Evaluation of Sample Handling in Relation to Levels of Tissue Inhibitor of Metalloproteinases-1 Measured in Blood by Immunoassay

Background

The possible effect of preanalytical conditions such as blood sample preparation and handling on TIMP-1 levels in blood needs thorough investigation.

Materials and Methods

Blood was collected in dry tubes and tubes containing EDTA and kept at 4°C or 20°C for 1, 3, 8, 24 or 72 hours before processing into serum or EDTA plasma. In addition, serum and EDTA plasma samples were frozen and thawed 1–8 times. TIMP-1 was measured by ELISA.

Results

Time to processing for up to 72 hours did not significantly affect TIMP-1 levels in serum. In EDTA plasma, TIMP-1 levels were stable for up to eight hours; however, if samples were kept for 24 hours or longer the TIMP-1 levels increased (p<0.0001). Repeated freezing and thawing had a significant effect on TIMP-1 levels in serum (p=0.04). In plasma, repeated freezing and thawing for up to six times did not influence TIMP-1. However, in plasma samples exposed to seven or eight freeze/thaw cycles TIMP-1 levels decreased, although not significantly (p=0.23).

Conclusions

Handling and processing of blood samples is crucial for TIMP-1 measurement by immunoassay. In serum, TIMP-1 levels are unaffected by time to processing. Plasma samples should be processed within eight hours to avoid a TIMP-1 increase. For the measurement of TIMP-1 in archival material, serum should not be used because TIMP-1 levels are significantly affected by repeated freezing and thawing; archival plasma can readily be used provided that samples have not been frozen and thawed more than six times.

Tetranectin in cerebrospinal fluid of patients with multiple sclerosis

OBJECTIVE

Tetranectin (TN) is a glycoprotein and C-type lectin thought to play a prominent role in tissue remodelling. The aim of this study was to determine the TN serum and cerebrospinal fluid (CSF) concentration in patients with multiple sclerosis (MS) and controls.

MATERIAL AND METHODS

Two-hundred-and-four patients, divided into four diagnostic groups, i.e. definite MS (n = 76), possible onset symptoms of MS (n = 48), other non-inflammatory neurological diseases (n = 61) and other inflammatory neurological diseases (n = 19) and 47 controls with no history of neurological disease were analysed for TN in serum and CSF using a polyclonal sandwich ELISA.

RESULTS

All tested groups, e.g. definite MS, possible onset symptoms of MS, other neurological disease, both inflammatory and non-inflammatory, had decreased concentrations of TN in the CSF compared to the concentrations in controls. The quotient of TN in CSF divided by the concentration in serum (QTN) correlated significantly with the same quotient of albumin (QALB), was significantly correlated with the same quotient of albumin QALB. To account for differences in blood brain barrier permeability, we calculated a TN-index defined as: TN-index = QTN/QALB. QTN was significantly decreased in all groups compared to that in controls. However, in definite MS and patients with first attack of MS, the TN-index was not significantly different from that of controls. In contrast, other neurological diseases, both inflammatory and non-inflammatory, were associated with a decreased TN-index.

CONCLUSION

These results indicate that TN may play a role in neurological diseases and may serve as a diagnostic aid in MS.

Cancer-associated serum antigen level: a novel prognostic indicator for survival in patients with recurrent ovarian carcinoma

The aim was to examine the value of the pretherapeutic serum cancer-associated serum antigen (CASA) level as a prognostic factor for survival in patients with recurrent epithelial ovarian carcinoma. Serum levels of CASA and cancer antigen (CA)125 were prospectively determined in 70 consecutive patients with recurrent ovarian cancer before the start of second-line chemotherapy. Univariate and multivariate analyses of survival were performed. The median level of serum CASA was 6.5 U/mL (range: 0.2-1437 U/mL). Univariate analysis showed that patients with a CASA level >10.0 U/mL had significantly shorter survival than patients with CASA level < or =10.0 U/mL (P= 0.002). Using different CASA cutoff levels (6.0, 6.5, and 10.0 U/mL), multivariate Cox analyses identified CASA as an independent prognostic factor for survival at every cutoff level. The strongest prognostic function for CASA was found at a cutoff level of 10.0 U/mL (>10 vs < or =10 U/mL; hazard ratio, 2.7; 95% confidence interval, 1.6-4.7; P < 0.001). The pretreatment CA125 level was not found to be significantly associated with survival by any of the cutoffs (35, 65, 132, and 339 U/mL). A pretreatment elevated level of the tumor marker CASA is an adverse prognostic factor for survival in patients with ovarian cancer relapse.

Do risk factors for epithelial ovarian cancer have an impact on prognosis? Focus on previous pelvic surgery and reproductive variables

OBJECTIVES

The prognostic impact of risk factors for ovarian cancer development is sparsely explored, but previous sterilisation has been shown to have a negative impact on survival.

METHODS

Ovarian cancer cases were from the Danish MALOVA study. Information on previous pelvic surgery as well as reproductive variables was obtained from a personal interview conducted closely after primary surgery. Cox regression models were used to estimate adjusted hazard ratios (HR) and 95% confidence intervals (95% CI) for ovarian cancer specific death in relation to previous pelvic surgery and reproductive variables including lifetime number of ovulation years.

RESULTS

A total of 295 women with Stage III ovarian carcinomas were identified and followed to death or for a median of 7.3 years (range 5.4-9.5 years). Previously sterilised or hysterectomised women seemed to have a slightly decreased risk of ovarian cancer death (HR = 0.62; 95% CI: 0.36-1.08 and HR = 0.82; 95% CI: 0.55-1.21), although none of these associations reached statistical significance. The prognostic impacts of the individual reproductive variables followed the same pattern as the impact of the variables on ovarian cancer development, although significance was only reached for age at menarche (HR = 0.91 per year; 95% CI: 0.84-0.99). By accumulation of the possible minor effects of the reproductive variables in calculation of the total lifetime number of ovulation years, we found that survival decreased significantly with increasing number of ovulations (HR = 1.53 per 10 years; 95% CI: 1.09-2.14).

