in terms of analgesia. Themorphine-cocaine combination provided significant analgesia, no different than morphine alone and greater than that provided by placebo or cocaine. In contrast, the combination was associated with one-third fewer reports of side effects (e.g., sleepiness, nausea) than morphine and with improvements in selected aspects of mood (e.g., cheerfulness) to a greater degree than other treatments. Conclusions: The combination of 10 mg PO cocaine with a standard IM morphine dose provides analgesia comparable to morphine alone but with fewer side effects and greater mood improvement in cancer patients with moderate to severe pain. Supported in part by USPHS NIH Grants DA-01707 and CA-32897 and NCI Core Grant CA-08748.