P. W. C. Kloppenborg

Heterozygosity for Homocystinuria in Premature Peripheral and Cerebral Occlusive Arterial Disease

Premature arteriosclerosis and thromboembolic events are well-known complications of homozygous homocystinuria due to cystathionine synthase deficiency. It is unknown whether heterozygosity for homocystinuria predisposes to premature vascular disease. We explored the frequency of excessive homocysteine accumulation after standardized methionine loading in 75 patients presenting with clinical signs of ischemic disease before the age of 50:25 with occlusive peripheral arterial disease, 25 with occlusive cerebrovascular disease, and 25 with myocardial infarction. In seven patients in each of the first two groups but in none of the patients in the third group, heterozygosity for homocystinuria was established on the basis of pathological homocysteinemia after methionine loading and cystathionine synthase deficiency in skin fibroblast cultures. Because the frequency of heterozygosity for homocystinuria in the normal population is 1 in 70 at the most, we conclude that this condition predisposes to the development of premature occlusive arterial disease, causing intermittent claudication, renovascular hypertension, and ischemic cerebrovascular disease.

Plasma metanephrines in the diagnosis of pheochromocytoma.

Pheochromocytoma is a tumor of chromaffin cells that usually presents as hypertension. The tumor has potentially life-threatening consequences if it is not promptly diagnosed, located, and removed. Evidence of excessive production of catecholamines is essential for diagnosis of the tumor. Traditional tests have relied on measurements of the 24-hour urinary excretion of catecholamines (norepinephrine and epinephrine) or of the products of catecholamine metabolism [1-4]. Because of the common problems of incompleteness and inconvenience associated with 24-hour urine collections, clinicians have long sought a diagnostic test based on sampling of antecubital venous blood. Measurements of plasma catecholamines are useful in this respect [4, 5]. However, patients with a pheochromocytoma can have plasma concentrations of catecholamines that fall within the range of those in patients with essential hypertension [4, 6] (that is, false-negative results). In addition, emotional distress or pathologic conditions other than pheochromocytoma (such as heart failure) can produce abnormally high catecholamine concentrations [7, 8] (that is, false-positive results). Glucagon stimulation and clonidine suppression testing can enhance the accuracy of plasma catecholamine determinations in the diagnosis of pheochromocytoma [9, 10]. These tests, however, can still yield false-negative or false-positive results [9-11]; they also require considerable time and effort. The search has continued for a single simple, highly sensitive and specific blood test with which to confirm the presence of the tumor in patients with pheochromocytoma. We studied the diagnostic accuracy of tests for specific catecholamine metabolites for this purpose, notably the metanephrinesnormetanephrine and metanephrine. An understanding of why plasma metanephrines may be particularly useful for diagnosis of pheochromocytoma requires an understanding of catecholamine metabolism. Norepinephrine and epinephrine are first metabolized intraneuronally by deamination to dihydroxyphenylglycol or extraneuronally by o-methylation to the metanephrines [12]. Because most dihydroxyphenylglycol is formed from norepinephrine leaking from neuronal stores and little is formed from circulating catecholamines [13, 14], plasma levels of this metabolite are relatively insensitive to the release of catecholamines into the circulation from a pheochromocytoma [6, 15]. The formation of most methoxyhydroxyphenylglycol from dihydroxyphenylglycol [14] and the formation of most vanillylmandelic acid from methoxyhydroxyphenylglycol within the liver [16] explains why a test for vanillylmandelic acid is also a poorer marker for pheochromocytoma than other tests [17]. In contrast, preferential metabolism of circulating catecholamines compared with neuronal catecholamines by extraneuronal pathways [14] suggests that the metanephrinesas extraneuronal metabolitesmay provide good markers for release of catecholamines from a pheochromocytoma. Furthermore, substantial production of metanephrines within adrenal tissue [18] suggests that metanephrines may be produced within the tumor itself. In humans, metanephrines are extensively sulfate-conjugated [18, 19]. Assays of metanephrines in urine depend on measurements after deconjugation to free metanephrines [19] so that measurements represent the sum of free and conjugated metabolites (total metanephrines). In contrast, good sensitivity of the assay for plasma metanephrines [20] enables measurements of both free and total metanephrines. We compared the sensitivity, specificity, and positive and negative predictive values of tests for plasma free and total metanephrines with those of tests for plasma catecholamines and urinary total metanephrines. Study participants included a relatively large sample of patients with pheochromocytoma, patients with essential hypertension or secondary hypertension from causes other than pheochromocytoma, and patients with either heart failure or angina pectoris in whom sympathetically mediated catecholamine release would be expected to be increased. Methods Patients Fifty-two patients with a histologically proven pheochromocytoma were studied. Thirty patients were studied retrospectively, and 22 were studied before the final diagnosis was made. The pheochromocytoma