The Importance of Gonadotropin Assays in the Clinical follow up Patients with Germinal Tumors of the Testis

Clinical-hormone studies were done on 34 patients with germinal tumors of the testis. The gonadotropin titres varied from normal to highly elevated values. Only in 4 cases (11.77%), however, were the gonadotropin titres above 10,000 mouse units/24 hours. These 4 were among the 9 cases (26.47%) with positive pregnancy tests. Gynaecomastia was present in 4 patients (11.77%). Total estrogens were assayed in these 4 cases and were found to be high. Gynaecomastia is attributed to excess estrogens. Elevated gonadotropin titres were found predominantly in cases of embryonal carcinoma, teratocarcinoma and choriocarcinoma, as well as in the most advanced clinical stages. As regards the correlation between gonadotropin titres and course of the tumor, it was found that the higher the titre the worse the prognosis. The results suggest that hormonal assays are of value in the clinical follow-up of testicular germinal tumors and should therefore be carried out in association with other clinical parameters.

Clinical and metabolic findings in a 6-year-old boy with a Leydig cell tumour

AIM

To analyse the urinary steroid metabolome in a boy who had true precocious puberty after a Leydig cell tumour.

METHOD

Case report and detailed description of clinical and metabolic findings in a 7-year-old-boy with a Leydig cell tumour.

RESULTS

  Before surgery, the urinary steroid metabolome showed an activation of an alternative route to gonadal androgens independent of dehydroepiandrosterone (DHEA). After surgery, the boy entered true precocious puberty. Under leuprolide acetate treatment, clinical and laboratory findings normalized.

CONCLUSION

Central precocious puberty after precocious pseudopuberty may be more common than expected and should be considered in children with persistent or recurrent symptoms after initial treatment of precocious pseudopuberty. Patients with a Leydig cell tumour seem to reactivate the so-called 'back door pathway' of androgen production, which is independent of the classical route via DHEA.

Monitoring of chemotherapy-induced proteinuria using capillary zone electrophoresis

Capillary zone electrophoresis (CZE) was investigated for its suitability to monitor proteinuria occurring during nephrotoxic drug therapy. Urine samples of tumor patients receiving chemotherapy consisting of carboplatin, etoposide, and ifosfamide were concentrated and desalted in microconcentrators and analyzed in two different alkaline CZE buffer systems. Reduction of electroosmotic flow (EOF) by the addition of putrescine increased the number of resolved protein peaks. Both CZE methods were linear between 2.5 and 50 microg/ml, exhibited satisfactory precision (relative standard deviation <10%) and were suitable for monitor the time course of proteinuria after chemotherapy administration. In contrast to sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE), CZE detected interindividual differences in protein patterns. Whereas these differences hampered a direct quantification of proteins in urine, they may contain information on the type or extent of kidney damage.

Immunological recognition and clinical significance of nicked human chorionic gonadotropin in testicular cancer

We studied the physical properties, immunological recognition, and clinical significance of nicked human chorionic gonadotropin (hCGn) in testicular cancer. Upon sodium dodecyl sulfate-polyacrylamide gel electrophoresis under reducing conditions, the beta-subunit of hCGn (hCG beta n) dissociated into two peptides, and, by reversed-phase chromatography, hCG beta n was found to be less hydrophobic than hCG beta. Immunologically, hCGn lacked two epitopes specific for holo-hCG (c1, c2), whereas at least five hCG beta epitopes (beta 1-beta 5) were preserved, and, as a result, recognition of hCGn by different hCG assays varied widely. In 309 sera and 88 urine samples from patients with seminomatous or nonseminomatous testicular cancer, hCG-only, hCG+hCGn, and hCG+hCGn+hCG beta+hCG beta n+hCG beta core-fragment assays gave parallel results. hCGn was more abundant in urine than in serum samples. In conclusion, hCGn lacks two conformationally dependent epitopes of hCG, causing a change in hydrophobicity and explaining its failure to react in certain holo-hCG assays. Recognition of hCGn, however, does not seem to be crucial in the routine use of serum hCG as a tumor marker in patients with testicular cancer.

