Colon and rectal carcinoma

In the United States the incidence of carcinoma of the colon or rectum appears to be increasing. Although certain dietary habits appear to be associated with disease incidence, the putative carcinogens in the lumen of the bowel remain unidentified. The use of clinical screening based on a combination of proctosigmoidoscopy and tests for occult fecal blood allows detection of colorectal carcinomas at an early stage; however, it is unclear whether such screening is cost-effective in persons over 40 years of age or if treatment undertaken on the basis of screening results truly alters the natural history of the disease. Surgical resection is the mainstay of curative therapy, and its effectiveness will probably be enhanced by adjuvant x-ray therapy and chemotherapy.

Advances in the diagnosis and treatment of medullary thyroid carcinoma

Medullary thyroid carcinoma accounts for 5 to 10 per cent of all thyroid malignancies and may occur in a familial or a sporadic pattern. This article reviews the authors' experience with 200 patients with medullary thyroid carcinoma and outlines the recent advances made in our understanding of the biochemical properties of these cancer cells and the relationship of different tumor markers to prognosis.

Fluoxymesterone stimulation of tumor marker secretion in patients with breast carcinoma

The gross cystic disease fluid protein of 15,000 MW (GCDFP-15) has been demonstrated to be a circulating glycoprotein tumor marker for breast carcinoma in approximately 40% of patients with advanced disease. A recent retrospective analysis of plasma GCDFP-15 levels in patients with advanced breast cancer suggested that androgen therapy could cause significant increases in plasma levels in the absence of disease progression. In order to evaluate the frequency, time course, and intensity of the androgen effect on GCDFP-15 production, a prospective study was initiated. Twenty-nine patients with stage IV breast carcinoma were treated with fluoxymesterone (20 or 30 mg/d). Plasma levels of GCDFP-15 and carcinoembryonic antigen (CEA) were measured by radioimmunoassay before and at various times during therapy. By day 6 of therapy, plasma GCDFP-15 had increased significantly (p = 0.03) from a mean basal level of 58 +/- 12 ng/ml to 160 +/- 60 ng/ml. By contrast, the mean CEA levels in the same patients increased only from 36 +/- 14 ng/ml. The distribution of percent increases in plasma GCDFP-15 was not uniform, but patients with high (greater than 82 ng/ml) basal levels had marked (greater than or equal to 75%) increases in 6/6 (100%) cases, whereas patients with low (less than 30 ng/ml) basal levels had similar increases in only 2/15 (13%) cases. Urinary excretion of GCDFP-15 usually paralleled the increases in plasma levels of the glycoprotein during the first six days of therapy. A linear correlation between percent change in plasma and percent change in urinary GCDFP-15 was demonstrated. A permanent cell line of human breast carcinoma, T47-D, was stimulated to secrete GCDFP-15 in vitro by androgen, but not by estrogen. From these data, we conclude that androgens can specifically stimulate secretion of GCDFP-15 by breast carcinoma tissue in most patients with elevated plasma levels of GCDFP-15, and in some patients with normal levels. The stimulation occurs within days and is not associated with clinical signs of tumor growth.

Human parathyroid antigen: characterization and localization with monoclonal antibodies

A cell surface antigen on human parathyroid cells was identified by monoclonal antibodies. The antigen, called parathyroid antigen (PTA), is found on both of two major polypeptides (190 kDa and 160 kDa) apparently associated exclusively with parathyroid cells. To determine whether PTA was a suitable target for in vivo imaging, 125I-labeled anti-PTA was injected into nude mice bearing human parathyroid xenografts. IgG1 anti-PTA antibody showed excellent radiolocalization of the grafts, whereas IgM anti-PTA, containing the same variable domains as the IgG1 antibody, showed little specific binding. These results suggest that antibody isotype is an important parameter for the in vivo immunoscintigraphy of specific cellular antigens.

Familial medullary thyroid carcinoma without associated endocrinopathies: a distinct clinical entity

In an evaluation of 213 patients from 15 kindreds with familial medullary thyroid carcinoma (MTC), we detected 41 subjects from two kindreds (L and O) who had MTC but no extra-thyroidal manifestations (hyperparathyroidism, phaeochromocytomas or mucosal neuromas) of multiple endocrine neoplasia (MEN) type IIa or IIb. In screening 178 members of the L and O kindreds, we found no evidence that any of them had died from MTC. To assess whether the malignancy was relatively indolent in these families, 20 selected subjects from the two kindreds were compared with 33 MEN IIa subjects. Both groups had clinically occult disease which was diagnosed biochemically by documenting elevated plasma calcitonin (CT) levels following stimulation with intravenous calcium and pentagastrin. There were no differences in the peak stimulated plasma CT levels at the time of diagnosis (1055 +/- 236 pg/ml versus 1096 +/- 191 pg/ml) or the incidence of regional lymph node metastases (0/20 versus 1/33) in the two groups. The mean age at diagnosis, however, was significantly higher in patients of the L and O kindreds than in patients with MEN IIa (43.1 +/- 3.4 years versus 21.1 +/- 2.2 years; P less than 0.001) indicating that in the two kindreds the MTC either developed at a later age or grew more slowly. This study demonstrates that MTC may occur in a familial pattern distinct from its presentation as MEN IIa or MEN IIb. In this setting it appears to be the least aggressive form of MTC yet described.

Stimulation of insulin secretion by a rapid intravenous calcium infusion in patients with beta-cell neoplasms of the pancreas

The effects of calcium on fasting plasma insulin and glucose levels were compared in 16 normal subjects and 11 patients with beta-cell neoplasms of the pancreas. Calcium was administered iv either as a rapid calcium infusion (RCI; 2 mg/kg in 1 min) or as a long calcium infusion (LCI; 12 mg/kg in 3 h). In normal subjects, the RCI produced a rise in mean plasma insulin from 11 +/- 1 (+/- SEM) microU/ml basally to a peak of 18 +/- 2 microU/ml (P less than 0.001). No consistent pattern of change in insulin levels occurred during the LCI, and plasma glucose levels did not change significantly with either test. In the patients with beta-cell neoplasms, the RCI resulted in a rapid increase in mean plasma insulin from 36 +/- 6 microU/ml to a peak level of 312 +/- 67 microU/ml (P less than 0.002). With the LCI, a more gradual rise in insulin from 35 +/- 11 to 92 +/- 36 microU/ml occurred (P less than 0.002). The mean increase in insulin in the patients with beta-cell neoplasms was significantly greater for the RCI than for the LCI (P less than 0.01). Pronounced increments in plasma insulin occurred in all 11 patients after the RCI, but in only 3 of 8 patients during the LCI. Plasma glucose levels declined significantly from 69 +/- 7 to 56 +/- 8 mg/dl during the RCI (P less than 0.05) and from 69 +/- 8 to 49 +/- 7 mg/dl during the LCI (P less than 0.005). Symptomatic hypoglycemia developed in 3 patients during the LCI but did not occur after the RCI. These data indicate that calcium is a more effective insulin secretagogue in patients with beta-cell neoplasms when administered as an RCI than as an LCI, and suggest that the RCI may be a useful test for the diagnosis of insulin-secreting tumors.

