Dax-1 as one of the target genes of Ad4BP/SF-1

The DAX-1 (also known as AHC) gene encodes an unusual member of the nuclear hormone receptor superfamily. DAX-1 plays a critical role during gonadal and adrenal differentiation since mutations of the human DAX-1 gene cause X-linked adrenal hypoplasia congenita associated with hypogonadotropic hypogonadism. In recent studies, DAX-1 was reported to function as a transcriptional suppressor of Ad4BP/SF-1, a critical transcription factor in gonadal and adrenal differentiation. With respect to implication of Ad4BP/SF-1 in the transcriptional regulation of the DAX-1 gene, inconsistent findings have been previously reported. We investigated the upstream region of the mouse Dax-1 (also known as Ahch) gene and identified a novel Ad4/SF-1 site by transient transfection and electrophoretic mobility shift assays. In addition, immunohistochemical analyses with a specific antibody to Dax-1 indicated the presence of immunoreactive cells in steroidogenic tissues, pituitary gland, and hypothalamus. Although the distributions of Dax-1 and Ad4BP/SF-1 were very similar, they were not completely identical. The expression of Dax-1 was significantly impaired in knock-out mice of the Ftz-f1 gene, which encodes Ad4BP/ SF-1. Taken together, our findings indicate that Ad4BP/SF-1 controls the transcription of the Dax-1 gene.

A reverse-sandwich enzyme-linked immunosorbent assay for verocytotoxin 1 and 2 antibodies in human and bovine sera

A reverse-sandwich enzyme-linked immunosorbent assay (ELISA), in which an antibody is sandwiched by antigens, was established for the titration of antibodies to verocytotoxins (VT) in human and animal sera. This assay has two advantages over a conventional indirect ELISA: (i) higher specificity and sensitivity and (ii) the ability to comparably titrate antibodies from different species. The VT1 (Shiga-like toxin 1) antibody-positive rates were 5% in 202 normal adult humans and 99% in 93 normal cattle at a dairy farm. This ELISA is most suitable for seroepidemiologic studies of infections with VT-producing Escherichia coli in humans and various animal species.

Dax-1 as one of the target genes of Ad4BP/SF-1

The DAX-1 (also known as AHC) gene encodes an unusual member of the nuclear hormone receptor superfamily. DAX-1 plays a critical role during gonadal and adrenal differentiation since mutations of the human DAX-1 gene cause X-linked adrenal hypoplasia congenita associated with hypogonadotropic hypogonadism. In recent studies, DAX-1 was reported to function as a transcriptional suppressor of Ad4BP/SF-1, a critical transcription factor in gonadal and adrenal differentiation. With respect to implication of Ad4BP/SF-1 in the transcriptional regulation of the DAX-1 gene, inconsistent findings have been previously reported. We investigated the upstream region of the mouse Dax-1 (also known as Ahch) gene and identified a novel Ad4/SF-1 site by transient transfection and electrophoretic mobility shift assays. In addition, immunohistochemical analyses with a specific antibody to Dax-1 indicated the presence of immunoreactive cells in steroidogenic tissues, pituitary gland, and hypothalamus. Although the distributions of Dax-1 and Ad4BP/SF-1 were very similar, they were not completely identical. The expression of Dax-1 was significantly impaired in knock-out mice of the Ftz-f1 gene, which encodes Ad4BP/ SF-1. Taken together, our findings indicate that Ad4BP/SF-1 controls the transcription of the Dax-1 gene.

Short report: prevalence of antibodies against spotted fever, murine typhus, and Q fever rickettsiae in humans living in Zambia

The causative agents of rickettsial diseases (Rickettsia conorii, R. typhi, and Coxiella burnetii) have been reported throughout the African continent. However, there have been no reports on epidemiologic surveys of these infections in Zambia. This study was designed to clarify the prevalence of three rickettsioses in 377 humans in Zambia. The seroprevalence of antibodies against R. conorii, R. typhi, and C. burnetii was 16.7%, 5.0%, and 8.2%, respectively. The rates of antibody positivity against R. conorii and C. burnetii were higher in the eastern (23.1% and 11.8%) and western (16.8% and 7.4%) areas of Zambia than in the northern (3.0% and 3.0%) area of this country. There was little difference among the three areas in the distribution of antibodies against R. typhi. Since cattle breeding is more extensive in the western and eastern areas than in the northern area, it is thought that cattle-breeding areas are foci of R. conorii and C. burnetii infections in Zambia.

