Urinary cyclic GMP after treatment of gynecological cancer. A prognostic marker of clinical outcome

BACKGROUND

The search for biological markers to predict malignant disease and its recurrence, or to monitor the effectiveness of treatment is a continuous process in medicine. Several years ago, urinary excretion of cGMP in urine was found to be a sensitive predictor in the follow-up of ovarian cancer and of monitoring treatment of cancer of the uterine cervix.

PATIENTS AND METHODS

In the present study, 27 patients with gynecological cancer, including cancer of the uterine cervix (n=13), cancer of the uterine corpus (n=8) and cancer of the ovaries (n=6), were monitored for 10 years. Blood and urinary samples were taken before primary treatment (baseline sample) and three months thereafter (three-month sample). The serum levels of CEA, CA-125 and PIIINP and urine excretion of cGMP and cAMP were determined. Creatinine levels in serum and urine were employed to determine renal clearance.

RESULTS

After 10 years' observation of women with cancer of the uterine cervix, seven patients showed no relapse and cGMP levels in baseline samples and three-month samples were 36.8+/-4.1 and 24.9+/-4.4 nmol cGMP/micromol creatinine (mean+/-SEM, p<0.01), respectively. The levels in patients (n=6) with relapse after 10 years' observation were 32.8+/-4.0 (baseline sample) and 43.5+/-4.2 (three-month sample) nmol cGMP/micromol creatinine (mean+/-SEM, p<0.02). Among the patients treated for cancer of the uterine corpus (n=9), none showed recurrent disease within the observation period of 10 years. The cGMP levels fell from 37.9+/-6.3 (baseline sample) to 22.3+/-2.3 (three-month sample) nmol cGMP/micromol creatinine (p<0.005). In the patients with ovarian cancer (n=6), 4 patients relapsed during the observation period of 10 years. In these women the cGMP levels increased from 34.5+/-2.7 (baseline sample) to 46.3+/-4.7 nmol cGMP/micromol creatinine whilst in both patients without relapse the levels decreased from 31.8 (range: 26.5-37.1) to 27.3 (range: 25.7-28.8) nmol cGMP/micromol creatinine, respectively. The changes in levels of cAMP, CEA, CA-125 and PIINP did not show statistically significant differences. Early changes in cGMP levels appear to predict long-term prognosis in gynecological cancers.

Urinary matrix metalloproteinases as a potential screening test for gynecologic malignancies

OBJECTIVE

This was a pilot study to determine the feasibility of using urinary matrix metalloproteinases (MMPs) as a screening test for gynecologic malignancies.

METHODS

Urine samples from ovarian (n = 29), cervical (n = 31), endometrial (n = 31), and vulvar (n = 5) cancer patients and 19 controls were collected. Substrate gel electrophoresis (zymography) was used to determine the presence of MMP-2 (72 kDa), MMP-9 (92 kDa) and two high-molecular-weight forms (130 and 220 kDa) of MMPs. The sensitivity, specificity, and positive and negative predictive values of the test for each tumor type were determined.

RESULTS

No association was noted between malignancy and presence of urinary MMPs in ovarian, cervical, endometrial, or vulvar cancer patients. Sensitivity, specificity, negative and positive predictive values, and likelihood ratios were determined. Sensitivities ranged from 28.1 to 51.0% for individual MMPs, peaking at 69.8% when the presence of any of the four proteinases was considered a positive test. Specificities ranged from 42.1 to 68.4%.

CONCLUSION

Our study suggests that the presence of MMPs in the urine of patients with a gynecologic malignancy is not an adequate screening test for disease. There was also little evidence of an association between urinary MMPs and stage or extent of disease. However, the limited number of patients in the various stages of each disease site, specifically advanced stage disease, make it difficult to state this definitively.

Urinary gonadotropin peptide (UGP) and serum CA 125 in gynaecologic practice, a clinical prospective study

BACKGROUND

Beta human chorionic gonadotropin (beta-hCG) is expressed in human fetal tissue and cancer cells of various histologic types. It is degraded to the beta-core fragment (beta cf-hCG) which is concentrated in urine, and is known as urinary gonadotropin peptide (UGP). The objective of this study was to assess 1) the value of urinary gonadotropin peptide (UGP) as a single test and the combination of UGP with CA 125 as a diagnostic test in predicting the benign or malignant origin of gynecologic disease, 2) the influence of surgical removal of the tumor on the levels of UGP and CA 125, 3) the influence of the urinary concentration on the UGP levels in relation to the test results. PATIENTS, MATERIALS, METHODS AND STATISTICS: Serum and urine were collected from 31 gynecological patients with malignant and non-malignant disease, preoperatively, and 1 week and 6 weeks after surgery. Optimal cut-off levels were determined by Receiver Operating Characteristic-curves (ROC). Sensitivity (SENS), specificity (SPEC), positive (PPV) and negative predictive value (NPV) and overall test accuracy (ACC) for their ability to discriminate benign from malignant masses were calculated. Logistic regression analysis was performed to calculate the contribution of CA 125, UGP and UGP/creatinine (UGP/creat) to a model predicting malignancy.

RESULTS

The optimal cut-off level for UGP was found 1 fmol/l, for UGP/creat 1.33 fmol/mg creatinine and for CA 125 100 kU/L. The distribution of the urinary creatinine values varied considerably (median = 8.3 mmol/l, range 0.6-25.8 mmol/l). The correlation coefficient (r) between log UGP and log CA 125 was 0.44 (p = 0.001) and between log UGP/creat and log CA 125 0.53 (p < 0.0001).

