Factors affecting survival in patients presenting with synchronous hepatic metastases from colorectal cancer: a clinical and computer analysis

A review of 90 patients presenting in Leeds over the period 1976-80 with synchronous hepatic metastases from colorectal cancer has been undertaken. The median survival for the group was 10.3 months (range 1-48 months). A multivariate analysis identified factors in the history and examination of the patient, results of biochemical and haematological investigations and characteristics of both the primary and secondary tumour, which influenced survival. Recognition of these factors allowed both a clinical scoring index and computer survival model to be constructed. When applied to the group as a whole both were reasonably accurate at predicting survival (62 per cent for the survival model and 66 per cent for the scoring index). However, the computer model correctly identified 80 per cent of the 'long-term' survivors (greater than 12 months from the time of diagnosis). It is concluded that many trials of therapy for hepatic metastases from colorectal cancer have failed to consider the natural history of the disease and the identification of prognostic indices should allow for adequate stratification within the treatment arms of any future study.

Evaluation of an amplified enzyme-linked immunoassay of placental alkaline phosphatase in testicular cancer

The levels of serum placental alkaline phosphatase (PLAP) have been examined in 81 male controls, 51 untreated testicular tumours (41 seminomas and ten non-seminomatous testicular tumours) and 34 patients in complete remission (11 seminoma and 23 non-seminoma). Smoking induced a significant rise of serum PLAP in the controls, with a median level of 0.055 U/1 in non-smokers compared to 0.25 U/l in smokers. The levels found in pre-treatment seminoma (median 1.7 U/1) were significantly higher than in untreated teratoma (median 0.7 U/1). Treatment produced a significant fall in seminomas in remission (median 0.07 U/1). The role of PLAP in routine monitoring of seminomas was evaluated in 17 patients studied for 1-4 yr. PLAP shows similar trends to beta HCG but is an independent variable. The main role of PLAP is to help determine that the response to treatment has been satisfactory and that there are no unexpected foci of tumour.

Fever and proximal tubular function in acute pyelonephritis

The urinary excretion of alpha 1-microglobulin (alpha 1M), beta 2-microglobulin (beta 2M), retinol-binding protein (RBP) and N-acetyl-beta-D-glucosaminidase (NAG) as markers of proximal tubular dysfunction was measured in various forms of urinary tract infections (UTI) and in fever due to non-renal infections. The urinary concentration of these proteins was significantly increased in acute pyelonephritis compared with acute cystitis and asymptomatic bacteriuria. Tubular proteinuria and enzymuria could also be demonstrated in subjects with fever of non-renal origin and corresponded to the findings of pyelonephritis. It is suggested that fever per se is the most likely cause of the tubular proteinuria seen in acute pyelonephritis. In localizing an acute UTI characterization of the urinary protein profile seems to have no advantage over a carefully measured body temperature. The urinary excretion of alpha 1M,beta 2M and RBP were highly correlated, while urinary NAG activity was less correlated to these low-molecular weight proteins. Fibrin degradation product D (FDP-D) was detected in the urines in 60% of the patients with acute pyelonephritis and in one third of those with acute cystitis. The estimation of FDP in urine therefore seems to be of little value in the level diagnosis of UTI.

Serum beta 2-microglobulin and C reactive protein concentrations in viral infections

Serum beta 2-microglobulin concentrations were assayed in a number of virus diseases. Infectious mononucleosis, cytomegalovirus, and influenza A were associated with pronounced increases in serum beta 2-microglobulin concentration. Smaller increases, with values generally less than 4 mg/l, were noted in other viral infections. Apart from in acute influenza A, the C reactive protein and beta 2-microglobulin responses were not associated.

Cluster analysis of chromatographic profiles of urine proteins

A method to examine and classify the chromatograms of urinary proteins, separated on a fast protein liquid chromatography system, is presented. For the analyses a measure of similarity between chromatogram profiles is defined and this is used to implement a statistical cluster analysis technique for the identification of a system of classification. The resulting classification can be related to a clinical assessment of the proteinuria of the sample urines, which are from patients with various renal disorders.

The prognostic significance of acute phase proteins in patients with inoperable squamous cell carcinoma of the bronchus

In 95 patients with inoperable squamous cell carcinoma of the bronchus, nine potential serum "markers" were analysed for their prognostic significance. Lactate dehydrogenase, alpha 1 HS-glycoprotein, ferritin, carcino-embryonic antigen and immunoglobulin E did not prove to be useful as prognostic indices. The erythrocyte sedimentation rate and the acute phase proteins alpha 1 acid glycoprotein, C-reactive protein and prealbumin were correlated with survival. After taking the performance status and tumour stage into account, C-reactive protein still proved to be a strong prognosticator. The clinical relevance of the acute phase proteins signifying a so-called "biochemical status" next to the "clinical status" is discussed.

