Methodological issues in the South African incomplete abortion study

In 1994, a national hospital-based study was undertaken of cases of incomplete abortion presenting to public hospitals in South Africa. Data were collected for all women admitted to a random sample of hospitals with incomplete abortion during a two-week period. The WHO protocol for such studies was used as a basis for developing the methods to describe the epidemiology of incomplete abortion and hospital management of cases. Attempts were made to estimate the proportion of cases that might have been induced. This report focuses on methodological issues arising from the study that have implications for future research. The findings demonstrate that only a small proportion of the women acknowledged having had an induced abortion and that only a few of those who did showed evidence of interference with pregnancy. Clinical opinion of sepsis and the likelihood of induction were found to be highly unreliable. These findings considerably reduce the usefulness of the WHO-protocol method of estimating the likely origin of incomplete abortions. Results presented in terms of three partially overlapping descriptive categories are judged to better reflect the limitations of the data collected.

Technetium-99m-labeled receptor-specific small-molecule radiopharmaceuticals: recent developments and encouraging results

The development of technetium-99m-labeled small-molecule radiopharmaceuticals directed at specific high-affinity binding sites, as are found in receptors for hormones and neurotransmitters, transport systems, and certain enzymes, is a natural outgrowth from the successful development of technetium radiopharmaceuticals for imaging flow and metabolism. Although many receptor-specific radiopharmaceuticals labeled with PET and other SPECT isotopes already exist, the low cost and widespread availability of technetium-99m would make their 99mTc-labeled counterparts much more accessible to the medical community. This review has four goals: (a) To survey and analyze critically the results of a flurry of research activity in this area in recent years, which has led to the preparation of a number of novel technetium-labeled radiopharmaceuticals targeted at high-affinity sites, a few of which appear to be very promising; (b) to provide a conceptual analysis of how these agents are being designed; (c) to provide a context in terms of binding and uptake behavior by which these agents should be judged; and (d) to highlight emerging knowledge on the structure of receptors and related high-affinity binding biomolecules and their distribution, which may serve as reference points for understanding the results that have been obtained so far, and may be useful guides for future design.

Synthesis of analogs of 2-methoxyestradiol with enhanced inhibitory effects on tubulin polymerization and cancer cell growth

A new series of estradiol analogs was synthesized in an attempt to improve on the anticancer activity of 2-methoxyestradiol, a naturally occurring mammalian tubulin polymerization inhibitor. The compounds were evaluated as inhibitors of tubulin polymerization and the binding of [3H]colchicine to tubulin, as well as for in vitro cytotoxicity in human cancer cell cultures. Overall, the most potent of the new compounds were 2-(2',2',2'-trifluoroethoxy)-6-oximinoestradiol, 2-ethoxy-6-oximinoestradiol, and 2-ethoxy-6-methoximinoestradiol. These agents lacked significant affinity for the estrogen receptor. The cytotoxicities of the compounds correlated in general with their abilities to inhibit tubulin polymerization, thus supporting inhibition of tubulin polymerization as the primary mechanism causing inhibition of cell growth.

The development of estrogen and progestin radiopharmaceuticals for imaging breast cancer

BACKGROUND

The presence of receptors for estrogens and progestins in many breast tumors provides a means for imaging these tumors using positron emission tomography (PET) with appropriate fluorine-18 labeled estrogen and progestin radiopharmaceuticals. In this context, the estrogen analog 16 alpha-[18F]fluoroestradiol (FES) has already proven to be an effective imaging agent for estrogen receptor-positive tumors.

METHODS

Clinical studies comparing FES images with those based on the metabolic probe 2-[18F]fluoro-2-deoxyglucose (FDG) in patients before and after tamoxifen hormone therapy are underway. Several fluorine-18 labeled progestins have been prepared, and efforts are underway to develop methods for labeling steroid receptor imaging agents with the widely available radionuclide technetium-99m, using both pendant and integrated approaches.

RESULTS AND CONCLUSION

Breast tumor imaging with FES and FDG shows an interesting relationship between tumor metabolic response (assessed with FDG) and tumor estrogen receptor levels (assessed with FES). The fluorine-18 labeled progestins show excellent target tissue selective distribution in experimental animals and are ready for imaging studies in humans. The development of steroids labeled with technetium-99m poses special challenges because of the metallic nature of this radioisotope.

