The impact of metastasectomy on survival of patients with synchronous metastatic renal cell cancer in Finland: A nationwide study

BACKGROUND AND OBJECTIVE

Most of the studies on metastasectomy in renal cell cancer are based on metachronous, often oligometastatic disease. Prior data on the impact of metastasectomy in synchronous metastatic renal cell cancer (mRCC) is, however, very scarce. We aimed to investigate the role of complete and incomplete metastasectomy in a large, nationwide patient population.

METHODS

We analyzed nationwide data, including all synchronous mRCC cases in Finland diagnosed during a 6-year period identified from the Finnish Cancer Registry, and complemented with patient records from the treating hospitals. We only included the patients who underwent removal of the primary tumor by nephrectomy. We performed univariate and multivariable adjusted analysis to identify the effect of metastasectomy on overall survival (OS) and cancer-specific survival (CSS).

RESULTS

We included 483 patients with synchronous mRCC. Overall, 57 patients underwent complete and 96 incomplete metastasectomy, while 330 patients had no metastasectomy. The median OS was 17.9 and CSS 17.2 months for all patients. The median OS and the median CSS were 59.3 and 60.8 months for the complete, 21.9 and 25.1 for the incomplete, and 14.5 and 14.8 months for the no metastasectomy groups (p < 0.001 for differences). In both applied multivariable statistical models, the OS and CSS benefit from complete metastasectomy remained significant (hazard ratios (HRs) varied between 0.42 and 0.54, p < 0.001) compared with the no metastasectomy group. However, there was no improvement in survival estimates in the incomplete metastasectomy group compared with the no metastasectomy group (HRs varied between 1.04 and 1.10, p > 0.40).

CONCLUSIONS

Complete metastasectomy, when possible, can be considered as a treatment option for selected patients with synchronous mRCC who are fit for surgery. By contrast, we found no survival benefit from an incomplete metastasectomy suggesting that such procedures should not be performed for these patients.

Pembrolizumab versus placebo as post-nephrectomy adjuvant therapy for clear cell renal cell carcinoma (KEYNOTE-564): 30-month follow-up analysis of a multicentre, randomised, double-blind, placebo-controlled, phase 3 trial

BACKGROUND

The first interim analysis of the KEYNOTE-564 study showed improved disease-free survival with adjuvant pembrolizumab compared with placebo after surgery in patients with clear cell renal cell carcinoma at an increased risk of recurrence. The analysis reported here, with an additional 6 months of follow-up, was designed to assess longer-term efficacy and safety of pembrolizumab versus placebo, as well as additional secondary and exploratory endpoints.

METHODS

In the multicentre, randomised, double-blind, placebo-controlled, phase 3 KEYNOTE-564 trial, adults aged 18 years or older with clear cell renal cell carcinoma with an increased risk of recurrence were enrolled at 213 hospitals and cancer centres in North America, South America, Europe, Asia, and Australia. Eligible participants had an Eastern Cooperative Oncology Group performance status of 0 or 1, had undergone nephrectomy 12 weeks or less before randomisation, and had not received previous systemic therapy for advanced renal cell carcinoma. Participants were randomly assigned (1:1) via central permuted block randomisation (block size of four) to receive pembrolizumab 200 mg or placebo intravenously every 3 weeks for up to 17 cycles. Randomisation was stratified by metastatic disease status (M0 vs M1), and the M0 group was further stratified by ECOG performance status and geographical region. All participants and investigators involved in study treatment administration were masked to the treatment group assignment. The primary endpoint was disease-free survival by investigator assessment in the intention-to-treat population (all participants randomly assigned to a treatment). Safety was assessed in the safety population, comprising all participants who received at least one dose of pembrolizumab or placebo. As the primary endpoint was met at the first interim analysis, updated data are reported without p values. This study is ongoing, but no longer recruiting, and is registered with ClinicalTrials.gov, NCT03142334.

