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Helland T, Hagen KB, Haugstøyl ME, Kvaløy JT, Lunde S, Lode K, Lind RA, Gripsrud BH, Jonsdottir K, Gjerde J, Bifulco E, Hustad S, Jonassen J, Aas T, Lende TH, Lien EA, Janssen EAM, Søiland H, Mellgren G. Drug monitoring of tamoxifen metabolites predicts vaginal dryness and verifies a low discontinuation rate from the Norwegian Prescription Database. Breast Cancer Res Treat 2019; 177:185-195. [PMID: 31144152 DOI: 10.1007/s10549-019-05294-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 05/22/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE Tamoxifen is an important targeted endocrine therapy in breast cancer. However, side effects and early discontinuation of tamoxifen remains a barrier for obtaining the improved outcome benefits of long-term tamoxifen treatment. Biomarkers predictive of tamoxifen side effects remain unidentified. The objective of this prospective population-based study was to investigate the value of tamoxifen metabolite concentrations as biomarkers for side effects. A second objective was to assess the validity of discontinuation rates obtained through pharmacy records with the use of tamoxifen drug monitoring. METHODS Longitudinal serum samples, patient-reported outcome measures and pharmacy records from 220 breast cancer patients were obtained over a 6-year period. Serum concentrations of tamoxifen metabolites were measured by LC-MS/MS. Associations between metabolite concentrations and side effects were analyzed by logistic regression and cross table analyses. To determine the validity of pharmacy records we compared longitudinal tamoxifen concentrations to discontinuation rates obtained through the Norwegian Prescription database (NorPD). Multivariable Cox regression models were performed to identify predictors of discontinuation. RESULTS At the 2nd year of follow-up, a significant association between vaginal dryness and high concentrations of tamoxifen, Z-4'-OHtam and tam-NoX was identified. NorPD showed a tamoxifen-discontinuation rate of 17.9% at 5 years and drug monitoring demonstrated similar rates. Nausea, vaginal dryness and chemotherapy-naive status were significant risk factors for tamoxifen discontinuation. CONCLUSIONS This real-world data study suggests that measurements of tamoxifen metabolite concentrations may be predictive of vaginal dryness in breast cancer patients and verifies NorPD as a reliable source of adherence data.
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Affiliation(s)
- Thomas Helland
- Hormone Laboratory, Haukeland University Hospital, 5020, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Kari Britt Hagen
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Breast and Endocrine Surgery, Haukeland University Hospital, Bergen, Norway
| | - Martha Eimstad Haugstøyl
- Hormone Laboratory, Haukeland University Hospital, 5020, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Jan Terje Kvaløy
- Department of Mathematics and Natural Science, University of Stavanger, Stavanger, Norway
- Department of Research, Stavanger University Hospital, Stavanger, Norway
| | - Siri Lunde
- Department of Breast and Endocrine Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Kirsten Lode
- Department of Research, Stavanger University Hospital, Stavanger, Norway
| | - Ragna Anne Lind
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Birgitta Haga Gripsrud
- Department of Caring and Ethics, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Kristin Jonsdottir
- Department of Breast and Endocrine Surgery, Stavanger University Hospital, Stavanger, Norway
- Department of Research, Stavanger University Hospital, Stavanger, Norway
| | - Jennifer Gjerde
- Hormone Laboratory, Haukeland University Hospital, 5020, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Ersilia Bifulco
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Core Facility for Metabolomics, University of Bergen, Bergen, Norway
| | - Steinar Hustad
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Core Facility for Metabolomics, University of Bergen, Bergen, Norway
| | - Janne Jonassen
- Department of Breast and Endocrine Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Turid Aas
- Department of Breast and Endocrine Surgery, Haukeland University Hospital, Bergen, Norway
| | - Tone Hoel Lende
- Department of Breast and Endocrine Surgery, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Ernst Asbjørn Lien
- Hormone Laboratory, Haukeland University Hospital, 5020, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Emiel Adrianus Maria Janssen
- Department of Mathematics and Natural Science, University of Stavanger, Stavanger, Norway
- Department of Pathology, Stavanger University Hospital, Stavanger, Norway
| | - Håvard Søiland
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Breast and Endocrine Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Gunnar Mellgren
- Hormone Laboratory, Haukeland University Hospital, 5020, Bergen, Norway.
- Department of Clinical Science, University of Bergen, Bergen, Norway.