Retardation of 17-oxidation of 16 alpha-[18F]fluoroestradiol-17 beta by substitution of deuterium for hydrogen in the 17 alpha position(6)

We describe the synthesis, in vitro metabolism and biodistribution of [17 alpha-2H]16 alpha-[18F]fluoroestradiol ([18F]DFES). The clinically useful breast cancer imaging agent, 16 alpha-[18F]fluoroestradiol-17 beta ([18F]FES), was deuterated at the C-17 alpha position to lower the rate of C-17 alcohol oxidation. Metabolism studies in immature female rat and mature female baboon isolated hepatocytes showed [18F]DFES being consumed ca. 2.5 times slower than [18F]FES. Biodistribution studies and time-activity curve measurements in female rats showed [18F]DFES to have superior uptake characteristics compared to [18F]FES for imaging estrogen-receptor rich targets.

The epidemiology of incomplete abortion in South Africa. National Incomplete Abortion Reference Group

OBJECTIVE

To describe the epidemiology of incomplete abortion (spontaneous miscarriage and illegally induced) in South Africa.

DESIGN

Multicentre, prospective, descriptive study.

SETTING

Fifty-six public hospitals in nine provinces (a stratified, random sample of all hospitals treating gynaecological emergencies).

PATIENTS

All women of gestation under 22 weeks who presented with incomplete abortion during the 2-week study period.

MAIN OUTCOME MEASURES

Incidence of, morbidity associated with and mortality from incomplete abortion.

MAIN RESULTS

An estimated 44686 (95% CI 35633-53709) women per year were admitted to South Africa's public hospitals with incomplete abortion. An estimated 425 (95% CI 78-735) women die in public hospitals from complications of abortion. Fifteen per cent (95% CI 13-18) of patients have severe morbidity while a further 19% (95% CI 16-22) have moderate morbidity, as assessed by categories designed for the study which largely reflect infection. There were marked inter-provincial differences and inter-age group differences in trimester of presentation and proportion of patients with appreciable morbidity.

CONCLUSIONS

Incomplete abortions and, in particular, unsafe abortions are an important cause of mortality and morbidity in South Africa. The methods used in this study underestimate the true incidence for reasons that are discussed. A high priority should be given to the prevention of unsafe abortion.

An analysis of the cost of incomplete abortion to the public health sector in South Africa--1994

OBJECTIVE

To analyse the medical costs incurred in treating women for incomplete abortion. This study was performed in conjunction with a nationwide survey of women who presented to public hospitals with incomplete abortion in 1994.

DESIGN

Cost analysis with two modified Delphi panels used to develop models of resource use reflecting three severity categories of symptoms and three hospital treatment settings.

SETTING

Public hospitals in South Africa.

PARTICIPANTS

A panel of 15 senior level obstetrician/ gynaecologists and a second panel of 11 patient care managers representing district, regional and tertiary level hospitals in 7 provinces.

MAIN RESULTS

A conservative estimate of the total cost of treating women is R18.7 million +/- R3.5 million for 1994. An estimated R9.74 million +/- R1.3 million of this was spent treating women with 'unsafe' incomplete abortions.

CONCLUSIONS

The management of incomplete abortion requires significant public sector expenditure. The long-term indirect costs to women, their families and communities are discussed and treatment costs estimated so that unmet needs for medical care resulting from unsafe abortions can be addressed.

Synthesis, estrogen receptor binding, and tissue distribution of [18F]fluorodoisynolic acids

Doisynolic acids, D-ring seco-steroids derived from alkaline fusion of estrones, are hormonal curiosities: Their binding affinity for the estrogen receptor is low (ca. 1-2% that of estradiol), but their in vivo potency is high and they have a long duration of action. To study the in vivo behavior of the doisynolic acids, we prepared fluorine-substituted analogs of both trans-doisynolic acid (with the natural 14 alpha-hydrogen configuration, trans-FDA) and the more active cis-doisynolic acid (with the unnatural 14 beta-hydrogen configuration, cis-FDA) from estrone and 14 beta-estrone, respectively. Modification of the D-ring haloform cleavage approach of Meyers allowed us to introduce fluorine (or fluorine-18) on the carbon atom derived from C-16 in the estrones. Fluorine substitution had little effect on the estrogen receptor binding affinity of the doisynolic acids. Tissue distribution of the fluorodoisynolic acids (trans-[18F]FDA and cis-[18F]FDA) was unusual and very different from that of typical, high-affinity ligands for the estrogen receptor. At 1-3 h in immature female rats, trans-[18F]FDA shows low and rather nonselective uptake in the principal estrogen target tissue (uterus) and slow clearance. By contrast, cis-[18F]FDA shows high uptake in nearly all tissues, with significant uterine uptake that continues to increase over the 1-6-h period. The uterine uptake of this isomer was blocked at the later times by a sufficiently high dose of unlabeled cis-FDA. After administration of the trans-[18F]FDA, a more polar metabolite slowly accumulates in the blood. The cis-[18F]FDA, however, showed no apparent metabolism, with 84% of the blood activity at 5 h assigned as the unmetabolized radioligand. After 5 h, only limited clearance from blood, liver, and kidneys has occurred. No metabolite from this isomer accumulates in the uterus. Although fluorodoisynolic acids will not be useful breast-tumor imaging agents, their behavior was found to be interesting as it deviates from that of other F-18 estrogens. Further long-term studies of cis-doisynolic acid, labeled with tritium, may be needed to explicate fully its unusual distribution properties and high in vivo activity.

