Early clinical stages (CS1, CS1Mk+ and CS2A) of non-seminomatous testis cancer. Value of pre- and post-orchiectomy serum tumor marker information in prediction of retroperitoneal lymph node metastases. Swedish-Norwegian Testicular Cancer Project (SWENOTECA)

During a 5-year period (1981-86) 588 consecutive patients with nonseminatous germ cell tumors of the testis were included into a prospective Swedish-Norwegian multicenter study (SWENOTECA) and clinically staged according to the Royal Marsden system. A total of 370 patients (63%) had early clinical stages (CS) of disease; 295 (50%) had CS1, 32 (5%) had CS1Mk+ (CS1 with pathological serum tumor marker patterns after orchiectomy) and 43 (7%) had CS2A disease. Pathological staging with retroperitoneal lymph node dissection (RPLND) of the retroperitoneum was performed in 345 (93%) of the early CS patients and 128 (37%) had pathological stage 2 (PS2) disease; 27% of the CS1, 100% of the CS1Mk+ and 66% of the CS2A patients. The overall clinical staging accuracy was 75%. All the 40 patients with pathological serum AFP and/or HCG patterns before RPLND had PS2 disease, compared to 81/282 (29%) of patients with normal marker patterns. The PS2 patients with pathological marker patterns had significantly more and larger retroperitoneal metastases than those with normal AFP and HCG values. Elevated pre-orchiectomy AFP level indicated significantly reduced risk of PS2 disease in CS1 patients, but this effect became non-significant if the CS1Mk+ and CS2A cases were included into univariate or multivariate analyses. We suggest that the 'good risk' effect of pre-orchiectomy AFP elevation for CS1 cases may be caused by a selection mechanism during the clinical staging process.

Neuron specific enolase (NSE) in serum of patients with malignant melanoma

Serial measurements of serum NSE were performed in 63 patients with metastatic melanoma. NSE was measured by a sensitive immunoradiometric assay based upon monoclonal anti-bodies with monodisperse magnetizable particles as the solid phase. Increased NSE values were found in 30 patients (48%) during the course of the disease. In 10 patients serum NSE normalized during systemic therapy. In 11 patients with initial normal serum NSE, the marker values became elevated as the tumor progressed.

Prognosis in patients with metastatic non-seminomatous testicular cancer

155 patients with metastatic non-seminomatous testicular cancer were treated with cisplatin-based chemotherapy which in most cases was combined with surgery. The 5 year crude survival was 90% for all patients (98 patients with small volume disease: 97%; 32 patients with large volume disease: 91%; 25 patients with very large volume disease: 64%). High pre-chemotherapy serum tumour marker levels (AFP greater than 500 micrograms/l; and/or HCG greater than 1000 U/l) decreased the survival rates in all groups. Only 4 of 17 relapsing patients were rendered tumour-free by salvage chemotherapy. In a multivariate analysis, a pre-chemotherapy alpha-foetoprotein (AFP) level greater than 500 micrograms/l was associated with poor survival as was the presence of a retroperitoneal tumour greater than 10 cm, lung metastases greater than 3 cm and/or extrapulmonary hematogenous metastases. It is concluded that easily assessable clinical pre-treatment variables can be used to define high risk or low risk patients with metastatic testicular cancer. Treatment intensity should be adjusted in accordance to such prognostic factors.

Is routine primary retroperitoneal lymph node dissection still justified in patients with low stage non-seminomatous testicular cancer?

We present 8 years' experience of primary retroperitoneal lymph node dissection (RLND) in 190 patients with low stage non-seminoma; 154 patients had clinical stage I (CSI) and 36 had clinical stage IIa (CSIIa) disease. Of the 154 patients with CSI tumours, 33 had increased serum AFP and/or HCG before RLND (CSIM+) and 121 had normal tumour markers (CSIM-). Retroperitoneal lymph node metastases (pathological stage II) (PSII) were found in 38 of 121 patients with CSIM-, in 19 of 33 patients with CSIIM+ and in 26 of 36 patients with CSIIa. In a multivariate analysis, the presence of small vessel infiltration (demonstrated in histological sections of the primary tumour) and a prolonged tumour marker half-life were predictive factors for PSII. These 2 factors enabled a group of non-seminoma patients with CSI disease to be identified who had a 15% risk of retroperitoneal tumour growth (low risk group) as compared with a high risk group where 60 to 70% of patients had retroperitoneal lymph node metastases. Relapses occurred in 7 of 107 patients with PSI and in 6 of 83 patients with PSII disease; in the latter group, 5 relapses developed before the start of routine adjuvant chemotherapy; 6% of patients developed major post-operative complications. In addition, "dry ejaculation" was the principal side effect following RLND (unilateral RLND: 20/132 patients; bilateral RLND: 50/54 patients). The comparative cost to the health service during the first year of follow-up was estimated for low risk non-seminoma patients with CSI subjected to RLND and for those in whom a surveillance policy was adopted. The latter approach was preferable. It was concluded that a surveillance policy should be followed in low risk non-seminoma CSI patients provided that frequent follow-up is possible. A more active policy is recommended in high risk patients (e.g. adjuvant chemotherapy without RLND). Nerve-sparing RLND may be considered in patients with CSIIa disease and negative tumour markers.

