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

The influence of sex hormones on renal cell carcinoma

Kidney cancer is a common malignancy that constitutes around 5% of all cancer cases. Males are twice as likely to acquire renal cell carcinoma (RCC) compared to females and experience a higher rate of mortality. These disparities indicate that sex hormone (SH)-dependent pathways may have an impact on the aetiology and pathophysiology of RCC. Examination of SH involvement in conventional signalling pathways, as well as genetics and genomics, especially the involvement of ribonucleic acid, reveal further insights into sex-related differences. An understanding of SHs and their influence on kidney cancer is essential to offer patients individualized medicine that would better meet their needs in terms of prevention, diagnosis and treatment. This review presents the understanding of sex-related differences in the clinical manifestation of kidney cancer patients and the underlying biological processes.

Assessing improvements in metastatic renal cell carcinoma systemic treatments from the pre-cytokine to the immune checkpoint inhibitor eras: a retrospective analysis of real-world data

OBJECTIVE

Studies assessing outcome improvements over a long period according to systemic therapy strategies for metastatic renal cell carcinoma using real-world data, including the results of the recent era of immune checkpoint inhibitors, are limited. Herein, we retrospectively evaluated patients who were diagnosed with metastatic renal cell carcinoma over a 40-year span.

METHODS

Patients were classified into four groups based on when their metastases were diagnosed as follows: (i) the pre-cytokine era (1980-1986), (ii) the cytokine era (1987-2007), (iii) the molecular-targeted therapy (mTT) era (2008 to August 2016) and (iv) the immune checkpoint inhibitor era (September 2016 to 2018). The immune checkpoint inhibitor era consisted of second- or later-line nivolumab. Overall survival from the diagnoses of metastases was evaluated.

RESULTS

In total, 576 patients were evaluated, including 22 (3.82%), 231 (40.1%), 253 (43.9%) and 70 (12.2%) patients from the pre-cytokine, cytokine, molecular-targeted therapy and immune checkpoint inhibitor eras, respectively. The overall survival significantly improved with each successive era (median: 13.1 vs. 24.5 vs. 44.4 months vs. not reached in pre-cytokine vs. cytokine vs. molecular-targeted therapy vs. immune checkpoint inhibitor eras, P < 0.0001). The implementation of molecular-targeted therapy improved overall survival compared with that of cytokine (cytokine vs. molecular-targeted therapy eras, P < 0.0001). Multivariate analysis demonstrated that the era was an independent factor for overall survival (P < 0.0001), together with histopathological type; metastasis status (i.e. synchronous or metachronous); systemic therapy status (i.e. absence or presence) and bone, liver or lymph node metastasis status (all, P < 0.05).

CONCLUSION

This retrospective study of real-world data indicated that metastatic renal cell carcinoma outcomes improved with successive systemic therapy paradigms.

Adjuvant Therapy in Renal Cell Carcinoma: Current Status and Future Directions

In recent years, incredible progress has been made in the treatment of metastatic renal cell carcinoma, with a paradigm shift from the use of cytokines to tyrosine kinase inhibitors, and more recently, immune checkpoint inhibitors (ICIs). Despite advances in the metastatic setting, effective therapies in the adjuvant setting are a largely unmet need. Currently, sunitinib (Sutent, Pfizer) is the only therapy for the adjuvant treatment of RCC included in the National Comprehensive Cancer Network guidelines, which was approved by the FDA based on the improvement in disease-free survival (DFS) seen in the S-TRAC trial. However, improvement in DFS has not translated into an overall survival (OS) benefit for patients at high-risk of relapse post-nephrectomy, illustrating the need for more effective therapies. This manuscript will highlight attributes of both historical and current drug trials and their implications on the landscape of adjuvant therapy. Additionally, we will outline strategies for selecting patients in whom treatment would be most beneficial, as optimal patient selection is a crucial step towards improving outcomes in the adjuvant setting. This is especially critical, given the financial cost and pharmacological toxicity of therapeutic agents. Furthermore, we will review the design of clinical trials including the value of utilizing OS as an endpoint over DFS. Finally, we will discuss how the incorporation of genomic data into predictive models, the use of more sensitive imaging modalities for more accurate staging, and more extensive surgical intervention involving lymph node dissection, may impact outcomes.