CONCLUSIONS

UGP may be used as a tumor maker in gynecological disease. However, CA 125 as single test discriminates malignant from benign disease better than UGP or UGP/creat. In a logistic model the combination of CA 125 with UGP and UGP/creat predicts the benign or malignant character in 89% of the study population. Significant changes in UGP and UGP/creat levels were seen after removal of benign tumors, however, this was not found in ovarian cancer patients. Correction of the UGP values for the urinary concentration improved the results slightly.

Presence of urokinase-type plasminogen activator receptor in urine of cancer patients and its possible clinical relevance

High levels of urokinase-type plasminogen activator receptor (uPAR) are expressed in various types of cancer. Recent studies showed that cancer patients may have increased levels of soluble (s)uPAR in their serum. In the present study, we show that urine samples from healthy volunteers contain measurable amounts of suPAR. suPAR/creatinine levels from healthy controls showed only little variation over the day and were even stable during a month of continued monitoring. Importantly, urinary suPAR/creatinine levels were highly correlated with serum suPAR concentrations. Urinary suPAR levels were elevated in patients with different types of cancer. Interestingly, part of the urinary suPAR seemed to be present in a cleaved form, as has been found in tumor tissue extracts. Together with the recently established, cell migration-promoting effect of certain cleaved fragments of suPAR, the present data suggest that the measurement of urinary suPAR and/or its cleaved forms might have clinical implications.

Molecular heterogeneity of hCGbeta--related glycoproteins and the clinical relevance in trophoblastic and non-trophoblastic tumors

We analyzed immunoreactive hCG/hCGbeta (IR-beta) in the sera and urine of patients with trophoblastic diseases and non-trophoblastic tumors by using enzyme immunoassays (EIAs) specific for intact hCG, free hCG beta, and beta-core fragment of hCG (beta-CF). In trophoblastic diseases, while intact hCG and free hCGbeta were contained in both serum and urine, the beta-CF could be detected only in the urine of the patients. The relative contribution of the beta-CF to the total urinary IR-beta accounted for about 30-50% in normal early pregnancy and hydatidiform mole, and more than 60% in choriocarcinoma. We conclude that intact hCG should be measured in the serum rather than in the urine as a tumor marker for trophoblastic diseases, and suggested that the ratios of intact hCG, free hCGbeta, and beta-CF to each other may be useful indices in the differential diagnosis of trophoblastic diseases. Ectopic IR-beta was also investigated in the sera and urine of the patients with cervical, endometrial, ovarian, lung, and bladder carcinomas. We found that even when IR-beta could not be detected in the serum, the urine of the same patients with cancer often contained the significant amounts of IR-beta. The chromatographic study indicated that these urinary IR-beta were essentially attributed to beta-CF, leading to the evaluation of urinary beta-CF as a tumor marker. The positive rated of urinary beta-CF were 48% for cervical, 38% for endometrial, and 84% for ovarian, 40% for lung, and 42% for bladder carcinomas. We conclude that ectopic production of hCG beta by non-trophoblastic tumors is not a rare phenomenon and it can be recognized as a tumor marker when beta -CF is measured in urine of the patients.

UGP--a tumor marker of gynecologic and breast malignancies? Specificity and sensitivity in pretherapeutic patients and the influence of hormonal substitution on the expression of UGP

Urinary gonadotropin peptide (UGP) is a 10,300 Dalton peptide which is present in the urine of pregnant women, those with trophoblast disease and those with, certain nontrophoblastic malignancies. We examined the efficiency of UGP measurement at differentiating benign from malignant gynecologic and breast diseases. UGP was measured in 1355 spot urine samples from 841 patients (343 samples from 323 healthy women and women with benign gynecologic and breast diseases, 1012 samples from 518 women with gynecologic malignant diseases or breast cancer). Using a cutoff of > 3 fmol UGP/mg urinary creatinine the specificity was 97%. The sensitivity of UGP was calculated from pretherapeutically collected samples (n = 210). The sensitivity of the test for all malignancies was 26% (ovarian malignancy (n = 27) 52%, endometrial cancer (n = 25) 32%, cervical cancer (n = 49) 29%, breast cancer (n = 72) 19%, vulvar cancer and vaginal cancer (n = 12) 17% and for carcinoma in situ of the breast or the cervix (n = 20) 0%). We also found significantly higher UGP values in postmenopausal women than in premenopausal women. Hormonal substitution significantly lowered the UGP values.

Cisplatin-induced nephrotoxicity and the protective effect of fosfomycin on it as demonstrated by using a crossover study of urinary metabolite levels

BACKGROUND

Cisplatin induces nephrotoxicity and this study evaluated the protective effect of fosfomycin on it in 11 gynecological cancer patients.

METHODS

The N-acetyl-beta-D-glucosaminidase (NAG), beta 2-microglobulin (beta 2MG), creatinine (uCr) and total protein (TP) levels in a 24-hour urine specimen as well as the blood urea nitrogen (BUN) and serum creatinine (sCr) were measured before and after CAPF chemotherapy alone (control) or with fosfomycin.