Histology of tumor residuals following chemotherapy in patients with advanced nonseminomatous testicular cancer

A total of 111 patients with advanced nonseminomatous testicular cancer underwent cisplatin-based combination chemotherapy, followed by surgical removal of residual masses in 101. Surgery included retroperitoneal lymph node dissection in 92 patients, thoracotomy in 19 and hepatic resection in 1 (11 patients underwent 2 operations). Complete necrosis and/or fibrosis was found in 52 operative specimens, mature teratoma in 37 and vital malignant tumor in 12. Of the 11 patients who underwent 2 operations 4 had complete necrosis and/or fibrosis in both histological specimens. After a median observation of 55 months 83 of 89 patients with complete necrosis and/or fibrosis or mature teratoma were without evidence of disease. Only 7 of 12 patients with vital malignant tumor in the operative specimen survived without evidence of disease. Relapses were observed in 16 patients, 4 of them in the retroperitoneal space. Of the 16 relapses 5 were in 12 patients with residual vital malignant tumor, 5 in 37 patients with post-chemotherapy mature teratoma and 4 in 52 patients with complete necrosis and/or fibrosis after chemotherapy. Two patients with recurrence did not undergo an operation. In patients in whom post-chemotherapy retroperitoneal lymph node dissection is considered complete necrosis and/or fibrosis can be predicted by the combination of several factors, including absence of teratomatous elements in the testicular tumor, complete response on post-chemotherapy computerized tomography, and normal alpha-fetoprotein and human chorionic gonadotropin levels after chemotherapy (sensitivity 83%, specificity 76% and correctly predicted 79%). With the knowledge of these factors it seems possible to omit post-chemotherapy retroperitoneal lymph node dissection in approximately 20% of the patients with advanced metastatic nonseminomatous testicular cancer with initial retroperitoneal tumors.

Immunoradiometric assay for alpha gamma- and gamma gamma-enolase (neuron-specific enolase), with use of monoclonal antibodies and magnetizable polymer particles

Monoclonal antibodies were raised against neuron-specific enolase, gamma gamma-enolase, and used in an immunoradiometric assay (IRMA), with mono-disperse magnetizable particles as the solid phase. The assay's sensitivity was 0.4 microgram/L and the interassay coefficient of variation was less than 5% in the working range from 0.4 to 170 micrograms/L. Compared with our radioimmunoassay based on polyclonal antibodies, the incubation time is shorter, and precision and sensitivity are improved. The IRMA also improved detection of neuron-specific enolase in sera from patients with lung cancer without a concomitant change in measured enolase in the reference population. The better sensitivity of the IRMA results from its ability to measure alpha gamma- and gamma gamma-enolase with equal response. Ninety percent of the small-cell lung carcinoma patients (36 of 40) had increased values before treatment, compared with 7% of non-small-cell lung carcinoma patients (8 of 114).

Immunoradiometric assay for alpha gamma- and gamma gamma-enolase (neuron-specific enolase), with use of monoclonal antibodies and magnetizable polymer particles

Monoclonal antibodies were raised against neuron-specific enolase, gamma gamma-enolase, and used in an immunoradiometric assay (IRMA), with mono-disperse magnetizable particles as the solid phase. The assay's sensitivity was 0.4 microgram/L and the interassay coefficient of variation was less than 5% in the working range from 0.4 to 170 micrograms/L. Compared with our radioimmunoassay based on polyclonal antibodies, the incubation time is shorter, and precision and sensitivity are improved. The IRMA also improved detection of neuron-specific enolase in sera from patients with lung cancer without a concomitant change in measured enolase in the reference population. The better sensitivity of the IRMA results from its ability to measure alpha gamma- and gamma gamma-enolase with equal response. Ninety percent of the small-cell lung carcinoma patients (36 of 40) had increased values before treatment, compared with 7% of non-small-cell lung carcinoma patients (8 of 114).