A case control study of breast cancer risk and exposure to injectable progestogen contraceptives. Methods and patterns of use among controls

OBJECTIVE

To describe the patterns of use of injectable progestogen contraceptives (IPCs) among coloured and black women in the Western Cape. These data are part of an ongoing study in the Western Cape, the main aim of which is to explore the relationship between IPCs and breast cancer.

DESIGN

A population-based case-control study of breast cancer risk in relation to the use of IPCs among coloured and black women.

SETTING

The Western Cape, including the Cape metropole and surrounding rural areas.

STUDY SUBJECTS

All coloured and black women with newly diagnosed breast cancer, resident in the study area and below age 55 years, who present at either of the two tertiary care hospitals in the Western Cape are recruited. Controls are a sample of hospitalised patients representative of the populations from which the patients are drawn. Cases are frequency-matched to controls according to cross-tabulation of age, ethnic group and residential area in a ratio of approximately 1:3.

MEASUREMENTS

Questionnaires are administered by trained nurse interviewers, information is elicited on a wide range of variables, including sociodemographic variables, medical history, family history of breast disease, lifetime history of all methods of contraception and use of non-contraceptive female steroids, reproductive variables, cigarette smoking, alcohol consumption and other potentially confounding variables.

RESULTS

Between January and December 1994, 122 incident cases and 389 controls were enrolled. Ever-use of IPCs among the controls was 72% (N = 280) and use for 5 years or more was 30% (N = 117). Use of IPCs in the distant past was common, with 61% (N = 232) of all controls having initiated use 10 or more years previously. Current use was also high (19%). Other contraceptive methods were used far less commonly.

CONCLUSION

Coloured and black women in South Africa have been using and continue to use IPCs for more commonly and for longer periods than women anywhere else in the world. It is therefore especially important to evaluate the risk of breast cancer and other health effects of IPCs. The rates of use identified in this study ensure that there will be adequate statistical power to evaluate long-term use, use in the distant past and current use of IPCs.

The estradiol pharmacophore: ligand structure-estrogen receptor binding affinity relationships and a model for the receptor binding site

The accumulated knowledge on the binding of estradiol (E2) and its analogs and the results of affinity-labeling studies have been reviewed and are used herein to derive a binding site model for the estrogen receptor (ER). Estradiol is nonpolar and hydrophobic, except at its molecular termini. Most of its skeletal flexibility resides in the B-ring, and it probably binds in a low-energy conformation. The phenolic OH group in the A-ring contributes about 1.9 kcal/mol to the binding free energy and probably acts primarily as a hydrogen bond donor. The 17 beta-hydroxyl group in the D-ring contributes approximately 0.6 kcal/mol to the binding and probably acts as a hydrogen bond acceptor, either directly or via a water molecule. There also seems to be a degree of flexibility in the region of the receptor that encompasses the D-ring. The aromatic ring contributes about 1.5 kcal/mol, probably through weak polar interactions with receptor residues that contact the beta-face of the steroid. The receptor seems to surround the ligand, so that all four rings contribute significantly to binding. Small hydrophobic substituents enhance binding affinity at positions 4, 12 beta, 14, and 16 alpha; whereas, larger hydrophobic substituents are tolerated at positions 7 alpha, 11 beta, and 17 alpha. In general, the ER is intolerant of polar substituents. Based on E2 analogs bearing affinity-labeling groups, cysteine residues might be present in the binding site in the area of C-4, C-17 alpha, and C-17 beta, and a lysine residue might be located near C-16. Models that represent the limits of deformability of the ligand binding site, the position of preformed pockets, and space occupied by the receptor are presented. The various elements in this model for the binding of steroidal estrogens by the estrogen receptor are consistent with evidence emerging from the crystal structures of related nuclear hormone receptor ligand complexes.