Hormone Treatment and Sex Steroid Receptors in Metastatic Renal Cell Carcinoma: Report of a Multicentric Prospective Study

Twenty-eight patients with metastatic renal cell carcinoma entered a multicentric prospective study to evaluate the response to high-dose medroxyprogesterone acetate (MPA) and testosterone in MPA failures in relation to sex steroid receptors. No objective remission was seen in the 24 evaluable patients, and only disease stabilizations of short duration were achieved in one-third of treated patients. Stabilizations achieved with second line testosterone were all seen in patients unresponsive to MPA. Receptor studies demonstrated that estrogen, progesterone, or androgen receptors were found in low concentrations and in only 6 of 23 tumors (26%) and 13 normal tissue samples (56%). Surprisingly, no disease stabilization was achieved in patients positive for receptors. It can be concluded that the occasional objective responses to hormone therapy reported in the literature may have been due to some cytotoxic effect of hormone therapy rather than to a true hormonal mechanism.

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.

Second Primary Renal Cell Carcinomas following Solid Tumors. Four Case Reports and Review of the Literature

We report multiple malignancies in four patients with metachronous renal adenocarcinomas. The group of patients includes two women treated for primary breast and ovarian cancer and two men with prostate and colon cancer respectively. The occurrence of renal cancer following these primary solid tumors was not associated with previous treatments. The authors review the literature and discuss pathogenic mechanisms underlying renal cell carcinoma.

Renal cancer

In Europe, renal cancer (that is neoplasia of the kidney, renal pelvis or ureter (ICD-9 189 and ICD-10 C64-C66)) ranks as the seventh most common malignancy in men amongst whom there are 29,600 new cases each year (3.5% of all cancers). Tobacco, obesity and a diet poor in vegetables are all acknowledged risk factors, along with specific occupational and environmental factors. A familial history of renal carcinoma is also likely to increase the risk. Renal carcinoma may remain clinically occult for most of its course. The classic presentation of pain, haematuria, and flank mass occurs in only 9% of patients and is often indicative of advanced disease. Approximately 30% of patients with renal carcinoma present with metastatic disease, 25% with locally advanced renal carcinoma and 45% with localized disease. Metastases are typically found in the lung, soft tissue, bone, liver, cutaneous sites, and central nervous system. The most important staging technique is a computed tomography (CT) scan of the whole abdomen. Survival rates are more favourable for patients with tumours confined to the kidney. Five-year survival for patients with metastatic renal carcinoma is comprised between 0 and 20%. Radical nephrectomy is the standard intervention for renal cancer. Intrinsic resistance to chemotherapy has long been a hallmark of renal carcinoma. Limited options are available for the systemic therapy, and no chemotherapeutic regimen is accepted as a standard of care. Biologic agents represent the major effective therapies for widespread metastatic renal cancer. An antiangiogenic strategy, the neutralization of VEGF, can slow the growth rate of advanced cancer.