was benign in 39 patients and malignant in 13. Sixty-seven healthy, normotensive persons and 51 patients with essential hypertension served as a reference group. Blood samples were obtained from 23 patients with secondary hypertension (12 patients with renal artery stenosis, 2 with kidney disease, 1 with Cushing disease, 1 with primary hyperaldosteronism, and 7 with cyclosporine-induced hypertension) and from 50 patients with either heart failure or angina pectoris. The age, sex, and specialty center where the patients were studied for each of the five groups are shown in Table 1. Except for the few patients who were being treated with phenoxybenzamine, no patients with pheochromocytoma had been receiving medication for at least 2 weeks at the time of blood sampling. No patients with essential hypertension had been receiving medication for at least 2 weeks at the time of blood sampling. Medications taken by the other patient groups included digoxin, calcium channel blockers, diuretics, acetylsalicylic acid, dipyridamole, and cyclosporine. Procedures used in our study were approved by the hospital ethics committee or intramural research board of each of the three centers where patients were studied. Table 1. Patient Characteristics* Blood and Urine Samples All patients refrained from ingesting methylxanthine-containing food products and from smoking after midnight on the day before blood sampling. Blood was collected from an indwelling catheter in an antecubital vein after the patients had rested supine for 20 minutes. In 39 patients with heart failure and 15 with secondary hypertension, arterial blood was obtained through an indwelling arm arterial catheter. Blood samples were collected into precooled tubes containing heparin or EGTA and glutathione and were centrifuged within 30 minutes to separate the plasma, which was stored frozen until assayed. All plasma catecholamine and urinary metanephrine assays were done within 2 weeks of sample collection. Seven of the 52 pheochromocytoma samples were assayed for plasma metanephrines after being stored at 80C for more than 2 years (range, 2 to 8 years), whereas the remaining 45 samples were assayed within 2 years of collection (22 samples within 4 weeks). In 46 of the 52 patients with pheochromocytoma, a 24-hour urine collection was obtained, with 30 mL of 6-M hydrochloric acid used as a preservative. Analytic Methods Plasma metanephrines were assayed at the National Institutes of Health (NIH) using liquid chromatography with electrochemical detection [20]. Concentrations of total metanephrines (the sum of concentrations of free and sulfoconjugated metanephrines) were measured after incubation of 0.25 mL of plasma with 0.1 units of sulfatase (Sigma Chemical Company, St. Louis, Missouri) at 37 C for 30 minutes. The detection limits were 0.013 nmol/L for normetanephrine and 0.019 nmol/L for metanephrine. At a plasma normetanephrine concentration of 0.31 nmol/L and a metanephrine concentration of 0.21 nmol/L, the interassay coefficients of variation were 12.2% for normetanephrine and 11.2% for metanephrine. As previously reported [20], the presence of acetaminophen in samples of plasma can substantially interfere with measurements of plasma normetanephrine concentrations. Therefore, this analgesic must not be used by patients for several days before blood samples are collected. No analytic interference of various other drugs with this assay has been shown [20]. Plasma catecholamines were assayed using liquid chromatography. Electrochemical detection was used for quantification at the NIH [21], and fluorometric detection was used at St. Radboud University Hospital, Nijmegen, the Netherlands [22]. At the NIH, the detection limits were 0.006 nmol/L for norepinephrine and 0.010 nmol/L for epinephrine. At a plasma norepinephrine concentration of 2.4 nmol/L and an epinephrine concentration of 0.39 nmol/L, the interassay coefficients of variation were 6.5% for norepinephrine and 11.4% for epinephrine. At St. Radboud University Hospital, the detection limits for norepinephrine and epinephrine were 0.002 nmol/L and 0.003 nmol/L, respectively. At plasma concentrations of 1.02 nmol/L for norepinephrine and 0.15 nmol/L for epinephrine, interassay coefficients of variation were 8.5% for norepinephrine and 7.2% for epinephrine. Urinary concentrations of metanephrines were measured according to a previously described method [23]; the upper reference limit of the normal range for the 24-hour urinary output of metanephrines was 6.8 mol/d. Data Analysis Because plasma concentrations of catecholamines and metanephrines were not normally distributed, only medians and ranges are presented for these concentrations. Differences in plasma concentrations of metanephrines and catecholamines among patients with pheochromocytoma and other groups were tested using the Kruskal-Wallis test. We assessed relations among variables using the Spearman rank correlation coefficient. Normal distributions of plasma concentrations of catecholamines and metanephrines were obtained after logarithmic transformation of the data. Thus, upper reference limits, defined as the 97.5th percentile, were determined after logarithmic transformation of individual values for the combined data from normotensive persons and those with essential hypertension (118 persons). The 97.5th percentiles were calculated from the antilogarithm of the mean plus 2 standard deviations of the transformed data. A false-negative result of a test for plasma metanephrines in a patient with pheochromocytoma was defined as plasma concentrations of both normetanephrines and metanephrines that were