Changes in urinary excretion of endothelin-1-like immunoreactivity in patients with testicular cancer receiving high-dose cisplatin therapy

To assess the value of endothelin-1 (ET-1) in estimating renal injury in patients receiving high doses of cisplatin, urinary excretion of ET-1-like immunoreactivity (U-ET-1), beta 2-microglobulin (U-beta 2-MG), and N-acetyl-beta-d-glucosaminidase (NAG) were measured before, 1 week after, and 2 weeks after the administration of cisplatin in eight patients with testicular cancer (mean age, 33.3 years). Levels of U-ET-1/creatinine (Cr) during and 1 week after cisplatin treatment were significantly higher than before cisplatin treatment. There were no differences in U-ET-1/Cr levels during, 1 week after, and 2 weeks after cisplatin treatment. The level of U-beta 2-MG/Cr during cisplatin treatment was significantly higher than levels before, 1 week after, and 2 weeks after treatment. However, there were no differences in U-beta 2-MG/Cr levels before, 1 week after, and 2 weeks after cisplatin treatment. The level of U-NAG/Cr during cisplatin treatment was higher than levels before, 1 week after, and 2 weeks after treatment; U-NAG/Cr during cisplatin treatment was higher than levels before, 1 week after, and 2 weeks after treatment; U-NAG/Cr gradually decreased after cisplatin treatment. Among the three parameters, only U-ET-1/Cr maintained a higher level after cisplatin treatment. The U-beta 2-MG/Cr level returned most rapidly to normal after cisplatin treatment. Although U-ET-1/Cr did not show any significant correlation with U-NAG/Cr (r = 0.282, P = NS), it showed a significant correlation with U-beta 2-MG/Cr (r = 0.454, P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Urinary endothelin-1-like immunoreactivity in young male patients with testicular cancer treated by cis-platinum: comparison with other urinary parameters

1. Urinary excretion of endothelin-1-like immunoreactivity and urinary excretion of other parameters (beta 2-microglobulin, N-acetyl-beta-D-glucosaminidase and microalbumin) were measured before, within 1 week after and 2 weeks after the administration of cis-platinum in five young male patients with testicular cancer (mean age 33.0 years) and were compared. 2. Urinary endothelin-1-like immunoreactivity/creatinine during, 1 week after, and 2 weeks after cis-platinum treatment was significantly higher than before cis-platinum. There was no difference in urinary endothelin-1-like immunoreactivity/creatinine during, 1 week after and 2 weeks after cis-platinum. 3. Among the four parameters, urinary endothelin-1-like immunoreactivity/creatinine showed the highest level after cis-platinum treatment. Urinary beta 2-microglobulin/creatinine most rapidly returned to normal levels after cis-platinum. 4. Although urinary endothelin-1-like immunoreactivity/creatinine did not show any significant correlations with urinary N-acetyl-beta-D-glucosaminidase (r = 0.291, not significant) or urinary microalbumin/creatinine (r = 0.076, not significant), it showed a significant correlation with urinary beta 2-microglobulin/creatinine (r = 0.475, P < 0.05). 5. These results suggest that endothelin-1 may be a sensitive urinary parameter in detecting cis-platinum-induced renal tubular injury.

Granulocyte colony-stimulating factor inhibits the endogenous leukotriene production in tumour patients

Granulocyte colony-stimulating factor (G-CSF) is virtually devoid of inflammatory side-effects when given to patients in therapeutic doses. This is in contrast to other haemopoietic cytokines such as granulocyte-macrophage colony-stimulating factor (GM-CSF) or interleukin-3 (IL-3) which may promote inflammatory reactions by increasing the number and/or activity of monocytes, eosinophils, mast cells and basophils. Inflammatory reactions to GM-CSF and IL-3 appear to be related to an increased formation of leukotrienes, known as potent mediators of allergy and inflammation. Here we report that, in contrast to GM-CSF or IL-3, G-CSF has the potential to inhibit the leukotriene production in vivo. G-CSF may thus act as an anti-inflammatory agent. The differential effects of G-CSF and other haemopoietins on endogenous leukotrienes may be of major clinical significance.

Melanotic neuroectodermal tumor of infancy. A case report of paratesticular primary with lymph node involvement

A 17-month-old boy had a melanotic neuroectodermal tumor of infancy in the left paratesticular region affecting the retroperitoneal lymph nodes. Immunohistochemical and ultrastructural study showed phenotypical diversity of the proliferating cells within a spectrum of neuroectodermal differentiation. Urinary catecholamine levels were initially elevated but returned to normal values after complete eradication of the tumor. The patient received chemotherapy and is now well, without evidence of disease 28 months after surgery.