Proximal renal tubular function in myelomatosis: observations in the fourth Medical Research Council trial

Proximal renal tubular function was studied in 522 consecutive patients entered into the Medical Research Council's fourth myelomatosis trial. Assessment was made at presentation after a 48 h period of hydration but before administration of chemotherapy. The most common abnormalities in the urine other than light chain proteinuria were raised concentrations of the low molecular weight proteins alpha 1-microglobulin and alpha 1-acid glycoprotein. These were usually accompanied by increases in urinary beta-N-acetyl-D-glucosaminidase concentrations. The concentration of these substances in the urine directly correlated with urinary free light chain output. This tubular proteinuria was seen whether or not patients had impaired glomerular function, as assessed by a rise in serum creatinine concentration. Urinary concentrations of retinol binding protein, however, were generally increased only when serum creatinine concentrations were raised. This applied even when there were high concentrations of light chains, alpha 1-microglobulin, alpha 1-acid glycoprotein, and beta-N-acetyl-D-glucosaminidase in the urine. There is therefore a selective tubular proteinuria in myelomatosis which is seen in almost all patients with urinary light chain values greater than 1 u/l. This proteinuria is generally reversible, when light chains no longer appear in the urine. Patients whose serum creatinine was greater than 200 mumol/l, however, had increased urinary output of retinol binding protein in addition to increased excretion of alpha 1-microglobulin, alpha 1-acid glycoprotein, and beta-N-acetyl-D-glucosaminidase. Tubular proteinuria in many of these patients presenting in renal failure persisted even when light chain output was reduced after chemotherapy.

Immunoglobulin A, G and E levels in Egyptians with cancer: influence of schistosomiasis

The main patient series consisted of 415 Egyptians attending the Cairo Cancer Institute and comprising 286 bladder cancer, 97 breast cancer, 14 head and neck cancer and 18 gastrointestinal cancer cases. Also included in the study were 36 patients with active schistosomiasis and 89 health controls. Serum IgA, IgG, IgG subclasses, IgE, Schistosoma and Ascaris-specific IgE (RAST) and the acute-phase protein CRP were measured in all, or sub-sets, of the main patient group. The well-established increase in IgE and IgG levels, and the more recently reported increase in the levels of IgG3 and IgG4 subclasses in patients with schistosomiasis, were also found in bilharzial bladder cancer, indicating that humoral immunity persists in cancer-bearing patients. However, the plasma protein profile in bilharzial bladder cancer is further modified by significant increases in the levels of IgA, IgG, IgG1, IgG2 and CRP when compared to levels in patients with Bilharzia in the absence of neoplastic change. Patients with cancers not associated with parasitic infestation also had significant increases in their serum levels of IgG1, IgG2, IgG, IgE and CRP when compared to healthy Egyptian controls, but 41% of these non-bladder cancer patients showed IgE responses to previous parasitic infestations suggesting that any immunological response to cancer would be on the background of a variable non-specific increase of IgE.

Renal proximal dysfunction in patients with rheumatic diseases

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C reactive protein: an aid to assessment and monitoring of acute pancreatitis

An evaluation of C reactive protein as an indicator of the progress of acute pancreatitis has been made, and the data have been compared with the information given by the white cell count, erythrocyte sedimentation rate, and temperature and by two antiproteases--alpha 1 protease inhibitor and alpha 1 antichymotrypsin. The main value of C reactive protein is to provide a guide to the severity of the inflammation and to increase clinicians' awareness of the patient's enhanced risk of developing pancreatic collections when the C reactive protein concentration remains high (greater than 100 mg/l) at the end of the first week of the illness. In this respect C reactive protein concentrations are superior to white cell count, erythrocyte sedimentation rate, and temperature and the concentrations of antiproteases.

Plasma beta-2-microglobulin and fibronectin levels in beta-thalassaemia

The plasma beta 2-microglobulin (beta 2-MG) levels in 118 children with thalassaemia were investigated. The mean level was higher than in healthy children. A significant increase of beta 2-MG was associated with hypersplenism (3.14 +/- 0.6 mg/l). The beta 2-MG levels appeared to reflect reticuloendothelial system activity but were not related to iron overload. Fibronectin levels were generally lower than in healthy adults; profound chronic fibronectin depletion was not accompanied by an increased liability to infection.