Hyperparathyroidism associated with the enlargement of two or three parathyroid glands

Eighty-five (23%) of 375 patients undergoing surgery for primary hyperparathyroidism were found to have enlargement (greater than 50 mg) of two or three parathyroid glands. Of 76 patients followed from 12 to 140 months after surgery, eight (10.5%) developed hypercalcemia at 1, 4, 45, 64, 74, 79, 84, and 133 months. In a comparison of pertinent preoperative biochemical and pathologic data between 55 patients with two- or three-gland hyperparathyroidism and 55 age- and sex-matched patients with single-gland hyperparathyroidism, only the preoperative serum phosphate differed significantly, being lower in the patients with single-gland disease (2.4 +/- 0.1 vs. 2.6 +/- 0.1; p less than 0.04). In the eight patients with two- or three-gland hyperparathyroidism who developed postoperative hypercalcemia, the preoperative concentrations of serum calcium were lower (10.8 +/- 0.2 vs. 11.5 +/- 0.2; p less than 0.019), the preoperative concentrations of serum phosphate were higher (3.1 +/- 0.2 vs. 2.5 +/- 0.1; p less than 0.020), and the weights of the excised parathyroid tissues were less (356 +/- 72 mg vs. 1354 +/- 215 mg; p less than 0.02) than those of patients with two- or three-gland disease who did not develop postoperative hypercalcemia, indicating a milder form of hyperparathyroidism. In the 68 patients without recurrent hypercalcemia, there was no tendency for the serum calcium concentration to increase with time. Patients with primary hyperparathyroidism associated with two or three enlarged parathyroid glands have an appreciable incidence of persistent or recurrent hypercalcemia, which may increase even further with longer observation.

Parathyroid hormone secretion from dispersed human hyperparathyroid cells: increased secretion in cells from hyperplastic glands versus adenomas

The in vitro secretion of PTH by dispersed human parathyroid cells was examined under conditions of low and high extracellular Ca+2 using tissue from patients with primary hyperparathyroidism and hyperparathyroidism resulting from chronic renal failure (CRF). The PTH secretion rate (nanograms of PTH per 10(5) cells/h) was lower in adenomatous tissues than in either primary hyperplastic cells or CRF cells under conditions of low (0.5 mM) or high (2.0-3.0 mM) extracellular Ca+2. Among the adenomas, a wide spectrum of degree of suppressibility of PTH secretion by high Ca+2 was found, ranging from 0% (completely nonsuppressible) to 98%. Suppression of the hyperplastic tissues in general was similar. The most suppressible adenomas demonstrated 2-fold greater PTH secretion rates in low Ca+2 conditions than the least suppressible adenomas, but in high Ca+2 conditions, the two groups had similar secretory rates. We conclude that the rate of PTH secretion by cells from adenomas was substantially lower than that of cells from tissues exhibiting either primary hyperplasia or hyperplasia resulting from CRF under these in vitro conditions. Thus, in adenomas, an increase in absolute cell number as well as alterations in the degree of calcium responsiveness may prove to be important etiological factors in the expression of hyperparathyroidism.

Relationship of tissue carcinoembryonic antigen and calcitonin to tumor virulence in medullary thyroid carcinoma. An immunohistochemical study in early, localized, and virulent disseminated stages of disease

The distribution of carcinoembryonic antigen (CEA) and its relationship to calcitonin in early, localized, and disseminated (virulent) medullary thyroid carcinoma (MTC) have been studied using immunoperoxidase methods. Carcinoembryonic antigen can be demonstrated within C-cells through all stages of progression of MTC. In early disease (C-cell hyperplasia and microscopic carcinoma), CEA, and calcitonin have a similar distribution, being present in virtually every cell. Likewise, calcitonin and CEA have a similar, homogeneous distribution among cells in gross medullary carcinoma confined to the thyroid region. In both primary and metastatic tumors from patients with virulent, disseminated disease there is an inverse relationship between calcitonin and CEA distribution such that CEA expression is retained and frequently present in the greatest amounts in cells which have poor or absent staining for calcitonin, and present in the least amounts where cellular staining for calcitonin is greatest. It is postulated that in MTC expression of CEA (a marker for early epithelial differentiation), in the face of loss of calcitonin (a marker for terminal differentiation/cellular maturity), may reflect a degree of maturation block in tumors from patients with aggressive disease.

Bone and liver images in medullary carcinoma of the thyroid gland: concise communication

Thirty-four patients with surgically documented medullary carcinoma of the thyroid (MCT) and elevated serum calcitonin levels had Tc-99m phosphate bone and/or Tc-99m sulfur colloid liver images for suspected metastases. Liver images demonstrated metastatic lesions in nine of 32 patients (28%). Bone images were positive for metastases in eight of 30 patients (27%). Four of these eight abnormal bone studies detected only skeletal lesions, two demonstrated only extraosseous metastases, and two showed both kinds. Of 18 patients with both radionuclide bone studies and skeletal radiographs, four demonstrated skeletal metastases, and lesions were recognized on both examinations. This study demonstrates that radionuclide bone and liver images frequently detect metastatic lesions in patients with MCT and elevated serum calcitonin levels, and that some nonskeletal metastases in patients with this tumor display an unusual affinity for bone-seeking radiotracers.

Sex steroid receptor concentration in breast carcinoma tissue: effect of devascularization during mastectomy

The accurate determination of sex steroid receptors at the time of mastectomy (MX) for breast carcinoma is important for the determination of subsequent therapy of patients who develop metastases in inaccessible sites. The estrogen (E) and progesterone (P) receptor (R) proteins are heat labile, and measured levels may be vulnerable to alterations once the tumor is devascularized. To evaluate potential differences in ER and PR determinations in tumor tissue acquired at biopsy as compared with tumor from the MX specimen, quantitative analyses of ER (21 patients) and PR (17 patients) were performed on dual samples acquired from the initial biopsy (BX) and the subsequent MX specimen. Receptor concentrations were determined both by sucrose density gradient analysis and titration analysis, and results were expressed as fmol/mg cytosol protein. ER values were classified as receptor-rich (greater than 10 fmol/mg), intermediate (3 to 10 fmol/mg), or receptor-poor (less than 3 fmol/mg); PR values greater than 3 fmol/mg were considered positive. ER BX values were found to be rich or intermediate in 18 patients. When compared with BX values, MX ER values were quantitatively unchanged in 11 patients, lower (MX less than BX) in four patients, and higher in three patients (MX greater than BX). In no patient was the BX ER rich or intermediate and the concomitant MX ER poor. In two patients the PR value was "positive" at BX but "negative" at MX. Accordingly, malignant tissue from a pre-MX biopsy specimen is preferred for receptor analysis although it is apparent that tumor tissue from a properly handled MX specimen is satisfactory for the determination of ER status for clinical purposes.