[Clinical study of epidermal growth factor in the urine of the patients with urological malignant tumor]

We measured epidermal growth factor (EGF) in the urine of 54 untreated patients with malignant tumors (7 prostatic cancer, 11 renal tumor, 31 bladder cancer, 3 renal pelvic tumor, 2 ureter tumor) in the Toyama Medical & Pharmaceutical University Hospital. We also measured EGF in the urine of 77 normal subjects (43 males, 34 females). Urinary concentration of EGF in normal subjects decreased with increasing age. It was significantly higher in females than males (p less than 0.05). Urinary concentration of EGF in patients with prostatic cancer or renal tumor was similar to that in normal subjects. The patients with prostatic cancer controlled by estrogen showed a slightly high level of EGF in the urine. In patients with renal tumor, urinary concentration of EGF decreased after nephrectomy. Patients with bladder cancer showed a significant decrease of EGF in the urine compared with normal subjects (p less than 0.05), and urinary concentration of EGF in the patients with bladder cancer of high stage was remarkably low. Low concentration of EGF in the urine was recognized in patients with renal pelvic tumor or ureter tumor. However, the relationship between the decrease of urinary concentration of EGF in these urothelial tumors and the growth of these tumors remains to be elucidated.

A case-control study of cancer among du pont employees with potential for exposure to dimethylformamide

This case-control study was undertaken to determine whether the risk of developing cancers of the buccal cavity and pharynx (N = 39), liver (N = 6), prostate (N = 43), testis (N = 11), or malignant melanoma of the skin (N = 39) is related to exposure to dimethylformamide (DMF). Case and control subjects were obtained from four Du Pont plants. DMF is produced at one plant and used at the other three. Cancer cases identified from the company Cancer Registry comprise those reported among active male employees at the study plants during 1956 to 1985. For each case, two control subjects were selected, matched on sex, payroll class (wage or salary), birth year, and plant. To determine whether an employee could have been exposed to DMF during his career at the plant, all jobs with potential for exposure to DMF were identified. Each job was assigned an exposure ranking based on DMF industrial hygiene air monitoring, DMF metabolite (measured as N-methylformamide in urine) monitoring, and knowledge of the evolution of manufacturing processes and workplace exposure controls. Each employee's DMF exposure pattern was then characterized as (a) ever v never having been exposed to DMF and (b) highest DMF exposure experienced. Summary analyses for all plants combined showed no statistically significant association between ever having been exposed to DMF and subsequent development of cancers of the buccal cavity and pharynx, liver, malignant melanoma, prostate, and testis. Examined by plant site, prostate cancer at one plant was significantly elevated, based on three case subjects exposed out of four.(ABSTRACT TRUNCATED AT 250 WORDS)

Urine and semen cytomorphology in patients with testicular tumors

Our original technique of preparing urinary and seminal sediment was modified in order to identify neoplastic cells in cases of testicular malignancies. In a series of 24 patients with testicular tumor-like conditions, 18 tumors were diagnosed, 12 cytologically. In one case, the result of cytological examination was falsely positive since histopathology revealed necrosis of the testicle only. The morphology of neoplastic cells in the seminal sediment is demonstrated.

Single agent activity of methotrexate in advanced non-seminomatous testicular germ cell tumours

The single agent activity of methotrexate in non-seminomatous germ cell tumours (NSGCT), and thus the rationale for its inclusion in combination regimens, has never been documented clearly. We have therefore reviewed all patients with NSGCT treated in this hospital from 1967 to 1970. Seventeen patients were identified who had a rising HCG excretion and who were treated with methotrexate alone as first line chemotherapy. Nine patients (53%) obtained a partial remission and a further seven patients a reduction in HCG production that was less than one log. Methotrexate is an active agent in testicular germ cell tumours and should be of particular value in treating CNS disease where intrathecal treatment may be required.