FINDINGS

Between June 30, 2017, and Sept 20, 2019, 994 participants were assigned to receive pembrolizumab (n=496) or placebo (n=498). Median follow-up, defined as the time from randomisation to data cutoff (June 14, 2021), was 30·1 months (IQR 25·7-36·7). Disease-free survival was better with pembrolizumab compared with placebo (HR 0·63 [95% CI 0·50-0·80]). Median disease-free survival was not reached in either group. The most common all-cause grade 3-4 adverse events were hypertension (in 14 [3%] of 496 participants) and increased alanine aminotransferase (in 11 [2%]) in the pembrolizumab group, and hypertension (in 13 [3%] of 498 participants) in the placebo group. Serious adverse events attributed to study treatment occurred in 59 (12%) participants in the pembrolizumab group and one (<1%) participant in the placebo group. No deaths were attributed to pembrolizumab.

INTERPRETATION

Updated results from KEYNOTE-564 support the use of adjuvant pembrolizumab monotherapy as a standard of care for participants with renal cell carcinoma with an increased risk of recurrence after nephrectomy.

FUNDING

Merck Sharp & Dohme LLC, a subsidiary of Merck & Co, Inc, Rahway, NJ, USA.

Intraoperative complications in kidney tumor surgery: critical grading for the European Association of Urology intraoperative adverse incident classification

INTRODUCTION

The European Association of Urology committee in 2020 suggested a new classification, intraoperative adverse incident classification (EAUiaiC), to grade intraoperative adverse events (IAE) in urology.

AIMS

We applied and validated EAUiaiC, for kidney tumor surgery.

PATIENTS AND METHODS

A retrospective multicenter study was conducted based on chart review. The study group comprised 749 radical nephrectomies (RN) and 531 partial nephrectomies (PN) performed in 12 hospitals in Finland during 2016-2017. All IAEs were centrally graded for EAUiaiC. The classification was adapted to kidney tumor surgery by the inclusion of global bleeding as a transfusion of ≥3 units of blood (Grade 2) or as ≥5 units (Grade 3), and also by the exclusion of preemptive conversions.

RESULTS

A total of 110 IAEs were recorded in 13.8% of patients undergoing RN, and 40 IAEs in 6.4% of patients with PN. Overall, bleeding injuries in major vessels, unspecified origin and parenchymal organs accounted for 29.3, 24.0, and 16.0% of all IEAs, respectively. Bowel (n = 10) and ureter (n = 3) injuries were rare. There was no intraoperative mortality. IAEs were associated with increased tumor size, tumor extent, age, comorbidity scores, surgical approach and indication, postoperative Clavien-Dindo (CD) complications and longer stay in hospital. 48% of conversions were reactive with more CD-complications after reactive than preemptive conversion (43 vs. 25%).

CONCLUSIONS

The associations between IAEs and preoperative variables and postoperative outcome indicate good construct validity for EAUiaiC. Bleeding is the most important IAE in kidney tumor surgery and the inclusion of transfusions could provide increased objectivity.

Randomised double-blind phase 3 clinical study testing impact of atorvastatin on prostate cancer progression after initiation of androgen deprivation therapy: study protocol

INTRODUCTION

Blood cholesterol is likely a risk factor for prostate cancer prognosis and use of statins is associated with lowered risk of prostate cancer recurrence and progression. Furthermore, use of statins has been associated with prolonged time before development of castration resistance (CR) during androgen deprivation therapy (ADT) for prostate cancer. However, the efficacy of statins on delaying castration-resistance has not been tested in a randomised placebo-controlled setting.This study aims to test statins' efficacy compared to placebo in delaying development of CR during ADT treatment for primary metastatic or recurrent prostate cancer. Secondary aim is to explore effect of statin intervention on prostate cancer mortality and lipid metabolism during ADT.