Ablative procedures in patients with metastatic breast carcinoma

The ability to determine the content of sex steroid receptors in breast carcinoma cells has markedly enhanced the clinician's ability to predict the response to hormonal therapy in patients with metastatic breast carcinoma. Formerly the surgical ablation of endocrine organs (hypophysectomy, adrenalectomy, and oophorectomy) was used as the initial therapy in many patients with metastatic breast carcinoma. Currently, however, only oophorectomy is employed as the initial treatment of choice in patients with recurrent breast carcinoma, and its use is exclusively limited to premenopausal or perimenopausal patients whose tumors are estrogen-receptor positive. The decreased utilization of surgical ablative procedures is primarily due to the introduction into clinical practice of two pharmacologic agents, the antiestrogen, tamoxifen, and the adrenal blocking agent, aminoglutethimide. When administered to postmenopausal patients with metastatic breast carcinoma, these pharmacologic agents induce remissions as frequently as do surgical ablative procedures; however, their use is associated with distinctly less morbidity and virtually no mortality.

Comparison of four provocative tests for the diagnosis of gastrinoma

In an attempt to determine the best provocative test for the diagnosis of gastrinoma, ten normal subjects, 13 patients with known gastrinoma, and one patient with presumed gastrinoma were administered four regimens: (1) rapid calcium infusion (2 mg Ca++/kg/min), (2) secretin (2 clinical units (CU)/kg/bolus), (3) long calcium infusion (12 mg Ca++/kg/3 h) and (4) a combination test consisting of a rapid calcium infusion followed immediately by secretin. Blood was drawn for serum gastrin levels before and following infusion of the test agents. The administration of rapid calcium followed by secretin provoked the greatest increases in serum gastrin above basal levels in both normals (29%) and patients (362%). Peak gastrin levels in patients were similar following the long calcium infusion (341%) but were less following the rapid calcium infusion alone (124%) and secretin alone (207%). There were no false-positive or false-negative tests with the calcium plus secretin when the criterion for diagnosis was either a 50% increase or a 200 pg/ml increase above the basal gastrin level. The distinct advantages (short test period, low patient morbidity, and relatively great potency) of the calcium plus secretin test make it an attractive alternative to other previously described provocative tests for the diagnosis of gastrinoma.

Histamine and calcitonin release from medullary thyroid carcinoma

The secretagogue effect of histamine on calcitonin secretion has been studied in 15 patients with medullary thyroid carcinoma and compared with known stimuli: glucagon and calcium in combination with pentagastrin. The effect of concomitant histamine H2-receptor blockade on these responses has been studied in the same patients. Seven patients with undetectable basal plasma calcitonin concentrations had measurable responses to calcium/pentagastrin but not to histamine or glucagon. In the remaining eight subjects, significant responses were seen to all three test substances, calcium/pentagastrin proving to be the most potent secretagogue. Establishment of H2-receptor blockade with cimetidine had no effect on basal calcitonin concentrations and did not suppress responses to histamine, calcium or pentagastrin. The variable secretagogue effect of histamine could be mediated through H1-receptors, through nonspecific vascular dilation "washing out" preformed calcitonin, or through its destruction to varying degrees by histaminase, present in most medullary thyroid tumors. Histamine is unlikely to replace calcium/pentagastrin as the most discriminative, provocative diagnostic agent in medullary thyroid carcinoma, but correlation of secretory responses with tissue histaminase concentrations and attempted blockade with differing antihistamines will further our understanding of this tumor.

Relationship of age and menopausal status to estrogen receptor content in primary carcinoma of the breast

The cytosolic estrogen receptor (CER) content of 1037 primary breast carcinomas was evaluated by sucrose density gradient analysis. Tumor specimens from premenopausal patients had significantly lower levels of CER (14.6 +/- 1.5 (mean +/- SEM) 8S binding fmole/mg protein) compared with carcinomas from postmenopausal patients (57.5 +/- 3.9 fmole/mg protein; p less than 0.001). The proportion of specimens with CER levels above threshold values of 3, 7, or 10 fmoles/mg protein were significantly higher for postmenopausal patients (72%, 63%, 59%, respectively) than for premenopausal patients (56%, 42%, 36%, p less than 0.001). When compared within half-decades, no statistically significant differences between premenopausal and postmenopausal patients were observed for mean, median, or rank sums of CER levels (p greater than 0.3). When patients were compared by half-decades, both mean and ranked sums of CER levels were significantly different (p less than 0.001). The proportion of specimens that demonstrated CER levels above a threshold value of 10 fmole/mg protein increased sequentially from a low of 13/51 (26%) for patients less than 35 years to a high of 60/81 (74%) for patients greater than 75 years.

Metastatic medullary thyroid carcinoma in sputum. A light and electron microscopic study

Medullary thyroid carcinoma (MTC) was diagnosed in a 43-year-old male by light microscopy, electron microscopy and immunohistochemistry. Five years after thyroidectomy, malignant cells with the typical cytologic and electron microscopic features of MTC were seen in his sputum, and extensive pulmonary metastases from MTC were subsequently documented at autopsy. Sputum examination is a useful diagnostic technique in patients with MTC in whom pulmonary metastases are suspected.