Different residues of the human estrogen receptor are involved in the recognition of structurally diverse estrogens and antiestrogens

We have previously examined, by alanine scanning mutagenesis, amino acids 515-535 of the estrogen receptor (ER) ligand binding domain to determine which of these residues are important in estradiol binding. Mutation at four sites that potentially lie along one face of an alpha-helix, Gly521, His524, Leu525, and Met528, all significantly impaired estradiol binding by the ER (Ekena, K., Weis, K. E., Katzenellenbogen, J. A., and Katzenellenbogen, B. S. (1996) J. Biol. Chem. 271, 20053-20059). In this report, we compare the pattern of residues that are important in the recognition of several structurally diverse estrogen agonists and antagonists (the synthetic nonsteroidal agonist hexestrol, an agonist derived from the mold metabolite zearalenone, P1496, and the partial agonist-antagonist trans-hydroxytamoxifen) with those that are predicted to contact estradiol in the receptor-ligand complex. Although there are some similarities in the pattern of residue recognition among all four ligands, each ligand showed distinct differences as well. Interestingly, alanine substitution at only one residue, the leucine at position 525, was found to inhibit binding of all the ligands tested. Another residue, His524, was found to be important in the recognition of three different agonists but not trans-hydroxytamoxifen (the only ligand lacking a second hydroxyl group). The recognition of estradiol and another agonist, P1496, was impaired by the G521A mutation, whereas ligand-induced activity by the two compounds that lack B- and C-rings, hexestrol and trans-hydroxytamoxifen, was unaffected. Our findings demonstrate that these ligands fit into the ER ligand binding pocket differently and that each contacts a distinct set of amino acids. The smaller ligands (estradiol and hexestrol) have a narrower footprint of interacting residues than the larger ligands (P1496 and trans-hydroxytamoxifen). This pattern of interaction is most consistent with the amino acids within this region being in contact with the portion of these ligands that corresponds to the D-ring end of estradiol. The interplay between the shape of an ER ligand and the residues that support its binding to ER may potentially underlie the selective actions of different ER ligands in various cell and promoter contexts.

Bisphenolic compounds that enhance cell cation transport are found in commercial phenol red

We have isolated two bisphenolic compounds (4 and 5) that have a marked effect on K+ and Na+ concentrations in human cells from commercial preparations of the pH indicator dye phenol red (phenolsulfonphthalein). We used a bioassay to identify active chromatographic fractions from the lipophilic impurities present in phenol red, and we determined the structure of two active components (4 and 5) by 1H and 13C NMR and mass spectrometry. When added to human fibroblasts in serum-free medium, the bisphenol fluorene derivative 9,9-bis(4'-hydroxyphenyl)-3-hydroxyfluorene (5) produced a rapid loss of K+ and a gain of Na+, at low concentrations, with an EC50 between 30 and 60 ng/mL (80-160 nM). The 2- and 4-hydroxy isomers of the fluorene 5 (i.e., compounds 6 and 7), prepared by synthesis, had similar activity, although compound 6 was somewhat less potent. The bisphenol xanthene derivative 9,9-bis(4'-hydroxyphenyl)xanthene (4) elicited a similar biological response but was less potent than 5-7; it also had a strong effect on cell adhesion, causing release of cells from the plastic substrate at concentrations as low as 2-5 microg/mL (5.5-14 microM). The structures of xanthene (4) and fluorene (5) bisphenols have been confirmed by synthesis from xanthone and hydroxyfluorenone, respectively, by Friedel-Crafts alkylation with phenol. In the latter case, the desired 3-hydroxyfluorene isomer was formed in situ by rearrangement of the 1-hydroxy isomer.

Hypertension in the black community of the Cape Peninsula, South Africa

Hypertension prevalence, treatment status and factors relating to high blood pressure were determined in an urban black community of the Cape Peninsula, South Africa. A study population of 986 subjects aged 15-64 years was randomly selected. Blood pressure, height, weight and serum cholesterol levels were measured, while demographic information, personal and family history relating to hypertension and attendance of health services were determined by questionnaire. Overall 9.2% of males and 12.9% of females were hypertensive according to WHO criteria. Blood pressures between 160/95 and 140/90 mmHg were found in 10% of males and 10.5% of females. The treatment status of hypertensives showed that 24.3% had a blood pressure below 160/95 mmHg, and 16% below 140/90 mmHg. Hypertensives used more alcohol and were more overweight than normotensives. Multiple logistic regression revealed that hypertension was independently related to age, being overweight and more urbanised. The degree of urbanisation also predicted to what extent hypertension prevalence increases with age. This black population had low hypertension rates compared with other similar groups in South Africa. These data suggest that as rural blacks increasingly undergo urbanisation, hypertension prevalence increases. Necessary diagnostic and treatment regimens and hypertension services are not yet in place in the South African health services, and need to be established.

Haloenol lactones as inactivators and substrates of aldehyde dehydrogenase

Human aldehyde dehydrogenase (EC 1.2.1.3) isozymes E1 and E2 were irreversibly inactivated by stoichiometric concentrations of the haloenol lactones 3-isopropyl-6(E)-bromomethylene tetrahydro-pyran-2-one and 3-phenyl-6(E)-bromomethylene tetrahydropyran-2-one. No inactivation occurred with the corresponding nonhalogenated enol lactones. Both the dehydrogenase and esterase activities were abolished. Activity was not regained on dialysis or treatment with 2-mercaptoethanol. The inactivation was subject to substrate protection: NAD afforded protection which increased in the presence of the aldehyde-substrate competitive inhibitor chloral. Saturation kinetics gave positive gamma-axis intercepts, allowing the determination of binding constants. Inactivation stiochiometry determined with 14C-labeled 3-(1-naphthyl)-6(E)-iodomethylene tetrahydropyran-2-one was found to correspond to the active-site number. The nonhalogenated lactone, 3-(1-naphthyl)-6(E)-methylene tetrahydropyran-1-one was shown to be a substrate for aldehyde dehydrogenase via its esterase function. Inactivation and enzymatic hydrolysis occurred within a similar time frame. Opening of the lactone ring to form enzyme-acyl intermediate with active site cysteine appears to be a necessary prerequisite to inactivation, since halogen in the lactone ring is nonreactive. Thus, the inactivation of aldehyde dehydrogenase by haloenol lactones is mechanism-based. Inactivation by haloenol lactones occurs in a manner analogous to that of chymotrypsin with which aldehyde dehydrogenase shares esterase activity and binding of haloenol lactones at the active site.

Identification of amino acids in the hormone binding domain of the human estrogen receptor important in estrogen binding

The initial step in the regulation of the transcriptional activity of the estrogen receptor (ER) is the binding of hormone. Previous studies have suggested that the region between amino acids 515 and 535 near the C terminus of the human ER is likely to be important in ligand binding. In order to explicitly define which amino acids in this region are critical for ligand recognition and binding, we have utilized alanine-scanning mutagenesis over the complete 515-535 region. The ability of these 21 mutants to activate transcription in response to the natural estrogen, 17beta-estradiol (E2), was evaluated in cell co-transfection assays with estrogen-responsive reporter genes. In addition, their ability to bind E2 was also tested. Mutations at four sites in the 521-528 region had the greatest effects on E2-induced transcription, with L525A reducing responsiveness 250-fold, G521A and H524A 35-fold, and M528A 11-fold. Mutations at other sites had either no effect or a 4-fold or lesser reduction in sensitivity to E2 (M517A, Y526A, N532A, and P535A). Three of the mutants most affected in their transcriptional response, G521A, H524A, and M528A, showed a coordinate reduction in E2 binding affinity. E2 binding by the most affected mutant, L525A, could not be detected. Thus, the altered transcriptional response of these ER mutants appears to derive solely from an alteration in their affinity for the ligand E2. The four sites most affected by alanine substitution, 521, 524, 525, and 528, follow an alpha-helical periodicity, such that they would be positioned on one face of an alpha-helix. Furthermore, they correspond precisely to residues in an alpha-helix shown to be in contact with ligand in the recently described x-ray crystal structures of two other members of the nuclear hormone receptor superfamily, namely the retinoic acid receptor- and thyroid hormone receptor-ligand complexes. Our findings, which broaden observations to the steroid receptor family within the superfamily of nuclear receptors, suggest that this region of the estrogen receptor is in contact with its cognate ligand in a similar fashion.