METHODS AND ANALYSIS

In this randomised placebo-controlled trial, a total of 400 men with de novo metastatic prostate cancer or recurrent disease after primary treatment and starting ADT will be recruited and randomised 1:1 to use daily 80 mg of atorvastatin or placebo. All researchers, study nurses and patients will be blinded throughout the trial. Patients are followed until disease recurrence or death. Primary outcome is time to formation of CR after initiation of ADT. Serum lipid levels (total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL) and trigyserides) are analysed to test whether changes in serum cholesterol parameters during ADT predict length of treatment response. Furthermore, the trial will compare quality of life, cardiovascular morbidity, changes in blood glucose and circulating cell-free DNA, and urine lipidome during trial.

ETHICS AND DISSEMINATION

This study is approved by the Regional ethics committees of the Pirkanmaa Hospital District, Science centre, Tampere, Finland (R18065M) and Tarto University Hospital, Tarto, Estonia (319/T-6). All participants read and sign informed consent form before study entry. After publication of results for the primary endpoints, anonymised summary metadata and statistical code will be made openly available. The data will not include any information that could make it possible to identify a given participant.

TRIAL REGISTRATION NUMBER

Clinicaltrial.gov: NCT04026230, Eudra-CT: 2016-004774-17, protocol code: ESTO2, protocol date 10 September 2020 and version 6.

Does every Clavien-Dindo complication matter? A national multi-center study in kidney cancer surgery

BACKGROUND

There is huge variation in Clavien-Dindo (CD) complication rates in urology. We sought to optimize the use of the CD system in kidney tumor surgery.

METHODS

We retrospectively analyzed 1,286 patients undergoing kidney tumor operations in 12 Finnish hospitals during 2016-2017. Primary CD assignments were made by site urologists. Data were centrally reviewed by two authors in consensus meetings. Consistency of the primary assignments was assessed by the number of cases requiring correction. Complication load was compared as different outcome rates between five university hospital regions.

RESULTS

The overall complication rate in primary data was 40% (517/1286) and varied significantly from 32 to 62% (p < 0.001) between the regions. The need for corrections in central review was significantly greater for CD1 (54%) compared to CD2 (16%, p < 0.001) and CD3-5 (11%, p < 0.001) categories. The final data comprised 500 CD complications after 390 surgeries. The most frequent pathologies were bleeding (8.4%), urological complications (5.9%) and postoperative fever (4.7%). The overall CD2 complications rate was statistically (p < 0.001) higher in region D and that of CD3-5 was higher (p = 0.007) in region B. In multivariable analysis, university hospital region, male sex, BMI ≥ 27, ECOG ≥ 1, partial nephrectomy type and open surgery significantly increased the risk of complications.

CONCLUSIONS

Comparative use of CD1 complications may be too inconsistent and only CD2-5 complications should be reported. Central review of the primary data and detailed guidelines are necessary.

Nephrectomy improves the survival of metastatic renal cell cancer patients with moderate to good performance status-results from a Finnish nation-wide population-based study from 2005 to 2010

Background

The purpose of this study was to evaluate the effects of cytoreductive nephrectomy (CN) and metastasectomies on the survival of patients with synchronous metastatic renal cell cancer (mRCC) using real-life, population-based national dataset.

Methods

Nationwide data, including all cases of synchronous mRCC in Finland diagnosed on a 6-year timeframe, based on the Finnish Cancer Registry and complemented with patient records from the treating hospitals, were analyzed. Patients with Eastern Cooperative Oncology Group (ECOG) performance status 3–4 were excluded. Univariate and adjusted multivariable survival analysis were performed, including subgroup analysis for patients with different medical therapies. Nephrectomy complications were also analyzed.

Results

A total of 732 patients were included in the analysis. CN was performed for 389 (53.1%) patients, whereas 68 (9.3%) patients underwent nephrectomy and metastasectomies of all lesions (surgery with curative intent). Median overall survival (OS) for patients who did not undergo nephrectomy was 5.9 (95% confidence interval [CI] = 4.6–7.2) months. Patients who had a CN had a median OS of 16.6 (95% CI = 14.2–19.1, p < 0.001) months, whereas patients who had surgery with curative intent had a median OS of 51.3 (95% CI = 36.0–66.6, p < 0.001) months. The survival benefit of CN and metastasectomies remained significant in all medical therapy subgroups and in both of the applied multivariable statistical models.