RESULTS

The results were statistically analyzed by using the t-test. NAG, beta 2MG, uCr and TP levels increased significantly after chemotherapy in the control patients, but BUN and sCr levels did not change significantly. The NAG level in the control group was twice as high as in the fosfomycin group 8 days after chemotherapy (p < 0.01). The uCr and TP in control patients increased significantly after chemotherapy when compared to those in patients coad-ministered fosfomycin. There were no significant changes in beta 2MG, BUN and sCr levels.

CONCLUSIONS

Cisplatin affected the levels of NAG, beta 2MG, uCr and TP without influencing BUN and sCr levels. Fosfomycin, therefore, may be useful as a supplemental treatment for reducing cisplatin nephrotoxicity, especially proximal tubular damage.

Combined use of urinary UGP and serum CA 125 in the diagnosis of gynecological cancers

UGP, the beta-core fragment of human chorionic gonadotropin has been proposed as a tumor marker for gynecological malignancies. This fragment may be detected in a single morning-specimen of urine using an enzyme immunoassay. In this study, the diagnostic usefulness of urine UGP and serum CA 125 measurement for gynecological neoplasias (149 cases) was evaluated using a control group of patients with benign gynecological diseases (69 cases) and healthy females (99 cases). Considering the neoplastic patients in comparison to patients with benign diseases, the best diagnostic efficiency (78%) was found to correspond to a cut-off level of 120 pmol/mol creatinine the sensitivity being 73% and the specificity 90%. With this cut-off, an efficiency of 82% for healthy controls was obtained. Since the menopausal condition increases UGP levels, and though no significant difference for UGP was found between healthy subjects and patients with benign diseases, we decided to consider the reference populations as a single group. Thus, we evaluated the UGP performance on the basis of menopausal status. When a specificity of 95% was fixed, the cut-off values were 120 and 180 pmol/mol creatinine for pre- and postmenopausal women respectively, the sensitivity being 73% and 64%. Finally the combined evaluation of UGP and CA 125 improved their individual clinical efficiency for the diagnosis of ovarian serous cystadenocarcinomas, assuring a sensitivity of 86% and a specificity of 89%.

The clinical significance of calculated versus measured creatinine clearance in patients with gynecologic malignancy

Measurement of creatinine clearance remains in convenient because of the need for 24-hour urine collection. Our study compared creatinine clearance calculated from serum creatinine (CC alpha) to measured creatinine clearance (MC alpha) using an unsupervised 8-hour urine collection at home. Forty-two women admitted to our gynecologic oncology service participated in this study. Twenty-six of these patients had cancer originating from the ovaries, 8 from the uterus, 7 from the cervix, and 1 from the fallopian tube. There were adequate data for 61 collections. MC alpha using unsupervised 8-hour urine collection at home correlated well with CC alpha. This calculated value may be sufficient to be used as a guide in evaluating renal function in patients with gynecologic malignancy. However, if it becomes necessary to measure creatinine clearance, our data suggest that an 8-hour collection may be used.

Urinary 8-hydroxy-2'-deoxyguanosine (8-OHdG) levels in women with or without gynecologic cancer

OBJECTIVE

To detect the level of 8-hydroxy-2'-deoxyguanosine (8-OHdG) which is an oxygen-radical-forming agent, in the urine of patients with (n = 18) or without (n = 10) carcinoma of the female genitalia. None of the patients had been receiving any treatment before their urinary 8-OHdG levels were measured.

METHODS

Urinary 8-OHdG was extracted by a solid-phase technique, and its level was determined by high-performance liquid chromatography (HPLC) with an electric chemical detector (ECD).

RESULTS

We determined that the urinary 8-OHdG level decreased with as the age of the patient increased, and was extremely high in advanced cancer and recurrent cancer in a considerable number of patients. The urinary 8-OHdG level (1,827 +/- 1,500 pmol/kg/day, mean +/- SEM) in 18 patients with carcinoma was significantly higher (p < or = 0.05) than that (747 +/- 425 pmol/kg/day) in 10 patients without carcinoma.

CONCLUSION

These results suggest that it might be possible to determine the spread of cancer to some extent by determining a patient's urinary 8-OHdG level.

Beta-core fragment (beta-core/UGF/UGP), a tumor marker: a 7-year report

In 1988 we published three papers describing immunoassay results for urine beta-core fragment as a marker of gynecological cancers. Many other papers have been published since, and three commercial immunoassays have been established. beta-Core fragment is called beta-core, UGF, or UGP by different commercial vendors. To avoid confusion we call it beta-core/UGF/UGP here. In this 7-year report, we compare the three commercial assays, establish cutoff limits, and use the Ciba-Corning kit for two large studies. The first was a retrospective study, measuring beta-core/UGF/UGP in gynecological cancer and control urines accumulated in our freezers (n = 486). The second is a first prospective study, testing over a 16-month period beta-core/UGF/UGP levels in urines of all new patients attending the Gynecology Oncology Clinic (n = 548). In the retrospective study, elevated beta-core/UGF/UGP levels ( > 1.9 ng/ml) were detected in 11% of urines from healthy individuals (n = 132), in 11% from women with benign gynecological disease (n = 196), in 44% from cervical cancer (n = 68), 56% from ovarian cancer (n = 54), and 47% from endometrial cancer (n = 38). Altogether, beta-core/UGF/UGP levels were elevated in 50% of 170 samples from gynecological cancers. Overall, sensitivity increased with advancing stage of malignancy. Sensitivity was 28% for stage I, 50% for stage II, 47% for stage III, and 68% for stage IV malignancies. In the prospective study very similar results were recorded. Elevated beta-core/UGF/UGP levels ( > 1.9 ng/ml) were detected in 11% of urines from healthy individuals (n = 99), 11% from individuals with benign gynecological disease (n = 196), 7% from women with carcinoma in situ (n = 28), in 42% of samples from cervical cancer (n = 69), 56% from ovarian cancer (n = 59), and 52% from endometrial cancer. Altogether, beta-core/UGF/UGP levels were elevated in 48% of 225 gynecological cancer samples. Overall, sensitivity increased with advancing stage of malignancy. Sensitivity was 29% for stage I, 66% for stage II, 60% for stage III, and 77% for stage IV malignancies. In both studies sensitivity for beta-core/UGF/UGP increased with advancing stage of disease. Sensitivity for cervical and endometrial cancers was slightly lower than that for ovarian malignancies. This difference may be due to the preponderance of advanced-stage-disease patients in the ovarian cancer group. beta-Core/UGF/UGP may be a general stage-dependent marker for all gynecological cancers. The same false-positive results and very similar sensitivity values were found in a retrospective and a prospective study. They confirm each other, and suggest a definitive false-positive rate and sensitivity of this tumor marker for gynecological cancers.