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Helland T, Haugstøyl ME, Hagen KB, Kvaløy JT, Lunde S, Lode K, Lind RA, Gripsrud BH, Bifulco E, Gebreslase NS, Jonassen J, Hustad SS, Aas T, Lende TH, Lien EA, Janssen EA, Mellgren G, Søiland H. Abstract P4-14-08: Serum concentrations of tamoxifen and Z-endoxifen may predict sexual dysfunction in the 2nd year of adjuvant endocrine treatment. Cancer Res 2019. [DOI: 10.1158/1538-7445.sabcs18-p4-14-08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background and rationale: Side effects of adjuvant treatment with tamoxifen (tam) may impair Quality of Life (QoL) and have been suggested as an independent variable for discontinuation of tam1. There are large inter-patient variabilities in prevalence and severance of side effects among tam users. Therefore, there is a need for biological markers that can predict side effects. A potential biological predictor is the serum concentrations of tam and/or its metabolites. In this prospective observational study we have analyzed serum concentrations of tam and 9 metabolites over 3 years. Patients Reported Outcome Measures (PROM) were obtained to elucidate possible associations between side effects, adherence and tam metabolism.
Methods: Breast cancer patients using adjuvant tam (20mg/d) were recruited through the Prospective Breast Cancer Biobank project between 2011 and 2016. Inclusion criteria were ER positive status, ≥ 6 months tam use, tumor size of ≥0.1 cm and being able to read and write Norwegian. Concentration levels of tam and metabolites in serum were analyzed by LC-MS/MS2 and adherence data were collected through the Norwegian prescription database. PROM-data comprised of validated questioners reporting side effects of endocrine treatment and QoL. Statistical analyses comprised non-parametric tests, logistic regression, chi square tests and the Benjamin-Hochberg procedure to correct for multiple testing.
Results: Associations between metabolite concentrations and side effects were run as a cross sectional analysis (N=149) and separate analysis of each year of follow-up with 85, 77 and 65 patients at the 1st, 2nd and 3rd year respectively. We found that 78 % of patients reported side effects, 66 % reported mood swings, 21 % reported severe hot flushes and 71 % reported decreased libido. When analyzing years separately, we found that on the 2nd year patients experiencing vaginal dryness had significantly higher levels of tamoxifen (P=0.032, after correction for multiple testing and adjustment for clinical relevant variables) compared to patients not experiencing vaginal dryness. Also, on year 2 the patients in the lower quartile of Z-endoxifen (≤17.9 nM) had significantly lower libido (p=0.015) compared to patients with Z-endoxifen levels >17.9 nM after adjustment for clinical relevant variables and correction for multiple testing. Analyses regarding adherence are not complete and more results will be presented in the poster.
Discussion: Our data indicates that high serum concentrations of tam and low concentrations of Z-endoxifen are associated with vaginal dryness and sexual dysfunction. Patients reporting “very low libido” had the highest levels of tam, suggesting that slow metabolic conversion and accumulation of tam may contribute to sexual dysfunction. Our results were only significant in the second year of follow-up, possibly because patients wait to resume sexual activity after diagnosis, chemo and surgery. After receiving advice (i.e. lubricants), the symptoms are often reduced in the subsequent follow-up (3rd year). In conclusion, our results indicate that monitoring tam serum concentrations may be used to predict side effects.
1 Owusu C. et al. JCO. 2008
2 Helland T. et al. BCR. 2017
Citation Format: Helland T, Haugstøyl ME, Hagen KB, Kvaløy JT, Lunde S, Lode K, Lind RA, Gripsrud BH, Bifulco E, Gebreslase NS, Jonassen J, Hustad SS, Aas T, Lende TH, Lien EA, Janssen EA, Mellgren G, Søiland H. Serum concentrations of tamoxifen and Z-endoxifen may predict sexual dysfunction in the 2nd year of adjuvant endocrine treatment [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-14-08.