Adjuvant Therapy of Renal Cell Carcinoma

Metastatic renal cell carcinoma (RCC) has a highly variable natural history and carries a dismal prognosis. Unlike many other tumors, RCC is generally unresponsive to cytotoxic, hormonal, and radiation adjuvant therapies after cytoreductive surgery. Different modalities of treatment have been tried and tested with modest success. Until recently, only immunotherapies such as interleukin-2 and interferon-alpha have been shown to provide a response, albeit in a minority of patients and often with severe treatment-associated toxicities. Other adjuvant therapies, such as active specific immunotherapy with Bacillus Calmette-Guerin and autologous renal tumor cell vaccines, have not provided alternative solutions. Recent approaches include heat-shock protein peptide complex 96 vaccine and cG250 monoclonal antibody therapy. Novel targeted therapies have been developed using our knowledge of the molecular genetics that belie RCC. This culminated in sorafenib and sunitinib, the first Food and Drug Administration-approved drugs for RCC in more than a decade in the United States. The future will see further trials being carried out in the development of targeted therapies with emphasis placed on patient selection. Staging systems will need to be updated to integrate molecular biomarkers, which could potentially act not just as diagnostic and prognostic predictors, but also as tools for appropriate patient selection for treatment. In the future, this could potentially lead us to our ultimate goal of personalized medicine.

Randomized Phase II Study Comparing Thalidomide With Medroxyprogesterone Acetate in Patients With Metastatic Renal Cell Carcinoma

Purpose

To investigate escalating doses of thalidomide compared with medroxyprogesterone in patients with metastatic renal cell carcinoma (RCC), who had either progressed after first-line immunotherapy or who were not suitable for immunotherapy.

Patients and Methods

Thalidomide was started at 100 mg/d orally (PO) and escalated by 100 mg/d every 2 weeks to the maximum dose of 400 mg/d. Medroxyprogesterone was given at a fixed dose of 300 mg PO daily.

Results

Sixty patients were entered (thalidomide:medroxyprogesterone = 29:31; median age, 59 [thalidomide], 60 [medroxyprogesterone]; No. of patients assessable for response, 22 [thalidomide], 26 [medroxyprogesterone]). In the thalidomide arm, there was no objective response seen. The best response was SD in three patients lasting 5+, 6+, and 12 months, respectively. All patients in the medroxyprogesterone arm progressed. There was no difference in overall survival between the two arms; median survival in the thalidomide arm was 8.2 months compared with 4.8 months in the medroxyprogesterone arm (P = .62). Hazard ratio was 0.88 (95% CI, 0.67 to 1.94). Median duration of treatment was 73 days (range, 14 to 364 days) in the thalidomide arm, and 84 days (range, 7 to 175 days) in the medroxyprogesterone arm. The high incidence of toxicity in the thalidomide arm, mainly somnolence, constipation, fatigue and paraesthesia, meant that only 30.8% of patients were able to tolerate the maximum dose of 400 mg/d of treatment.

Conclusion

Thalidomide is not superior to medroxyprogesterone acetate in patients with metastatic RCC. Its risk/benefit ratio does not favor its use in this patient population.

Allogeneic stem cell transplantation as immunotherapy for renal cell carcinoma: from immune enhancement to immune replacement

The lack of efficacy of chemotherapeutics, radiotherapy, and cytokine-based immunotherapy has catalyzed the preliminary enthusiasm for nonmyeloablative stem cell transplants as a novel investigational tool for treating metastatic RCC. The observation that cytokine-refractory metastatic RCC may regress following allogeneic transplantation attests to the powerful nature of the graft-versus-tumor effect that results from this treatment modality. Pilot trials and recent in vitro data provide the first clear evidence that the graft-versus-tumor effect mounted against RCC can produce clinically meaningful regression of a metastatic solid tumor. Given this observation, the authors have begun to expand the investigational use of nonmyeloablative stem cell transplants to other treatment-refractory genitourinary tumors, including metastatic bladder and prostate cancer. It is hoped that future demonstrations of graft-versus-tumor effects in other solid malignancies will lay the groundwork for the development of tumor-targeted strategies that use allogeneic transplantation of donor lymphocytes as an immunotherapeutic platform. Further advances in systemic and selective immunosuppressive agents that limit acute GVHD hold the potential to decrease the toxicity associated with nonmyeloablative stem cell transplants and may ultimately broaden the clinical applicability of this approach.