Postoperative reduction of serum beta-HCG in testicular seminoma

Serum beta-HCG and urinary HCG were measured in 17 patients with histologically proved pure seminoma of the testis. The patients have been followed to date for 10 to 74 months after orchiectomy, and have no residual disease or recurrence of their disease. Preoperative urinary HCG levels were abnormal in 9 patients (53%). Serum beta-HCG levels were slightly elevated in 6 out of 12 patients evaluated, and were reduced after orchiectomy even in patients with preoperative normal beta-HCG levels (P less than 0.05). Preoperative levels of the tumour marker in seminoma were far lower than in patients with non-seminomatous germ cell tumours, but it would not be rare to see a small amount of HCG produced by the tumour cells in the seminoma.

Sexual function after bilateral retroperitoneal lymph node dissection for nonseminomatous testicular cancer

This study concerns the sexual functions of 101 patients who had undergone bilateral retroperitoneal lymph node dissection for stage I or II nonseminomatous testicular cancer between 1969 and 1982. All patients were without evidence of disease after at least 4 years of follow-up. Antegrade ejaculation was present in 12 patients, while 89 patients experienced "dry ejaculation." Urine collected after intercourse or masturbation from 75 patients with dry ejaculation showed retrograde ejaculation in 55 and lack of ejaculatory emission into the urethra in 20 patients. Regarding other sexual functions, 17 patients had a diminished sexual desire (especially those patients who had received radiotherapy), 12 experienced difficulty reaching organism, and 6 complained of erectile dysfunction. The incidence of a contralateral hydrocele developing after retroperitoneal lymph node dissection seems to correlate with ligation of the contralateral spermatic vessels and their lymphatics. A review of the literature is presented comparing the types of dissection with the incidence of sexual disorders after retroperitoneal lymph node dissection. Since preserving normal ejaculation and fertility is important, a modified or unilateral retroperitoneal lymph node dissection, when required, is advocated. In patients, with stage I disease the therapy may be limited to an orchiectomy without lymph node dissection. In patients with retroperitoneal lymph node metastases combination chemotherapy with cisplatin and tumor excision gives good results. Patients with true retrograde ejaculation can be treated with alpha-sympathomimetic drugs such as imipramine HCl, and thus be offered the chance of fatherhood by coitus.

Leydig cell tumor and metachronous Leydig cell hyperplasia: a case associated with gynecomastia and elevated urinary estrogens

We report a case of unilateral Leydig cell tumor associated with gynecomastia and elevated urinary estrogens. Nine years after orchiectomy urinary estrogens became elevated and Leydig cell hyperplasia but no distinct tumor was identified in the remaining contralateral testicle.

Flow-cytophotometric studies on urine sediments of patients treated with anti-cancer-drugs

Urine specimens of 24 patients receiving polychemotherapy for malignancies of the gonads were examined by flow cytophotometry (FCM) and routine cytology. The results show abnormal DNA histograms during chemotherapy due to an arrest of the cell cycle at the S- and G2M level. In treatment protocols with ifosfamide leucocyturia develops. No cytological changes of the urothelial cells occur during treatment. All these alterations are completely reversible within 4 weeks. It is concluded that the measurable nuclear changes of urothelial cells may serve as parameters for cellular events during polychemotherapy.

Human chorionic gonadotropin detected in urinary concentrates from patients with malignant tumors of the testis, prostate, bladder, ureter and kidney

Human chorionic gonadotropin levels in concentrated 24-hour urine and serum were determined by a specific radioimmunoassay of beta-human chorionic gonadotropin in 47 patients with genitourinary carcinoma. Elevated human chorionic gonadotropin levels in urine were observed in 6 of 8 patients with active testicular tumor, 3 of 14 with prostatic cancer, 2 of 10 with bladder cancer, 1 of 2 with ureteral or renal pelvic tumors and 2 of 6 with renal cancer. Of the 14 patients with positive urinary human chorionic gonadotropin 4 had undetectable human chorionic gonadotropin levels in the serum. The tumors of all 8 patients with nontesticular cancer who had increased urinary human chorionic gonadotropin levels were in an advanced clinical stage or of poor histological differentiation. Our results suggest that some nontrophoblastic carcinomas of the genitourinary system are capable of ectopic production of human chorionic gonadotropin, particularly if the malignancy is advanced or poorly differentiated. The radioimmunoassay of beta-human chorionic gonadotropin in concentrated 24-hour urine specimens enhances the sensitivity of detection of ectopic human chorionic gonadotropin production.