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Affiliation(s)
- T Helland
- Haukeland University Hospital, Bergen, Norway; University of Bergen, Bergen, Norway; Stavanger University Hospital, Stavanger, Norway; University of Stavanger, Stavanger, Norway
| | - ME Haugstøyl
- Haukeland University Hospital, Bergen, Norway; University of Bergen, Bergen, Norway; Stavanger University Hospital, Stavanger, Norway; University of Stavanger, Stavanger, Norway
| | - KB Hagen
- Haukeland University Hospital, Bergen, Norway; University of Bergen, Bergen, Norway; Stavanger University Hospital, Stavanger, Norway; University of Stavanger, Stavanger, Norway
| | - JT Kvaløy
- Haukeland University Hospital, Bergen, Norway; University of Bergen, Bergen, Norway; Stavanger University Hospital, Stavanger, Norway; University of Stavanger, Stavanger, Norway
| | - S Lunde
- Haukeland University Hospital, Bergen, Norway; University of Bergen, Bergen, Norway; Stavanger University Hospital, Stavanger, Norway; University of Stavanger, Stavanger, Norway
| | - K Lode
- Haukeland University Hospital, Bergen, Norway; University of Bergen, Bergen, Norway; Stavanger University Hospital, Stavanger, Norway; University of Stavanger, Stavanger, Norway
| | - RA Lind
- Haukeland University Hospital, Bergen, Norway; University of Bergen, Bergen, Norway; Stavanger University Hospital, Stavanger, Norway; University of Stavanger, Stavanger, Norway
| | - BH Gripsrud
- Haukeland University Hospital, Bergen, Norway; University of Bergen, Bergen, Norway; Stavanger University Hospital, Stavanger, Norway; University of Stavanger, Stavanger, Norway
| | - E Bifulco
- Haukeland University Hospital, Bergen, Norway; University of Bergen, Bergen, Norway; Stavanger University Hospital, Stavanger, Norway; University of Stavanger, Stavanger, Norway
| | - NS Gebreslase
- Haukeland University Hospital, Bergen, Norway; University of Bergen, Bergen, Norway; Stavanger University Hospital, Stavanger, Norway; University of Stavanger, Stavanger, Norway
| | - J Jonassen
- Haukeland University Hospital, Bergen, Norway; University of Bergen, Bergen, Norway; Stavanger University Hospital, Stavanger, Norway; University of Stavanger, Stavanger, Norway
| | - SS Hustad
- Haukeland University Hospital, Bergen, Norway; University of Bergen, Bergen, Norway; Stavanger University Hospital, Stavanger, Norway; University of Stavanger, Stavanger, Norway
| | - T Aas
- Haukeland University Hospital, Bergen, Norway; University of Bergen, Bergen, Norway; Stavanger University Hospital, Stavanger, Norway; University of Stavanger, Stavanger, Norway
| | - TH Lende
- Haukeland University Hospital, Bergen, Norway; University of Bergen, Bergen, Norway; Stavanger University Hospital, Stavanger, Norway; University of Stavanger, Stavanger, Norway
| | - EA Lien
- Haukeland University Hospital, Bergen, Norway; University of Bergen, Bergen, Norway; Stavanger University Hospital, Stavanger, Norway; University of Stavanger, Stavanger, Norway
| | - EA Janssen
- Haukeland University Hospital, Bergen, Norway; University of Bergen, Bergen, Norway; Stavanger University Hospital, Stavanger, Norway; University of Stavanger, Stavanger, Norway
| | - G Mellgren
- Haukeland University Hospital, Bergen, Norway; University of Bergen, Bergen, Norway; Stavanger University Hospital, Stavanger, Norway; University of Stavanger, Stavanger, Norway
| | - H Søiland
- Haukeland University Hospital, Bergen, Norway; University of Bergen, Bergen, Norway; Stavanger University Hospital, Stavanger, Norway; University of Stavanger, Stavanger, Norway
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Helland T, Søiland H, Hustad S, Lash TL, Kvaløy JT, Renolen A, Borgen E, Bifulco E, Henne N, Lien EA, Mellgren G, Naume B, Janssen EA. Abstract P3-12-05: Serum levels of the active tamoxifen metabolite Z-4OHtam is predictive of long-term survival in luminal B subtype of breast cancer patients. Cancer Res 2018. [DOI: 10.1158/1538-7445.sabcs17-p3-12-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background
Tamoxifen (tam) is the main adjuvant endocrine treatment option in premenopausal breast cancer (BC) patients comprising luminal-like tumors. However, a significant proportion of tam-users will experience a relapse within 15 years of primary surgery. We postulate that some patients do not achieve the full clinical benefit of tam due to inter-individual differences in the metabolism of the drug and that the clinical relevance of this may be different between molecular subtypes of BC. Here, we have compared the prognostic value of threshold levels of active tam metabolites in PAM50 luminal (lum) A and B molecular subtypes.