Conclusions

Surgical treatment of metastatic renal cell cancer is associated with a significant survival benefit in patients with good and moderate performance status, regardless of the chosen medical therapy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-021-02308-0.

Tumor infiltrating CD8+ T lymphocyte count is independent of tumor TLR9 status in treatment naïve triple negative breast cancer and renal cell carcinoma

Toll-like receptor 9 (TLR9) is a cellular DNA-receptor of the innate immune system that is widely expressed in cancers. We demonstrated that low tumor TLR9 expression predicts poor disease-specific survival in triple negative breast cancer (TNBC) and renal cell carcinoma (RCC). We hypothesized that this is because TLR9 expression affects tumor immunophenotype. To begin to test this, we compared the number of tumor infiltrating CD8⁺ T lymphocytes with TLR9 expression in treatment naïve breast cancer (n = 197) and RCC (n = 94) cohorts with known TLR9 expression status. CD8⁺ T lymphocyte counts were assayed with image analysis after immunohistochemistry (IHC). Tumor TLR9 expression was not correlated with CD8⁺ T cell counts in breast cancer or RCC. CD8⁺ T cell counts were significantly associated with tumor proliferation index in TNBC, but not in non-TNBC. CD8⁺ T cell counts were also significantly associated with tumor grade in non-TNBC, but not in TNBC. In RCC, CD8⁺ T cell counts were significantly associated with tumor stage. CD8⁺ T cell counts were significantly associated with prognosis in TNBC and RCC, but the presence of CD8⁺ T cells in these tumors had opposite effects on disease-specific survival: High CD8⁺ counts were associated with better prognosis in TNBC and worse prognosis in RCC. Among TNBC patients, those with low tumor TLR9 and low CD8⁺ T cell counts had the poorest prognosis (log-rank p = 0.0002 vs. high tumor TLR9 and high CD8⁺ T cell count). In conclusion, pre-treatment tumor TLR9 status is not associated with tumor infiltrating CD8⁺ T lymphocytes in TNBC or RCC. The combination of TLR9 and CD8⁺ TIL count might be a novel composite prognostic marker in TNBC.

Absent Toll-like receptor-9 expression predicts poor prognosis in renal cell carcinoma

Background

Toll-like receptor 9 (TLR9) is a cellular DNA-receptor whose activation with cognate ligands triggers an immune reaction, with increased production of inflammatory cytokines. The aim of this study was to examine the expression of TLR9 in renal cell carcinoma (RCC), which is generally renowned of its immunogenic nature. We also evaluated the prognostic value of TLR9 in RCC.

Methods

TLR9 expression in RCC was characterized with immunohistochemistry in a retrospective study population of 152 RCC patients who underwent renal surgery. The TLR9 staining intensity was compared with clinical parameters.

Results

Of the studied tumours, 112 (81%) exhibited cytoplasmic TLR9 immunostaining. No association was detected between cytoplasmic TLR9 immunoexpression intensity and stage, nuclear grade, histological subtype or tumour necrosis. Cytoplasmic TLR9 immunoexpression was, however, a marker of favourable RCC specific survival both in univariate analysis and in multivariate regression model.

Conclusions

We conclude that TLR9 expression is an independent prognostic marker of RCC and the absence of TLR9 expression is related to poorer prognosis in RCC.

Anillin expression is a marker of favourable prognosis in patients with renal cell carcinoma