Establishment and evaluation of a radioimmunoassay for neuron-specific enolase. A marker for small cell lung cancer

Neuron-specific enolase (NSE) was purified from human brain to a specific activity of 91 U/mg with no demonstrable impurities. The enzyme has a molecular weight of 96,000, consists of two subunits of 47,000, and has an isoelectric point at pH 4.5. A radioimmunoassay based on antibody raised in sheep was established. The assay has a sensitivity of 2 micrograms/l, and an interassay coefficient of variation of 6.4% at 10 micrograms/l. The reference limit was defined as 10 micrograms/l, as found in sera from a population of 389 persons. Of 50 untreated patients with small cell lung cancer (SCLC), 70% had NSE levels above 10 micrograms/l. None of 170 patients with non-SCLC neoplasms had elevated enzyme levels.

An enzyme antigen immunoassay for the determination of neuron-specific enolase in serum samples

A method is presented for the detection and quantification of neuron-specific enolase (NSE) in serum samples. It is an enzyme antigen immunoassay (EAIA), relying on specific antibodies to 'catch' the enzyme on a solid support (ELISA-plate) whereafter the enzymatic activity of the immunocaptured enzyme is determined, by coupling the reaction to lactate dehydrogenase. The oxidation of NADH to NAD is followed at 340 nm in an ELISA photometer. The method is proven to work well and is able to measure the low amounts of NSE present in serum samples from normal individuals. It does not require labelling of neither antigen nor antibody, and is therefore superior to the commercially available radioimmunoassay (RIA). The method will also work with monoclonal antibodies towards the enzyme as demonstrated by preliminary observations.

Early detection of response in small cell bronchogenic carcinoma by changes in serum concentrations of creatine kinase, neuron specific enolase, calcitonin, ACTH, serotonin and gastrin releasing peptide

Creatine kinase (CK-BB), neuron specific enolase (NSE), ACTH, calcitonin, serotonin and gastrin releasing peptide (GRP) were measured in serum or plasma before and immediately after initiation of treatment in patients with small cell lung cancer (SCC). Pretherapeutic elevated concentrations of CK-BB were found in 82% of extensive disease patients and in 50% of patients with local disease. NSE was raised in 72% with extensive disease versus 14% of patients with local disease. Calcitonin and ACTH were raised in 27% and 28%, respectively, in all patients without significant difference between extensive and local disease patients. Serotonin was generally overall elevated in 10% and GRP in 7% but elevations were seen only in patients with extensive disease. Out of the four most frequently elevated substances at least one marker was elevated in 80% of all the patients, including 91% in extensive stage patients and 71% in limited stage patients. Frequent initial monitoring of the substances showed an increase in the concentrations of pretherapeutic elevated CK-BB and NSE on day 1 or 2 followed by a sharp decrease within 1 week. These changes were correlated to objective clinical response determined within 4-8 weeks. The results indicate that serum CK-BB and NSE are potential markers for SCC at the time of diagnosis and that changes in the concentrations during the first course of cytostatic therapy are promising as biochemical tests for early detection of response to chemotherapy.

High frequency of incomplete human chorionic gonadotropin in patients with testicular seminoma

We measured human chorionic gonadotropin by 2 immunometric assays that require that the entire human chorionic gonadotropin molecule is intact, and by a competitive radioimmunoassay that measures intact human chorionic gonadotropin and its free beta-chain. The sera tested were samples from male cancer patients with elevated human chorionic gonadotropin levels obtained by the radioimmunoassay method. Elevated levels were confirmed in 67 of 92 samples (72 per cent) with the immunometric methods. However, in 25 of 97 patients (28 per cent) elevated human chorionic gonadotropin was found with the radioimmunoassay, whereas the values were in the normal range when measured with the immunometric assays. These discrepancies were found in 22 patients with seminomatous tumors, including 2 extragonadal germ cell tumors, which constitutes 42 per cent of all seminoma patients tested. Of the remaining 3 discrepant patients 2 had lung cancer and 1 had metastases from an unknown primary cancer.