Synchronous renal cell carcinoma and gynecologic malignancies

BACKGROUND

Synchronicity of renal cell carcinoma and gynecologic malignancies is a rare condition and standardized treatment does not exist.

CASES

Three cases of synchronous renal cell carcinoma and gynecologic malignancies are described. All three cases underwent optimal cytoreductive surgery for the gynecologic malignancy and a radical nephrectomy for the renal cell carcinoma. Adjuvant treatment, after surgery, was individualized in each case. Estrogen and progesterone receptors were positive in all the gynecologic tumors but negative in the renal cell tumors.

CONCLUSIONS

This is apparently the largest report of synchronous renal cell carcinoma and gynecologic malignancies. Despite this rare condition, surgery should still be considered as primary treatment for these patients.

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.

Medical treatment of advanced renal cell carcinoma: present options and future directions

The treatment of patients with metastatic renal cell carcinoma (MRCC) continues to be disappointing. A large number of hormones, chemotherapeutic agents and combinations have been tested with poor and non-reproducible results. Among the immunological treatments investigated in MRCC, the best results have been claimed with interferons (IFNs) and interleukin-2 (IL-2) and, although no randomized studies have shown higher activity than cytotoxic drugs, hormones or even no treatment, many oncologists feel it justified to consider these biologic agents the treatment of choice for this disease. Of patients treated with alpha-IFN, 15-20% achieve an objective remission and 3-5% achieve a long-lasting complete response. No substantial increase of the therapeutic activity of alpha-IFN was produced by combination with chemotherapeutic agents and gamma-IFN or tumour necrosis factor. High doses of IL-2 with or without lymphokine-activated killer cells led to successful results in about 20-30% of patients with 5-10% complete responses. More recently, less toxic regimens with lower doses of IL-2 alone or combined with alpha-IFN produce similar response rates. Many studies have clarified the importance of prognostic factors in patient selection for response and survival during treatments with IFNs and IL-2. Good performance status, a long interval from diagnosis to treatment, and only one site of disease seem to be the most important predictors for survival. Both IFNs and IL-2 appear to possess encouraging antitumour activity in patients with favourable prognostic factors, but further studies are needed to identify the treatment of choice, the optimal dose regimen and route of administration in this subgroup of patients. Patients with poor prognosis should be encouraged to enter controlled studies aimed to evaluate investigational drugs and new therapeutic methods.

The use of interferon in renal cell carcinoma

Metastatic renal cell carcinoma remains an incurable disease and current modalities can only offer major palliation to a small percentage of patients. Since treatment is palliative, choice and type of therapy must be carefully considered and reconciled with patient desires. When possible, patients should be offered participation in a clinical trial. For patients choosing progestin therapy, treatment with interferon (IFN) or other biological response modifiers can be instituted at the time of progestin failure. Those patients who have slow tumour progression and maintain a high quality of life can be observed without continued progestin therapy. Although pretreatment characteristics predict response to biologicals, no pretreatment characteristic should preclude an individual patient from a trial of IFN therapy. Whether high-dose interleukin-2 (IL-2), IL-2/lymphocyte-activated killer cells, or IL-2/IFN are superior to IFN alone is uncertain, but clinical trials currently underway should help resolve these issues.

Experience with hormone receptors in renal cancer

The hormone receptor concentrations in tumour tissues from 20 renal carcinoma patients were determined before postoperative medroxyprogesterone acetate (MPA) therapy was started. Except for glucocorticoid receptors, the concentrations were either not measurable or were extremely low. The question is whether MPA therapy, solely on the strength of its character as a general roborant, is still useful in the treatment of renal tumours, even when it fails to exercise primary influence because of the absence of suitable receptors. None of the 20 patients was treated with MPA.