CONCLUSION

Increasing lifetime number of ovulations was a negative prognostic factor for ovarian cancer specific survival. Previous sterilisation or hysterectomy seemed to be associated with improved survival.

Increased risk of ovarian cancer in integrin beta3 Leu33Pro homozygotes

We previously demonstrated that integrin beta(3) Leu33Pro homozygotes have an increased risk of cancer, possibly most pronounced for ovarian cancer. We now test the latter hypothesis in case-control and prospective studies. We genotyped 463 Danish women with ovarian cancer, and 4291 women from the Danish general population. Calculation of odds ratios by conditional logistic regression was performed in the case-control study (n = 463 + 3543), and of ovarian cancer incidence, log-rank statistics and hazard ratios by Cox regression in the prospective study (n = 4291) with 9.5-year follow-up. In the case-control study matched for age and marital status, the odds ratio for ovarian cancer in homozygotes versus non-carriers was 1.6 (95% confidence interval: 1.0-2.6). In the prospective study with 28 incident ovarian cancers, non-carriers and homozygotes had incidences of 7 (4-11) and 30 (10-92) per 10 000 person-years (log-rank P = 0.02). The age-adjusted hazard ratio for ovarian cancer in homozygotes versus non-carriers was 3.9 (1.1-13). Risk of ovarian cancer did not differ between heterozygotes and non-carriers in either study. Integrin beta(3) Leu33Pro homozygotes have an increased risk of ovarian cancer.

Alpha-fetoprotein in plasma and serum of healthy adults: preanalytical, analytical and biological sources of variation and construction of age-dependent reference intervals

Alpha-fetoprotein (AFP) is a tumor marker for hepatomas and germ cell tumors, and the serum concentration has prognostic significance in other diseases. We examined the normal serum concentration of AFP in adults and sources of variation in the immunochemical variation of AFP. The serum concentration of the tumor marker alpha-fetoprotein (S-AFP) was log-normally distributed in 284 adult blood donors. S-AFP increased with age (p < 10(-7)), whereas no gender-related difference was found. Reference intervals (95-interpercentile) were constructed for persons < or =40 years (0.60-9.30 kIU/L) and >40 years (1.40 12.60 kIU/L). The concentration of AFP was significantly, albeit slightly, higher in serum than in plasma, whereas hemolysis, pretreatment with KCl and food intake did not influence S-AFP. S-AFP only changed 6% when measured twice 2 months apart (p=0.04). Three enzyme immunoassays, using three different anti-AFP monoclonal antibodies for detection, were compared and two assays gave S-AFP values significantly higher, 2.8% (p=0.03) and 19.0% (p<10(-4)), than the other assay. Thus, the choice of antibody may influence the result of immunochemical concentration determination. This can be explained by the existence of conformational variants of AFP with different antibody reactivities, and calls for careful standardization of monoclonal antibodies used in assays for AFP. With broad population reference ranges and slight intra-personal variation, the most effective reference range for S-AFP is previous values obtained in the same person.

The prognostic value of pretherapeutic tetranectin and CA-125 in patients with relapse of ovarian cancer

OBJECTIVE

The aim of the study was to examine the prognostic values of, respectively, tetranectin (TN) and CA-125 measured in serum from patients presenting with relapse of ovarian cancer (OC).

METHODS

TN and CA-125 were measured in serum samples from 75 patients with relapse of OC before the start of second-line chemotherapy. The endpoint used was death of OC. The variables were analyzed by univariate life table analysis and multivariate Cox analysis.

RESULTS

A significantly shortened survival was found for patients with low serum TN values compared to patients with serum TN levels above one of the cutoff levels. The survivals are illustrated by life tables. No prognostic function was found for CA-125. TN and relapse </=12 months after primary treatment were the only significant independent prognostic variables among the following variables tested in the Cox analyses: primary and second-line treatment, CA-125, age, histology, performance score, tumor localization, and size.

CONCLUSION

Serum TN determination may be valuable in the selection of patients with relapse of OC for new treatment strategies in future studies.

Predictive values of serum tumour markers tetranectin, OVX1, CASA and CA125 in patients with a pelvic mass

Our objective was to compare the predictive value of the well-established tumour marker CA125 with the newer tumour markers tetranectin (TN), OVX1 and CASA in distinguishing benign and malignant pelvic masses in women. Participants included 185 women, 19 years or older, with a pelvic mass planned for surgical exploration. Significantly different CA125 levels were found between benign tumours and localised ovarian cancer (OC), advanced OC and other non-OCs. Significantly different TN levels were found between benign tumours and advanced OC (stage III/IV), between benign tumours and other cancers and between all OCs and other cancers. For CASA, significant differences were found between benign tumours and all OCs as well as advanced OC. No significant differences could be demonstrated for OVX1. Significant correlations for the 44 OC patients were found between CA125, TN and CASA. No significant correlations were found for OVX1, possibly because of the method used for collection and handling of serum samples. None of the new markers had any additional predictive value compared to CA125. TN and CASA levels correlated with FIGO stage and could be used to discriminate between benign and advanced OC. However, in comparison to the performance of CA125, the additional discriminative value of TN and CASA was minor.

Serum tetranectin and CA125 in endometrial adenocarcinoma

BACKGROUND

CA125 and tetranectin (TN) are prognostic markers in ovarian cancer. This study examines the values of these markers in endometrial cancer.