Coinfection of Spodoptera exigua and Spodoptera frugiperda cell lines with the nuclear polyhedrosis viruses of Autographa californica and Spodoptera exigua

The Autographa californica multinucleocapsid nuclear polyhedrosis virus (AcMNPV) has a broad host range among Lepidoptera. In contrast, the Spodoptera exigua MNPV (SeMNPV) can replicate efficiently only in S. exigua larvae or S. exigua-derived cell lines. In this study, we examined the coinfection of S. exigua Se301 and Spodoptera frugiperda IPLB-SF21AEII (Sf21) cell lines with SeMNPV and AcMNPV recombinant (Ac360-501beta-gal) which was constructed for expression of beta-galactosidase under control of the polyhedrin promoter. Coinfection led to the restriction as the level of late gene expression, nonoccluded virus production, and DNA replication of Ac360-501beta-gal in both Se301 and Sf21 cell lines. In contrast, Ac360-501beta-gal supported the SeMNPV replication in Sf21 cells. Occurrence of recombinants, between Ac360-501beta-gal and SeMNPV, with expanded host range was not observed in coinfected Sf21 cells. This suggests that Ac360-501beta-gal supports the SeMNPV replication through trans-activation.

Human Ad4BP/SF-1 and its related nuclear receptor

Ad4BP (or SF-1) is an essential transcriptional factor for steroidogenesis as well as for the development of the reproductive axis. We elucidated the structure of the human Ad4BP gene. The spliced variants of Ad4BP gene, ELP1 and ELP2 in mice, are unlikely to be present in humans since the analysis of the human gene revealed an in frame stop codon, 36-bp before the first ATG of Ad4BP. The promoter sequence of human Ad4BP, upstream of non-coding exon 1 was highly conserved, and E-box was also found to be essential for the transcription of human Ad4BP gene. During the process of the human Ad4BP gene cloning, we happened to obtain an Ad4BP-related gene, FTZ-F1beta which also belongs to the nuclear receptor family. We revealed cDNA structures of rat FTZ-F1beta, and found that rat has at least two types of FTZ-F1beta isoforms, which differ only by 21 amino acids length in the A/B domain. The tissue distributions of FTZ-F1beta in rat examined by RT-PCR, was found to be abundant in liver, pancreas, and gastrointestinal tracts. These results suggest that the physiological significance of FTZ-F1beta is different from that of Ad4BP.

Sleep stage and skin temperature regulation during night-sleep in winter

To clarify the thermally comfortable environment for satisfied sleep, we investigated the relationship between skin temperatures and sleep stages during night-sleep in winter, summer and autumn. Four healthy young females served as the subjects. The experiments were performed in a climate chamber under three conditions: at 13 degrees C-RH70% with futon and blanket in winter, at 20-18 degrees C-RH60% with futon and towelket in autumn and at 29 degrees C-RH70% with towelket in summer. The subjects' skin temperature on the sole was lower until about 4 hours after lights off in winter than in autumn and summer, and the percentage of st.2 was lower and st.4 was higher in winter than in autumn and summer, although the bed climate both in winter and autumn was much the same.

Novel germline mutations of the MEN1 gene in Japanese patients with multiple endocrine neoplasia type 1

Multiple endocrine neoplasia type 1 (MEN1) is an autosomal dominant disorder characterized by tumors of the parathyroid glands, the pancreatic islet cells, and the anterior pituitary. Germline mutations of the MEN1 gene in three independent Japanese cases with MEN1 were analyzed. Case 1 has revealed a 2-bp (TA) insertion at nucleotide position 341 (341insTA) in exon 2, which shifts the reading frame such that the mutant protein has a completely different amino acid sequence from codon 78 to the premature stop codon at 119. In case 2, a nucleotide substitution, i.e., TAG in place of TGG, which encodes tryptophan at codon 198 was identified (nonsense mutation). These mutations were heterozygously present and have not been reported previously. Case 3 showed no mutations in the protein-coding exons and exon-intron junctions of the MEN1 gene by single-strand conformation polymorphism or direct sequencing of the polymerase chain reaction (PCR) fragments. We confirmed the finding that patients with MEN1 carry heterozygous germline mutations in the MEN1 gene, which is compatible with the idea that the MEN1 gene is a tumor suppressor gene. The reason why mutations in the coding region of the MEN1 gene could not be detected by PCR-based analysis in some of the MEN1 patients, e.g. case 3, needs to be clarified further.

Serosurvey of wild rodents for Rickettsioses (spotted fever, murine typhus and Q fever) in Java Island, Indonesia

The prevalence of antibodies against spotted fever group rickettsia (SFGR), murine typhus and Q fever were investigated in wild rats captured in Indonesia. Sera of 327 rats were collected from Jakarta and Boyolali on Java Island. The prevalences of antibodies against SFGR and murine typhus were 128 (39.1%) and 48 (14.7%), respectively. Antibodies against Q fever were not detected in these serum samples. Antibodies against SFGR were found in all species of rats (20.8-51.9%). The antibody positive rate against murine typhus in Rattus norvegicus (38.0%) was significantly higher than that in other rat species (0-4.8%, p<0.01). The antibody positive rates against SFGR and murine typhus in rats captured in Jakarta were significantly higher than those in rats captured in Boyolali (p<0.01). In this survey, all species of rats had antibodies against SFGR, indicating that the 4 species of tested rats (R. norvegicus, R. rattus, R. exulans, R. tiomanicus) were infected with SFGR and that SFGR may infest the whole of Java Island. Most of the rats that were antibody-positive against murine typhus were captured in Jakarta. Therefore, R. norvegicus and R. rattus are likely to be important hosts of murine typhus in Jakarta. The antibody-positive rates against SFGR and murine typhus in rats captured in the dry season were significantly higher than those in rats captured in the rainy season. This may coincide with the active periods of ticks and fleas in Indonesia.

Molecular basis of hypokalemic myopathy caused by 17alpha-hydroxylase/17,20-lyase deficiency

We describe a 28-year-old woman presenting with hypokalemic myopathy caused by 17alpha-hydroxylase/17,20-lyase deficiency caused by a homozygous mutation consisting of a G-to-C transition in the initiation codon in exon 1 of the CYP17 gene resulting in expression of an enzymatically inactive truncated P450c17 protein.

Subcutaneous or visceral adipose tissue expression of the PPARgamma gene is not altered in the fatty (fa/fa) Zucker rat

We cloned 537 basepairs (bp) of rat partial peroxisome proliferator-activated receptor gamma2 (PPARgamma2) cDNA and examined the effect of fasting or obesity on the expression of two isoforms of rat PPARgamma, gamma1 and gamma2, in either subcutaneous or mesenteric adipose tissue specimens using an RNase A protection assay. In Wistar rats, expression of both isoforms was dramatically reduced after 48 hours of fasting in the two fat tissue specimens. In comparing genetically obese (fa/fa) Zucker rats and lean control rats, no significant difference was observed in expression of the two isoforms in either type of adipose tissue. From these findings, we conclude that the adipose tissue level of rat PPARgamma depends on nutritional deprivation but is not closely associated with either obesity or insulin resistance in obese Zucker rats.

[Studies of childhood non-Hodgkin's lymphoma--treatment results with the CCLSG NHL 960 protocol. Children's Cancer and Leukemia Study Group (CCLSG)]

We report here on the preliminary treatment findings of a CCLSG NHL 960 study that was initiated in March 1996. In this study, 37 patients with non-Hodgkin's lymphoma were assigned to 4 different treatment groups according to disease stage and histology: (1) localized disease; (2) advanced disease, lymphoblastic type; (3) advanced disease, large cell type; and (4) advanced disease, Burkitt type. The first three groups received the modified protocols of the NHL 890 study. Groups 1 and 3 received COPADM induction therapy (CPM, VCR, PRD, ADR, and MTX). After achieving remission, Group 1 received only maintenance therapy consisting of alternate administration of 7 drugs, while Group 3 received additional intensification therapy with combination chemotherapy consisting of MTX and Ara-C, followed by a maintenance phase involving the administration of 9 drugs. Group 2 received COPADL induction therapy (CPM, VCR, PRD, ADR, and LASP) and consolidation/intensification therapies followed by a maintenance phase. Group 4 received short-term intensive COPADM polychemotherapy. Twelve patients with localized with localized disease (stage I-II) and 25 patients with advanced disease (stage III-IV) were enrolled in this study. Except for 2 patients in the advanced disease stages who died earlier in the course of the study, all patients remained in remission.

Replication of Spodoptera exigua nucleopolyhedrovirus in permissive and non-permissive lepidopteran cell lines

The Spodoptera exigua multinucleocapsid nucleopolyhedrovirus (SeMNPV) was inoculated to eight lepidopteran cell lines derived from Spodoptera exigua (Se301), Spodoptera frugiperda (SF21AEII), Spodoptera littoralis (CLS-79), Spodoptera litura (SpLi-221), Pseudaletia separata (LeSe-11), Trichoplusia ni (hi-5), Plutella xylostella (PXL/C) and Bombyx mori (BmN4). The productive infection of SeMNPV was observed only in Se301 cells. However, a dot-blot hybridization analysis revealed that SeMNPV DNA replicated in five non-permissive cell lines: SF21AEII, CLS-79, SpLi-221, hi-5 and BmN4. In addition, the virus-infected hi-5 and BmN4 cells displayed morphological changes. In contrast, CLS-79 cells inoculated with SeMNPV showed membrane blebbing at 20 hrs post inoculation (p.i.) and fragmentation of genomic DNA. All that indicated that the infected CLS-79 cells underwent apoptosis. These findings indicate that the SeMNPV replication was restricted at various points in dependence upon each cell line.

Low level of glucocorticoid receptor messenger ribonucleic acid in pituitary adenomas manifesting Cushing's disease with resistance to a high dose-dexamethasone suppression test

OBJECTIVES

The overnight 8-mg dexamethasone suppression test is often used to differentiate Cushing's disease, due to an oversecretion of ACTH from the pituitary gland, from other kinds of Cushing's syndrome. However, a few patients with ACTH-producing pituitary adenoma show no suppression of plasma cortisol after the administration of 8 mg of dexamethasone. To clarify the relationship between the level of glucocorticoid receptor (GR) in the pituitary adenoma and the sensitivity to dexamethasone in Cushing's disease, we thus examined the levels of GR alpha and GR beta mRNAs in the pituitary adenomas in six patients who were proven at surgery to have pituitary ACTH-producing adenomas.

MATERIALS

Total RNA was extracted from six pituitary adenomas and pituitary tissue adjacent to one of the adenomas, and the mRNA levels of GR alpha, GR beta, pro-opiomelanocortin (POMC) and beta-actin in these samples were sampled by quantitative RT-PCR.

RESULTS

The GR alpha mRNA levels in the adenomas from the two patients who showed no response to the 8-mg dexamethasone suppression test were significantly lower than those in the adenomas of four patients who showed suppression. The GR beta mRNA level was much lower than that of GR alpha mRNA but not significantly different among the six adenomas.

CONCLUSIONS

These results suggest strongly that decreased expression of GR alpha in pituitary adenomas may be the major reason for the marked insensitivity to the 8-mg dexamethasone suppression test observed in two patients with Cushing's disease.

Characterization of temperature rise of the brain and the rectum following intracerebroventricular administration of alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionate and kainate in rats

Intracerebroventricular administration of alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionate (AMPA) or kainate caused a rise of the temperature of the brain and the rectum in urethane-anesthetized rats. An AMPA-kainate receptor antagonist, 6,7-dinitroquinoxaline-2,3-dione (DNQX), significantly suppressed the AMPA- and kainate-induced rises of brain and rectal temperatures. An N-methyl-d-aspartate receptor antagonist, MK-801, also suppressed the rises of the brain and rectal temperatures induced by AMPA or kainate, but the profiles of the suppressive effects of MK-801 were different between rats treated with AMPA and kainate. An antipyretic agent, indomethacin, completely suppressed the AMPA-induced rises of brain and rectal temperatures. Although indomethacin completely suppressed the kainate-induced rise of the rectal temperature as well, the brain temperature was still raised. These findings suggest that distinct mechanisms may be involved in the temperature rise of the brain and the rectum mediated through AMPA and kainate receptor stimulation.

A rare case of 46,XX true hermaphroditism with hidden mosaicism with sex-determining region Y chromosome-bearing cells in the gonads

The sex-determining region Y chromosome (SRY) triggers testis determination. We report a 46,XX true hermaphrodite who had ambiguous genitalia at birth. A laparotomy at one year of age revealed this patient to have a testis on the right side and an ovotestis on the left side. By polymerase chain reaction analysis no SRY was detected in the DNA from the leukocytes but it was found in the DNA from the ovotestis. The hidden mosaicism with the Y-bearing cells in the gonads is likely the cause of the dual gonads in this patient.

Detection of Coxiella burnetii from dust in a barn housing dairy cattle

We attempted to detect Coxiella burnetii in dust samples collected from a barn housing dairy cattle by the polymerase chain reaction (PCR) method. Ten dust samples (five from ventilation fans and five from crossbeams) were collected from two areas in a barn on a farm near Sapporo, Hokkaido. C. burnetii was detected in 5 of the 10 dust samples. It was believed that aerial contamination by C. burnetii occurred in the barn.

Analysis of defective genomes of bombyx mori nucleopolyhedrovirus generated by serial undiluted passage in cell culture

Viral DNA was extracted from cells infected with bombyx mori nucleopolyhedrovirus (BmNPV) D1 strain after 34 serial undiluted passages (P34). P34 DNA was subjected to restriction analysis and Southern blot hybridisation using standard D1 DNA and P34 DNA of BmNPV as probes. Based on hybridisation profiles, the BmNPV DNA regions retained in the P34 DNA were localised on HindIII and PstI restriction maps. Two regions of BmNPV DNA located at 0-12.8 and 40.2-65.0 map unit (m.u.) were highly conserved in P34 DNA. These regions contained two of three interspersed homologous sequences (ihss), but only one of five homologous regions (hrs). This suggests that ihss may have an essential role in BmNPV replication.

[Treatment of children with non-Hodgkin's lymphoma with CCLSG NHL 855/890 protocols long-term outcome and incidence of secondary malignancies]

We report here on treatment results of consecutive CCLSG NHL studies (NHL855, 1985-1989; NHL890, 1989-1996). The NHL855 protocol consisted of an induction phase of five drugs (VCR, PRD, CPM, DXR, and high-dose MTX) and a maintenance phase of 7 drugs. The probabilities of EFS at 7 years were 78% (SE, 10%) for the patients with localized disease, and 38% (SE, 7%) for those with advanced disease. In the NHL 890 protocol, the patients were assigned to two different treatment groups according to their histology and received different consolidation therapy; non-lymphoblastic subtype was treated almost identically to NHL855 while LASP and VP-16 were newly added for the lymphoblastic subtype. The 7-year EFS improved to 91% (SE, 6%) for localized disease, and 61% (SE, 6%) for advanced disease. A remarkable improvement was particularly evident for lymphoblastic type with mediastinal mass. Optional trial of high-dose sequential chemotherapy and peripheral blood progenitor cell auto grafting resulted in an unfavorable outcome. The 7-year EFS according to main histological subgroups were as follows: 84% (10%) for large cell type, 67% (11%) for Burkitt's-type, 58% (10%) for lymphoblastic type. Secondary cancer occurred in two of the 163 patients studied. Both patients were AML (M0/M4) and MLL rearrangement was detected in the M4 case.

Novel mutation of the DAX1 gene in a patient with X-linked adrenal hypoplasia congenita and hypogonadotropic hypogonadism

X-linked adrenal hypoplasia congenita (AHC) is characterized by primary adrenal insufficiency and is frequently associated with hypogonadotropic hypogonadism (HHG). Mutations of the DAX1 gene have been reported in patients with AHC and HHG. We found a novel DAX1 mutation in our patient. Sequence analysis of the patient's DAX1 demonstrated a 1-bp (G) deletion at codon 49 in exon 1. The mutation shifts the reading frame, resulting in completely different amino acid sequences from codon 49 to the premature stop codon at 84. The G was present at this position in the sequences of the father and 2 younger brothers. Direct sequence and single-strand conformation polymorphism analyses of polymerase chain reaction fragments revealed that the mutation at codon 49 was heterozygously present in the mother's DAX1 gene. The codon 84 is located in the first half of the DNA binding domain, and the mutation site is closer to the N-terminus than those in previously reported cases. The onset of adrenal insufficiency in the neonatal period as seen in our patient has also been reported in other patients with different DAX1 mutations, especially in a patient with DAX1 protein lacking 11 amino acids at the C-terminus. Therefore, it is less likely that position of termination codons correlate to clinical manifestations.