Treatment of mild hyperhomocysteinemia in vascular disease patients.

Mild hyperhomocysteinemia is recognized as a risk factor for premature arteriosclerotic disease. A few vitamins and other substances have been reported to reduce blood homocysteine levels, but normalization of elevated blood homocysteine concentrations with any of these substances has not been reported. Therefore, we screened 421 patients suffering from premature peripheral or cerebral occlusive arterial disease by oral methionine loading tests for the presence of mild hyperhomocysteinemia. Thirty-three percent of patients with peripheral and 20% of patients with cerebral occlusive arterial disease were identified with mild hyperhomocysteinemia (14% of the men, 34% of the premenopausal women, and 26% of the postmenopausal women). Mildly hyperhomocysteinemic patients were administered vitamin B6 250 mg daily. After 6 weeks methionine loading tests were again assessed to evaluate the effect of treatment. Patients with nonnormalized homocysteine concentrations were further treated with vitamin B6 250 mg daily and/or folic acid 5 mg daily and/or betaine 6 g daily, solely or in any combination. Vitamin B6 treatment normalized the afterload homocysteine concentration in 56% of the treated patients (71% of the men, 45% of the premenopausal women, and 88% of the postmenopausal women). Further treatment resulted in a normalization of homocysteine levels in 95% of the remaining cases. Thus, mild hyperhomocysteinemia, which is frequently encountered in patients with premature arteriosclerotic disease, can be reduced to normal in virtually all cases by safe and simple treatment with vitamin B6, folic acid, and betaine, each of which is involved in methionine metabolism.

Unique efficiency of methionine metabolism in premenopausal women may protect against vascular disease in the reproductive years.

Premenopausal women develop occlusive artery disease less frequently than postmenopausal women. In coronary heart disease, higher blood levels of homocysteine-cysteine mixed disulphide have been reported. Therefore, in healthy subjects, we studied the role of menopausal status in the transsulphuration of methionine in 10 premenopausal and 10 postmenopausal women. To exclude the role of aging, we compared these results with those in 10 younger and 10 older men of comparable age groups. An oral methionine load (0.1 g/kg of body weight) was administered after overnight fasting. Before and during 8 h, thereafter, serum levels of methionine, homocystine, and homocysteine-cysteine mixed disulphide were measured. In the fasting state, serum methionine levels were similar in the premenopausal women and both groups of men. Postmenopausal women had significantly lower fasting levels. Peak levels and clearances of methionine after loading did not differ between the groups. In the fasting state, homocystine was never detectable; yet, after methionine loading, slight homocystinemia was present in 12 out of 20 men, and was more pronounced in all postmenopausal women. However, homocystinemia did not occur in any of the premenopausal women after loading. Fasting serum homocysteine-cysteine mixed disulphide levels did not differ between both groups of men and postmenopausal women. In premenopausal women, both fasting and postloading disulphide levels were significantly lower than in any other group. We conclude that premenopausal women have a unique efficiency of methionine handling, and thereby are preserved against the accumulation of homocysteine after methionine loading. We speculate that this phenomenon might account for the lower incidence of vascular disease in women in the reproductive life cycle.