Spontaneous regression of cerebral and pulmonary metastases in renal cell carcinoma

In a 57-year-old female with a metastatic renal cell carcinoma lung metastases decreased after nephrectomy. Simultaneously, she developed a 3 cm large brain metastases with clinical signs of hemiparesis. Palliation treatment consisted of a 6-week course of oral Dexamethasone. One year later the lung and brain metastases had regressed completely as evidenced by chest X-ray and cerebral computer tomography. The role of corticosteroid treatment for the spontaneous regression is discussed.

Tissue specific regulation of renal N-nitrosodimethylamine-demethylase activity by testosterone in BALB/c mice

Nitrosodimethylamine (NDMA), like several other nitrosamines, is activated by the enzymes--mixed-function oxidases--present in the tissue microsomal fractions, producing mutagenic and carcinogenic effects. Previous studies in BALB/c mice have shown an age, sex and androgenic regulation of NDMA-induced mutagenicity. The present study was designed to test the correlation between renal NDMA-demethylase activity and previously published reports on NDMA-induced mutagenicity. Renal and hepatic NDMA-demethylases were determined from the microsomal fractions by quantitating formaldehyde. Renal NDMA-demethylase showed the presence of two isozymes, I and II, with Km values of 0.6 +/- 0.2 and 20.2 +/- 6.8 mM respectively. Isozyme I was detected in adult males and first appeared at the onset of puberty; it was absent in adult females and in immature mice. Renal isozyme II was detected in both males and females and was independent of age. Testosterone treatment of adult females resulted in the appearance of renal isozyme I. Castration of adult males caused a dramatic decrease in activity, whereas testosterone administration to such castrates increased activity, of renal isozyme I. Hepatic NDMA-demethylase activities were independent of age, sex or testosterone treatment. In conclusion, these results show an age, sex and tissue specific regulation of renal NDMA activity. Renal and hepatic NDMA-demethylase activities correlated positively with earlier studies on NDMA-induced mutagenesis and carcinogenesis.

A study of adrenal corticol function and its reserve activity in long-acting injectable contraceptive users

Adrenal function and its reserve capacity were studied in eighteen healthy non-lactating women who received depot-medroxyprogesterone acetate (DMPA: 9 subjects) and norethisterone enanthate (NET-EN: 9 subjects) as long-acting injectable contraceptives. Methodological assessments included: (i) morning fasting concentration of serum cortisol; (ii) diurnal variation of adrenal corticol activity as evidenced by cortisol concentration in serum samples taken at 0700 and 1600 hours; (iii) urinary free cortisol excretion; and (iv) cortisol response to insulin-induced hypoglycaemia. None of these assessments was significantly altered by contraceptive administration. This finding indicates that the subject's ability to release cortisol in response to a stressful situation, as well as to normal day-to-day activity, was not impaired by these contraceptive steroids.

Interferon therapy of metastatic renal cell cancer

There is no curative therapy for metastatic or recurrent renal cell carcinoma (RCC). Almost three-quarters of such patients die of their malignancy in 1 year and less than 5% of such patients are alive at 3 years. Few patients respond to hormonal therapy or chemotherapy, and when responses occur, they are usually brief and partial with little impact on survival. Interferon therapy in metastatic RCC has been associated with response rates of approximately 15-20%, and tumor regression has been demonstrated in patients treated with both partially purified and, more recently, recombinant interferon. Analysis of published trials shows no clear dose-response relationship; however, the highest therapeutic index appears associated with a daily dosage of 5-10 million units. The time to response is variable and may occasionally be prolonged; however, some patients have durations of response exceeding 12 months. Although nephrectomy may be associated with higher response rates, review of available data indicates that nephrectomy has frequently been an eligibility criteria, and indeed there are adequate descriptions of responses in patients that have not undergone this procedure. Patients with pulmonary metastases have the highest response rate. Recently, laboratory and clinical investigations of interferons and several chemotherapeutic agents, notably vinblastine, suggest synergy, but further data is needed to confirm these findings. The role of interferon therapy in improving survival is unknown. There is little doubt, however, that symptomatic patients who respond to interferon therapy may show improvement in their quality of life and prolongation of survival.