Antibody reacting with the murine mammary tumor virus in the serum of patients with breast carcinoma: a possible serological detection method for breast carcinoma

Sera from patients with Stages A and B infiltrating ductal carcinoma of the breast, benign breast disease, cancers other than breast carcinoma, and normal female controls were examined by indirect immunoelectron microscopy (IEM) and a viral agglutination test for evidence of antibodies directed against murine mammary tumor virus (MMTV). Sera from 41 (79%) of 52 patients with breast carcinoma and eight (19%) of 42 normal subjects or patients with benign breast disease (noncancer subjects) showed evidence of MMTV labeling by IEM. In the MMTV agglutination test, significant virus agglutination (2+ to 4+) was present in eight (13%) of 61 noncancer sera, 58 (86%) of 68 breast carcinoma sera, and two (11%) of 18 other cancer sera. The results of the more rapid MMTV agglutination test correlated well with IEM. Analysis of reacting antibody by IEM revealed no immunoglobulin A and significant immunoglobulin M and immunoglobulin G antibody. Serum reactivity against MMTV was completely absorbed by MMTV but not by the glycoprotein with a molecular weight of 52,000 of MMTV, Friend murine leukemia virus, avian myeloblastosis virus, or sheep erythrocytes. It is concluded that reactivity of human antibodies to MMTV is strongly associated with, but is not entirely specific for, breast carcinoma. It remains to be determined if normal persons with these antibodies will ultimately develop breast cancer and should therefore be considered at high risk. These tests may have potential usefulness as a diagnostic screen for breast cancer.

Androgen stimulation of gross cystic disease fluid protein and carcinoembryonic antigen in patients with metastatic breast carcinoma

Plasma levels of carcinoembryonic antigen (CEA) and the 15,000 molecular weight gross cystic disease fluid protein (GCDFP-15) were determined in 30 patients with metastatic breast carcinoma before, during, and after treatment with fluoxymesterone. Within 2 weeks after initiation of treatment, plasma levels of GCDFP-15 increased 50% above basal values in 15 (79%) of 19 patients. Similar increases in plasma CEA levels occurred in only 5 (23%) of 22 patients. Eight (33%) of 24 patients achieved increases in GCDFP-15 of 500% or more above basal levels after 14-336 days of therapy. Within 2 weeks of fluoxymesterone termination, 14 (93%) of 15 patients had a decrease in plasma GCDFP-15 levels, and in 12 (80%) the decrease exceeded 33% (the inverse of a 50% increase). Conversly, only 5 (33%) of 15 patients experienced a decrease in plasma CEA levels within 2 weeks of therapy termination, and in only 1 (6.7%) subject did the decrement exceed 33%. Nine (90%) of 10 patients who had 50% increases in plasma GCDFP-15 during initial androgen therapy also had significant decreases in plasma GCDFP-15 following termination of therapy. Data on 3 prospectively studied patients demonstrated that plasma GCDFP-15 rose within 24 hours of initiation of fluoxymesterone therapy and continued to rise for at least 6 days. Increased plasma levels of GCDFP-15 were reflected in increased urinary excretion of the glycoprotein.

Thyroid venous catheterization in the early diagnosis of familial medullary thyroid carcinoma

In kindreds with familial medullary thyroid carcinoma (MTC), individuals are often detected whose peripheral plasma calcitonin (CT) levels are undetectable in the basal state but increase minimally following provocative testing. The proper management of such patients has been uncertain, but most investigators have advocated repeat testing and evaluation after an interval of several months. The present study was conducted to evaluate the diagnostic implications of these modest increases in plasma calcitonin. In 25 kindred members at direct risk for familial medullary thyroid carcinoma (MTC), basal peripheral plasma calcitonin (CT) levels were less than 240 pg/ml. Following provocative testing with intravenous calcium or pentagastrin or both, calcitonin values remained below 240 pg/ml in eight subjects (Group A), however, they were mildly elevated (260-580 pg/ml) in 12 subjects (Group B) and moderately elevated (700-940 pg/ml) in five subjects (Group C). Following the transfemoral placement of a catheter into the inferior thyroid vein (ITV), provocative testing was repeated, and ITV and peripheral blood samples were collected simultaneously. Basal ITV plasma CT levels were below 240 pg/ml in all patients in Group A, however, they were mildly elevated (500 pg/ml) in one of the 12 patients in Group B and moderately elevated (800 pg/ml, 1400 pg/ml) in two of the five patients in Group C. Following provocation, ITV plasma CT levels became markedly elevated in one patient in Group A and in all of the patients in Groups B(2520+/-635 pg/ml) and C (6322+/-2598 pg/ml). Thyroidectomy was performed in patients whose ITV plasma CT level was elevated following provocative testing. Medullary thyroid carcinoma of C-cell hyperplasia were evident either on microscopic (1/1 patient in Group A;9/12 patients in Group B; and 2/5 patients in Group C), or gross (3/12 patients in Group B;3/5 patients in Group C) examination of thyroidectomy specimens. In only one of 14 patients was metastatic MTC noted on histologic examination of resected cervical lymph nodes. Postoperative peripheral plasma CT levels were unchanged from basal and less than 240 pg/ml following provocative testing in all but one patient. The present study then provides definitive evidence that patients at direct risk for familial MTC who have even minimally abnormal responses in peripheral plasma CT following provocative testing generally harbor some stage of a C-cell proliferative disorder. Identification of such individuals with early disease is important because thyroidectomy offers an extremely high cure rate.

Carcinoembryonic antigen in nonhuman primates

Blood levels of carcinoembryonic antigen (CEA) have been measured in several nonhuman primate species. Only gorillas and chimpanzees were found to have significant elevations of CEA-like activity in their blood compared to the normal values of less than 2.5 ng/ml in humans. The average CEA level in 134 chimpanzees was 25.2 ng/ml (range, 4.2--95 ng/ml) and in 13 gorillas it was 32 ng/ml (range, 12.4--61.9 ng/ml). These levels were not related to sex. Blood levels repeatedly taken over a 1 1/2-year period remained relatively stable in both species. Analysis of parallelism of immunologic reactivity showed chimpanzee CEA to be similar to but not identical with human CEA. The molecular size of chimpanzee CEA was also similar to that of human CEA.

Estrogen receptor status in inflammatory breast carcinoma

Sixteen women with a clinical diagnosis of inflammatory breast carcinoma had estrogen receptor analysis performed. Eleven of 16 were premenopausal. Median age of all patients was 46 years. All patients had estrogen receptor (ER) assay by either dextran charcoal method or by sucrose gradient method. Five patients were ER + ( greater than or equal to 10 fmol/mg cytosol protein) and 11 were ER -, with almost no binding at all. Response to therapy for metastatic disease using either hormones or chemotherapy was disappointing.