The clinical course of renal cell carcinoma (RCC) can be difficult to predict. In this study we evaluated the prognostic value of anillin and Ki-67 in predicting survival in RCC. Immunohistochemical analysis using anillin and Ki-67 antibodies was performed on tissue microarrays constructed from paraffin-embedded specimens from 152 patients with primary RCC. The mean follow-up time was 90 months. Levels of anillin and Ki-67 staining were correlated with clinical factors, pathological features and survival. Anillin expression in cytoplasmic and nuclear fractions of the RCC cell line 786-O was examined using Western blot analysis. Cytoplasmic anillin immunopositivity was detected in 121 (83%) tumours. Nuclear anillin expression was present in 40 (27%) tumours and increased Ki-67 activity in 98 (66%) tumours. A positive association was found between nuclear anillin and Ki-67 proliferation activity (p=0.005). The mean RCC-specific survival times for anillin immunopositive and immunonegative tumours were 158 (95% CI 143-173) and 109 (78-141) months, respectively, with p=0.03. Increased Ki-67 activity showed a tendency towards a poorer prognosis, although this was not statistically significant. In the Cox regression analysis for cytoplasmic anillin, nuclear anillin or Ki-67 rate, and age, gender, stage and nuclear grade, the only significant factor in RCC-specific survival was stage (p<0.001). Western blot analysis showed anillin expression in both nuclear and cytosolic fractions of the RCC cell line. To conclude, anillin expression can be observed both in the cytoplasm and nuclei in patients with RCC. Cytoplasmic anillin expression is a marker of favourable prognosis in RCC patients.

HuR expression is a marker of poor prognosis in renal cell carcinoma

The HuR protein is a nucleocytoplasmic protein which plays an important role in the regulation of mRNA stability, and dysregulation of its expression has been linked to carcinogenesis. We studied 152 patients with primary renal cell carcinoma (RCC) who underwent surgery for the removal of kidney tumours between 1990 and 1999. The mean follow-up was 90 months. The expression of HuR and cyclooxygenase-2 (COX-2) was determined by immunohistochemistry using monoclonal antibodies. The immunostaining results were associated with patient age, clinical stage, Fuhrman grade and patient outcome. Cytoplasmic expression of HuR and COX-2 was positive in 37 (25%) and 22 (15%) of the tumours, respectively. The expression of HuR was associated with stage. The expression of COX-2 was associated with stage and nuclear grade. The RCC-specific survival was reduced in patients whose tumours expressed HuR or COX-2. The hazard ratio (HR) of patients with HuR-expressing tumours was 2.18 (95% confidence interval (CI), 1.16-4.09; p = 0.015) and the HR of patients with COX-2-expressing tumours was 2.29 (95% CI, 1.15-4.54; p = 0.018). In the Cox regression analysis the only independent prognostic factor was stage (p < 0.001). Treatment of an RCC cell line (769-P) with HuR-targeted small interfering RNA resulted in the reduced expression of HuR and COX-2. We conclude that cytoplasmic HuR expression is associated with reduced RCC-specific survival. The HuR protein regulates the expression of COX-2 in RCC cells, which is one potential mechanism of action for the HuR-associated aggressive behaviour of RCC.

Evaluation of neuroendocrine markers in renal cell carcinoma

Background

The purpose of the study was to examine serotonin, CD56, neurone-specific enolase (NSE), chromogranin A and synaptophysin by immunohistochemistry in renal cell carcinomas (RCCs) with special emphasis on patient outcome.

Methods

We studied 152 patients with primary RCCs who underwent surgery for the removal of kidney tumours between 1990 and 1999. The mean follow-up was 90 months. The expression of neuroendocrine (NE) markers was determined by immunohistochemical staining using commercially available monoclonal antibodies. Results were correlated with patient age, clinical stage, Fuhrman grade and patient outcome.

Results

Eight percent of tumours were positive for serotonin, 18% for CD56 and 48% for NSE. Chromogranin A immunostaining was negative and only 1% of the tumours were synaptophysin immunopositive. The NSE immunopositivity was more common in clear cell RCCs than in other subtypes (p = 0.01). The other NE markers did not show any association with the histological subtype. Tumours with an immunopositivity for serotonin had a longer RCC-specific survival and tumours with an immunopositivity for CD56 and NSE had a shorter RCC-specific survival but the difference was not significant. There was no relationship between stage or Fuhrman grade and immunoreactivity for serotonin, CD56 and NSE.

Conclusions

Serotonin, CD56 and NSE but not synaptophysin and chromogranin A are expressed in RCCs. However, the prognostic potential of these markers remains obscure.