Thyroglobulin radioimmunoassay and 131I scintigraphy in patients with differentiated thyroid carcinoma

Serum thyroglobulin (Tg) radioimmunoassay and 131I whole-body scintigraphy were performed in 134 patients with previous total thyroidectomy for differentiated thyroid carcinoma. Distant spread was found in 46 patients (34%), 42 of whom had serum Tg greater than 10 micrograms/l. Accumulation of 131I in metastases was seen in 39 patients. Serum Tg in patients with iodine-accumulating metastases was significantly higher in follicular than in papillary carcinoma. Scintigraphy showed thyroid tissue remnant and no metastases in 60 patients. Serum Tg was elevated in 19 of these patients and normal in 41. The respective mean uptake of 131I in these two groups was 3.8% and 1.15% of the administered dose (p less than 0.002), indicating that ablation of normal thyroid tissue is important to avoid misinterpreting Tg findings. Scintigraphy performed after 131I in therapeutic doses of 4.5 GBq gave no information additional to that in scans after only 40 MBq 131I. The latter dose thus is adequate for depicting iodine-accumulating metastases. For diagnostic purposes, therefore, a 131I dose of 40 MBq is recommended.

The diagnostic value of human chorionic gonadotrophin in patients with testicular seminoma

Human chorionic gonadotrophin (HCG) was measured in sera from seminoma patients by an immunoassay which recognised both free beta-chains and intact HCG molecules. This seemed to increase the sensitivity of the assay without affecting its specificity. The HCG values were correlated to the clinical course in 151 patients. Pre-orchiectomy samples were assayed in 57 patients. Elevated pre-operative HCG levels were found in 15 of 38 patients (39%) in stage I and in 13 of 19 patients (68%) in stages II to IV. After orchiectomy the HCG values were normal in 114 of 115 patients in stage I and elevated in 13 of 36 patients (36%) in stages II to IV. Relapses were observed more often in stage II to IV patients who produced HCG at the time of diagnosis than in non-producers (3 of 13 patients versus 1 of 23 patients). In 7 of 11 relapses the serum HCG was elevated. HCG positive relapses were seen in patients both with and without initially elevated serum HCG.

A pharmacokinetic evaluation of IM administration of bleomycin oil suspension

Bleomycin oil suspension was given IM twice daily to four patients, and bleomycin saline solution infused to three patients with cervical carcinoma. The serum levels of bleomycin were followed for 12 h by radioimmunoassay. Both regimens revealed comparable side effects. Only minor responses were seen. Bleomycin oil suspension produced prolonged levels of bleomycin in serum.

Intramuscular administration of hydroxyprogesterone caproate in patients with endometrial carcinoma. Pharmacokinetics and effects on adrenal function

A radio-immunoassay for the determination of the serum concentration of hydroxyprogesterone caproate (HPC) was established. After a single intramuscular injection of 1000 mg, the mean serum level reached its maximum (44-81 nmol/l) after 2-7 days. Patients on long-term adjuvant HPC treatment (consisting of 1000 mg daily for 5 days followed by 1000 mg every 2 weeks) presented peak hormone levels 2 weeks after commencing treatment. After a drop at 5 weeks, the mean serum level slowly increased again to 130 nmol/l after 25 weeks of treatment. Patients being treated with weekly injections had significantly higher serum levels than those treated every 2 weeks. Considerable inter-individual differences were observed. The serum concentrations of HPC measured in this study compare favorably with those previously found in patients treated with medroxyprogesterone acetate. The patients on adjuvant HPC showed no significant change in the levels of cortisol, dehydroepiandrosterone sulphate, androstenedione, or estrone during the first 25 weeks of treatment.

Whole-body distribution of radioactivity after intraperitoneal administration of 32P colloids

The whole-body distribution of radioactivity after intraperitoneal instillation of 32P-labelled chromic hydroxide particles has been studied in patients operated for early-stage ovarian cancer. Gamma-camera imaging of the abdominal 32P-distribution revealed that the administration procedure was critical for obtaining a homogeneous plating of the radiocolloids on the serosal surface. Dose calculations based on a uniform distribution of 32P in a capillary layer covering the intraperitoneal surface gave an estimated tissue surface dose of about 30 Gy per 370 MBq of 32P administered. The amount of 32P in peripheral blood increased for seven days after instillation followed by a continuous decrease. Bone marrow concentration was from two to five times as high as that in blood, but the total amounts were too small to give significant radiation doses. Gel chromatography showed that 33% of the activity in blood consisted of high molecular weight material, probably colloids. The remainder of the activity (67%) was attached to material of very low molecular weight, appearing as a consequence of physiological degradation of the colloids.