Large, Compressive Goiters Treated with Radioiodine

Surgical treatment is considered standard therapy for patients with a large, compressive multinodular goiter. However, although thyroid surgery leads to rapid tracheal decompression in most patients [1], it is not without risk [2-4]. Moreover, goiters recur after surgery in 10% to 20% of patients [5, 6]. Surgical morbidity (hemorrhage and infection, dyspnea caused by tracheomalacia or recurrent nerve damage, and hypoparathyroidism) and mortality are highest in patients with very large goiters and in those who have another operation [2, 4, 7]. In elderly patients, surgical treatment of a large, compressive goiter may be contraindicated because of cardiac or pulmonary disease; in addition, some patients refuse to be operated on. Berghout and colleagues [8] reported that in about half of their patients with a smaller, nontoxic goiter (mean volume, 53 mL), thyroid volume decreased by 25% during treatment with l-thyroxine in thyroid-stimulating hormone (TSH)-suppressive doses. The efficacy of this treatment in large, compressive nodular goiters is probably much lower [9]. Radioiodine therapy may be an alternative for these patients. However, most clinicians are reluctant to use radioiodine in patients with a large, compressive multinodular goiter because, until now, reduction of thyroid volume by radioiodine therapy had not been assessed with objective methods and reversibility of compressive symptoms had not been shown. We treated 21 patients with a large, compressive multinodular goiter using a single dose of radioiodine followed by daily administration of a nonsuppressive dose of l-thyroxine. Before and 1 year after radioiodine treatment, anatomical assessment was done by magnetic resonance imaging (MRI). This technique allows high-precision measurements of thyroid volume, tracheal compression, and tracheal deviation [10]. We used medical interview, physical examination, and pulmonary function tests to assess functional results. Methods Patients Twenty-one patients, 18 women and 3 men (mean age SD, 67 14 years; range, 46 to 86 years), were entered into the study. All patients had a large, multinodular goiter (>100 mL) that caused tracheal compression. Multinodularity was confirmed by thyroid scintigraphy that was done 2 hours after intravenous administration of 37 MBq (1 mCi) of sodium iodide (Iodine-123). Nineteen patients had intrathoracic extension of the goiter of more than 2 cm, as shown on MRI. One patient had a completely intrathoracic goiter. There was no clinical suspicion of thyroid malignancy in any patient. In two patients with a large cold nodule, examination of fine-needle aspiration biopsy specimens showed no signs of malignancy. Radioiodine treatment was chosen because of the high operative risk primarily related to cardiopulmonary disease or because the patient refused to have surgery. Seventeen patients were clinically euthyroid and had serum free thyroxine (fT4) and total triiodothyronine (T3) levels within the normal range of our laboratory (fT4, 9.0 to 17.0 pmol/L; T3, 1.5 to 3.5 nmol/L). In 5 of these patients, the serum TSH level was clearly suppressed (<0.1 mU/L). For treatment of hyperthyroidism, 4 patients received a thyroid-blocking dose of methimazole, which was combined with l-thyroxine to prevent hypothyroidism. Thyroid surgery had been done in 8 patients (in 1 patient twice and in another three times) 4 to 50 years before radioiodine treatment. One euthyroid patient had been treated with 1.1 GBq (40 mCi) of radioiodine for hyperthyroidism 4 years before entering into our study. In 3 of the euthyroid patients, previous TSH-suppressive treatment with l-thyroxine had not reduced goiter size and had been stopped 3 months before radioiodine treatment. Radioiodine Therapy Radioiodine was given as a single intravenous dose on an in-patient basis. Corticosteroids were not administered routinely. The administered activity was aimed at delivering 3.7 MBq (100 microcuries) of 131I/g of thyroid tissue retained at 24 hours according to the following formula: administered activity (GBq) = (thyroid weight [g] 0.37)/24-hour thyroid radioactive iodide uptake (%) [11]. Twenty-four hours after patients orally ingested 7.4 MBq (200 microcuries) of Iodine-131, we measured thyroid radioactive iodide uptake (normal range, 10% to 59%) and made a rectilinear thyroid scintigram. We estimated thyroid weight from the planimetric surface on the scintigram using the formula of Doering and Kramer [12]: thyroid weight (g) = 0.326 x (surface in cm2)3/2. After radioiodine therapy, euthyroid patients were treated with l-thyroxine to keep serum TSH levels below 1.5 mU/L. Hyperthyroid patients continued to receive the combination therapy with methimazole and l-thyroxine during the first 6 months after radioiodine therapy (patients did not receive methimazole for 3 days before and 3 days after therapy). Assessment of Anatomical and Functional Results We assessed anatomical and functional