Hormonal effects of high dose medroxyprogesterone acetate treatment in males with renal or prostatic adenocarcinoma

In 18 patients, 12 with renal and 6 with prostatic carcinoma, the gonadal, pituitary and adrenal functions were studied by measurements of steroid hormones and gonadotrophins, before and after six weeks treatment with medroxyprogesterone acetate (MPA), injected intramuscularly 500 mg per day for 5 days each week. The testosterone-oestradiol-binding globulin (TeBg) was measured and the amount of albumin and TeBg bound and unbound testosterone was calculated. Treatment with high doses of MPA caused a profound decrease in serum concentrations of testosterone, dehydroepiandrosterone sulphate (DHEAS), cortisol and TeBg. There were significant decreases in serum concentrations of luteinizing hormone (LH), follicle stimulating hormone (FSH) and oestradiol-17 beta. The serum concentration of prolactin was significantly elevated. The protein unbound testosterone fraction was lowered by MPA treatment but less than total testosterone. In conclusion, MPA therapy in high dose alters the gonadal, pituitary and adrenal functions suppressing serum concentrations of androgens, gonadotrophins, cortisol and TeBg but elevating prolactin concentration.

The effect of medroxyprogesterone acetate on the hepatic drug-metabolizing enzymes in normal and protein-deficient female rats

Effect of depot medroxyprogesterone acetate on the hepatic drug-metabolizing enzymes was studied in female protein-deficient and normal pair-fed rats. Treatment with this drug did not cause any change in organ weight, microsomal protein, and soluble protein yield per gram of tissue in both groups. MPA administration resulted in significant increases in the content of cytochrome P-450 and b5, and activities of benzo[a]pyrene hydroxylase, UDP-glucuronosyltransferase, and NADPH-Cyt c reductase in both pair-fed control and protein-deficient rats. However, the content of glutathione and activity of glutathione-S-transferase were not affected appreciably. The present study suggests that MPA treatment induces drug-metabolizing enzymes in liver to almost the same extent in both protein-deficient and normal pair-fed rats.

Increased dihydrotestosterone receptor levels in high-stage renal adenocarcinoma

Primary renal adenocarcinoma tissue, metastatic deposits, and normal kidney parenchyma from 16 patients were assayed for sex hormone receptors by dextran-coated charcoal adsorption and sucrose gradient centrifugation techniques. Dihydrotestosterone receptors (DHTR) were found in all renal carcinomatous tissue (20/20) and in 93% (13/14) autologous normal kidneys analyzed. Testosterone receptors were found in 84% (16/19) of tumors and 93% (14/15) or normal kidneys analyzed. Estrogen receptors in small amounts (ER) were detected in only 5% (1/19) of tumors and in 7% (1/15) of normal kidneys. Progesterone receptors (PR) in low quantities were detected in 30% (6/20) of renal tumors and in 40% (6/15) of normal kidneys. DHTR levels in high-stage tumors (T3, T4) were significantly elevated over levels in autologous normal kidney, whereas in low-stage tumors localized to the kidney (T1 and T2 tumors) DHTR levels were not significantly different from autologous normal kidney. The mean levels of DHTR in high-stage kidney tumors were significantly elevated over levels in low-stage tumors (P less than 0.001). DHTR estimation in renal neoplasms may help in biologic staging of renal adenocarcinoma and could define a group of patients in whom anti-androgen therapy may be worth a trial.

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.

Steroid receptors in renal cell carcinoma: relevance to hormonal therapy

The relevance of the presence of steroid receptors in the response to hormonal therapy was examined in 19 patients with renal cell carcinoma who were treated by surgery and progestins. Estrogen and progesterone receptors were determined in tissue samples obtained from the tumors, and normal (autologous) and control kidneys. The tumoral tissues had the lowest content of estrogen and progesterone receptors, and the lowest percentage of samples positive for receptor. Autologous kidneys had a higher percentage of positive estrogen and progesterone receptors compared to tumoral tissues, and a lower estrogen receptor content compared to control kidneys. The 18-month survival rate under progesterone therapy for 9 patients with stages I and II tumor was 86 per cent and for 10 with stage IV tumor it was 8 per cent. The low content of progesterone and estrogen receptors in patients with renal cell carcinoma may explain the poor response rate of these patients to hormonal therapy.