Purification and characterization of a mouse serum protein with growth inhibitory properties in vitro against tumor cell lines

A factor which is responsible for the growth inhibitory properties of certain mouse sera and related to NK-activity, has been studied. The factor was isolated from hybrid B6D2F1 (C57Bl/6 x DBA/2) serum, which is histo-compatible with the mouse tumour (B16 melanoma) used and has high NK-activity. Growth inhibitory activity was measured in an in vitro assay. It was independent of complement activation. The responsive factor was isolated and characterized by ion exchange chromatography. Concanavalin A affinity chromatography, gel filtration and iso-electric focusing. It appears to be a protein and had been labelled growth-inhibitory factor (GIF). It has a molecular weight of 230 000-260 000 daltons and an iso-electric point in the pH range 4.6-5.0. It was not retained on Concanavalin A columns.

Reaction of alpha-mannosidase from Phaseolus vulgaris with group-specific reagents. Essential carboxyl groups

When the pKm of alpha-mannosidase was determined at different pH values, the results indicated that ionizable groups with pK values of approx. 3.8 and 5.7 could be essential. Modification with carbodiimide or Woodward's Reagent K abolished the enzyme activity. The substrate analogue, alpha-methyl-D-mannoside, protected the enzyme against inactivation. Incorporation of a 14C-labeled nucleophile reagent in the presence or absence of the analogue suggested that 2--4 carboxyl groups were protected. Exchange studies indicated that the essential Zn2+ could be bound to such groups. There was no indication that hydroxyl groups, sulphydryl groups, guanidino groups or amino groups take part in the catalytic activity.

Studies on IgM polymerization: reassociation to non-covalently and covalently linked Fc5mu fragments

Fc5mu fragments were purified from a trypsin digest of native IgM by gel filtration and isoelectric focusing. Polyacrylamide gel electrophoresis of Fc5mu fragments in sodium dodecyl sulphate disclosed a major and a minor band with molecules of 320,000 and 285,000 daltons, respectively. The mu chain fragments showed a molecular weight of 34,500. After reduction of the Fc5mu fragments to free mu chain fragments and J chain removal of the reducing agent by dialysis for 24 h under nitrogen in the presence of Zn ions gave non-covalently linked Fc5mu fragments. This shows that the non-covalent interactions operating between the mu chains of non-covalently linked native IgM are present in the C-terminal part of the mu chains. Additional dialysis in the presence of Zn and Cu ions resulted in the formation of covalently linked Fc5mu fragments.

The chemical modification of tryptophan residues of alpha-mannosidase from Phaseolus vulgaris

Reaction of alpha-mannosidase (alpha-D-mannoside mannohydrolase, EC 3.2.1.24) from Phaseolus vulgaris with N-bromosuccinimide or 2-hydroxy-5-nitrobenzyl bromide- resulted in loss of enzyme activity. Spectral absorption and fluorescence studies, as well as amino acid analysis, suggested that only tryptophan residues had been modified. No change in conformation could be detected by density gradient ultracentrifugation or circular dichroism of alpha-mannosidase modified by N-bromosuccinimide to virtually zero enzyme activity. The inhibition was partly offset by the substrate analogue alpha-methyl-D-mannoside and the competitive inhibitor mannono-1,4-lactone. Concomitantly, two tryptophan residues fewer were oxidized per molecule. After modification V was reduced, while Km seemed unchanged. Further, there was found evidence for the enzyme having a secondary structure dominated by beta-pleated sheets.

alpha-Mannosidase from Phaseolus vulgaris. Composition and structural properties

Both alpha-mannosidases I and II from Phaseolus vulgaris have molecular weights about 210000-220000 and contain approximately 2 mol zinc/mol protein. alpha-Mannosidase I seems to consist of more glutamic acid than alpha-mannosidase II, while the latter is richer in serine. They are glycoproteins: alpha-mannosidase I contains 8.3% carbohydrate by weight while alpha-mannosidase II contains 16.5%. This enzyme form shows a greater thermal stability than alpha-mannosidase I. The structure of alpha-mannosidase has been investigated by equilibrium sedimentation analysis in guanidine hydrochloride, electrophoresis in dodecylsulphate, and alkaline electrophoresis after exposure to high pH. The protein appears to be composed of two non-covalently bound subunits of molecular weights about 110000. Electron micrographs revealed images of molecules that consisted of two rod-shaped monomers of roughly square cross-sections 4.2 X 4.2 nm. Each rod was about 7.4 nm long. The monomers seemed parallell along the long axis.