[Preliminary experience with a new tumor marker in obstetrics and gynecology: UGP (Urinary Gonadotropin Protein)]

AIM

To evaluate the use of UGP (urinary gonadotropin protein) as a tumor marker in gynaecologic and obstetric malignant diseases.

MATERIALS AND METHODS

The study was carried out in the division of Gynaecology and Obstetrics of the Ospedali Riuniti in Bergamo. 63 patients, with obstetric or gynaecologic benign or malignant diseases, entered the study. 66 healthy volunteers were examined as a group-control. In both the groups UGP levels were determined in morning urine, using an immunoenzymatic commercial kit.

RESULTS

Results, expressed in fmol UGP/ml of urin, show that UGP is produced by several neoplasms, but the false-positive percentage is still high; a higher precision can be obtained with an accurate choice of the cut-off value and with a standardization of the analytical technics. Besides, the contemporary determination of UGP and CA 125 levels reduces the possibility of false-positive and false-negative results.

CONCLUSIONS

More studies must be carried out to confirm the value of UGP as a tumor marker in obstetrics and gynaecology. Anyway, this recently purified protein can already be useful, in combination with the usual tumor markers, in the prompt diagnosis and management of primary neoplasms or recurrences, with a higher sensibility in comparison with traditional clinical and radiological examinations.

Combination assay of urinary beta-core fragment of human chorionic gonadotropin with serum tumor markers in gynecologic cancers

Ectopic production of the immunoreactive beta-subunit of human chorionic gonadotropin (IR-hCG beta) by gynecologic malignancies has been well recognized, but IR-hCG beta has not yet been established as a clinically useful tumor marker, except for germ cell tumors. We measured the concentrations of IR-hCG beta-related molecules, intact hCG, free hCG beta, and beta-CF, in the sera and urine of patients with various gynecologic cancers (cervical, endometrial, and ovarian cancers) to assess their clinical usefulness as a tumor marker in comparison with serum tumor markers such as CEA, SCC, CA125, and CA19-9. The highest incidence of IR-hCG beta was obtained in the assay for beta-CF in the urine, with positive rates of 47.7% (94 of 197) for cervical, 37.8% (14 of 37) for endometrial, and 84.4% (38 of 45) for ovarian cancers with a cut-off value of 0.2 ng/mg of creatinine. In cervical cancer, there was no significant correlation between the concentrations of urinary beta-CF and serum SCC, and 57.9% (114 of 197) of the patients were detected by the combination assay of these tumor markers. Serial determination in 22 cervical cancer patients with elevated urinary beta-CF level prior to therapy showed that its level decreased after successful treatment, but 4 of 5 patients with persistent or recurrent disease had elevated levels of urinary beta-CF. All of the ovarian cancer patients examined were detected by the combination assay of urinary beta-CF and serum CA125. The levels of urinary beta-CF showed little correlation with those of the serum tumor markers, indicating the usefulness of the combination assay of urinary beta-CF with serum tumor markers for detecting cervical and ovarian cancers.

Urinary tract infection in patients of gynecological malignancies undergoing external pelvic radiotherapy

A total of 216 midstream urine (MSU) samples from 36 patients with gynecological malignancies undergoing external pelvic radiotherapy (RT) were studied periodically every week for any evidence of urinary tract infection (UTI). UTI was detected in 33.3% patients of whom 8.3% had infection at the onset of RT and the rest developed UTI during the course of therapy. All three patients who had UTI at the onset of RT underwent cystoscopy as a part of routine pretreatment workup. A higher preponderance of UTI was observed in patients of stage III carcinoma cervix (33.3%) compared to stage II (16.7%) during the course of RT. Half of the patients with UTI had repeated episodes of infection despite appropriate antibiotic treatment. The study emphasizes the importance of conducting periodic MSU examination in patients with gynecological malignancies during RT and its treatment with appropriate antibiotics to minimize the risks of further injury to the already susceptible uroepithelium following radiotherapy.