Improved human chorionic gonadotropin detection with carboxyl-terminal radioimmunoassay of the beta subunit on concentrated 24-hour urine in patients with testicular cancer

The value of measuring serum levels of human chorionic gonadotropin in detecting and monitoring testicular cancer has been demonstrated convincingly. In this study the human chorionic gonadotropin was extracted by the kaolin-acetone procedure from 24-hour urine specimens and the total volume of the extract was adjusted to 15 ml. With a highly specific immunoassay system (H93) that recognizes the unique carboxyl-terminal peptide of human chorionic gonadotropin beta subunit (residue numbers 123 to 145) as described previously, the urinary human chorionic gonadotropin was measured serially in 32 patients of 15 patients with initially human chorionic gonadotropin-producing testicular tumors. These 15 patients had simultaneous measurements of serum human chorionic gonadotropin using an antiserum against the beta subunit (Sb6) and urinary human chorionic gonadotropin concentrates using H93 radioimmunoassay. The initial serum hormone levels of these 15 patients were elevated and returned to normal after therapy. However, despite this occurrence the urinary hormone levels also were elevated. The initial 5 patients with elevated urinary but normal serum human chorionic gonadotropin levels had recurrence. The use of this highly specific radioimmunoassay in measuring urinary human chorionic gonadotropin coupled with effective chemotherapeutic agents has been valuable in selecting patients in whom further therapy is warranted despite normal serum human chorionic gonadotropin and clinically undetectable tumor.

Studies on the clinical significance of nonesterified and total cholesterol in urine

Gas-liquid chromatographic determinations of nonesterified and total urinary cholesterol were performed in 137 normals, 264 patients with various internal diseases without evidence of neoplasias or diseases of the kidney or urinary tract, 497 patients with malignancies and 236 patients with diseases of the kidney, urinary tract infections or prostatic adenoma with residual urine. A normal range (mean +/- 2 SD) of 0.2-2.2 mg/24 hours nonesterified cholesterol (NEC) and of 0.3-3.0 mg/24 hours total cholesterol (TC) was calculated. Values of urinary cholesterol excretion were independent of age and sex and did not correlate with cholesterol levels in plasma. Patients with various internal diseases, without evidence of neoplasias nor diseases of the kidney or obstruction of the urinary tract, showed normal urinary cholesterol excretions, as did patients with infections of the urinary tract. However, elevated urinary cholesterol was found in patients with diseases of the kidney or urinary tract obstruction (prostatic adenoma with residual urine), malignant diseases of the urogenital tract and metastasizing carcinoma of the breast. In patients with other malignant diseases urinary cholesterol was usually normal. Lesions of the urothelial cell membranes are considered to be the most likely cause of urinary cholesterol hyperexcretion. The clinical value of urinary cholesterol determinations as a possible screening test for urogenital carcinomas in unselected populations is limited by lacking specificity, expensive methodology and low prevalence of the mentioned carcinomas, although elevated urinary cholesterol excretions have been observed in early clinical stages of urogenital cancers.

Serum alpha-fetoprotein and human chorionic gonadotropin as markers for the effect of postoperative radiation therapy and/or chemotherapy in testicular cancer

Human alpha1-fetoprotein (AFP) and chroiongonadotropin (hCG) have been studied in 67 patients with malignant germ cell neoplasia of the testis admitted to the Radium Centre, Aarhus Municipal Hospital within an 18 month period. In 34 patients with nonseminoma, AFP was elevated in 35% of cases and hCG in 38% of cases. Nonseminoma patients who presented with or developed distant metastases showed a significantly higher incidence of elevated tumor markers than patients with local or regional disease. In patients with distant metastases monitoring of AFP and/or hCG was a most sensitive and reliable indicator of disease activity. In the management of such patients these tests are as important as clinical and x-ray examinations.

Case report: possible diagnostic error: the use of urinary human chorionic gonadotropin tests to differentiate testicular tumor from inflammatory lesions within the scrotum

A case of a probable falsely positive urinary human chorionic gonadotropin (pregnancy screening) test is reported in association with chronic epididymitis in a patient with a single testis. The urinary human chorionic gonadotropin test was used in an asymptomatic patient to attempt to differentiate a firm mass that was associated intimately with the lower pole of the testis and obliterated the lower pole of the epididymis. The use of currently available tests for human chorionic gonadotropin in the male subject is discussed.