Biochemical correlates of morphologic differentiation in human breast cancer

In 115 breast carcinoma tissues, histologica grade and cell cytosol concentrations of estrogen receptor (ER) and progesterone receptor (PR) and two breast cyst fluid proteins (gross cystic disease fluid protein [GCDFP-15] and nonreceptor progesterone-binding protein [PBP]) were deterMined. Higher levels (expressed as femtomoles per milligram of protein) of ER (128 +/- 28 versus 11 +/- 1, P less than 0.001) and PR (82 +/- 16 versus 3 +/- 1, P less than 0.001) were found in grade 1 (well-differentiated) carcinomas as compared with grade 3 (poorly differentiated) carcinomas. Similarly, higher concentrations (expressed as nanograms per milligram of cytosol protein) of GCDFP-15 (2110 +/- 840 versus 210 +/- 40, p less than 0.001) and PBP (4920 +/- 1200 versus 370 +/- 60, P less than 0.001) were found in grade 1 as compared with grade 3 carcinomas. Tumor cytosols that contained low levels of both cyst proteins (less than 225 ng/mg GCDFP-15 and less than 750 ng/mg PBP) had a high incidence of grade 3 (35 of 46, 78%) or grade 2 (15 of 46, 33%) histologic findings and had a high incidence of receptor-negative specimens (27 of 52, 52%). Based on these cutoff levels, grade 2 lesions were subdivided into a "high" cyst protein group, which had ER and PR levels similar to grade 1 tumors (93.1 +/- 26.7 for ER and 84.7 +/- 32.4 for PR, P greater than 0.3), and a "low" group, which had receptor values similar to grade 3 carcinomas (14.1 +/- 5.3 for ER and 9.1 +/- 5.2 for PR, P less than 0.3). Although the mean cytosol content of carcinoembryonic antigen (CEA) was significantly higher in malignant tissues (125 +/- 27 ng/mg cytosol protein) than in benign tissues (4.8 +/- 1 ng/mg cytosol protein), the CEA content was not significantly different between grades 1 and 3 tumors.

Review: Medullary carcinoma of the thyroid: radiographic features of a unique tumor

Medullary carcinoma of the thyroid is a unique neoplasm characterized by consistent production of a hormonal marker, calcitonin, calcification of both primary and metastatic foci, and association with other endocrine neoplasms. It accounts for 3.5%--10% of all thyroid malignancies. First described by Hazard et al. [1] in 1959, this neoplasm has become the focus of increasing clinical and experimental investigation. It occurs both sporadically and in families. When familial, it is seen as a component of the multiple endocrine neoplasia type II (MEN-II) syndromes. Interest in medullary carcinoma of the thyroid far exceeds that warranted by its infrequent occurrence. Over 200 articles dealing with this tumor have appeared in the medical literature in the last 10 years. This may be attributed to the number of distinctive properties of the tumor: the familial occurrence when associated with endocrinopathies, the propensity to produce amyloid, and the great synthetic capability for the biogenic amines calcitonin, serotonin, histaminase, and prostaglandins. Of greatest importance is the value of calcitonin radioimmunoassay for detecting patients with the tumor even though it may be evident clinically. Fifty-three patients with surgically and biochemically proven medullary carcinoma were evaluated and followed at Duke University Medical Center from 1968 to 1981. Ten patients with sporadic tumor, 37 with MEN type IIa, and six with MEN type IIb prompted this review. They will be used to illustrate the varied and sometimes characteristic radiographic manifestations of medullary carcinoma of the thyroid. This tumor has a spectrum of radiographic features in multiple organs that, when familial, facilitate its recognition and treatment.

Localization of I-131-labeled goat and primate anti-carcinoembryonic antigen(CEA) antibodies in patients with cancer

Thirty patients with anti-carcinoembryonic antigen (CEA)-producing cancers of the colon, breast, or thyroid were injected with 1 to 2 mCi of Iodine-131 (131I)-labeled, affinity-purified, goat or baboon anti-CEA antibodies. Images were obtained daily for four days. Computerized background subtraction using technetium 99m (99mTC)-labeled compounds was used. Images obtained with and without background subtraction were correlated with other evidence of disease. Activity levels in plasma, urine, and thyroid gland were monitored. Significant deiodination of antibody occurred within the first 24 hours. The mean plasma half-disappearance-time of baboon antibody was significantly longer than the mean half-disappearance-time of goat antibody. With exogenous blockade, total thyroid uptake was less than 0.1% of the injected dose. Without background subtraction, scintigraphic localization of known tumor was possible in one of two patients with colon carcinoma, in three of 20 patients with breast cancer, and in one of five patients with medullary carcinoma of the thyroid. With background subtraction, potential false-positive results could be generated for every patients, depending on the normalization site chosen and the degree of subtraction used. In contrast to results of previous reports, CEA-producing tumor was found to be infrequently localized using highly purified goat or primate radiolabeled anti-CEA. Furthermore, the subtraction technique described by previous investigators may lead to a high false-positive rate.

The importance of early diagnosis in patients with hereditary medullary thyroid carcinoma

Ninety-two patients from 12 kindreds with hereditary medullary thyroid carcinoma (MTC) were evaluated. We sought to determine if the stimulated plasma calcitonin (CT) level at the time of diagnosis was of prognostic significance. The patients were divided into four groups according to their preoperative stimulated plasma CT levels (1) 250-1,000 pg/ml (n=25); (2) 1,000-5,000 pg/ml (n=36); (3) 5,000-10,000 pg/ml (n=8); (4) greater than 10,000 pg/ml (n=23). Compared between the four groups were several parameters, including incidence of regional lymph node metastases, incidence of residual MTC post-thyroidectomy (as indicated by increased (greater than 300 pg/ml) plasma CT levels after operation), incidence of distant metastases, and incidence of death. Also compared were the incidences of microscopic or gross MTC in thyroidectomy specimens. The incidence of regional lymph node involvement ranged from a minimum of one (4%) of 25 patients in Group 1 to 13 (57%) of 23 patients in Group 4. Similarly, plasma CT levels were elevated in only one (4%) of 25 patients in Group 1 compared to 14 (61%) of 23 patients in Group 4. There was no evidence of distant metastases or death in the patients in Groups 1, 2, or 3. In the 23 patients in group 4, however, four (17.4%) had distant metastases and two (8.7%) died of disease during the period of observation. Of th 25 patients in Group 1, MTC was evident only by microscopic examination in 14 (56%). Eleven (44%) of the patients in Group 1 had macroscopically evident medullary thyroid carcinoma. This is in contrast with patients in Group 4 where all 23 had grossly evident MTC. These data indicate that the stimulated plasma CT level at the time of diagnosis is an excellent prognostic indicator of the extent of a disease in patients with hereditary MTC. Aggressive screening of kindred members at risk is of critical importance for establishing the diagnosis and instituting therapy at a time when the neoplasm is confined to the thyroid gland.