Urinary gonadotropin peptide (UGP) as a marker of gynecologic malignancies

Urinary gonadotropin peptide (UGP) was measured in 866 urines from normal women and women with benign and malignant gynecologic disease using the Triton UGP enzyme immunoassay. The greatest level of overexpression of the marker was observed in patients with ovarian cancer. Using a cutoff of 4 fmol/mg creatinine, UGP was overexpressed in samples from 2% of normal premenopausal women, 15% of normal postmenopausal women, 5% of women with benign gynecologic disease, and 59% of women with ovarian cancer. UGP expression was independent of the histologic type of ovarian cancer. The expression of UGP and CA 125 were not correlated and use of the two markers in tandem increased the sensitivity of detection of disease by greater than 20% over that which was observed using each marker individually. UGP levels were correlated with clinical status, and doubled in value in 67% of patients with progressive disease, and were halved in 93% of patients who were in remission at the time of the study.

[Coproporphyrin level in urine from healthy humans and oncology patients]

Content of coproporphyrin was estimated in urine of females with genital, thyroid and gastrointestinal cancer. A rate of coproporphyrin elimination with urine depended on the type of tumor and its site. Concentration of coproporphyrin was decreased in urine of patients with both malignant and benign tumors as compared with that of healthy persons.

Urinary chorionic gonadotropin subunits and beta-core in nonpregnant women. A study of benign and malignant gynecologic disorders

BACKGROUND

The presence of urinary excretion products of human chorionic gonadotropin (hCG) has been proposed as a tumor marker. To ascertain the clinical value in gynecologic cancers, the authors studied 612 nonpregnant women.

METHODS

Three different assays in four clinical groups were compared: no disease, benign disease, malignant disease, and complete remission of previously treated malignant disease. The assays were for the urinary beta-core, "total" beta-hCG, and free alpha-subunit.

RESULTS

Measurement of the alpha-subunit was of no obvious clinical value. In some patients with benign disease, hCG metabolites were elevated. In the 141 patients with active gynecologic malignancy the sensitivity of the total beta-hCG assay was 47% and that of the beta-core assay was 36%. The specificities were 80.3% and 90.4%, respectively. Advanced cancers generally had higher levels of total beta-hCG and beta-core. Squamous cell and poorly differentiated cervical tumors had higher levels of total beta-hCG than did adenocarcinomas and well-differentiated cervical tumors. Invasive, serous, endometrioid, and germ cell ovarian tumors had higher total beta-hCG, beta-core, and alpha-subunit levels than did borderline, mucinous, and clear cell ovarian tumors. Six of 16 patients with disease in complete remission had elevated levels.

CONCLUSION

The excretion of hCG and its metabolic fragments is a common event in gynecologic cancer, but sensitivity and specificity are low, and there is little consistent relationship between tumor stage and histologic type.

The purification and development of a radioimmunoassay for beta-core fragment of human chorionic gonadotrophin in urine: application as a marker of gynaecological cancer in premenopausal and postmenopausal women

The beta-core fragment of human chorionic gonadotrophin (hCG) is a major part of the immunoreactive hCG-like material found in the urine of normal pregnant women. Patients with non-trophoblastic gynaecological malignancies have been found to have raised levels of urinary beta-core. We describe the purification of beta-core, the preparation of a polyclonal sheep antiserum and the development of radioimmunoassay. The minimum detection limit of this assay was 0.025 micrograms beta-core/l. There was no significant cross-reaction with the free alpha-subunit, hLH, hFSH and hTSH (less than 0.7%), and only partial cross-reaction with intact hCG and free beta-subunit of hCG (6.9 and 18%). Within-assay variability ranged from 2.03 to 12.5% and between-assay variability from 2.25 to 13.4%. The assay was applied to urine samples from 92 normal non-pregnant premenopausal women, 54 normal postmenopausal women and 65 women with active gynaecological disease (47 postmenopausal and 18 premenopausal). In normal premenopausal women the values ranged from less than 0.025 to 0.62 micrograms beta-core/l (median 0.043 micrograms beta-core/l). The values for normal postmenopausal women ranged from less than 0.025 to 0.64 micrograms beta-core/l (median 0.26 micrograms beta-core/l). Postmenopausal women with gynaecological malignancy had values which ranged from less than 0.025 to 4.0 micrograms/beta-core/l (median 0.31 micrograms beta-core/l); premenopausal women in this group had values which ranged from less than 0.025 to 1.15 micrograms beta-core/l (median 0.12 micrograms beta-core/l). On molecular sieve chromatography, the material found in the urine of normal postmenopausal women showed the physicochemical characteristics of authentic beta-core.(ABSTRACT TRUNCATED AT 250 WORDS)

Urinary gonadotropin fragment, a new tumor marker. I. Assay development and cancer specificity

Urinary gonadotropin fragment (synonyms: UGF and human chorionic gonadotropin beta-subunit core fragment) is a small peptide which is present in the urines of pregnant women, of those with trophoblast disease and of those with certain nontrophoblastic malignancies. We developed a new UGF assay with improved specificity and then investigated levels in urines of 493 women: 155 healthy and postmenopause, 79 healthy and premenopause, 89 with benign gynecologic disease, and 170 with active gynecological cancer. A UGF cutoff level of greater than 3 fmole/ml was chosen to monitor the progress of patients during and after cancer therapy. Using this cutoff value, UGF specificity and sensitivity for active cancer were 90 and 66%, respectively. Levels exceeded this cutoff in 74% of women with recurrent disease. For screening purposes and for differentiating benign and malignant disease a cut-off of 8 fmol/ml, was indicated. At this higher cutoff specificity and sensitivity for active cancer were 99 and 46%, respectively.