measurements before and 1 year after radioiodine therapy. In a medical interview and physical examination, special attention was paid to compressive symptoms and signs (such as inspiratory stridor, dyspnea, voice changes, and the Horner syndrome). The same observer measured maximal neck circumference and central venous pressure before and 1 year after radioiodine therapy. Blood samples were obtained for measurement of serum levels of TSH (Delfia hTSH Ultra, Wallac Oy, Turku, Finland), T4 (in-house radioimmunoassay), T3 (Amerlex-M T3, Kodak Clinical Diagnostics Ltd., Amersham, United Kingdom), fT4 (SPAC fT4, Byk-Sangtec Diagnostica, Dietzenbach, Germany) and thyroglobulin (IRMA-mat Thyroglobulin, Byk-Sangtec Diagnostica). We determined 24-hour thyroid radioactive iodide uptake as described above. Thyroid volume was measured with MRI (Siemens Magnetom 63SP, Erlangen, Germany) operating at a field strength of 1.5 tesla). We obtained T1-weighted images (TR [relaxation time] = 270 ms, TE [echo time] = 15 ms) by using a Helmholtz neck coil and covering the entire thyroid in the coronal, sagittal, and axial planes. The thyroid outline was drawn manually on each slice, and a computer program calculated the surface of the traced areas. To calculate the thyroid volume, we multiplied the sum of the traced surfaces in each plane by the slice distance (0.88 cm). Thyroid volume, as used hereafter, is the mean of the measurements in the three imaging planes. Precision of this method is high. In patients with a large, multinodular goiter, the intraobserver coefficient of variation is 2.2% 2.0%, and the interobserver coefficient of variation is 4.1% 2.2% [10]. We used axial MRI slices to measure the largest deviation of the center of the tracheal lumen from the midline (oriented on the center of the vertebral canal and the spinous processes and supraspinal ligaments). The smallest cross-sectional area of the tracheal lumen, a measurement of tracheal compression [13], was measured planimetrically in axial MRI slices. All measurements were done blinded. We measured forced inspiratory volume in 1 second (FIV1) as a functional index of upper airway obstruction. We compared values of our patients with values obtained from age- and sex-matched normal persons [14]. Reference values are described by the following equation: FIV1 (mL) = ( 0.0025 x age in years + 0.69) x total lung capacity (mL). An FIV1 that was more than 20% less than the reference value was considered below normal. An otolaryngology specialist tested the vocal cord motility of all patients before and 1 year after radioiodine therapy. Statistical analyses were done using the Wilcoxon sign-rank test for paired observations (P values denoted as P) and the Spearman rank-correlation test (P values denoted as P*). The mean values 1 standard deviation are given. Results After intravenous administration of Iodine-131 at a dose of 2.6 1.0 GBq (7126 mCi) (range, 1.4 to 5.6 GBq [37 to 150 mCi]), patients were hospitalized for 5 to 21 days. We observed no exacerbation of compression symptoms after patients received radioiodine. Two patients had a sore throat that was probably caused by radiation sialadenitis or esophagitis, but spontaneous and complete recovery was reached within 4 weeks. We observed no symptoms or signs of thyrotoxicosis caused by radiation thyroiditis. Of the 21 patients who entered the study, 19 could be evaluated 1 year after radioiodine therapy. An 84-year-old euthyroid woman had died of an unrelated cardiac cause 1 month after radioiodine therapy. A 67-year-old hyperthyroid woman had thyroid surgery because of insufficient relief of tracheal compression despite a second dose of Iodine-131 that was given 7 months after the first dose (total dose, 6.4 GBq [173 mCi]). Thyroid volume was reduced 10% as measured by MRI at the time of operation (10 months after the first dose of Iodine-131), and the smallest cross-sectional area of the tracheal lumen and the FIV1 had not changed. Anatomical Results Table 1 shows anatomical results for the 19 patients who were evaluated before and 1 year after radioiodine therapy. Before therapy, thyroid volume as measured with MRI was 269 153 mL (range, 109 to 825 mL). One year after radioiodine therapy, thyroid volume was 154 73 mL (range, 57 to 381 mL; P < 0.001). Expressed as the percentage of pretreatment thyroid volume, reduction was 40% 15% (range, 19% to 68%) (Figure 1). Neck circumference decreased by 3 2 cm [range, 0 to 8 cm]. The circumference of one patient with a completely intrathoracic goiter decreased 0 cm). The decrease in neck circumference was significantly correlated with the percentage of volume reduction (r = 0.557; P* < 0.02). Table 1. Results of Treatment with Radioiodine and l-Thyroxine in 19 Patients with a Large, Compressive Multinodular Goiter* Figure 1. Thyroid volume (left), maximal deviation of the tracheal center from the midline (middle), and smallest cross-sectional area of the tracheal lumen (SCAT) (right) measured befor