Human chorionic gonadotropin (HCG) in monitoring the course of testicular tumours

In 29 patients with metastasising testicular tumours serial determination of HCG was performed for monitoring cytostatic chemotherapy. Clinical remissions and stable disease were accompanied by normalisation of elevated HCG values in 85% and 80% of all cases, respectively. Despite the normalisation of HCG levels, no complete disappearance of clinically detectable tumour lesions could be seen in the herein presented cases. Seventeen percent of the patients showed normal HCG levels, although they had progressive disease. Recurrent disease was associated with preceeding increase of HCG in only 33% of the cases. Because of the frequency of mixed tumour tissues in teratomas, additional methods for monitoring therapy should be used.

Feminizing interstitial cell tumor of the testis: personal observations and a review of the literature

A 28-year-old man with evidence of feminization was demonstrated after 4 years of investigation to have a estrogen-secreting interstitial cell tumor. Such feminizing neoplasms are uncommon, only 37 having been described. They are usually benign and are characterized by gynecomastia, a testicular mass and, with lesser frequency, by decreased libido and potency and poor semen quality. The urinary excretion and plasma levels of estrogen are increased and, by selective testicular catheterization, the site of increased estrogen production can be localized. Secondary histologic changes occur in the nontumorous portions of the testis as well as in the contralateral testis; they are most marked in the area immediately adjacent to the tumor. Postoperatively, the gynecomastia regresses, the excessive levels of estrogen return to normal, libido improves, and the sperm count increases to normal.

Urinary gonadotropins in management and prognosis of testicular tumor

Ninety-three cases of germinal testicular tumors with urinary gonadotropin (HCG) values, estimated by biologic or radioimmunoassay techniques, were reviewed. Preoperative values of HCG and subsequent postoperative values were related to response to treatment and prognosis. Twenty-five patients (26.9 per cent) comprised the seminoma group, and 68 patients (73.1 per cent) the nonseminomatous groups of germinal neoplasms. High HCG values were observed in the nonseminomatous group pre- and postoperatively by both assay procedures. Most significant was the high HCG values postoperatively (p smaller than 0.05, x2 equals 5.21 and p smaller than 0.05, x2 equals 5.23) for the biologic assay and radioimmunoassay, respectively, with high HCG values being associated with a poor cumulative 24 per cent two-year survival rate. Urinary HCG assay is of prognostic value in the ongoing management of testicular neoplasms. In the future, serum HCG assays may be of additional benefit.

Preliminary evaluation of urinary polyamines in the diagnosis of genitourinary tract malignancy

Normal ranges for urinary polyamines have been obtained. Non-malignant genitourinary tract disease is not associated with elevated urinary polyamines. A high correlation exists between the presence of active urologic cancer and elevated urinary excretion of polyamines. Post-treatment polyamines correlate with the continued presence or absence of genitourinary tract malignancy.

Combination chemotherapy for testicular tumours

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A modified method for the analysis of urinary 17-ketosteroids, pregnanediol and pregnanetriol by gas liquid chromatography in normal subjects and subjects with various endocrine disorders

A modified method using gas-liquid chromatography (GLC) is described for the determination of androsterone*, aetiocholanolone, dehydroepiandrosterone, pregnanediol and pregnanetriol in the same urine aliquot. After sequential enzymatic hydrolysis and solvolysis, the urine extract is separated into 3 main fractions by silica gel column chromatography; one containing mainly the 17-ketosteroids, androsterone, aetiocholanolone and dehydroepiandrosterone; a second containing pregnanediol and the third pregnanetriol. After formation of the trimethylsilyl ethers (TMSi), the respective fractions are subjected to gas-liquid chromatography for quantitation. Tritiated androsterone, pregnanediol and pregnanetriol are added prior to extraction of the urines to check for recoveries. The method is specific and reproductible and is sufficiently sensitive to permit determination of urinary steroid excretion levels as low as 0.025 mg/24 hours. Results obtained with this method in the study of normal males and females and various pathological conditions are presented.

The effects of ACTH and HCG on the urinary excretion of testosterone in male patients with various endocrine disorders

The effects of HCG and/or ACTH administration have been investigated in 2 normal subjects and in 12 male patients suffering from various endocrinopathies. It was found that: