A clinical and pathological study of adrenocortical carcinoma: therapeutic implications

Twenty-one patients with adrenocortical carcinoma (ACC) diagnosed at three hospitals over a ten-year period were reviewed for clinical and pathologic features that might have therapeutic implications. Depending upon the extent of cellular pleomorphism, ACC could be defined as anaplastic or differentiated. Anaplastic ACC occurred more often in male patients, produced more frequent cutaneous metastases (P = 0.01), and was associated with a lack of clinical or laboratory evidence of hormone production (P = 0.01). In contrast, differentiated ACC usually occurred in women and produced clinical or laboratory evidence of hormonal excess. Median survival time of patients with anaplastic ACC was only five months, while median survival time of those with differentiated ACC was 40 months (P = 0.005). Patients with differentiated ACC survived for long periods, even with metastatic disease. Three of 5 such patients had objective responses to o,p'-DDD (Mitotane) therapy. The histopathology of ACC is an important prognostic factor and should be considered in the design of future therapeutic trials.

Abnormalities in water homeostasis in small cell anaplastic lung cancer

Forty-one patients with newly diagnosed small cell anaplastic lung cancer were evaluated for abnormalities in water homeostasis. Each patient underwent a standard water load (SWL) test. Overall, 68% had abnormalities in the SWL test. Abnormalities were found in 47% of the patients with carcinoma clinically limited to one hemithorax and in 86% of the patients with more extensive carcinoma. The determination of urinary antidiuretic hormone levels was available for 27 patients. Abnormally elevated levels were found in 44% of those patients. Forty-six patients had clinically detectable syndrome of the inappropriate secretion of antidiuretic hormone (SIADH); in 12% of patients water restriction was necessary. The incidence of detectable abnormalities in water homeostasis in this study was higher than has been previously recognized. The SWL test is a sensitive and useful means of determining the presence of impaired water handling in patients with small cell carcinoma of the lung.

Urine calcitonin levels in patients with bronchogenic carcinoma

We demonstrated previously that high serum calcitonin values in bronchogenic carcinoma are useful clinically as a parameter of progress of the disease and response to therapy. After developing a procedure for the measurement of calcitonin in urine, we studied serum and urine levels in 41 patients with lung cancer, using both a carboxyl terminus and a midportion recognizing antiserum. In general, midportion antiserum was more useful. Urine calcitonin measurements alone were superior to serum in terms of numbers of patients having increased values with one or both antisera (76% vs 46%). When both antisera were used to assay both serum and urine, 90% of patients had abnormal values. Once a tissue diagnosis has been established, the radioimmunoassay of urinary calcitonin offers a new dimension to the utility of this hormone as a marker for bronchogenic carcinoma.

Deoxycorticosterone and aldosterone excretion in Cushing's syndrome

We have used specific radioimmunoassays to measure urinary free deoxycorticosterone (DOC) and total aldosterone excretion in 15 patients with Cushing's syndrome. Free DOC excretion was increased in 6 of 8 patients with pituitary-dependent adrenal hyperplasia, in 2 of 3 patients with adrenal adenoma, and in all 4 cases with adrenal carcinoma. The most marked increase was noted in the adrenal carcinoma cases. Aldosterone excretion was high, normal, or low in each of the three types of Cushing's syndrome. The free DOC response to metyrapone in Cushing's syndrome due to adrenal adenoma was markedly different from that in patients with adrenal hyperplasia (pituitary-dependent) and may serve as a test to ascertain the etiology of the disorder. Correlations of free DOC and aldosterone excretion with free cortisol excretion, and their responses to the administration of metyrapone and dexamethasone were compatible with ACTH dependency in adrenal hyperplasia, autonomous production of steroids in adrenal adenomas and a chaotic steroidogenesis in adrenal carcinoma.

[Evaluation of hydroxyproline excretion in the urine (UHP) in prostate carcinoma]

82% of the male patients with healthy urogenital tract showed an isoelectric line in the stimulataneous EMG-derivation of the sphincter of the bladder under conditions of rest; in 18% of the males a moderate activity was present. In voluntary innervation at once an intensive electric activity of a spinle-shaped discontinuous pattern of the action potential developed in 76% of the patients. In the pressing trial in 83% of the cases a slight to moderately strong activity appeared. In contrast to the examined patients with healthy outlet of the vesicle the patients in whom an adenoma of the prostate gland or a carcinoma of the prostate gland, respectively, was present exhibited deviations from the normal pattern of the action potential, in which cases carriers of adenoma and carcinoma differed. Whether and to what extent the electromyography on the m. sphincter vesicae allows the possibility of the differentiation between adenoma of the prostate gland and carcinomaof the prostate gland in the early clinical stage shall be reserved for further examination.

Studies of 16-androstenes in an infant with virilizing adrenal carcinoma

An 18-month-old girl with virilization was found to have an encapsulated right adrenal carcinoma (2 x3 cm) with great variation in nuclear size, frequent mitoses, and possible blood vessel invasion. Preoperative urinary excretions of 17-ketosteroids, androsterone, etiocholanolone, dehydroepiandrosterone, testosterone, pregnanetriol, 3alpha-androstenol, and 3 beta-androstadienol were elevated; all showed a noticeable decrease postoperatively. Cortisol acetate, given preoperatively, produced a definite decrease in the urinary excretion of 17-ketosteroids and dehydroepiandrosterone; administration of corticotropin resulted in an increase in levels of urinary 17-ketosteroids, 17-hydroxycorticosteroids, and pregnanetriol. Urinary testosterone and 3beta-androstadienol may have diagnostic value since neither was suppressed by cortisol therapy. The behavior of both 3alpha-androstenol and 3beta-androstadienol in this study suggests that they are of adrenal origin.

Urine calcitonin as a test for medullary thyroid cancer: a new screening procedure

Although the radioimmunoassay of serum calcitonin (CT) has facilitated the diagnosis of medullary thyroid cancer (MTC) one may encounter patients whose basal serum levels of CT are normal or nearly normal. In such cases clinicians have utilized intravenous stimulation tests such as calcium or pentagastrin to obtain a diagnostic increase in serum CT. We have reported finding immunoreactive CT in the urine of man and have found it to be a useful technique for the diagnosis and study of patients at risk for MTC or other hypercalcitonemic diseases. Using basal urine CT alone we were able to separate 73% of patients at risk for MTC into clearly normal or abnormal groups. For the remaining 27% a stimulation test with subsequent determination of urine CT was required. The radioimmunoassay of urine CT is a simple, reliable, accurate test for the screening diagnosis of MTC. A protocol for the screening workup of a patient at risk for MTC is given.

Urinary etiocholanolone and prognosis in early carcinoma of the breast

Etiocholanolone levels have been measured in both premastectomy and postoperative urines from 86 women with early breast cancer. Levels did not differ between patients subsequently surviving five years following mastectomy and those dying from recurrent disease within this period.

Urinary oxalate on a high-oxalate diet as a clinical test of malabsorption

100 g of spinach a day was added to the hospital diet of fifty-four patients with suspected malabsorption. Hyperoxaluria was found in thirty-eight patients; all of them had steatorrhoea. No patient with steatorrhoea had a urinary oxalate excretion of less than 40 mg a day. Ten other patients had hyperoxaluria, but the faecal fat determinations were regarded as unreliable in almost all and malabsorption could not be confirmed. It is suggested that in clinical practice determination of urinary oxalate after an oral load of oxalate could replace faecal fat determination in most patients with suspected malabsorption.

[Feminizing adrenal cortex carcinoma in a 66-year-old man]

Feminizing tumors of the adrenal cortex in man are very rare. The case is reported of a 66-year-old man who had a carcinoma of the right adrenal cortex which produced various steroid fractions. In the primary tumor and in the second reccurrence the estrogens were dominant. In electron microscopy the tumor cells are poorly differentiated. They may be attributed to the fasciculo-reticular layer and show no signs specific for their secretory activity. The patient died 2 1/2 years after onset of the disease. The case is discussed in the light of the pertinent literature.