Adrenocortical function: an indicator of severity of disease and survival in chronic critically ill patients

Plasma cortisol levels and modified Apache II (Apache IIm-stay) severity of disease scores were determined at weekly intervals in 159 patients who were treated for at least 7 days at the Critical Care Unit of our hospital. The mean (±SD) plasma cortisol level (0.60±0.28 μmol/l) was clearly elevated in these patients. The highest plasma cortisol levels were measured in patients treated with vasoactive drugs (0.76±0.39 μmol/l). Non-survivors (n=36) had a significantly higher mean plasma cortisol level and Apache IIm-stay score than survivors (respectively 0.78±0.40 vs. 0.54±0.21 μmol/l;p<0.0003 and 12.6±4.8 vs. 7.3±4.1;p<0.0001). A significant correlation was found between the individual weekly plasma cortisol levels and the Apache IIm-stay scores (r=0.41;p<0.0001), especially in the subgroup of patients, who never received glucocorticoids during their stay at the ICU (r=0.51;p<0.0001). During the 14-month study period only two patients showed a clinical picture of adrenocortical insufficiency and a blunted response of cortisol to 0.25 mg synthetic ACTH(1-24). In conclusion, our data suggest that a high plasma cortisol level, like a high Apache IIm-stay score, indicates severity of disease and poor survival in critically ill patients. De novo adrenocortical insufficiency is rare and therefore routine screening of adrenocortical function is superfluous.

Improved identification of heterozygotes for homocystinuria due to cystathionine synthase deficiency by the combination of methionine loading and enzyme determination in cultured fibroblasts

SummaryPrevious data on tentative identification of the carrier state for homocystinuria due to cystathionine synthase deficiency using methionine loading or measurement of cystathionine synthase activity in tissue extracts are conflicting. We studied the results of standardized oral methionine loading in 20 obligate heterozygotes and compared them with those of determination of cystathionine synthase activity in cultured fibroblasts. Special attention was devoted to our recently reported observation on the small but striking differences in methionine metabolism between healthy pre- and postmenopausal women and men. Fasting and after load peak levels of methionine in serum did not discriminate the carriers from the control subjects. The mean fasting level of total homocysteine was only significantly higher in the group of premenopausal heterozygotes than in the corresponding control group. Nevertheless, the individual values overlapped with the normal range in 4 of 12 premenopausal heterozygotes. After loading peak levels of total homocysteine in 18 out of the 20 obligate heterozygotes exceeded the upper limit of the ranges in the three control groups. Thus, this parameter discriminated 90% of the obligate carriers. Measurement of cystathionine synthase activity in cultured fibroblasts from a skin biopsy identified the obligate heterozygotes to a similar degree (85%). No significant correlation between the measurements of cystathionine synthase activity and the after load peak levels of total homocysteine in the individual heterozygotes was established. Combination of both methionine loading and determination of cystathionine synthase activity in cultured fibroblasts identified all of these carriers.