MATERIALS AND METHODS

TN and CA125 were determined preoperatively in 99 patients with primary endometrioid adenocarcinoma and evaluated in relation to tumor grade, stage and cancer survival.

RESULTS

The CA125 levels correlated significantly with tumor stage. Dichotomized according to a cut-off level of 35 U/ml, CA125 significantly correlated with cancer death. Multivariate regression analysis of cancer survival time showed that CA125 > 35 U/ml was not an independent factor when stage was introduced. TN levels were within the normal range in all patients and did not show any association with tumor grade, stage or survival.

CONCLUSIONS

The study confirmed the role of CA125 as a prognostic factor in endometrial cancer and may be of aid in pointing out patients at high risk, whereas tetranectin did not show any prognostic effect.

Stability of YKL-40 concentration in blood samples

The stability of YKL-40, a mammalian member of the family of 18 glycosylhydrolases, in blood samples handled under different temperatures and different time intervals before centrifugation was studied in paired serum and plasma samples from 25 healthy premenopausal Danish women. Significant elevations of YKL-40 were found in 8 paired serum samples left on the clot for more than 3 h at room temperature compared to paired serum samples left on the clot for 3 h or less. Significant elevations of YKL-40 were found in 8 paired plasma (EDTA) samples left on the blood cells for more than 8 h at room temperature compared to paired plasma (EDTA) samples left on the blood cells for 8 h or less. No elevations were found in YKL-40 levels in serum samples left on the clot at 4 degrees C for 24 h or in plasma (EDTA) samples left on the blood cells for 72 h before centrifugation. Significantly lower concentrations of YKL-40 were measured in plasma (EDTA) compared with paired serum samples with a serum/plasma ratio of 1.4 in samples left on the clot or on blood cells at 4 degrees C for up to 24 h. Repetitive freezing and thawing had no significant effect on the measured YKL-40 concentrations. In conclusion, we have shown that YKL-40 is very dependent on the handling procedures. All the blood samples must be processed into plasma (EDTA) within 8 h at room temperature or into serum in less than 3 h at room temperature. If this is not possible, the blood samples must be stored at 4 degrees C until processed.

Alpha-fetoprotein in human fetal cerebrospinal fluid

Alpha-fetoprotein (AFP) is a fetal glycoprotein. It has been ascribed a regulatory function of growth factor responses and immune functions. The concentrations of AFP and albumin (ALB) are highly variable in fetal serum and CSF and change with gestational age. The AFP index=[AFP(CSF)/AFP(SERUM)]/[ALB(CSF)/ALB(SERUM)] was determined in six normal fetuses at gestational age 17-23 weeks and found to be independent of gestational age and close to unity, mean 0.90+/-0.11 (S.D.). The ratio of CSF-serum concentrations of AFP and ALB both decreased significantly (p<0.05) with gestational age. The mean fraction of AFP being non-reactive with concanavalin A was 1.7% in serum and 1.9% in CSF, suggesting a common hepatic origin of AFP in both compartments. In conclusion, the concentration of AFP in CSF seems to be determined largely by the serum-CSF concentration gradient in normal fetuses. This finding, combined with the remarkable constancy of the AFP index compared to the highly variable absolute concentrations of AFP in both serum and CSF should make the AFP index the marker of choice when analyzing for intrathecal AFP synthesis during development and in pathological conditions.

Human tetranectin: methodological and clinical studies

From its discovery in 1986 tetranectin (TN) has been suggested to participate in proteolytic processes through its binding to plasminogen, which enhances the activation of plasminogen to plasmin. Because extracellular proteolysis is an important factor in the ability of malignant cells to infiltrate normal tissues and metastasize, TN was considered to be a potential marker for this proteolysis. We have studied the variations in blood and tissue levels of TN in clinical conditions such as cancer and infection, where increased proteolysis can be expected. Five monoclonal antibodies (MAbs) were produced against human TN, and our study is the first report of stable hybridomas producing MAbs against human TN. All the MAbs reacted with epitopes located within aa-residues 50-181 of the primary sequence. In relative epitope mapping with enzyme immuno assay and isotachophoresis the five MAbs defined two independent epitope groups. Different combinations of MAbs were suitable for enzyme immuno assays and two MAbs could be used for immunohistochemical detection of TN in both fresh frozen and paraffin embedded tissues. The MAbs will facilitate future studies on structure, function, clinical significance and immunolocalization of TN. In primary ovarian cancer neither s/p-TN nor CA 125 were found valuable for diagnosis of localized cancer versus benign tumors. However, s/p-TN combined with CA 125, increased both sensitivity and specificity. S/p-TN should therefore be considered one of the screening markers in conjunction with CA 125, or other comparable markers, in future ovarian cancer screening research studies. Preoperative s-TN was significantly correlated to residual tumor and survival in ovarian cancer patients undergoing second or third look surgery. In conjunction with CA 125 and CASA the predictive value of TN for residual tumor was greatly improved, as the markers were found to supplement each other. If the second look operation had been restricted to patients who had a marker negative test, up to 37% would have avoided surgery. We therefore recommend that these tests are included as potential selection parameters in other studies evaluating second-look surgery. Low p-TN concentration and heavy extracellular staining of TN in the tumors was significantly correlated with a poor prognosis for patients with localized stage I or II or advanced primary ovarian cancer. The prognostic information can be especially valuable for patients with a localized ovarian cancer stage I or II, because about 20% of these patients, believed to be radically operated later present with relapse. We found the p-TN level to be especially useful for patients with localized cancer, indicating that adjuvant chemotherapy may be considered if the p-TN level is low. For patients with advanced primary ovarian cancer and low p-TN the survival was significantly reduced compared to patients with a higher p-TN. The p-TN level was significantly negatively correlated to the extracellular (stromal) staining of TN in the tumors. A heavy stromal TN staining was correlated with a shortened survival and was an independent prognostic factor in the Cox analyses. Patients with advanced primary cancer and a low p-TN, possibly in combination with a heavy stromal staining of TN in the tumors, should tentatively be offered palliative treatment or experimental chemotherapy. Furthermore, patients receiving chemotherapy may be monitored by s/p-TN measurements, as a decrease in TN concentration indicated recurrence 3.6 months prior to clinical diagnosis. A decrease in TN concentration during chemotherapy may therefore indicate change of treatment. Serum TN was a very strong independent prognostic factor of poor treatment response and a shortened survival in patients with metastatic breast cancer. A low pre-chemotherapy s-TN value together with clinical signs of poor treatment response may be an ominous combination, which may suggest change of treatment. For patients with Dukes' stage