Design, synthesis, and biological evaluation of ellipticine-estradiol conjugates

Three ellipticine-estradiol conjugates were synthesized in an effort to target the cytotoxicity of ellipticine to estrogen-receptor positive cells. The three conjugates were prepared with linker chains extending from the 17 alpha position of the estradiol to N-2 (compound 3), N-6 (compound 4), and C-9 (compound 5) positions of ellipticine. The ellipticine-estradiol conjugates were evaluated for their abilities to bind to estrogen receptors, to inhibit topoisomerase II, and for their cytotoxicities in human cancer cell lines. Conjugates 3 and 5 displayed weak binding affinities of 0.132 and 0.303 for the estrogen receptor (relative to estradiol = 100), while conjugate 4 did not show any detectable binding to the estrogen receptor. Compound 3 was a moderate inhibitor of topoisomerase II (IC50 24.1 microM), while 4 and 5 were inactive. Conjugate 3 was consistently more cytotoxic (GI50 values 1-10 microM) than compounds 4 and 5 (GI50 values 10-100 microM) in a variety of human cancer cell lines. None of the compounds displayed any selectivity for estrogen-receptor positive cell lines, which probably reflects their weak affinities for estrogen receptors.

Public sector primary care of diabetics--a record review of quality of care in Cape Town

AIM

To evaluate the quality of health care received by diabetics.

DESIGN

External audit by means of retrospective record review. SITE: Ambulatory outpatient diabetes clinics at community health centres in black areas of Cape Town.

METHOD

A stratified random sample (520) of all patients who attended any of five health centres during 1991 was reviewed by a clinician who had been trained to do structured record reviews.

RESULTS

The response rate was 73.1%. Of all patients reviewed 91% had non-insulin-dependent diabetes mellitus and the remainder insulin-dependent diabetes mellitus; 65% were female and 35.8% were employed. Only 35% attended optimally. Fingerprick blood glucose values were recorded at 98.4% of visits, blood pressure was recorded at 74.1% of all visits and for 97.4% of patients; urine dipstick test results were recorded at 84.6% of visits and for over 99% of patients in 1991, and weight was recorded at 68.8% of visits. In contrast, fundoscopy was recorded for 6% of patients and examination of the feet was performed in 4.7% of patients. Fewer than half (48.9%) of visits resulted in any change in management. Polypharmacy is frequent, with an average of 2.3 non-hypoglycaemic drugs prescribed per visit.

CONCLUSION

Attendance and examination for treatable complications are inadequate. Care is routinised and reactive and there is polypharmacy.

RECOMMENDATIONS

Simple but appropriate protocols and matching in-service education are likely to improve the care of and health outcome for diabetics at these sites.

Nuclear hormone receptors: ligand-activated regulators of transcription and diverse cell responses

Signal transduction via nuclear hormone receptors is unusual in that the hormone ligand forms an integral part of the protein complex involved in DNA binding and transcriptional activation. New structural and biochemical results have begun to unravel how these receptors produce different effects in different cells, and the structural changes involved in transcriptional activation.

Preclinical evaluation of fluorine-18-labeled androgen receptor ligands in baboons

A noninvasive method for detecting and quantifying androgen receptors (AR) in metastatic prostate cancer may be helpful in choosing the method of treatment and in better understanding the pathophysiology of this disease. Nine previously synthesized fluorinated androgens exhibited high affinity binding to AR and showed AR-mediated uptake in the ventral and dorsal prostate of the rat. Further evaluation of these agents for PET imaging is needed since sex hormone binding globulin (SHBG), a glycoprotein which binds androgens with high affinity, is absent in rat blood but is present at high levels in the blood of primates. We chose to study three of the nine fluoro-androgens by PET in the baboon.

METHODS

In this study, 16beta-[18F]fluoro-5 alpha-dihydrotestosterone (I), 16beta-[18F]fluoromibolerone (II) and 20-[18F]fluoromibolerone (III) were synthesized and studied in both a young and old male baboon using PET. Blood samples were withdrawn in three of the 10 studies and analyzed for total radioactivity and percent unmetabolized radioligand. Tissue radioactivity was evaluated semiquantitatively, using prostate absolute, standard and target to nontarget uptake values.

RESULTS

Prostate uptake was observed with all three 18F-androgens. At 60 min postinjection, compound I gave the highest prostate to soft tissue ratios in both baboons and prostate uptake was shown to be AR-mediated by blocking uptake through the coadministration of testosterone. Compound I gave the highest level of unmetabolized radioligand present in blood up to 45 min postinjection, and gave a 37-fold greater prostate-to-bone ratio at 2 hr postinjection in baboons compared to rats. The favorable behavior of this compound in the baboon may be related to its high affinity for SHBG.

CONCLUSION

All three compounds can be used to determine AR-positive tissue in primates. Compound I was selected for the evaluation of AR in men with prostate cancer using PET.

Positron emission tomography with 2-[18F]Fluoro-2-deoxy-D-glucose and 16alpha-[18F]fluoro-17beta-estradiol in breast cancer: correlation with estrogen receptor status and response to systemic therapy

We assessed the value of positron emission tomography (PET) with 2-[18F]fluoro-2-deoxy-D-glucose (FDG) and 16alpha-[18F]fluoro-17beta-estradiol (FES) in women with breast cancer for predicting response to systemic therapy. Results of FES-PET were correlated with estrogen receptor (ER) status. Forty-three women with locally advanced or metastatic breast cancer underwent FDG-PET and FES-PET prior to institution of systemic therapy. All patients had measurable disease and had tumors submitted for ER determination. Cancers were considered functionally hormone sensitive if the standardized uptake value of the lesion on FES-PET was >/=1.0 (FES+) and hormone resistant if the standardized uptake value was <1.0 (FES-). Information obtained by FES-PET was compared with the results of ER assays. The tumor response to chemotherapy and hormonal therapy was correlated with intensity of uptake by both FDG-PET and FES-PET. The ER status of the breast cancers was negative (ER-) in 20 patients, positive (ER+) in 21 patients, and unknown in 2 patients. All 20 of the ER- tumors were also FES-. However, of the 21 ER+ tumors, 16 were FES+ and 5 were FES-. Thirty patients were treated initially with chemotherapy, and 21 (70%) demonstrated objective responses. We were unable to correlate the response to chemotherapy with information obtained by FDG-PET or FES-PET. Thirteen patients were treated with hormone therapy, and 8 (61%) responded to that therapy. Only 1 of the 5 patients whose tumors were ER+ but FES- received hormone therapy, and this treatment resulted in disease stabilization only. Multiple sites of disease were assessed by FES-PET in 17 patients with metastatic breast cancer. Functional hormone sensitivity, defined by FES-PET, was concordant with multiple lesions in 13 (76%). Ten patients with locally advanced breast cancer developed recurrent disease. The initial site of recurrence was the breast in 5 patients. Of the 5 patients with systemic recurrence, 4 had disease detected at the site of recurrence on the pretreatment FDG-PET study but not detected on pretreatment computed tomography. In our experience, FDG-PET imaging is more sensitive than conventional imaging methods, including computed tomography, in staging women with breast cancer. When compared with the in vitro assay of ER status, FES-PET has an apparent sensitivity of 76% and specificity of 100%. Our finding of a subset of patients who have tumors that are ER+ and FES- suggests that the functional assessment of hormone sensitivity by PET imaging can identify patients with ER+ disease whose tumors are likely to be hormone refractory.

Carbon-11-labeled estrogens as potential imaging agents for breast tumors

We have prepared two estrogens labeled with carbon-11, 17 alpha-[11C] methylestradiol and 11 beta-ethyl-17 alpha-[11C]methylestradiol, at a specific activity of 300-1000 Ci/mmol (11.1-37 TBq/mmol), and we have determined their in vivo biodistribution in immature female rats. Both compounds accumulated selectively in two target tissues, the uterus and ovaries, reaching levels of 3.5-4.9%ID/g at 20 min and 4.6-6.6%ID/g at 40 min; uterus-to-blood ratios reached 12-23. Uterine uptake showed a saturation dependence with the amount of injected mass, and was displaced by unlabeled estradiol, indicating that this uptake was receptor mediated. These results suggest that these compounds may be useful in estrogen receptor-based imaging of breast tumors.