Immunohistochemical study of cytochrome b5 in human adrenal gland and in adrenocortical adenomas from patients with Cushing's syndrome

Cytochrome b5, a component of the electron transfer system increases the relative activity of 17,20-lyase to 17alpha-hydroxylase of P450c17 in vitro. In the present study, immunohistochemical analysis of cytochrome b5 was performed in the human adrenal gland and in adrenocortical adenomas from patients with Cushing's syndrome. In the human adrenal gland, cytochrome b5 was stained in all three adrenocortical layers but the staining was most remarkable in the zona reticularis. All of the adenomas were composed mainly of compact cells, which exhibited immunoreactive staining for cytochrome b5 as well as for P450c17 and 3beta-hydroxysteroid dehydrogenase (3beta-HSD). The distribution of b5 in the adenomas was correlated with that of P450c17 rather than with that of 3beta-HSD. The immunoreactive staining for cytochrome b5 appeared to be more prominent in the two adenomas that produced relatively high concentrations of adrenal androgens than in adenomas that produced low concentrations of adrenal androgens. These results immunohistochemically support the functional association of b5 with androgen production through interaction with P450c17 and the previous finding that higher concentrations of cytochrome b5 are associated with greater production of adrenal androgens in adrenocortical adenomas from patients with Cushing's syndrome.

Glomerular score as a prognosticator in IgA nephropathy: its usefulness and limitation

Glomerular sclerosis, mesangial hypercellularity, extracapillary lesions, interstitial fibrosis, and vascular sclerosis have been reported to be the significant pathologic prognosticators in IgA nephropathy (IgAN). We developed our own scoring for the following main glomerular changes in 248 patients with IgAN: 1) glomerular hypercellularity (mesangial and endocapillary), 2) segmental lesions such as tuft adhesion, crescent and segmental sclerosis, 3) global glomerular sclerosis. Indices of each lesion were semiquantitatively determined. The sum of these three indices was defined to be a glomerular score. We found that a glomerular score significantly related to the outcome of patients with IgAN in univariate life table analysis. We also semiquantitatively determined total score including tubulo-interstitial and vascular lesions as well as glomerular score and compared the predictive power as a prognosticator between glomerular score and total score. Using Cox's proportional Hazard model and log-likelihood ratio test, we confirmed that predictive power of glomerular score was better than that of total score. Furthermore, we assessed the reproducibility of glomerular score using Kappa statistics. Three pathologists read 100 biopsies which were randomly selected from the materials and all pathologists read them twice. A value of Kappa between the first and second observation of pathologist A, B and C was 0.68, 0.71 and 0.60, respectively. Values of Kappa between Pathologist A and B were ranging from 0.45 to 0.47, those between Pathologist A and C from 0.30 to 0.36, and finally those between Pathologist B and C were ranging from 0.12 to 0.23. Therefore, intra-observer reproducibility was nearly excellent. And inter-observer reproducibility between Pathologist A and B was satisfactory. However, inter-observer reproducibility between Pathologist A and C and between B and C was not satisfactory. We feel our scoring system is very convenient and easy to be understood as a prognosticator in patients with IgAN. It, however, should be used by one pathologist because of excellent intra-observer reproducibility and rather unsatisfactory inter-observer reproducibility.

Acinar-islet cell carcinoma presenting as insulinoma

A case of acinar-islet cell carcinoma presenting as insulinoma is reported. The patient was a 28-year-old man who presented with two convulsive episodes. Fajans' index [immunoreactive insulin (IRI; microU/ml/ glucose mg/dl)] and Turner's [IRI (microU/ml) x 100/glucose (mg/dl) - 30] index were high (2.8 and 308, respectively), as were serum proinsulin levels (550 pg/ml). Abdominal computed tomography and angiography revealed a highly vascular tumor in the pancreatic tail and several similar tumors in the liver. Histologic features of a biopsy specimen from a hepatic tumor were those of a malignant pancreatic endocrine tumor. Insulin secretion by the liver metastases was confirmed by venous sampling after arterial stimulation with calcium. These findings led us to diagnose malignant insulinoma with liver metastases. Serum levels of alpha-fetoprotein and trypsin were markedly elevated, to 2234 ng/ml (normal < 10) and 22,000 ng/ml (normal < 460) respectively, and these levels continued to rise with further growth of the liver metastases. Immunohistochemically, the metastatic liver tumor specimen was positive for alpha-fetoprotein, alpha 1-antichymotrypsin, chromogranin A, and neuron-specific enolase. These findings of amphicrine features in the tumor were indicative of acinar-islet cell carcinoma that produced alpha-fetoprotein and trypsin in addition to insulin.