Immunological detection of human bladder carcinoma

A rabbit antiserum (RABCa) to membrane antigenic extracts of human bladder carcinomas was produced. RABCa failed to detect bladder cancer-specific antigens in gel diffusion reaction against antigenic extracts of bladder carcinoma and normal bladder mucosa. However, RABCa showed higher complement fixation activity against urines from bladder cancer patients compared with normal urines. The micro-complement fixation (CF) assay (108 patients) was positive in 17 of 27 bladder cancer patients (62.9%) compared to only 1 of 29 normals (3.4%). However, 10 of 11 patients with urinary infections also were positive. A micro-Ouchterlony agar gel diffusion assay was also used to study urine samples (118 patients). RABCa produced separate precipitin bands against 20 of 30 bladder cancer urines (66.7%) while only 1 of 24 normal urines gave these bands (4.2%). Again, infected urines were positive (9 of 11). Additionally, urine from patients with benign urological disease was often positive in CF (11 of 41) and Ouchterlony (15 of 43) assays. RABCa serum was absorbed with normal bladder mucosa membrane extracts either once (1X) or three times (3X) to increase the specificity of the Ouchterlong gel diffusion assay. Using RABCa (1X) the per cent of positive bladder cancer urines and normals decreased only slightly, while the number of positive reactions against benign urological disease urines dramatically decreased (17.9%). RABCa (3X) further reduced the per cent of positive reactions with benign urological disease urines (10.3%), greatly reduced the reactivity with infected urines (60.0%), and gave no positive reactions with normal urines, without significantly decreasing the abiltiy to detect bladder carcinoma (51.9%). Although RABCa was 100% effective in detecting high grade (III) bladder tumors, almost two-thirds of all transitional cell papilloma urines were also positive. The nature of the material detected in bladder cancer and infected urines by RABCa is probably a product of in vivo inflammation. It does not appear to be part of the bacterial cell membrane or a bacterial metabolite. CEA (up to 10 ng/ml) did not produce positive precipitin bands with RABCa. Sephadex G-100 fractionation of urines suggests that RABCa reacts in the CF and Ouchterlony assays with a component or urine which has a molecular weight greater than 100,000-200,000 M.W. In summary, an antiserum has been prepared which may be used in micro-complement fixation and micro-Ouchterlony agar gel diffusion assays for immunological screening in the early detection of clinical disease, especially bladder cancer and urinary infection.

Urinary polyamine levels in the diagnosis of carcinoma of the prostate

Urinary excretion of the basic polyamine, spermidine, was significantly elevated in patients with prostatic carcinoma as compared to a control group of patients, Of 44 urine specimens from patients with prostatic malignancy 31 had spermidine levels more than 2 mg. per 24 hours, while only 3 of 13 urine specimens from the control groups had levels in excess of this value. The increase in spermidine appeared to be correlated with the histologic grading of the tumor, that is 30 of 34 specimens from patients with grade II, III or IV carcinoma had excessive spermidine excretion and only 1 of 10 urine specimens from patients with grade I tumors had similiar spermidine elevations. High spermidine levles were found in tumors localized to the prostate and in 7 of 8 patients with negative pelvic and para-aortic lymph node biopsies. This study raises the possibility that urinary spermidine determinations may aid in the development of a biochemical screening test for prostatic neoplasms.

Total urinary hydroxyproline excretion before and after hypophysectomy in patients with bone metastases from breast carcinoma

Recent investigations indicate that the urinary excretion of total hydroxyproline is a measure of the metabolism of collagen, particularly the bone matrix.

The total hydroxyproline excretion has been determined in 28 women with bone metastases from breast cancer, and in 12 healthy volunteers. In 22 of the 28 cases with bone metastases the urinary excretion of hydroxyproline was measured shortly before and repeated shortly after hypophysectomy. In addition, the measurements were repeated 3 to 12 months after hypophysectomy in 8 of the patients.

The mean excretion of hydroxyproline was significantly higher in patients with bone metastases from breast cancer (52.9 mg/24 h) than in healthy subjects (22.1 mg/24 h). A correlation was found between the urinary excretion of hydroxyproline and serum alkaline phosphatase levels.

The mean excretion of total hydroxyproline was 51.0 mg/24 h before hypophysectomy and 63.8 mg/24 h after hypophysectomy. This difference is not statistically significant.

Determinations of urinary hydroxyproline excretion in patients with breast cancer has not been found of great value in the assessment of the clinical condition of these patients.