Analysis of the structural core of the human estrogen receptor ligand binding domain by selective proteolysis/mass spectrometric analysis

The structure of the ca. 250 amino acid hormone binding domain of the human estrogen receptor (hER-LBD), expressed in E. coli and purified as a complex with estradiol, has been probed by selective proteolysis, with analysis of the protein fragments both by classical methods (SDS-PAGE and Edman N-terminal sequencing) and by mass spectrometry (HPLC-coupled electrospray ionization mass spectrometry (LC/ESI-MS)). Rapid cleavage by several proteases (trypsin, chymotrypsin, thermolysin, and Asp-N endoproteinase) is observed within a localized region (residues 297-303) at the N-terminus. In contrast, proteolytic scission at the C-terminus is less localized and more progressive; initial cuts by trypsin, chymotrypsin, thermolysin, V8, and Asp-N proteinases are observed to occur in the region 553-571, followed by further cleavage with thermolysin (548) and trypsin (548, 531, and 529). Thus, N304 and K529 define the protease-resistant N- and C-termini of a core structure for this domain that appears to contain the elements sufficient for ligand binding. The remaining segment of this domain (530-553), which is known to embody elements essential for ligand-modulated transcription activation (AF-2), is likely a surface-exposed region that, through these studies, is shown to be accessible to proteases. Only a single region within the 26 kDa ligand-binding core (N304-K529) has been identified as being readily accessible to proteases; rapid proteolysis using the proteases trypsin, chymotrypsin, and thermolysin, is localized to residues 465-468, with cleavage occurring at residues K467, L466, and both T465 and S468, respectively. The flexibility implied by the cuts in this internal 465-468 region suggest that the hER-LBD may actually consist of two subdomains. These proteolysis studies provide a substantially refined view of the conformational nature of the human estrogen receptor ligand binding domain.

Methodological issues in a disablement prevalence study: Mitchells Plain, South Africa

The Mitchells Plain Disability Survey was undertaken primarily to expand a community-based rehabilitation programme in an underprivileged South African urban community. This descriptive survey used a proportional stratified random cluster sampling strategy (sample size 2424), with stratification by suburb and clusters consisting of 15 adjacent plots. A household screening questionnaire (based on the WHO disability questionnaire), identified people who reported health problems affecting their functional ability, while a second follow-up interview confirmed disablement status and obtained a medical, disablement and demographic profile of the disabled and ascertained their needs. This paper discusses different methodological issues related to the survey design and emphasizes the need for standardization of methods in the disablement field. Sampling issues include sample loss in a multi-staged data collection strategy as well as the non-independence of observations when sampling entire house- holds. The trade-off between studying disability across diagnostic, disablement and age categories, and wide confidence intervals for specific prevalence rates, is discussed. Because of the prohibitive costs validation of disablement status is often omitted in a low-budget project (as this one was), weakening the design of such studies. Even if the 'disabled' are correctly identified, the criteria for identifying respondents determine what type of disablement prevalence will be obtained, Different diagnoses reported on screening yielded different positive predictive values of disability--the most debilitating conditions yielding the highest proportion of disabled people. The quality of the data--evaluated through comparisons of initial and repeat screening interviews, and proxy and self-reporting--is described. There is a need for disability research to continue developing suitable methods for a wide range of purposes. One such is a 'good-enough' survey design which can be implemented rapidly, at relatively low cost, to yield useful results at local level.

Positron tomographic assessment of estrogen receptors in breast cancer: comparison with FDG-PET and in vitro receptor assays

The purpose of this study was to assess the results of PET with 16 alpha-[18F]fluoro-17 beta-estradiol (FES) and [18F]fluoro-2-deoxy-D-glucose (FDG) to validate the concordance between tumor estrogen-receptor (ER) status as determined by FES-PET and in vitro assays and to assess the relationship between tumor metabolic activity determined by FDG-PET and tumor ER status, both of which may provide information about tumor aggressiveness and prognosis.

METHODS

We studied 32 patients with primary breast masses and 21 patients with clinical or radiological evidence of recurrent/metastatic breast carcinoma. A diagnosis of breast carcinoma was subsequently proven in 43 patients (24 primary, 15 metastatic and 4 recurrent tumors). In vitro assessment of ER status was available for 40 malignant lesions (23 primary and 17 metastatic/recurrent). The patients underwent PET with both FES and FDG, and the uptake of each tracer within each lesion was evaluated qualitatively as well as semiquantitatively using the standardized-uptake-value (SUV) method.

RESULTS

We found good overall agreement (88%) between in vitro ER assays and FES-PET. This degree of agreement is similar to that observed between replicate in vitro assays (with discordances due to interlaboratory, interassay and specimen variability). We were, however, unable to demonstrate any significant relationship between tumor FDG uptake and ER status or between tumor FDG and tumor FES uptake in these patients.

CONCLUSION

These results indicate that in vitro ER assays and/or FES-PET provide unique direct information about breast cancer ER status that cannot be obtained indirectly by FDG-PET.