[Development of highly sensitive enzyme immunoassay to measure urinary beta-core fragment in patients with gynecological cancer]

In addition to human chorionic gonadotropin (hCG) and its free subunits, low molecular weight hCG beta-related fragments have been previously demonstrated in pregnancy urine and in the urine of patients with trophoblastic and nontrophoblastic tumors. The urinary beta-core fragment in particular is focused on as a new tumor marker in gynecological malignancies. We developed an EIA for the beta-core fragment using the monoclonal antibody (MoAb229) which specifically recognized the core portion of hCG beta. By measuring with MoAb229-EIA, it was clearly revealed that urine obtained from normal pregnant women as well as from patients with choriocarcinoma and nontrophoblastic ovarian cancer contains a large amount of the beta-core fragment when separated on Sephadex G-100. We conclude that our MoAb229-EIA is a useful tool to use in detecting the beta-core fragment, a new tumor marker, in the urine of gynecological cancer patients.

Urinary gonadotropin fragments (UGF) in cancers of the female reproductive system. I. Sensitivity and specificity, comparison with other markers

UGF is a mixture of human chorionic gonadotropin free beta-subunit and its fragments, and is detected in pregnancy and trophoblast disease urines. An examination of 67 nonpregnant cancer-free women showed average urine levels of 0.13 ng/ml. Six of the 67 (8.9%) had levels exceeding a selected cutoff value, 0.2 ng/ml. Of 112 woman with active gynecologic cancer, 72 (64%) had urine UGF levels exceeding this cutoff value. When urines were limited to those with creatinine greater than 0.5 mg/ml, or to first morning samples (mean creatinine 1.0 ng/ml), the sensitivity of UGF for all gynecologic cancers was raised to 76%. The sensitivity of UGF for cervical (73%), for endometrial (65%), and for ovarian (83%) cancers exceeded that of plasma CA 125 and lipid-associated sialic acid in plasma (LASA) in the same population. UGF is an exciting new tumor marker which warrants further evaluation.

Urinary human chorionic gonadotropin free beta-subunit and beta-core fragment: a new marker of gynecological cancers

Many investigators have shown that a small proportion (13-36%) of subjects with nontrophoblastic gynecological cancers have elevated serum levels of human chorionic gonadotropin (hCG). The low proportion with detectable levels and the accompanying low titers have limited the use of hCG as a tumor marker. hCG is a glycoprotein composed of two noncovalently linked subunits (alpha and beta), which are the products of separate genes. With the intent of expanding the use of hCG as a tumor marker we investigated levels of hCG free beta-subunit and asialo free beta-subunit and its core glycopeptide (composed of beta-subunit residues 6-40 disulfide-linked to 55-92), collectively called urinary gonadotropin fragments (UGF), in healthy and cancer patients. An immunoradiometric assay was developed, using the core glycopeptide-directed antibody B204, that similarly measures the hCG free beta-subunit and the asialo free beta-subunit and its core glycopeptide. Parallel urine and serum samples were collected from 87 women with active gynecological cancer and hCG and UGF were measured. Just 18% of the women tested had detectable serum levels of hCG (greater than 0.2 ng/ml); none had elevated serum levels in the UGF assay (greater than 0.2 ng/ml). Of the same group, 32% had detectable urine hCG levels (mean titer, 0.50 ng/ml) and 74% exhibited elevated urinary levels in the UGF assay (mean titer, 2.0 ng/ml). In a control group (urines from 50 nonpregnant healthy women), 47 negative and three borderline positive results (0.30, 0.35, and 0.48 ng/ml) were observed in the UGF assay. These results suggested a sensitivity of 74% and specificity of 92% for the UGF test for gynecological cancers. By disease, 70% of those with cervical, 73% of those with ovarian, and 77% of those with endometrial cancers had detectable UGF levels (greater than 0.2 ng/ml). By stage, 50, 62, 75, 86, and 100% of those with stage 1, 2, 3, 4, or recurrent disease, respectively, had positive results. UGF is a promising new marker of gynecological malignancies.

Urinary 6-keto-prostaglandin F1a in patients with gynaecological tumours

The production of the antiaggregatory and vasodilatory prostacyclin (PGI2) in patients with gynaecological tumours was studied by assaying urinary 6-keto-prostaglandin F1a (= 6-keto-PGF1a), a hydration product of PGI2), by radioimmunoassay following high performance liquid chromatography (HPLC) in 59 patients with gynaecological tumours and 12 non-tumourous control women. Urinary 6-keto-PGF1a excretion in patients with cervical cancer (28.3 +/- 3.6 pmol/mmol creatinine, mean +/- S.E., n = 12), endometrial cancer (22.8 +/- 3.7 pmol/mmol creatinine, n = 12, uterine fibroids (26.0 +/- 3.5 pmol/mmol creatinine, n = 12) benign ovarian cysts (22.4 +/- 1.8 pmol/mmol creatinine, n = 12) did not differ from that in the control women (29.9 +/- 3.6 pmol/mmol creatinine, n = 12). However, patients with ovarian cancer excreted increased amounts of 6-keto-PGF1a (55.4 +/- 10.4 pmol/mmol creatinine, n = 11, P less than 0.05), although this bore no relation to tumour histology, clinical stage or the outcome of the patients. Thus, ovarian cancer is accompanied by increased PGI2 production, perhaps in the kidneys and/or in the cancer tissue.