Acute stimulation of the hypothalamic-pituitary-adrenal axis by IL-1ß, TNFα and IL-6: A dose response study

We investigated the effects of iv and intracerebroventricular (icv) administration of increasing doses of recombinant human IL-1ß, TNFα and IL-6 on plasma corticosterone (B) levels in rats. Rats were equipped with a jugular cannula for repeated blood sampling and a subgroup of rats also received an icv implanted cannula. Iv administration of IL-1ß, TNFα or IL-6 and icv administration of IL-1ß and IL-6 induced a significant dose-dependent increase in plasma B levels, whereas icv injection of TNFα in doses up to 1000 ng/rat was not effective. Iv pretreatment of rats with anti-CRH antiserum had no significant overall effect on the plasma B response to iv administered IL-1ß (500 and 3000 ng/rat), whereas the plasma B response to iv TNFα or IL-6 administration (3000 ng/rat) were significantly reduced. Iv pretreatment of the animals with recombinant human IL-1 receptor antagonist (IL-1ra) significantly blocked the plasma B response to iv treatment with IL-1ß, whereas the TNFα- and IL-6-induced increases in plasma B levels were not affected. Our data show that: 1) iv administration of IL-1ß, TNFα or IL-6 and icv administration of IL-1ß or IL-6 dose-dependently stimulate the HPA axis; 2) when given iv or icv, IL-1ß is more powerful than TNFα and IL-6 in activating the HPA axis; 3) endogenous CRH is involved in the activation of the HPA axis by acute iv administration of TNFα and IL-6. It is most likely that in case of iv treatment with IL-1ß a CRH-independent mechanism is involved. This study provides no arguments for the involvement of endogenous IL-1 in TNFα- or IL-6-induced activation of the HPA axis.

STEROID HORMONE RECEPTOR ACTIVITY OF PRIMARY HUMAN BREAST CANCER AND PATTERN OF FIRST METASTASIS

SummaryA series of 258 breast cancer patients with known estrogen receptor (ER) status of the primary tumour who subsequently developed metastases were reviewed for site of first metastasis. In 188 cases progesterone receptor (PgR) data were also available.Univariate analysis showed metastatic patterns to differ statistically significantly related to ER status and (less pronounced) PgR status of the primary tumour. Patients with ER-positive tumours had bone metastases three times more often than patients with ER-negative tumours. With respect to PgR-positive and PgR-negative tumours this frequency differed by a factor of two. With regard to visceral metastases ER and PgR status were equally potent prognosticators, patients with receptor negative tumours having a 50% higher frequency of visceral metastasis than patients with receptor positive tumours. Assessment of metastatic patterns in relation to combined receptor status did not substantially enhance the discriminatory value of ER and PgR when assessed separately.Multivariate analysis showed that the observed differences in metastatic patterns were all attributable to differences in the ER status of the primary tumour, and were not influenced by age, menopausal status, axillary lymph node involvement, duration of disease-free interval (DFI), mode of postoperative treatment, or the PgR status of the primary tumour.

Human breast cancer: survival from first metastasis

SummarySurvival from the detection of first metastasis (SAM) was analyzed in a single center series of 258 patients with advanced breast cancer. During the 15 year period covered by this study 230 patients died, 215 of their disease. The overall median SAM was 28 months.Univariate analysis of SAM stratified by first dominant site of metastasis, estrogen receptor status (ER), progesterone receptor status (PgR), tumor size, axillary lymph node status, patient age, menopausal status, and disease-free interval (DFI) showed the first dominant site of metastasis, ER, PgR, and axillary lymph node status to be significantly associated with SAM. Patients with visceral metastasis as first dominant site of metastasis had significantly shorter survival than those with either bone or soft tissue metastasis, median SAM 16 vs. 34 vs. 41 months respectively (P<0.001). SAM also differed according to the steroid hormone receptor status of the primary tumor: median SAM 34 and 33 months for patients with ER-positive or patients with PgR-positive tumors against 14 months for patients with ER-negative or with PgR-negative tumors (P<0.001). Patients with axillary lymph node involvement at primary disease had a shorter SAM than those without, median SAM 24 vs. 35 months (P=0.006). No association between SAM and either tumor size, patient age, menopausal status, or DFI could be observed.Multivariate analysis including first dominant site of metastasis, ER, PgR, and axillary lymph node status showed the first dominant site of metastasis, ER, and axillary lymph node status to be independently associated with SAM.