Determination of serum tetranectin: technical and clinical evaluation of three sandwich immunoassays

The performance of two sandwich-type immunoassays for the determination of the tumour marker tetranectin using monoclonal antibodies Hyb 130-13 and 130-14 as catching layer was compared with the performance of a polyclonal assay. Sensitivities were 0.4-0.6 microg/l, and intra- and inter-assay coefficients of variation were < 10% in all assays. One-hundred-and-ten blood donors were examined, and women had higher concentrations of tetranectin in serum than men when measured with monoclonal assays (P < 0.05). In preoperative serum samples from 43 patients with ovarian cancer, tetranectin concentrations were reduced (P < 0.001), and the mean tetranectin concentration decreased with increasing FIGO stage of the patients (P < 0.05). In sera from patients with ovarian cancer, tetranectin concentrations were lower in the polyclonal assay than in the monoclonal assays. This could, hypothetically, be explained by ligand-binding or other conformational changes in tetranectin, influencing the antigenicity of the molecule.

Monoclonal antibodies against human tetranectin, epitope characterization and use in immunohistochemistry

Two IgG2a/kappa- and three IgG1/kappa monoclonal antibodies (MAbs) were produced against human tetranectin (TN): this is the first report of stable hybridomas producing MAbs against TN. All the MAbs reacted with non-conformational epitopes located within amino acid residues 50-181 of the primary sequence. In relative epitope mapping with enzyme immunoassay and isotachophoresis the five MAbs defined two independent epitope groups. One of them is suggested to be immunodominant in rabbits, since MAbs inhibited binding of a polyclonal rabbit antibody. Several combinations of MAbs were suitable for TN-ELISA and two MAbs could be used for immunohistochemical detection of TN in both fresh frozen and paraffin-embedded tissues. The MAbs will facilitate future studies on structure, function, clinical significance and immunolocalization of TN.

Immunoreactive inhibin concentration in blood tested under variable sampling conditions

The stability of immunoreactive (i.r.) inhibin in blood samples drawn and handled under different conditions and at different time intervals were studied. Ten serum and plasma samples drawn in 1994 from healthy volunteers were compared to samples collected in 1986 from 10 healthy women admitted for laparoscopic sterilization and analysed 6 years later. All samples were drawn on the twelfth day of the menstrual cycle and handled under identical clinical conditions (22 degrees C). The concentrations in the 1986 samples were similar to the Se-i.r. inhibin levels from 1994. Different clotting temperatures, repetitive freezing and thawing or hemolysis had no effects on the i.r. inhibin values, whereas non-hemolysed samples left at room temperature (22 degrees C) for 3 days were significantly lower, which might be due to a statistical type 2 error. No differences in concentration between serum and plasma i.r. inhibin were demonstrated. In conclusion, i.r. inhibin is a very stable peptide hormone in both serum and plasma if drawn and handled under normal conditions.

Use of tetranectin, CA-125 and CASA to predict residual tumor and survival at second- and third-look operations for ovarian cancer

Tetranectin (TN), CA-125 and CASA were measured in serum prior to 63 second-look and 5 third-look operations for ovarian cancer. Patients with residual tumor had significantly lower levels of TN and higher levels of CASA and CA-125 compared with tumor-free patients. The predictive values PVPos = 100% and PVNeg = 50.9% were found for TN at 9.3 mg/l. For CASA, a predictive value PVPos = 100% was found at 10 U/ml with a corresponding PVNeg = 52.7%. At the cut-off 35 U/ml for CA-125, the PVPos was 100% and the PVNeg = 53.6%. By combining the markers, PVNeg increased to 61.7% with a PVPos on 100%. Significantly differences in survival were found by lifetable analysis between patients tested as positive and negative respectively for any of the markers. Using multivariate Cox analyses, it was found that every marker had an independent prognostic function for survival.

Plasma tetranectin and colorectal cancer

The prognostic significance of plasma tetranectin (PL-TN) in colorectal cancer was retrospectively examined in 504 patients (80 Dukes' A, 174 Dukes' B, 98 Dukes' C and 152 Dukes' D). Follow-up time was 7-12 years. No significant prognostic variable was found for Dukes' A patients by Cox multivariate analysis. In stage B, PL-TN was the second strongest prognostic variable [relative hazard (RH) = 3.3 for patients with PL-TN < or = 7.5 mg/l]. The other prognostic variables were perineural invasion (RH = 3.7), tumour distance < or = 10 cm from the anal verge (RH = 3.0), postoperative radiotherapy (RH = 2.9) and a high carcinoembryonic antigen (CEA) score (RH = 1.8). In Dukes' C, only CEA score and gender were of prognostic significance. For Dukes' D, PL-TN was the only prognostic variable (RH = 1.7). Testing all patients in one multivariate analysis, Dukes' staging was the strongest and PL-TN the second strongest prognostic variable. The shortened survival for patients with low PL-TN levels is illustrated with lifetables.