[Initial experiences with the determination of neopterin in the urine of females with genital and breast tumors]

The quantitative analysis of urinary neopterin was carried out ahead of the operation by means of high performance liquid chromatography (HPLC). The sample included 98 women with genital or breast neoplasias. Significant differences have been found between the patients with benign or preinvasive neoplasias as well as women with malignancies (p less than 0.001) as compared to a control group of healthy females. The neopterin levels of the malignant tumors were definitely higher than those of the benign tumors (p less than 0.01). As far as genital tract cancer ist concerned, the neopterin levels found were in 51.5 per cent of the cases above the estimated limit with a specificity of 95.1 per cent in healthy patients and 79.5 per cent within the group of nonmalignant gynecologic lesions. The neopterin levels established in patients with genital tract malignancies appear to be related with the stage of the development of the disease (i.e. levels and positive rate are significantly higher in stages III and IV as compared to stages I and II; p less than 0.01). Tests of women with breast cancer showed the smallest number of raised neopterin levels. The average level of the last mentioned cases didn't differ greatly from the levels of the benign breast tumors. Tests of the patients with cancer after treatment showed in 68.8 per cent of all cases neopterin levels corresponding to the clinical findings. However, cases of smaller recurrent tumors may be accompanied by normal neopterin levels as well.(ABSTRACT TRUNCATED AT 250 WORDS)

Urinary modified nucleosides as tumor markers in cancer of the urinary organs or female genital tract

Using a sensitive and specific method involving high-performance liquid chromatography, urinary levels of four modified nucleosides--pseudouridine (psi), 1-methylinosine (m1I), 1-methyladenosine (m1A), and 1-methylguanosine (m1G)--were investigated before and after treatment in 31 patients with cancer of the urinary organs or the female genital tract. Before treatment m1I was the most frequently elevated nucleoside (77%). Pretreatment urinary levels of psi, m1I, and m1A in patients with stage 2-4 cancer of the female genital tract were significantly elevated compared to human healthy volunteers (p less than 0.005). Compared with the other nucleosides, psi appeared to correlate more closely with the clinical outcome (progression or regression) of patients with cancer of the female genital tract. In the case of patients with cancer of the urinary organs, m1I followed the clinical outcome better than the other nucleosides measured. Therefore psi and m1I seem to be useful for monitoring genito-urinary cancers.

Polyamine levels in gynecologic malignancies

Polyamines are closely related to many aspects of cell growth. Since increased amounts of polyamines in the urine of human cancer patients were reported in 1971, polyamines have been studied from the standpoint of tumor markers. In this study, polyamines in erythrocytes, plasma and urine were determined in 42 controls and 105 patients with gynecologic malignant tumors. The changes in polyamine levels were investigated before and after treatment. With advances in the stage of uterine cervical cancer, the frequency of abnormal levels of polyamines (concentrations greater than two standard deviations above the mean control level) became greater, and reached nearly 80% in recurrent and ovarian cancer. In the early stage of cancer, the diagnostic value was low. Comparison with carcinoembryonic antigen (CEA) was also performed. The polyamines lack specificity for malignant diseases, but they can be used to some extent as a tumor marker in the gynecologic field.

Levels of urinary cathepsin B-like substance in patients with gynecologic malignancy

Because certain proteolytic enzymes are thought to be released by malignant cells, we have measured the activity of cathepsin B in the urine samples of 57 patients with gynecologic malignancies and 60 disease-free controls. A unit (U) of enzyme activity is the release of one n-mol of 7-amino-4-fluoromethylcoumarin (AFC) from BZ-val-lys-lys-arg-MNA min-1 ml-1. Units of activity in the malignant group (10.6 +/- 9.8) differed significantly (p less than 0.0001) from controls (2.8 +/- 3.3). Although enzyme activity in both groups correlated with increasing age, the difference between those subjects with malignancies and those with none remained significant (p = 0.049) by analysis of covariance after adjusting for age. There was no correlation between titers and the race or weight of the subjects in either group. Enzyme activity of subjects with malignant disease correlated (p = 0.003) with the clinical stage of disease. Optimum sensitivity and specificity as determined by Receiver Operator Characteristic Analysis with an upper normal level of 5 U were 84.2% and 86.7%, respectively. Our findings suggest that measurement of urinary cathepsin B might be useful in detecting and managing patients with gynecologic tumors.

Urinary neopterin in the diagnosis and follow-up of neoplasia: a biochemical parameter to detect cell-mediated immune response

Neopterin is excreted at high levels during disease states challenging the T-lymphocyte-macrophage system. Stimulation of T-lymphocytes in mixed lymphocyte culture in the presence of macrophages is accompanied by raised neopterin levels in the supernatant. Neopterin may therefore be considered a specific indicator of cell-mediated immunity. Pretreatment analysis of patients with hemopoietic (191), urological (82) and gynecological (224) neoplasia revealed neopterin levels above the upper normal limits, with frequencies ranging from 57% (cervical carcinoma) to 96% (chronic lymphocytic leukemia). In patients with tumors of the genitourinary tract or with hemopoietic neoplasms, urinary neopterin levels were correlated with the tumor burden and became normal when remission was achieved. In gynecological cancer long term follow-up studies showed the value of neopterin excretion levels as a tumor marker. Tumor progression was indicated early by a rising neopterin level. Based on a comparison of different tumor types, the association of cell-mediated immunity and of neopterin excretion levels in less differentiated neoplasm is discussed.

