The use of progestogen in the treatment of metastatic carcinoma of the kidney and uterine body

Tamoxifen Treatment for Advanced Renal Cell Cancer

Twelve patients with metastatic clear cell renal cancer received a course of tamoxifen. Three showed stable disease for a period from 2 to 12 months and 1 a mixed response for a short time. It does not appear that tamoxifen may be a useful agent in the treatment of metastatic renal cell carcinoma.

Renal cell carcinoma

Renal cell carcinoma (RCC) is characterized by (a) lack of early warning signs, which results in a high proportion of patients with metastases at the time of diagnosis; (b) protean clinical manifestations; and (c) resistance to radiotherapy and chemotherapy. The estimates of new diagnoses and deaths from kidney cancer in the United States during 1996 are 30,600 and 12,000, respectively. RCC occurs nearly twice as often in men as in women. The age at diagnosis is generally older than 40 years; the median age is in the midsixties. The incidence of RCC has been rising steadily. Between 1974 and 1990, there was a 38% increase in the number of patients who had a diagnosis of RCC. This increase was accompanied by a significant improvement in 5-year survival. Both trends are likely the result of improved diagnostic capability. Newer radiographic techniques, including ultrasonography, computed tomography, and magnetic resonance imaging, are detecting kidney tumors more frequently and at a lower disease stage, when tumors can be resected for cure. Surgical treatment is the only curative therapy for localized RCC. Radical nephrectomy remains the mainstay of surgical management, but techniques are being modified. These modifications include partial nephrectomy and resection of vena caval thrombi. In highly selected cases, surgical resection of locally recurrent RCC or of disease at a solitary metastatic site is associated with long-term survival. Metastatic RCC is highly resistant to the many systemic therapies that have been extensively investigated. A minority of patients achieve complete or partial response to interferon, interleukin-2, or both. Response can be dramatic but is rarely durable. Because most patients do not achieve response, these agents are not considered effective treatments for RCC, but the response in some patients indicates the need for continued research on their use. Identification of new agents with better antitumor activity against metastases remains a high priority in clinical investigation of therapy for this refractory disease.

Modulation of adriamycin resistance in human breast carcinoma MCF-7 cells in vitro and in vivo by medroxyprogesterone acetate

The combination effect of adriamycin (ADM) and medroxyprogesterone acetate (MPA) was examined in vitro against human breast carcinoma MCF-7 and its ADM-resistant line (MCF-7/ADM). MCF-7 cells, which are positive for estrogen receptors, progesterone receptors and high-affinity MPA-binding activity, were more susceptible to the growth-inhibitory activity of ADM or MPA than MCF-7/ADM cells. A combination effect of ADM and MPA was observed against MCF-7/ADM cells, which are negative for steroid receptors, and furthermore against human nasopharynx carcinoma KB and its ADM-resistant line KB-A1. This combination effect of ADM and MPA against MCF-7/ADM cells was demonstrated to be synergistic by using the median effect plot method. The activity of MPA was almost equivalent to that of chlormadinone acetate or tamoxifen, greater than that of progesterone, and less than that of verapamil. The accumulation of ADM in MCF-7/ADM cells was enhanced by treatment with 10 microM MPA as well as 10 microM verapamil. The efflux of accumulated ADM from MCF-7/ADM cells was also partially inhibited by treatment with MPA or verapamil. MPA augmented the growth-inhibitory activity of ADM against MCF-7/ADM tumors inoculated into nude mice, although statistical significance was not observed. It is suggested that the clinical advantage of the combination of MPA with ADM against advanced breast cancers may be partly explained by the modulation of ADM resistance by MPA.

Steroid hormone receptors in normal and malignant human renal tissue: relationship with progestin therapy

Documented hormone dependence of renal tumors in animal models, hypothetical hormonal environment of human kidney neoplasms and their controversial response to endocrine therapy prompted us to undertake a prospective multicentric cooperative study to evaluate the hormone-dependence/responsiveness of renal tumors. Patients with renal carcinoma were stratified according to the TNM classification and after nephrectomy were treated with high-dose medroxyprogesterone acetate (MPA). Specimens of tumor and healthy surrounding kidney tissue were studied for titration of steroid receptor proteins (78 for androgen, AR, 89 for estrogen, ER, and progestin, PgR). Their true receptor nature was estimated. Very low titers (on an average less than 10 fmol/mg protein) were found, especially for ER and PgR in neoplastic samples. Occurrence rate of AR was low for both tissues (less than 20%), whereas ER and PgR were detected at a higher frequency in healthy parenchyma than in tumor tissue (42.2 vs 23.3% and 30.7 vs 11.2%, respectively). AR was moderately affected by metastatic status of the disease and by sex. All three steroid receptors were simultaneously detected in normal tissue in 11.7% of cases and in tumor tissue in only 3.8%. No significant correlation between receptor status in the tumor and clinical response to hormone therapy was found. In 27 cases who received adjuvant MPA therapy, relapses were respectively 43.8 and 18.2% in the patients with negative receptors or with at least one detectable receptor. In metastatic renal carcinoma, stabilization of the disease with MPA was achieved more frequently in receptor-negative patients. Therefore, we conclude that the receptor assay is not a valid tool to select renal carcinoma patients for therapy with MPA.

Hormone receptor in renal cell carcinoma and correlation with clinical response to endocrine therapy

Analyses of hormone receptors in cytosols from 41 renal cell carcinoma specimens were performed by the dextran-coated charcoal technique, using estradiol, synthetic progestin R5020 and synthetic androgen R1881. Binding data were calculated according to the method of Scatchard. Of 41 renal cell carcinomas estradiol receptor was detected in 11, R5020 receptor in 11 and R1881 receptor in 13. No significant correlation between histopathological findings and hormone receptors was observed. Patients were classified into those positive and negative for receptors. The clinical response of endocrine therapy for 17 with advanced residual or metastatic lesions after nephrectomy was studied in regard to the survival rates. Although there was no complete or partial regression in tumor size, the survival rate of patients with 1 or more receptors was significantly higher than that of patients negative for receptors (p less than 0.01). In conclusion, hormonal manipulation in patients with renal cell carcinoma cannot induce an antitumor effect but seems to increase survival in patients with receptors.

Long acting contraceptives. Present status

Long acting injectable hormonal contraceptives are among the most effective fertility regulating agents developed; yet they are also among the most controversial because of animal data indicating a possible carcinogenic potential in several species. A critical analysis of these animal findings has revealed, in all instances, the existence of specific mechanisms not occurring in the human. For this reason, most national and international scientific bodies who have reviewed this issue have concluded that there are no toxicological reasons for not using long acting hormonal contraceptives. Long acting agents can be divided into 2 separate groups: those having a duration of action of one month, which are composed of a long acting oestrogen and a progestagen, and those lasting for several months which consist of only a progestagen. Among the injectable progestagen-only contraceptives tested, only 2 have so far reached the international market: depot medroxyprogesterone acetate (DMPA), which has been administered at 3- or 6-month intervals and norethisterone enanthate, which has been injected at intervals ranging between 2 and 3 months. The most important side effect observed with these 2 agents is a complete disruption of the menstrual bleeding pattern, leading - in some cases - to total amenorrhoea, which is more frequent with depot medroxyprogesterone acetate than with norethisterone enanthate. The latter, however, has a shorter duration of action with a higher pregnancy rate than the former. Other adverse reactions are rare and of no real importance. Metabolic effects with progestagen-only injectable preparations are, in general, mild and less marked than with combined oestrogen-progestagen formulations. Recent investigations have shown that the return of fertility following their use is delayed but in no way impaired. Monthly injectable oestrogen-progestagen combinations have been tested to a more limited extent and these agents are available only in a very few countries. Their main advantage over progestagen-only preparations is that they allow a reasonable menstrual bleeding pattern in the majority of cases. Their obvious disadvantage is that they contain a long acting oestrogen.

Studies on ovarian and adrenal steroids at different phases of the menstrual cycle. III. Steroid and lutropin levels before and after the administration of a single contraceptive dose of depot-medroxyprogesterone acetate (DMPA)

Ovarian and adrenal steroids and biologically active lutropin were measured in peripheral plasma samples obtained from 5 normally menstruating women. Plasma samples were collected every 3 h for a period of 39 hours in the periovulatory period of a pretreatment (control) cycle and then 16 and 54 days after a single i.m. injection of 150 mg of depot-medroxyprogesterone acetate (DMPA). Sixteen days after DMA administration, the levels of estradiol, progesterone, 17-hydroxyprogesterone, and lutropin were reduced to early follicular phase levels. No further decrease was found in 17-hydroxyprogesterone and lutropin levels; however an additional decrease occurred in the levels of estradiol and in the "morning" levels of progesterone 54 days after the administration of DMPA. Furthermore, the levels of pregnenolone, androstenedione, testosterone and dihydrotestosterone were significantly diminished in all samples collected after the administration of DMPA. Fifty-four days following the administration of DMPA, the levels of cortisol and 17-hydroxypregnenolone were significantly reduced. The administration of DMPA did not interfere with the circadian rhythm of cortisol, pregnenolone, 17-hydroxypregnenolone, dehydroepiandrosterone, 17-hydroxyprogesterone, and androstenedione levels. A significant circadian rhythm was also found in testosterone (after 16 days) and lutropin (after 54 days) levels. No circadian variation was found in estradiol, progesterone and dihydrotestosterone levels.

Oestrogen-induced renal carcinoma

Oestrogen may be implicated as an aetiological factor in the development of some renal carcinomas in man. The development of a renal carcinoma in 2 patients who had been treated with low-dose oestrogen for periods of 3 and 3 1/2 years because of prostatic carcinoma is described. It is suggested that patients receiving prolonged oestrogen therapy should be evaluated for the presence of a renal carcinoma at regular intervals.

Current status of the therapy of advanced renal carcinoma

A preclinical murine renal model system is available for evaluation of the effectiveness of therapeutic agents. Clinical review reveals that objective response rates to hormonal agents reported since 1971 have been substantially lower than those reported prior to 1971. Many chemotherapeutic agents have not been adequately evaluated clinically or with the experimental model. Vinblastine to date may be the most active single agent with a 25% objective response rate. At the present time, it is uncertain whether combination chemotherapy or hormonal chemotherapy add to response rates obtained with single agents. There is some evidence that immunotherapy may be of some adjuvant benefit and, thus may provide an additional avenue of investigation.

Oestrogen-binding components in human renal cell carcinoma

Specific binding of [3H]oestradiol-17beta by the cytosol fraction of human renal cell carcinoma was studied. The binding reaction displayed marked ligand specificity and high affinity of binding. Unlabelled oestradiol, oestriol and oestrone inhibited the binding of [3H]oestradiol-17beta to the cytosol binding sites, wehereas all other steroids tested turned out to be only weak or insignificant competitors for the oestrogen binding sites. Scatchard analyses suggested the existence of a single class of binding sites. The dissociation constant of the oestradiol-binding complex was found to be 2.51 +/¿.75 x 10(-9) mol/l. The number of binding sites was limited (17.5 +/- 3.8 fmoles per mg of cytosol protein). Sucrose gradient centrifugation revealed these binding components to be macromolecules either displaying a complex sedimentation pattern (peaks at 3.5 S, 4S, 5.7S and, in addition, high molecular weight aggregates) or sedimenting in the 4S region alone. By agar gel electrophoresis it could be demonstrated that the oestradiol-inding components migrated into the receptor region of the gel. Binding of [3H]oestradiol-17beta to these entities was markedly reduced, when the cytosol was heated (60 min at 45 degrees C) prior to the reaction with the labelled hormone. Since the specific binding components exhibit properties of oestradiol receptors in target tissues, a direct effect of oestradiol on human renal cell carcinoma is suggested.

Hormonal treatment of metastases of renal carcinoma

A series of 33 patients with metastatic renal cancer and evidence of progression of the disease-apart from pulmonary metastases-was treated with hormones (progestogens in 31 cases, androgens in 2 cases) at the Rotterdamsch Radio-Therapeutisch Instituut. Complete or partial spontaneous regression (or non-progression of pulmonary metastases) before hormone treatment was observed in 8 patients (24%). A favourable subjective response to hormone treatment was obtained in 12 patients (36%), while a positive objective response was obtained in 2 (or 3) cases (6-9%).A favourable response was obtained slightly more frequently in men than in women. The hormonal effect was not demonstrably related to any of the following factors: age of the patient, type of progestogen used, the behaviour of concomitant pulmonary metastases, or the presence or absence of the primary growth.The prognosis was unaffected by hormone therapy, but the 2 year survival rate was significantly higher in patients that showed signs of spontaneous regression of pulmonary metastases, as compared with those without these signs.

Medroxyprogesterone acetate (Provera) in the treatment of metastatic renal cancer

Eighty patients with advanced metastatic renal cancer have been treated with hormones, chiefly medroxyprogesterone acetate (Provera). This progestational compound is remarkably free from side-effects and can be given in high dosage for long periods without serious complications. Ninety per cent of cases had multiple metastases: in 76% more than one organ was involved and nearly 50% were seriously ill or "terminal".Subjective improvement occurred in at least 55%. In 11 patients there was marked improvement in the radiological or clinical signs of tumour within 2 to 6 weeks of commencing treatment or changing to a different hormone. In two further cases improved general health was associated with stationary metastases for 20 months. A significant objective response occurred in 16% of the total series. A favourable response was seen more often in men (21%) than in women (8%). If deaths within 6 weeks are excluded the objective response rate in men is increased to 27%. Although the response of advanced renal cancer to hormonal treatment is usually incomplete and of brief duration, it is possible for such treatment to offer a "new lease of life" to a seriously ill patient, even in old age, for 2 to 3 years.