Serum tetranectin in patients with acute pelvic inflammatory disease (PID). Correlation to clinical and laboratory findings

AIM OF STUDY

To clarify the impact of the presence of pelvic inflammatory disease (PID) and activation of the acute phase response on the serum level of tetranectin (Se-TN), a potential new tumor marker for ovarian cancer.

MATERIALS AND METHODS

The study group consisted of 70 patients with a laparoscopically verified PID and 47 healthy female controls.

RESULTS

Lower Se-TN levels were found for the PID group compared to the control group (p < 0.0001). It was not possible to relate the decreases in Se-TN levels to any distinct bacterial strain. Neither was it possible to find any correlation between Se-TN and severity of PID (p = 0.5). A significant positive correlation was found between Se-TN and ALB (p < 0.001). A just significant negative correlation was found between Se-TN and C-reactive protein (CRP) (p = 0.04), while no correlation was found with any of the other acute phase reactants. Highly significant correlations were found between all the acute phase reactants and grade of PID.

CONCLUSIONS

A slight, but significant reduction in Se-TN was found in PID patients. The decrease was minor compared to the reported findings of very low Se-TN levels for ovarian cancer patients. However, the finding is important in the assessment of TN used as a potential screening marker for ovarian cancer, or as a diagnostic tool for pelvic tumors. Furthermore, Se-TN does not seem to behave as a negative acute phase reactant.

Ovarian carcinoma serum markers and ovarian steroid activity--is there a link in ovarian cancer? A correlation of inhibin, tetranectin and CA-125 to ovarian activity and the gonadotropin levels

In a previous study, we have demonstrated that inhibin-production may be associated with improved survival and, also, that tetranectin (TN) is a valuable prognostic marker in ovarian epithelial cancer. We investigated the possible correlation between inhibin, tetranectin, CA-125, ovarian steroid activity and the gonadotropin levels. Preoperative serum levels of the tumor markers inhibin, tetranectin (TN) and CA-125 were measured and related to ovarian steroid function and the pituitary-gonadal axis (gonadotropin levels) in 28 postmenopausal ovarian cancer patients. The following median levels and 95% confidence limits were demonstrated for the tumor markers: Inhibin 0.4 U/l (0.2-0.9), TN 8.9 mg/l (6.8-9.2), CA-125 160 kU/l (75-687). A significant inverse correlation was demonstrated between inhibin and the gonadotropins. The Spearman correlation coefficients showed a highly significant correlation of inhibin with the examined ovarian steroid hormones except DHEAS which also has a suprarenal component. This indicates a synthesis of inhibin and the steroid hormones from the same cell compartment as known from the normal ovary and an apparently intact negative feed back mechanism. Inhibin may be produced in the normal ovary as a defense mechanism against an elevated gonadotropin level and inhibin acts by lowering the gonadotropins or by altering their biological activity. Elevated values of the tumor markers TN and CA-125 due to gonadotropin stimulation could not be demonstrated but a significant inverse correlation between TN and CA-125 was confirmed.

Alpha-fetoprotein and the acute phase response. A study using acute pelvic inflammatory disease as a model system

Alpha-fetoprotein (AFP) is used as a tumor marker for hepatomas and germ cell tumors. In healthy non-pregnant adults the serum concentration (S-AFP) is very low and we examined whether it was affected when the acute phase response was activated, using patients with acute pelvic inflammatory disease (PID) as a model system. In 70 PID patients the median S-AFP was 1.2 kIU/l (range: 0.5-5.9 kIU/l), within the normal range. S-AFP did not correlate with the clinical grade of disease nor with the serum concentrations of acute phase reactants and albumin. Thus, S-AFP is not significantly affected by activation of the acute phase response and presence of infection should not per se interfere with the use of S-AFP as a tumor marker. However, a negative correlation was found with the serum concentration of alpha-2-macroglobulin (P = 0.05), but whether this has any biological significance remains to be clarified.

The role of serum tetranectin, CA 125, and a combined index as tumor markers in women with pelvic tumors

Serum tetranectin (Se-TN) and CA-125 were measured in 315 patients with a pelvic tumor and 458 healthy females. At a false-positive rate of 0.7% the sensitivity for ovarian cancer stage 1 and 2 was 33% for Se-TN and 76% for both CA 125 and an index based on Se-TN and CA 125 (Index 1). At a false-positive rate of 0.4% the sensitivity was 29% for Se-TN, 62% for CA 125 (35 U/ml), and 76% for Index 1. A negative correlation was found between the Se-TN level and the stage of cancer. The sensitivity for benign tumors was 6% for Se-TN, 17% for CA 125, and 21% for Index 1 at a false-positive rate of 0.4%. In the present study the sensitivity and specificity levels of Se-TN were not sufficiently high to warrant the use of Se-TN as an individual marker for ovarian cancer. The sensitivity rose with the index-based Se-TN and CA 125 without causing a concomitant increase in the rate of false-positive results. None of the markers rose to levels that would allow their use in clinical diagnosis to discriminate between localized cancer and benign tumors.

Serum tetranectin and CA-125 used to monitor the course of treatment in ovarian cancer patients

Serum tetranectin (Se-TN) and CA-125 were measured in serum samples obtained before primary surgery, before start of chemotherapy and monthly during chemotherapy in 8 patients with ovarian cancer. The median Se-TN level before chemotherapy (7.3 mg/l) increased significantly after the start of chemotherapy (13.7 mg/l), with the highest increase for one survivor (145%). Five patients who died of cancer in the study period, had pronounced decreases (30-50%) in Se-TN with a maximal concentration during chemotherapy to the lowest concentration in the last sample. One patient who died 10 months after closure of the study had continuously normal Se-TN values, but the last CA-125 value elevated. The lead time could be calculated in four patients for Se-TN and six patients for CA-125. Median lead times of 3.6 months and 3.8 months were found for Se-TN and CA-125 respectively. In conclusion, chemotherapy induces significant increases in Se-TN levels. A decrease in Se-TN during chemotherapy is highly suspect for recurrence and a poor outcome. Measurements of TN should therefore be included in other comparative studies.

[Tetranectin, a plasma and tissue protein--a prognostic marker of breast and ovarian cancer]

A new plasma protein, tetranectin, was discovered in 1986. It is composed of four non-covalently linked identical peptide chains, each with a molecular weight of 20 kDa. The protein structure is known and it has been found to bind to plasminogen, Ca++ and sulphated polysaccharides. All normal epithelial and mesenchymal cells contain tetranectin in their cytoplasm, but tetranectin is not seen in normal extracellular matrix. The concentration of tetranectin in blood from healthy individuals is about 10 mg/1 with slight sex and age variations. The biological function of the protein is still unknown. The amount of tetranectin in the blood is reduced in patients with various cancer diseases. The degree of tetranectin reduction in the blood from patients with ovarian carcinoma and metastasizing breast carcinoma correlates with survival. While tetranectin is absent in normal extracellular matrix, it is found extracellulary in granulation tissues and in some carcinomas of the breast and the ovary. Lifetables of patients with ovarian carcinoma show that high concentrations of extracellular tetranectin is associated with a poor prognosis. Tetranectin may be a new prognostic marker which should be included in future clinical studies evaluating the prognosis for cancer patients.

Feasibility study of a randomised trial of ovarian cancer screening

OBJECTIVES

To assess the feasibility of a randomised trial of ovarian cancer screening by vaginal ultrasonography.

SETTING

A population based study, recruiting a random sample of the female population aged 46 to 65 years living in Copenhagen, Denmark.

DESIGN

Randomised controlled trial allocating 50% to the study group having vaginal ultrasonography, and 50% to the control group having no examination. (a) Acceptability of the study was evaluated by the proportion of eligible women willing to participate in the study. (b) The false positive rate was evaluated as the proportion of women without ovarian cancer referred for an operation because of abnormal ovaries detected by ultrasonography.

RESULTS

950 (64.3%) of the 1477 eligible women participated in the study. At the first scan abnormal ovaries were detected in 54 of 435 women (12%), significantly more frequently among younger women. Nine women were referred for an operation because of abnormal findings in the ovaries, giving a false positive rate of 2%. Ovarian size and morphology found at operation corresponded with those at ultrasonography; none of them was malignant.

CONCLUSIONS

A randomised controlled trial of ovarian cancer screening using vaginal ultrasonography seems acceptable in the general population. The rate of abnormal ovaries at ultrasonography with the cut offs used in this study was quite high. Such a study is, therefore, feasible, but it is proposed that it is carried out in an older age group (50-64 years) and that the cut offs used for ovarian size and morphology are re-evaluated. Second line tests, such as colour Doppler flow, should be considered in order to reduce the false positive rate.

Postpartum amenorrhoea and breast-feeding in a Danish sample

The duration of postpartum amenorrhoea was studied in a Danish sample of 361 women. The median duration of amenorrhoea was 17 weeks. The 25th and 75th percentiles were 10 and 30 weeks, respectively. A significant correlation was found between the duration of postpartum amenorrhoea and of breast-feeding. However, lactation for more than 9 months did not extend the duration of amenorrhoea. Menstruation before weaning occurred in 57% of the women, and 43% terminated breast-feeding before the first menstruation. Four weeks after weaning menstruation had returned in 79% and by 8 weeks after in 93% of the mothers. At 6 months postpartum, frequency of breast-feeding, and of night-time feeding were determinants of amenorrhoea.

A new simple and rapid dual assay for AFP and free beta hCG in screening for Down syndrome

We have evaluated a simple and rapid 2-step dual-label assay (DELFIA) for alphafetoprotein (AFP) and free beta subunit of human gonadotropin (hCG beta) in second-trimester screening for Down syndrome. Based on stored serum samples from 1059 normal control pregnancies and 72 cases of Down syndrome, we have found the mean Multiple of Median (MoM) for AFP and free hCG beta to be 0.70 and 2.31, respectively. This is slightly but not significantly better than the values for the separate assay for AFP (0.76 MoM) and for intact hCG (2.11 MoM). However, the dual assay is much simpler than the separate assays and therefore prospective comparison trials should be carried out.

Pre-operative plasma tetranectin as a prognostic marker in ovarian cancer patients

Plasma tetranectin (TN) was tested as a biochemical prognostic marker in ovarian cancer on 39 patients. In stage I + II the 5-year survival was 33% (2/6) if plasma TN was < or = 6.7 mg l-1 and 100% (15/15) with plasma TN > 6.7 mg l-1. For stage III + IV the survival was 0% (0/11) at 26 months for patients with plasma TN < or = 6.7 mg l-1 and 29% (2/7) after 5 years with plasma TN > 6.7 mg l-1. By multivariate testing the relative hazard (RH) of death was found to be 73 times higher in patients with plasma TN < or = 6.7 mg l-1 compared to patients with values above 6.7 mg l-1 (p < 0.001). For comparison, the maximal RH for the other tested variables were: 15 for advanced stage, 2.5 for grade, four for residual tumour and 2.5 for younger age.

The prognostic value of tetranectin immunoreactivity and plasma tetranectin in patients with ovarian cancer

BACKGROUND

Tetranectin (TN), a tetrameric, plasminogen-binding protein, was reduced in the plasma of patients with cancer and appears extracellularly in "stimulated" connective tissues, such as the proliferative, connective tissue response to carcinomas known as desmoplasia.

METHODS

Tissue samples from 37 patients with ovarian cancer were examined immunohistochemically for stromal and cellular TN. Plasma samples obtained before the primary surgery were quantitated for TN. The univariate log-rank test and the multivariate Cox proportional hazards regression model were used to analyze the prognostic function of the variables.