Quantitation of response to therapy in patients with metastatic breast carcinoma by serial analysis of plasma gross cystic disease fluid protein and carcinoembryonic antigen

The maximum percent change (MPC) of plasma carcinoembryonic antigen (CEA) and gross cystic disease fluid protein (CDP) were correlated with response to therapy in 92 metastatic breast carcinoma patients. In patients treated with hormone therapy MPC values were significantly different between patients with disease progression (Prog) and regression (Reg): MPC-CEA for Reg = -72 +/- 7%, for Prog = 396 +/- 150%; MPC-CDP for Reg = -86 +/- 6%, for Prog = 702 +/- 330%, P less than 0.001 in a one-way ANOVA for CEA and CDP. Similar differences were noted in patients treated with chemotherapy. Decreased (greater than 50%) plasma CEA levels were observed in 24/29 (83%) of Reg, 18/35 (51%) stable and 0/49 (0%) of Prog; decreased (greater than 50%) plasma CDP levels were noted in 19/24 (79%) of Reg, 21/28 (75%) of stable and 2/35 (6%) of Prog. Patients with plasma marker decreases greater than 50% had significantly longer responses to therapy (14.2 months for CEA, 14.1 months for CDP) compared to patients with less than 20% decrease (2.0 months for CEA, 0.8 months for CDP), P less than 0.001 in a one-way ANOVA. Decreasing marker levels during the initial six weeks of therapy (negative slope) accurately identified Reg or stable patients: the predictive value of a negative slope was 92% for CEA and 86% for CDP. Rising marker values correctly identified treatment failures (Prog): the predictive value of a positive slope was 90% for CEA and 76% for CDP. These data indicated that changes in plasma CEA and CDP levels reflected increasing or decreasing tumor burden during hormone or chemotherapy treatment of metastatic breast carcinoma. Criteria have been established to predict therapeutic outcome based on the slope of CEA or CDP after six weeks of treatment.U

The prognostic and biological significance of cellular heterogeneity in medullary thyroid carcinoma: a study of calcitonin, L-dopa decarboxylase, and histaminase

We evaluated the cellular distribution of calcitonin (CT), L-dopa decarboxylase (DDC), and histaminase [diamine oxidase (DAO)] in 33 patients with medullary thyroid carcinoma (MTC). CT immunostaining was uniform (greater than 90% of the cells) and intense (4+) in lesions from 7 patients with C-cell hyperplasia and 6 with microscopic MTC: conversely, patchy CT staining (less than 40% of the cells) and diminished intensity (1+) were found in metastases from 8 patients who died of virulent disease. In 17 patients who underwent thyroidectomy for macroscopic cervical MTC with no evidence distant metastases, CT staining was intense (3-4+) and homogeneous (greater than 90%) in 11 subjects who were well 0.5-16 yr postoperatively. Six patients with similar clinical presentations had heterogeneous staining for CT in primary tumor (less than 40% of the cells; 1-2+ intensity); 5 died of disseminated MTC 0.5-5 yr postoperatively (P less than 0.001). Biochemical studies of distant metastases revealed an inverse relationship between the distribution of CT and that of both relationship between the distribution of CT and that of both DDC (r = 0.71; P less than 0.01) and DAO (r = 0.81; P less than 0.001). We conclude that cellular heterogeneity in MTC tissue is associated with a distinct biochemical pattern, and its presence, whether in a primary or metastatic lesion, indicates a virulent neoplasm associated with a grave prognosis.

Aminoglutethimide as treatment of postmenopausal women with advanced breast carcinoma

Hormone-dependent breast carcinomas respond to deprivation of biologically active estrogens with objectively quantifiable tumor regression. Aminoglutethimide, a known inhibitor of steroid synthesis, is also a potent blocker of the aromatase enzyme and, thus, of estrogen production. We developed an effective regimen to inhibit estrogen production in postmenopausal women using aminoglutethimide and replacement glucocorticoid. One hundred forty-seven women initially received aminoglutethimide and replacement glucocorticoid as treatment of metastatic breast carcinoma. One hundred twenty-nine women are currently evaluable for assessment of clinical and hormonal responses. Thirty-seven percent of unselected women and 49% of estrogen receptor-positive patients experienced objective tumor regression. Responses occurred predominantly in soft tissue (47%) and bone (35%) and lasted 30 +/- 9.1 months for complete and 14 +/- 1.5 months for partial regressions. Plasma and urinary estrogen levels fell equally in responder versus nonresponder groups whereas androgen levels declined less in patients with progressive disease.

How effective is surgical adrenalectomy in lowering steroid hormone concentrations?

Surgical adrenalectomy produces objective tumour regression in 50-60% of estrogen receptor-positive women with metastatic breast carcinoma. Additional responses to antiestrogens or further suppression of estrogens with aminoglutethimide after adrenalectomy suggest the possibility of continued adrenal steroid secretion even after surgical ablation. The use of sensitive and specific RIAs allows precise determination of the degree of hormone suppression after adrenalectomy and could provide documentation of nonsuppression or escape from suppression in individual patients. To evaluate the possibility of continued hormone secretion, we measured 14 hormones in 26 postmenopausal women with breast carcinoma before and after adrenalectomy. While the mean levels of androgens were markedly suppressed [dehydroepiandrosterone sulfate (DHEA-S), 99%, androstenedione, 94%; testosterone, 77%; dihydrotestosterone, 73%] after adrenalectomy, estrogen concentrations fell to a much lesser extent (plasma estrone, 73%; urinary estrone, 86%; plasma estradiol, 53%; urinary estradiol, 67%). Examination of data in individual patients revealed incomplete suppression in several women (less than 50% suppression of plasma estradiol in 14 of 25 patients, of urinary estradiol in 4 of 22, and of urinary estrone in 1 of 22). Androgen concentrations also fell incompletely after adrenalectomy in a few patients. Androstenedione concentrations were greater than 2 SD above the group mean in 2 of 23 patients, and in 2 of 25 patients, DHEA-S concentrations were also greater that 2 SD above the group mean. Serial measurements of hormones over a 1- to 3-yr period following surgery revealed escape from suppression over time (i.e. greater than 2-fold increase in hormone levels) in 7 of 26 women. The practical significance of the lack of suppression or of escape from inhibition was assessed by comparing estrogen levels in responders vs. nonresponders to surgical adrenalectomy. Of all steroids measured, greater suppression of only 1 hormone (urinary estrone) was observed in responders vs. nonresponders. These data indicate that adrenalectomy does not uniformly suppress circulating androgen and estrogen levels in postmenopausal patients. Women who initially suppress after adrenalectomy may show recovery of either androgen or estrogen levels with time.