Relation of alpha 2-macroglobulin and other antiproteases to the clinical features of acute pancreatitis

alpha 2-macroglobulin is probably the most important of the antiproteases in plasma. In this study, the relationships of plasma alpha 2-macroglobulin to the clinical features of acute pancreatitis as well as to plasma levels of other antiproteases, immunoglobulins, and immunoreactive trypsin, were investigated in 55 patients with acute pancreatitis. The mean level of alpha 2-macroglobulin in 395 plasma samples from the patients was 2.12 g/liter compared with 2.41 g/liter in 29 healthy subjects and 2.93 g/liter in 17 patients with septicemia. Plasma levels were lower in 12 patients with severe pancreatitis than in 43 with mild attacks, and the lowest levels in three fatal attacks were less than half the mean of the normal range. Lowest levels were recorded at a mean time of 3 days after admission in the patients with mild attacks, at 5 days after admission in the patients with severe attacks, and 9 days after admission in those with fatal attacks. In contrast, plasma levels of the alpha 1-proteinase inhibitor antichymotrypsin and C-reactive protein increased to above normal levels during the attack, significantly more so in severe compared with mild attacks. Plasma levels of IgA, IgG, and IgM remained within the normal range or were increased. In patients with severe pancreatitis, plasma levels of immunoreactive trypsin remained elevated for longer than in those with mild attacks although there was little initial difference in the levels. These data suggest that decreasing levels of alpha 2-macroglobulin during the course of acute pancreatitis are due to a specific mechanism and unrelated, for the most part, to any generalized effect of pancreatitis on protein synthesis. The formation of rapidly cleared complexes between alpha 2-macroglobulin and active proteases is the most tenable explanation for the depletion of plasma levels, but the clinical significance of the changes remains unclear.

Low molecular weight plasma proteins in the cerebrospinal fluid of children with hematological malignancies

The concentration of beta-2-microglobulin (beta 2-m) and of post gamma globulin (P gamma G) was examined in serum and cerebrospinal fluid from children with acute lymphatic leukemia (ALL) and non-Hodgkin's lymphoma (NHL). Data were analysed in order to determine whether concentration of beta 2-m or P gamma G during remission would be of value in predicting relapse or eventual outcome. Mean serum concentration of beta 2-m was similar in good and poor prognosis patients with ALL in remission and was not significantly altered in CNS or marrow relapse. Mean CSF concentration in NHL was also similar in both prognostic groups, and in poor prognosis patients was not significantly altered in relapse. The same pattern was seen when P gamma G was measured in CSF (serum concentration of this protein being too low for accurate determination). High within patient variability of levels of beta 2-m and P gamma G appeared to relate to chemotherapy rather than the disease process. Concentration of P gamma G was persistently raised in three children with brain damage of differing etiologies. Levels of two other low molecular weight proteins, retinol binding protein and alpha 1-microglobulin, were also determined in order to establish that beta 2-m and P gamma G concentration was not influenced by alteration in permeability of the blood-brain barrier. The beta 2-m and P gamma G concentration, although higher than reported in healthy children [5] does not appear to be of value as a prognostic indicator in ALL and NHL in children.

Biochemical aids in the monitoring of patients with ovarian cancer

A study of possible biochemical markers of tumor recurrence and progression was made in 93 patients with ovarian cancer followed longitudinally for up to 2 years during treatment by moderate or aggressive chemotherapy regimens. A panel of potential indicators was tested; the combination of serum albumin, C-reactive protein, alpha 1-acid glycoprotein, and phosphohexose isomerase levels was found to provide information that is useful as an adjunct to the clinical assessment of patients with advanced disease. However, the system could not detect a small tumor burden. The level of beta 2-microglobulin may have value in those patients whose tumor is associated with an increase of this analyte (77%), but it would appear to reflect a large tumor mass. Serum CEA, carcino-placental alkaline phosphatase, transferrin, and prealbumin were not found to be helpful.

Applications of fast protein liquid chromatography TM in the separation of plasma proteins in urine and cerebrospinal fluid

Fast Protein Liquid Chromatography TM (FPLC), in which an anion-exchange column is used, provides rapid separation and reproducible profiling of the plasma proteins in urine and cerebrospinal fluid (CSF). Chromatographic separation of the proteins takes 1 h for urine specimens and 45 min for CSF. The elution sequence from the anion-exchange column is similar to the electrophoretic mobility. Individual proteins have the same retention times independently of which type of specimen is used. The elution characteristics of 21 plasma proteins have been identified. We illustrated some applications of this system, including the profiling of tubular protein-uria, the isolation of Bence Jones proteins from urine, and the investigation of hemoglobin-derived products in the CSF.