Evaluation of myosin VI, E-cadherin and beta-catenin immunostaining in renal cell carcinoma

Background

Renal cell carcinoma (RCC) is a cancer of increasing incidence and mortality. Currently, there are no immunohistochemical prognostic markers for RCCs in routine use. The aim of this study was to examine for the first time the immunostaining of myosin VI in RCCs as well as its association with E-cadherin and beta-catenin immunostaining and the prognostic significance of these markers in RCCs.

Methods

Our study population consisted of 152 patients who underwent surgery for RCCs between 1990 and 1999. The tumours were examined with three immunohistochemical markers: myosin VI, E-cadherin and beta-catenin.

Results

The immunostaining for cytoplasmic myosin VI was common (72%). One-third of the tumours were immunopositive for nuclear myosin VI. Cytoplasmic myosin VI immunopositivity and nuclear beta-catenin immunostaining were associated with lower Fuhrman grades (p = 0.04 and p = 0.005, respectively), but not stages. There was no significant association between myosin VI immunostaining and the histological subtype of RCC. Nuclear myosin VI was associated with the nuclear expression of beta-catenin. A direct association could also be proven between membranous E-cadherin and cytoplasmic beta-catenin. Cytoplasmic myosin VI immunostaining was a marker of poorer prognosis in multivariate Cox regression model adjusted with stage and Fuhrman grade with hazard ratio 2.4 (95% confidence interval 1.1 to 5.0 with p = 0.024).

Conclusions

Cytoplasmic myosin VI immunopositivity and nuclear beta-catenin immunostaining were associated with lower Fuhrman grades, and there was a strong positive relationship between E-cadherin immunostaining and beta-catenin immunostaining in RCCs. Cytoplasmic myosin VI immunostaining was associated with poorer prognosis in RCCs.

Increased BTB-Kelch type substrate adaptor protein immunoreactivity associates with advanced stage and poor differentiation in renal cell carcinoma

Renal cell carcinoma (RCC) is a malignancy with increasing incidence. Despite the well-known prognostic factors - the stage, grade and histological subtype - the clinical course of RCC can seem quite random. The aim of this study was to evaluate markers of the oxidative system as candidate prognostic factors for RCC. Our study population consisted of 152 patients who underwent operation for RCC between 1990 and 1999. The tumours were examined with three immunohistochemical markers of the oxidative system, thioredoxin (Trx), NF-E2-related factor (Nfr2) and BTB-Kelch type substrate adaptor protein (Keap1). Cytoplasmic Keap1 staining was related to poorer prognosis in renal cancer-specific survival. The difference was statistically significant (P=0.02). Keap1 staining was associated with a more advanced stage and a higher nuclear grade. Cytoplasmic Trx staining was associated with a trend of better prognosis in renal cancer-specific survival. Nfr2 staining was not a prognostic factor in renal cancer-specific survival. In RCC, Keap1 is associated with a more advanced disease, a higher grade and a poorer prognosis.

Effects of physical exercise on the serum concentration of melatonin in female runners

The serum melatonin concentration was measured in 11 runners before and after a long-distance race, and during one menstrual cycle of another 11 runners who were performing a strenuous training programme, and in their 12 control subjects. The concentration of melatonin was significantly increased (p less than 0.05) after the competition, whereas during one menstrual cycle of female runners it did not differ from the corresponding concentrations of non-athletes. Training did not cause any chronic changes in melatonin secretion, and the serum melatonin increases following the physical exercise remained clearly below the nocturnal level. Hence, the antigonadotropic effect of endurance running activity is very likely not a melatonin-associated phenomenon.