RESULTS

A significantly higher survival rate was found for patients with a low-stromal TN score and a high-plasma TN concentration, whereas the cellular TN score did not have any significance. A significant negative correlation was found between plasma TN and stromal TN (RS = -0.36; P = 0.03). Independent significant correlations were found between stromal immunoreactivity for TN and tumor grade (R = 0.67; P = 0.03) and between plasma TN and tumor stage (R = -0.29; P = 0.01).

CONCLUSIONS

This study gives great expectations to TN as a useful parameter for prognostic evaluation of patients with ovarian cancer. According to the correlations, stromal TN may partly originate from plasma and enhance proteolytic degradation in the interstitial tissue, a process necessary for the spread and growth of cancer. Because plasma TN measurements are only valid when taken preoperatively, it is of great value that stromal TN immunoreactivity of stored tumor tissue can be used as a prognostic factor for ovarian cancer.

Hormonal factors and prognosis in epithelial ovarian cancer: a multivariate analysis

When a significantly lower follicle stimulating hormone (FSH) level was found in patients with epithelial ovarian carcinoma, it was decided to analyze the influence of hormonal factors on prognosis. Thirteen factors were tested for prognostic significance in 35 women with epithelial ovarian carcinoma. Age, FIGO-stage, histopathological grade, residual tumor, treatment, gonadotrophins and steroid hormones were tested. By univariate log-rank testing a significantly shorter survival time was found for patients with ascending FIGO-stage, residual tumor mass, estradiol < 0.10 nmol/l, progesterone < 2.0 nmol/l and DHEAS < 1300 nmol/l. In the Cox model the independently significant prognostic factors found were residual tumor mass (P < 0.001) with a risk estimate of 2.65, progesterone (P < 0.05) with a risk estimate of 0.29 for a progesterone level > 2.0 nmol/l and total testosterone (P < 0.03) with a risk estimate of 0.29 for a total testosterone level > 1.15 nmol/l. The present findings, together with the assumption that an elevated gonadotrophin level may induce ovarian tumor growth (the gonadotrophin theory), earlier findings of estrogen and progesterone receptors in human ovarian cancer, and the in vitro demonstration of gonadotrophin-growth-stimulation of human malignant epithelial tumors, justify a thorough investigation of the interaction between steroid hormones and receptors, gonadotrophins, tumor bulk and survival in future research protocols.

[Utilization of the right to maternity leave and resumption of work after delivery. A longitudinal prospective study]

A longitudinal interview study of 360 mothers was carried out to investigate: 1) utilization of maternity leave by the parents, 2) mothers' resumption of occupation after delivery and 3) duration of breast feeding seen in correlation with the mothers' resumption of work. 1) 95% of the families utilized the entire maternity leave. In 92% of the families, the mothers utilized all 24 weeks and, in 3% of the families, the fathers took part in the maternity leave. Only 46% of the fathers utilized the right to take leave in connection with delivery and 14% employed their holiday but were at home for a significantly shorter period. 2) Only one fourth of the mothers had resumed work 24 weeks after the delivery. 44% of the mothers prolonged the maternity leave with their holiday and 32% prolonged the maternity leave even longer. One year after delivery, significantly more mothers were housewives than previously. 3) A significantly positive correlation was found between the time for maternal return to work and the duration of breast feeding. We conclude that almost all of the families utilized the maternity leave and that prolongation of maternity leave (which is 24 weeks after delivery at present) might be necessary.

Prognostic value of serum tetranectin in patients with metastatic breast cancer

To evaluate serum tetranectin as a prognostic marker before first-line chemotherapy, serum levels were studied in 67 patients with metastatic breast cancer. In the Cox analyses, the relative risk (RR) for death of cancer varied with the cut-off level of serum tetranectin. A maximal RR of 5.0 was found for patients with serum tetranectin < or = 5.4 mg/l. The maximal RR of death for the other prognostic variables were multiple metastases 2.8, and for a poor performance status 2.0. Testing for the outcome, progressive disease, a maximal RR of 3.8 was found for patients with serum tetranectin < or = 5.3 mg/l, a maximal RR of 3.7 for multiple metastases and a maximal RR of 1.8 for a poor performance status. Significantly lower serum tetranectin values were found in patients with a poor treatment response compared to well responding patients. Serum tetranectrin seems to be useful as an additional prognostic factor in metastatic breast cancer.

Changes in plasma tetranectin following hip surgery with or without thrombotic complications

The fibrinolytic system seems to play a role in the development of postoperative thromboembolic complications (DVT). The newly described tetrameric protein tetranectin (TN), which has been found to enhance the activation of plasminogen to plasmin, therefore was studied in 55 patients who had total hip replacement and solely elastic stockings as physical thromboprophylaxis. No significant difference in plasma TN was found between the 5 patients with DVT and those without DVT, neither preoperatively or postoperatively at day 0, 1, 3, 7 or 10. A significant decrease in plasma TN was found from preoperative to postoperative values, indicating that TN may be a possible marker for other postoperative events. Because of the observed postoperative decrease it is important to consider the sampling time in the future research with TN.

CA-125 as a maternal serum marker for Down's syndrome in the first and second trimesters

CA-125, alpha-fetoprotein (AFP), and human chorionic gonadotropin (HCG) were determined in maternal serum in the first trimester from 14 women with a Down's syndrome fetus and 61 women with a healthy fetus. In the second trimester, 15 and 60 serum samples were determined from women with a Down's syndrome and a healthy fetus respectively. In both trimesters, maternal serum CA-125 was found to be elevated in Down's syndrome pregnancies compared with controls. Using discrimination functions, our preliminary results indicate that CA-125 is a better marker than AFP and HCG respectively for a Down's syndrome fetus in the first trimester and improves the detection rate in the second trimester.