Applications of fast protein liquid chromatography TM in the separation of plasma proteins in urine and cerebrospinal fluid

Fast Protein Liquid Chromatography TM (FPLC), in which an anion-exchange column is used, provides rapid separation and reproducible profiling of the plasma proteins in urine and cerebrospinal fluid (CSF). Chromatographic separation of the proteins takes 1 h for urine specimens and 45 min for CSF. The elution sequence from the anion-exchange column is similar to the electrophoretic mobility. Individual proteins have the same retention times independently of which type of specimen is used. The elution characteristics of 21 plasma proteins have been identified. We illustrated some applications of this system, including the profiling of tubular protein-uria, the isolation of Bence Jones proteins from urine, and the investigation of hemoglobin-derived products in the CSF.

Multivariate analyses as aids to diagnosis and assessment of prognosis in gastrointestinal cancer

The role of carcinoembryonic antigen (CEA), gamma glutamyl transpeptidase (gamma GT), phosphohexose isomerase (PHI), pseudouridine (psi) and acute phase reactant proteins (C-reactive protein (CRP) alpha 1-antichymotrypsin (ACT) and alpha 1-acid glycoprotein (AGP] in assessing the prognosis of gastrointestinal neoplasms and the discriminant function in distinguishing benign from malignant diseases of the GI tract was examined. In stomach cancer pre-operative levels of CRP can help in the identification of the patients with a resectable tumour; the pre-operative biochemical measurements do not give any further information on prognosis once stage and site are taken into account. In colorectal cancer pre-operative ACT levels give additional prognostic information once the clinical factors, Dukes stage, sex and age have been accounted for; PHI levels are on the border line of significance. A discriminant function has been devised using sex, CEA, psi, gamma GT, ACT and PHI that can identify 89% of Dukes "D" patients prior to surgery with a misclassification of 7% of other cases of colorectal cancer. A discriminant function using all the biochemical variates separated the cancer from non-cancer patients. The false positive rate for cancer was 16% and a false negative rate of 19%, when the cut-off level was set at 0.7.

Urinary protein isolation by high-performance ion-exchange chromatography

Proteins excreted in urine, following renal failure, were analysed by high-performance anion-exchange chromatography and chromatofocusing. The analysis involved three steps: (1) removal of the low-molecular-weight fraction by rapid desalting, (2) anion exchange of the high-molecular-weight fraction by using combined salt and pH gradients and (3) further separation of the main peaks by chromatofocusing. The selection of the column and conditions were based on data obtained from electrophoretic titration curves. The purity of selected peaks was evaluated by sodium dodecyl sulphate polyacrylamide gel electrophoresis.

Comparison of serum amyloid A protein and C-reactive protein concentrations in cancer and non-malignant disease

Serum amyloid A (SAA) concentrations correlate well with C-reactive protein (CRP) concentrations. However, SAA is sometimes raised in disease when CRP is normal. This appears to occur more often in certain diseases such as rheumatoid arthritis, primary biliary cirrhosis and chronic active hepatitis. SAA concentrations did not distinguish between cancer with and without metastases as previously indicated, although mean concentrations were higher in more advanced tumours. Despite the higher sensitivity of SAA over CRP in the inflammatory response, SAA has little advantage over CRP in the assessment of malignant disease.

Urinary protein profiles after burn injury

A study of the change of urinary protein excretion has been made in 26 patients followed from the time of admission to time of discharge from the Yorkshire Regional Burn Centre (7-200 days). Total protein, IgG and albumin (as indicators of glomerular function) and alpha 1-microglobulin, beta 2-microglobulin, retinol binding protein and N-acetyl-beta-D-glucosaminidase (as indicators of proximal tubular function) as well as the patterns on SDS polyacrylamide gel electrophoresis were examined. Patients were divided into three groups according to their urinary protein profiles. The first group was 3 patients who showed little or no evidence of proteinuria; the second group consisted of 7 patients who showed a mild and transient tubular proteinuria, all of whom recovered normal function within one week. The third group, 16 patients, developed moderate to severe proteinuria usually started as a mixed pattern of glomerular and tubular proteinuria, characterized by the excretion of a high level of total protein. After a few days, this pattern changed to a typical tubular proteinuria and the latter could last for as long as 200 days; in some of these patients a secondary increase of low molecular weight protein excretion occurred either due to a latent renal complication or induced by the administration of aminoglycosides. There is a close correlation between the intensity and patterns of the proteinuria and the severity and clinical progress of the burn.