Osteomalacia after parathyroidectomy in patients with uremia

Five patients on maintenance dialysis had symptoms of osteomalacia, proven by biopsy, after parathyroidectomy. In all five patients clinical and radiographic manifestations of secondary hyperparathyroidism were present before surgery, and in two patients preoperative biopsy of bone confirmed the existence of osteitis fibrosa. Like previously described patients with osteomalacia all five had multiple fractures and normal or high serum calcium concentrations that rose to abnormally high values on treatment with vitamin D or dihydrotachysterol. Quantitative histomorphometry of biopsy after parathyroidectomy showed no residual parathyroid hormone effect and nearly complete cessation of mineralization. Four patients had forearm autografts of parathyroid tissue that appeared to be functioning at very low rates according to paired venous sampling, and all five patients had relatively low circulating concentrations of parathyroid hormone. This and earlier experiences reported by others suggest that secondary hyperparathyroidism may have an important facilitative role in the mineralization of bone in uremic patients.

Stimulation of in vitro release of calcitonin from rat and human C-cells by cimetidine

Previous reports have suggested that the H2-receptor blocker, cimetidine, can inhibit parathyroid hormone (PTH) release. The present studies were designed in an attempt to see whether cimetidine affects secretion of calcitonin (CT) as well. Entire thyroparathyroid glands from 8-day-old baby rats or small pieces of a human medullary thyroid carcinoma were incubated at 37 C for up to 8 h in chemically defined culture medium gassed with 95% 02-5% CO2. With rat thyroparathyroids, both CT and PTH released into medium were measured using RIAs that detect that rat hormones. CT secreted from human C-cells was measured using an RIA for human CT. The results were: (A) As we had found previously, cimetidine at doses of 3 x 10(-3) M and 9 x 10(-3) M inhibited PTH release from rat thyroparathyroids by as much as 50-60% (p less than 0.05 - less than 0.001). In these same experiments, cimetidine produced increases of approximately 1- to 5-fold in the CT levels found in the medium (p less than 0.05 - less than 0.001). (B) Fragments of human medullary thyroid carcinoma incubated for 3 h in the presence of 10(-5) M cimetidine released considerably more CT than tissue incubated in control medium (48 +/- 9.3 vs 21 +/- 3.6 ng CT/microgram tissue protein, p less than 0.05). Our results show that cimetidine in vitro not only can inhibit secretion of PTH but also apparently can promote the release of CT from both rat and human C-cells. Whether this effect is mediated by H2 receptors and whether it is of any physiological significance awaits clarification.

A randomized trial comparing surgical adrenalectomy with aminoglutethimide plus hydrocortisone in women with advanced breast cancer

We randomized 96 postmenopausal women with metastatic breast carcinoma to receive surgical adrenalectomy or medical therapy with an adrenal inhibitor, aminoglutethimide (AG), plus replacement hydrocortisone. Before randomization, women were stratified according to disease-free interval, site of dominant disease, and estrogen-receptor status. Of 40 evaluable women treated with AG and hydrocortisone, 53 per cent had objective responses, as compared with 45 per cent of 29 women undergoing surgical adrenalectomy (P value not significant). Responses lasted a mean of 17.2 months in the medical group and greater than 17.1 months in the surgical group (not significant). Estrogen levels fell similarly in response to either treatment, whereas AG and hydrocortisone preserved androgen production. A null hypothesis tested the single question asked by this study: "Is surgical adrenalectomy superior to treatment with AG and hydrocortisone?" Rejection at significance levels of P = 0.01 and P = 0.07 for differences of 20 per cent and 10 per cent, respectively, suggested that medical therapy with AG and hydrocortisone may be logically chosen in place of surgical adrenalectomy.

Management of hereditary medullary thyroid carcinoma

In this paper we have briefly outlined our views on the management of hereditary MTC. We have stressed the fact that although many patients with the usual form of disease have an indolent clinical course there exists a population of patients who may be at risk for widely disseminated virulent tumour. Also, some patients can have marked invasion of adjacent tissues in the cervical region from localized tumour. Hence it seems rational to attempt removal of the primary tumour prior to the development of regional or distant metastases. The role of the combined calcium-pentagastrin provocative test to identify patients with preclinical disease has been outlined. The only definitive treatment for the disease is total thyroidectomy with resection of adjacent cervical nodes. Many patients who are treated at a time when the disease has become clinically detectable will have residual tumour or recurrence as indicated by abnormal calcitonin levels in the blood. Since most of these patients seem to take an indolent clinical course, it is suggested that they should not be treated with radiation therapy and/or chemotherapy, even though residual MTC is known to be present. Even in patients with advanced stages of MTC, the use of chemotherapy and radiation therapy has not been encouraging. However, some aspects of the management of patients with aggressive disease are discussed. Finally, the lack of features to predict which patients may have a poor prognosis is outlined and some new approaches to defining such parameters are discussed.

Medullary carcinoma of the thyroid in the multiple endocrine neoplasia IIA syndrome

Clinical, biochemical, and morphologic parameters in 72 patients with familial medullary thyroid carcinoma (MTC) associated with multiple endocrine neoplasia IIA (MEN IIA) were reviewed. Sixty-nine patients had undergone total thyroid resection. In 27 patients (Group I) the thyroid tumors were smaller than 0.7 cm in diameter; five of these patients had C-cell hyperplasia alone. In 19 patients (Group II) tumors ranged from 0.7 to 1.5 cm, and in 26 patients (Group III) they were larger than 1.5 cm. The mean ages at surgery were 19.6 years (Group I), 33.7 years (Group II), and 32.2 years (Group III). Regional lymph node metastases occurred less often in patients of Group I, 4/20 (20%) and Group II, 4/13 (30%) than in those of Group III, 14/17 (82%) [p = 0.0001]. Elevated postoperative plasma calcitonin levels, indicative of residual MTC, were observed less frequently in patients in Group I, 6/27 (22%) and Group II, 6/15 (50%) than in Group III, 11/15 (73%) [p = 0.005]. All of the patients in Group I and Group II are alive (mean follow-up of 3.5 years and 6.0 years following surgery), whereas 6/26 (23%) Group III patients have died of metastatic MTC, three within 2 years of initial diagnosis. Histologic features varied with tumor diameter. All tumors from patients in Group III contained amyloid, while the majority of those from patients in Group I had an infiltrative configuration and 9/22 tumors lacked amyloid. Among neoplasms from patients in Group III, mitotic figures correlated with distant metastases or death from tumor. Only 1/16 patients who died from MTC had a distinctive tumor morphology, namely a prominent component of small cell anaplastic carcinoma. Early detection of minimal MTC in MEN IIA family members offers the best chance of curing patients with this potentially fatal lesion.