Plasma tetranectin and ovarian neoplasms

Plasma tetranectin was measured in 67 controls, 121 patients with a benign or malignant ovarian tumor, and 24 patients with another benign gynecologic disease to evaluate the predictive value of plasma tetranectin. A significant reduction of plasma tetranectin was found in every malignant tumor type except for mucinous tumors. Further a significant correlation was found between stage of tumors and plasma tetranectin. Depending on the cutoff level the sensitivity for stage 1 cancer ranged from 52 to 71%. In stage 1 + 2 the sensitivity ranged from 58 to 75% and for advanced cancer (stage 3 + 4) from 80 to 95%. The corresponding specificities ranged from 97 to 84%. Plasma tetranectin may be a useful tool for detecting early stages of ovarian cancer.

[Duration of breast feeding]

A longitudinal prospective study was performed to investigate the total duration of breast-feeding. Three hundred and sixty six mothers were followed-up until three years after delivery. At three months, 73% were breast-feeding, at six months 52%, at one year 20% and 1% breast-fed more than three years. Correlations were found between duration of breast-feeding and maternal age, education and social class. Mature mothers who lived under good socioeconomic conditions breast-fed for longer periods than those who were less fortunate in these respects. Mothers who had breast-fed an older child usually breast-fed the next child for a similar period. Breast-feeding has become popular: only 1% did not want to breast-feed at all and 89% of mothers intended to breast-feed their children for six months or more. Solid food was most frequently introduced when the infants were four months old. At six months 4% were still exclusively breast-fed. Even though the mothers now breast-feed longer than previously, only 39% succeeded in breast-feeding for as long as or longer than they had intended.

Tetranectin in amniotic fluid, maternal serum and fetal fluids

The concentration of the newly discovered protein tetranectin has been measured in different fetal and maternal compartments. In amniotic fluid a significant, positive correlation between the tetranectin concentration and gestational age was found (a mean of 0.2 mg l-1 at week 14 to a mean of 0.5 mg l-1 at week 21). In maternal serum a slight negative correlation was found between tetranectin concentration and gestational week (a mean of 6.17 mg l-1 at week 14 to a mean of 5.79 mg l-1 at week 21). In-term cord blood collected at delivery a mean level of 6.0 mg l-1 was found, and no difference was found between arterial- and venous-blood tetranectin concentration. In fetal serum the overall mean level was 2.6 mg l-1 and a significant positive correlation between tetranectin concentration and gestational age was found. The mean level was 1.1 mg l-1 in fetal cerebrospinal fluid and no correlation to gestational age was found. Fetal tetranectin may, therefore, be correlated to fetal maturation.

The duration of breast-feeding. A longitudinal prospective study in Denmark

A longitudinal prospective study was performed to investigate the total duration of breast-feeding. Three hundred and sixty-six mothers were followed-up until 3 years after delivery. At 1 month 93% were breast-feeding, at 3 months 73%, at 6 months 52%, at 1 year 20% and 1% breast-fed more than 3 years. Correlations were found between duration of breast-feeding and maternal age, education and social class. Mothers who had breast-fed an older child usually breast-fed the next child for a period of similar length. Solid food was most frequently introduced when the infants were 4 months old. At 6 months 4% were still exclusively breast-fed. Breast-feeding has become popular: only 1% did not want to breast-feed at all and 89% of mothers intended to breast-feed their children for 6 months or more. Even though the mothers now breast-feed longer than earlier, only 39% succeeded in breast-feeding for as long as or longer than they had intended.

The significance of pregnancy, delivery and postpartum factors for the development of infantile colic

Infantile colic (IC) is a distressing condition with an unclear etiology. A prospective trial was undertaken to study the hypothesis that medication during labor increases the risk of IC. Of 365 singleton deliveries, 70 (19%) developed IC. The factors associated with a significantly increased occurrence of IC were: a "psychological" complication of pregnancy, a sibling with a history of IC, a bad subjective experience of pregnancy and second parity. No significant association to "true" obstetrical complications or labor occurrences (breech, vacuum extractor, cesarean section, shoulder dystocia, pudendal block, epidural analgesia, general anesthesia or intravenous Syntocinon) was found. Modern management of labor does not increase the risk of IC. Prevention of IC is therefore achieved by psychological support to the pregnant women in the risk groups, and not by depriving her of necessary obstetrical management or pain relief.

Spontaneous rupture of an ovarian-artery aneurysm in the third trimester of pregnancy

The first report of a ruptured ovarian artery aneurysm in the third trimester of pregnancy is presented. A 31-year-old woman, para 3, was admitted at 39 weeks of gestation with an acute onset of severe abdominal pain and signs of circulatory collapse. At the operation a 3 x 4 cm ruptured aneurysm of the right ovarian artery was found. The mother survived, with no sequelae. Intensive resuscitation of the infant was carried out in vain. Etiology, symptoms and differential diagnosis are discussed.

Reversal of female sterilization using macro technique

The pregnancy rate of 63 women who underwent macrosurgical reversal of sterilization is reported. The pregnancy rate is based on life table estimates. The present material is the largest reported with this method. No statistically significant correlation was found between pregnancy outcome and tube length, anastomotic site, technique of sterilization, day of refertilization in menstrual cycle, or time interval between sterilization and refertilization. Using life tables, the cumulative probability of intra-uterine pregnancy 6, 12, 24, 36, 48 and 66 months after surgery was 14%, 26%, 39%, 39%, 43%, and 51% respectively. Our results of macroscopic sterilization reversal are comparable to the reported results of microsurgical methods. They support the contention that atraumatic technique rather than the microscope is important for good results.