Depressed follicle-stimulating hormone, luteinizing hormone, and prolactin responses to the luteinizing hormone-releasing hormone, thyrotropin-releasing hormone, and metoclopramide test in endurance runners in the hard-training season

The responses of serum follicle-stimulating hormone (FSH) and luteinizing hormone (LH) to luteinizing hormone-releasing hormone (LH-RH) and the responses of prolactin (PRL) to thyrotropin-releasing hormone (TRH) and metoclopramide (MC) were measured in the late luteal phase of the cycle in 12 endurance runners and 11 control women and in 12 joggers and 7 control women. LH-RH (100 micrograms) and TRH (200 micrograms) were injected intravenously at the beginning of the test, and MC (10 mg) was injected 60 minutes later. Blood samples were obtained before and 20, 60, 80, and 120 minutes after the beginning of the test. Runners had significantly lower serum concentrations of estradiol and progesterone than control subjects, whereas the concentrations of FSH, LH, and PRL were similar at the beginning of the study. Compared with their controls, the runners had significantly lower FSH (P less than 0.05) and LH responses at 20 minutes (P less than 0.05) and lower LH responses at 80 minutes (P less than 0.01) to LH-RH and lower PRL responses to MC 20 minutes after MC injection (P less than 0.05). Joggers and their control subjects had similar LH, FSH, and PRL responses to these pharmacologic stimuli. It is concluded that decreased ovarian activity explains, at least partly, the lowered responses of FSH and LH to LH-RH and the lowered response of PRL to MC in endurance runners.

Physical exercise-induced changes and season-associated differences in the pituitary-ovarian function of runners and joggers

The hormonal responses to energetic chronic exercise and to seasonal shift from autumn to spring were evaluated by measuring concentrations of serum FSH, LH, PRL, estradiol (E2), progesterone (P), testosterone (T), and sex hormone-binding globuline (SHBG) during 1 menstrual cycle in the autumn (light training season) and 1 in the spring (hard training season) in 18 endurance runners and 12 age-matched nonrunning women, and in 13 joggers and 11 age-matched nonjogging women. The appearance, growth, and maximal size of the ovarian follicles were monitored by ultrasonography. The high intensity training of the runners was associated with decreased concentrations of FSH on cycle days 7-8 in the autumn, E2 on cycle days 12-13 in the spring and days 22-23 in both seasons, P on cycle days 20-21 in both seasons and days 22-23 in the autumn, and T on cycle days 12-13, 14-15, and 22-23 in the spring. Jogging, however, did not alter the concentrations of these hormones. Using as criteria the presence of 2 or 3 abnormal values of the 3 indicators used for evaluation of folliculogenesis (midfollicular E2 lower than 0.09 nmol/liter, luteal phase P lower than 7 nmol/liter, and peak diameter of the largest ovarian follicle less than 15 mm), seriously disturbed folliculogenesis was found in 50% of the 32 study cycles of the runners and 9% of the 23 cycles of their controls (P less than 0.01). In all four study groups, there was a significant seasonal difference in the concentrations of ovarian hormones, with lowered E2, P, and T levels in the autumn. There were no differences in the serum concentrations of SHBG between the study groups or between the autumn and the spring. High training activity and a dark photoperiod appeared to independently suppress ovarian activity and were not associated with chronic changes in anterior pituitary hormone or SHBG concentrations.

Pubertal and menstrual disorders of female runners, skiers and volleyball players

In order to evaluate the onset of puberty and the presence of menstrual disorders in Finnish sportswomen with different training programs, 53 long-distance runners, 39 skiers and their 93 controls, and 63 volleyball players with 64 controls were interviewed. All the sportswomen had trained intensively for several years and were in the top category of their sport in Finland. Menarche and thelarche in all the sportswomen and also pubarche in the volleyball players developed significantly later than in their controls. The runners and skiers (43%) suffered significantly more often from menstrual irregularities than their controls (27%), whereas volleyball players (19%) did not differ from their controls (13%) in this respect. Among runners and skiers, but not among volleyball players, premenarchal start of sports activity had an aggravating effect on these endocrine disorders. Dysmenorrhea was found to occur more seldom in sportswomen than in the control subjects, and physical exercise often alleviated menstrual distress. Because the runners and skiers trained as often and used as much time for their sport as the volleyball players, the more common occurrence of their menstrual disorders may be due to the nature of training and competition activity which is characterized by endurance physical exercise.