Measurement of progesterone receptor in human renal cell carcinoma and normal renal tissue

Progesterone receptor was measured in eight samples of renal cell carcinoma, nine samples of normal renal tissue, and one sample of melanoma tissue. Progesterone receptor was identified in all samples, with the exception of one renal cell carcinoma. Three patients, all with receptor-positive tumors, were treated with medroxyprogesterone acetate for metastatic disease. In one of these patients there was a partial objective response to treatment. Further research regarding progesterone receptor in renal cell carcinoma is indicated.

Advanced ovarian carcinoma: response to antiestrogen therapy

Three patients with Stage III serous cystadenocarcinoma of the ovary were successfully treated with estrogen antagonist therapy after failure of cytotoxic chemotherapy. All had histologic confirmation of progressive or persistent disease. High titers of estrogen receptor protein (ERP) and progesterone receptor protein (PRP) were detected in one patient prior to tamoxifen therapy. One patient had a complete remission lasting for 18 months. The other patients had partial responses and were able to return to normal activities. Simultaneous or prior sequential cytotoxic chemotherapy did not negate the effectiveness of the estrogen antagonists.

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.

Renal cell carcinoma: long-term survival and late recurrence

In a series of 506 patients with renal cell carcinoma survival was analyzed in terms of pathologic stage, histologic grade, and a combination of stage and grade. Data reveal that stage, grade and the combination are important prognostic indicators. Invasion of the renal pelvis is not an important factor in staging the disease. Women had a better survival rate than men. The prognosis for patients with dark cell tumors was no worse than that for patients with clear cell tumors when correlated with the more important factors of tumor stage and grade. Renal vein involvement alone, excluding concomitant capsular or nodal involvement, had an adverse effect on survival. Of the patients who survived 10 years from the date of nephrectomy 11 per cent had late recurrence.

Comparison of steroid receptor levels in renal-cell carcinoma and autologous normal kidney

Since a number of renal-cell carcinomas regress with hormonal manipulation, we have identified and measured the levels of estrogen, progestin and glucocorticoid receptors in 47 autologous pairs of normal and neoplastic kidney tissues. High-affinity receptors for these hormones were detected in kidney tissues of both sexes by means of a dextran-coated charcoal assay. Glucocorticoid receptors were demonstrated in renal cancer tissues for the first time, and were higher in the tumor (mean 31.3 +/- SEM 5.6) than in the normal tissue (mean 18.5 +/- 3.1 fmol/mg cytosol protein). There was a significant difference in the quantities of progestin receptors (expressed as fmol/mg cytosol protein) in normal (mean 18.4 +/- SEM 3.3) versus neoplastic (mean 10.4 +/- SEM 4.0) kidney specimens (p less than 0.007). There was a significant difference between the binding affinity of the progestin receptor in the male tumors (Kd = 2.2 +/- SEM 0.9 nM, n = 10) and that of the females, (Kd = 9.3 +/- SEM 6.5 nM) (p less than 0.04). When an affinity of less than 9.9 X 10(-9) M and greater than 10 fmol/mg cytosol protein were used as criteria for classifying a tissue as positive for progestin receptors, only 17% of tumors contained these receptors while 45% of normal tissues exhibited them. According to these criteria, no differences were observed in the frequency of occurrence of either estrogen receptors or glucocorticoid receptors in tumor versus normal kidney. Data from this study suggest that the use of endocrine therapy should be re-examined in the treatment of renal-cell carcinoma.