Adenylate cyclase activity in human parathyroid tissues: reduced sensitivity to suppression by calcium in parathyroid adenomas as compared with normal glands form normocalcemic subjects or noninvolved glands from hyperparathyroid subjects

To examine whether alterations in parathyroid adenylate cyclase might be associated with glandular hyperfunction, we compared enzyme activity in membranes from 7 normal glands with activity from 18 abnormal and 5 noninvolved glands from patients with primary hyperparathyroidism. Compared with the normal glands, the specific enzyme activity after full stimulation with guanyl-5'yl imidodiphosphate was significantly decreased in both hyperplastic and noninvolved glands from the hyperparathyroid subjects. While the enzyme activity of all tissues could be suppressed by calcium, a twofold higher calcium concentration was required for comparable suppression of the enzyme from adenomas as compared with normal or noninvolved glands. Alterations in the adenylate cyclase complex of hyperplastic parathyroid glands may explain, in part, the elevated "set point" for calcium homeostasis in primary hyperparathyroidism.

Histologic study of the ocular lesions in multiple endocrine neoplasia syndrome type IIb

We studied the clinical and histopathologic findings in the eyes of two patients with multiple endocrine neoplasia type IIb. A prominent clinical feature of this condition is enlarged nonmyelinated corneal nerves composed of bundles of axons associated with Schwann cells. Prominent corneal nerves within an otherwise normal corneal stroma are an important clinical feature of multiple endocrine neoplasia type IIb. Because of this, ophthalmologists are in a position to make an early diagnosis and hence to recommend diagnostic procedures and treatment for the associated potentially fatal medullary carcinoma of the thyroid and pheochromocytomas.

Comparison of sex steroid receptor analyses and carcinoembryonic antigen with clinical response to hormone therapy

This study corroborates previous reports which suggested the efficacy of estrogen receptor (ER) analysis in predicting responses of patients with metastatic mammary carcinoma to hormonal therapeutic manipulation. The predictive value of multiconcentration titration and sucrose density gradient analyses of ERs and progesterone receptors (PRs) are compared. The predictive value of ER analyses can be improved by the discrimination of 8S versus 4S binding species or by the use of PR analysis in combination with ER analysis. The tumor-associated antigen, carcinoembryonic antigen (CEA), is evolving as an important quantitative aid in evaluating the clinical responses to patients receiving hormonal therapy.

Evaluation of baboon antiserum to carcinoembryonic antigen

The common baboon (Papio), immunized with carcinoembryonic antigen (CEA), was found to form specific-site antibodies for CEA. The baboon antiserum does not recognize colon carcinoma antigen-III, but does demonstrate similar ionic strength effects to those previously described for goat antisera to the CEA-specific site(s). Baboon specific-site antibody for CEA can be used for radioimmunoassay of CEA in plasma and gives similar results to the commercial (Roche) goat anti-CEA.

Clinical and radiographic correlations in breast cancer patients with osseous metastases

Serial metastatic bone series on 12 patients with skeletal metastases from carcinoma of breast were studied. Changes in the clinical and radiographic parameters of the patients were correlated. Patients were all treated on a research protocol evaluating "medical adrenalectomy" with aminoglutethimide or surgical adrenalectomy. Seventeen clinical changes were noted in twelve patients. Sixteen of these observations demonstrated positive clinical correlations with concurrent skeletal radiographs. A lytic bone pattern correlated clinically with progressive tumor growth. A blastic bone pattern was present when objective clinical data indicated disease remission.

Evaluation of baboon antiserum to carcinoembryonic antigen

The common baboon (Papio), immunized with carcinoembryonic antigen (CEA), was found to form specific-site antibodies for CEA. The baboon antiserum does not recognize colon carcinoma antigen-III, but does demonstrate similar ionic strength effects to those previously described for goat antisera to the CEA-specific site(s). Baboon specific-site antibody for CEA can be used for radioimmunoassay of CEA in plasma and gives similar results to the commercial (Roche) goat anti-CEA.

Long-term evaluation of patients with primary parathyroid hyperplasia managed by total parathyroidectomy and heterotopic autotransplantation

Since 1973, we have performed total parathyroidectomy and forearm parathyroid autotransplantation in 36 patients with generalized (four gland) primary parathyroid hyperplasia. Twenty (56%) patients had nonfamilial parathyroid hyperplasia (NFPH) and 16 (44%) patients had familial parathyroid hyperplasia (FPH). Twenty-one patients (Group A) were undergoing operation for the first time and 15 (Group B) were having either second, third or fourth re-explorations for persistent hyperparathyroidism. All patients in Group A and nine patients in Group B had parathyroid resection and immediate autotransplantation as a single procedure. Six Group B patients had hyperfunctioning parathyroid tissue resected, cryopreserved, and subsequently grafted when it was evident that they had been rendered aparathyroid. A sustained differential elevation (13.7 fold +/- 2.7) of parathyroid hormone was detected in the antecubital vein of the grafted compared to the nongrafted arm in 35 (97%) patients. Two (5.6%) of the 36 patients (both with FPH; one Group A and one Group B) required permanent oral calcium and vitamin D replacement therapy and one (3%) patient (NFPH: Group A) had persistent hypercalcemia postoperatively, presumably due to a supernumerary gland. The remaining 33 (92%) patients became normocalcemia after surgery and 23 (70%) of them remained so. Ten (30%) of the 33 patients developed recurrent graft dependent hyperparathyroidism. Eight patients were from the group with FPH (8/14, 57%) and two were from the group with NFPH (2/19, 11%)(FPH vs. NFPH, p < 0.005). Because of symptoms of hypercalcemia or a serum calcium concentration exceeding 11 mg/dl, partial graft resection was performed in five patients and four became normocalcemic. Patients with generalized primary parathyroid hyperplasia may be difficult to cure, especially if the disease is familial. The technique of total parathyroidectomy and heterotopic autotransplantation of fresh or cryopreserved parathyroid tissue offers distinct advantages over alternative techniques.

Analysis of amniotic fluid, maternal plasma, and cord blood for a human breast gross cystic disease fluid protein

Amniotic fluid was analyzed for the presence of the 15,000 monomer molecular size glycoprotein found in human breast gross cystic disease fluid (GCDFP-15). From 24 weeks' gestation a log-linear increase in levels of GCDFP-15 was noted. The levels of GCDFP-15 doubled every 16 to 28 days, and the highest value recorded was 7,200 ng/ml. At delivery, levels of GCDFP-15 in cord blood plasma were in a background range (mean, 8 ng/ml). Maternal plasma levels of GCDFP-15 were one to tenfold higher in the third trimester of pregnancy when compared to those in nonpregnant women. Since saliva is known to contain high concentrations of GCDFP-15 (10 to 70 micrograms/ml), it is proposed that the levels in amniotic fluid originate from saliva and tracheobronchial secretions.