Excretion of a tumor-associated trypsin inhibitor (TATI) in urine of patients with gynecological malignancy

In earlier studies we reported the finding of a tumor-associated peptide that also occurred at high concentrations in early amniotic fluid. Determination of the N-terminal sequence of this peptide revealed that it is closely related or identical to the pancreatic secretory trypsin inhibitor. Therefore, the peptide is called tumor-associated trypsin inhibitor (TATI). The concentration of TATI was determined by radioimmunoassay in the urine of 148 patients with various forms of gynecologic malignancy and in a reference population consisting of 98 patients with non-malignant gynecologic disease, and also in 40 patients with severe infections or inflammatory disease. In the reference population, the median urinary concentration of TATI was 22 micrograms/g creatinine and the central 95% reference interval was 7-50 micrograms/g creatinine. Elevated urinary levels were observed in 53% of all patients with gynecologic cancer, in 63% of those with active disease and 26% of those in clinical remission. The highest urinary TATI level (11,000 micrograms/g creatinine) was over 200 times the upper limit of the reference range. Patients with cervical cancer had the highest frequency of elevated values. Increased excretion of TATI was also observed in patients with severe bronchopulmonary infections and pancreatitis. Although increased excretion of TATI is not cancer-specific, the distinction by elevated levels of TATI between malignant and nonmalignant gynecologic disease is better than by most other putative tumor markers, and the increased excretion of TATI in patients with active disease can be important for the understanding of tumor biology.

Measurement of urinary neopterin in normal pregnant and non-pregnant women and in women with benign and malignant genital tract neoplasms

Urinary neopterin was measured in healthy women (n = 209) and men (n = 208), in patients with benign gynecological tumors (n = 53), in women with precancerous lesions of the cervix and the endometrium (n = 24) and in women with cancer of the genital tract (n = 108). In addition urinary neopterin measurements were made in 109 pregnant women and 20 women in the puerperium. No significant difference was found between mean neopterin values in patients with benign gynecological tumors, in women with precancerous lesions and in healthy women. Patients with cancer had significantly higher mean urinary neopterin levels than the control group. Raised neopterin levels were found in 56% of patients with genital tract cancer, the figures varying between 93% for ovarian cancer and 47% for cancer of the cervix. Some of the cancer patients had serial urinary neopterin measurements and in about 80% there was some relation between urinary neopterin values and clinical progress as judged clinically and radiologically, the best agreement existing in patients with ovarian cancer. Significantly higher mean neopterin values were found during normal pregnancy and in the early puerperium than in non-pregnant healthy controls. Raised urinary neopterin excretion may be due to enhanced cell proliferation and alloantigenic activation of T-lymphocytes.

Urinary neopterine excretion in patient with genital cancer

Urinary neopterine values in 96 healthy women were compared with those in a group of 63 patients with cancer of the genitals who had not yet undergone treatment. Significantly higher median neopterine levels were found in the patients with carcinoma (p less than 0.001). In the 63 cancer patients who had not yet been treated, the diagnosis was made correctly in 65% of the cases by monitoring neopterine levels. In the follow-up of 72 patients with cancer of the genitals in 74% the neopterine values corresponded with the clinico-roentgenological findings. In 22%, false positive neopterine values (no recurrence of the tumor), and in 4% false negative values (recurrence, or progression of the carcinoma) were observed. These results confirm previous reports concerning the significance of pteridine excretion in patients with cancer. However, more investigations have to be performed to establish the value of neopterine sampling in monitoring patients with malignant tumors.

[The clinical significance of determination of red blood cell and urinary polyamines in gynecologic malignancy (author's transl)]

The polyamines spermidine (spd) and spermine (spm), and their diamine precursor, putrescine (put) were separately determined in red blood cells (RBC) and 24-hour urine samples of gynecologic malignant and non-malignant cases using high-pressure liquid chromatography (HPLC) technique. The results are as follows: 1) Patients with malignancy (49 cases) had the polyamine levels of RBC-spd; 5.85 +/- 3.32 (mean +/- SD), RBC-spm; 7.00 +/- 5.53 (nmol/ml packed RBC), urinary put; 3.92 +/- 4.13, urinary spd; 2.17 +/- 1.74 (mg/day) in pre-therapeutic state. These levels were greatly higher than those of control cases. 2) The diagnostic rate was 100% in the fourth stage of uterine cervical cancer, and 80% in the recurrent cases. 3) Patients with long-term abnormal polyamine levels had the tendency of poor prognosis. 4) In many cases, RBC polyamines and urinary polyamines showed somewhat different fluctuations in the course of treatment. In conclusion, it is suggested that the measurement of polyamines is very useful in the diagnosis of progressive cases and recurrent cases, and can be helpful in the evaluation of therapeutic effects and prognosis.

Urinary polyamine levels in patients with localized malignancy

Polyamine levels (putrescine, spermidine, and spermine) were determined in 24-hour urine samples by a high voltage electroporesis techique. Twenty-four of 26 patients with localized malignant tumors had two or more elevated urinary polyamine levels. Seven of 12 patients with regional spread of their cancer and five of 11 patients with localized benign and/or noninvasive tumors had elevated urinary polyamine levels. Elevations were seen more frequently frequently in patients with gynecologic tumors. Our data suggest that there is no significant difference between the individual of total polyamine levels obtained in patients with localized malignant tumors, and those levels obtained in patients previously studied with widespread metastatic disease.