Material and Methods
A number of 64 lum-like BC patients who were relapse-free 3 years after surgery, were retrospectively analyzed in the observational Oslo1 study. All patients received 20 mg tamoxifen daily for 5 years. Serum was obtained at the time of the 3 years follow-up. A sensitive and accurate LC-MS/MS method was developed and validated for the detection and quantification of tam and 9 metabolites in human serum. The median follow-up time from serum sampling to BC death or last follow-up was 13.9 years (0.6-16.5). Recurrence score and molecular subtype of the patients were determined on FFPE-tumor samples using the PAM50 classification algorithm.
Results
A linear trend was identified for the correlation between active metabolite Z-4OHtam and BCSS (p=0.021, HR=0.64, CI95=0.43–0.93). There was no linear association between the remaining metabolites and BC outcome. We further explored the possible association between survival and concentration thresholds for the active metabolites Z-4OHtam and Z-endoxifen and identified supervised cut off values representing low concentrations for Z-4OHtam (≤3.26 nM) and Z-endoxifen (≤9.00 nM). BC patients with low Z-4OHtam had a BCSS of 33.3% compared to 82.8% in patients with Z-4OHtam >3.26 nM (p<0.001, logrank; HR=6.83, CI 95=2.09-22.36). Lum status (A vs B; HR=5.50, CI95= 1.66-18.25) and Z-4OHtam concentration status (high vs low; HR=6.05, CI95=1.74-21.06) were the only factors left in the final multivariable model. A log-linear relationship between the ROR score and BCSS (p=0.002, HR=1.09, CI95=1.03–1.15) was identified after adjustment of clinically relevant variables and lum status was highly prognostic, (Lum A vs B; p=0.001, HR=5.2, CI=1.72-15.46). Therefore, we wanted to compare the prognostic value of the Z-4OHtam threshold in patients subgroups stratified by lum status. Low concentrations of Z-4OHtam were associated with poorer survival for patients in the lum B group only (HR=4.94, CI 95=1.16-21-02). For the lum A patients no significant association was found.
Discussion
Low levels (≤ 3.26 nM) of the active tam metabolite Z-4OHtam was associated with a poorer long-term outcome in tam-treated BC patients. However, when grouping patients according to the PAM50-based molecular subtype, this was only significant in patients belonging to the lum B subtype. Our results suggest that higher levels of active tam metabolites and thus better ER blockage are more important in the more aggressive lum B subtype.
Citation Format: Helland T, Søiland H, Hustad S, Lash TL, Kvaløy JT, Renolen A, Borgen E, Bifulco E, Henne N, Lien EA, Mellgren G, Naume B, Janssen EA. Serum levels of the active tamoxifen metabolite Z-4OHtam is predictive of long-term survival in luminal B subtype of breast cancer patients [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-12-05.
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Affiliation(s)
- T Helland
- Hormone Laboratory, Haukeland University Hospital, Bergen, Hordaland, Norway; University of Bergen, Bergen, Hordaland, Norway; Stavanger University Hospital, Stavanger, Rogaland, Norway; Rollins School of Public Health, Winship Cancer Institute, Emory University, Atlanta, GA; Radium Hospital, Oslo University Hospital, Oslo, Norway; Oslo University Hospital, Oslo, Norway; Stavanger University Hospital, Stavanger, Stavanger, Rogaland, Norway; University of Stavanger, Stavanger, Rogaland, Norway
| | - H Søiland
- Hormone Laboratory, Haukeland University Hospital, Bergen, Hordaland, Norway; University of Bergen, Bergen, Hordaland, Norway; Stavanger University Hospital, Stavanger, Rogaland, Norway; Rollins School of Public Health, Winship Cancer Institute, Emory University, Atlanta, GA; Radium Hospital, Oslo University Hospital, Oslo, Norway; Oslo University Hospital, Oslo, Norway; Stavanger University Hospital, Stavanger, Stavanger, Rogaland, Norway; University of Stavanger, Stavanger, Rogaland, Norway
| | - S Hustad
- Hormone Laboratory, Haukeland University Hospital, Bergen, Hordaland, Norway; University of Bergen, Bergen, Hordaland, Norway; Stavanger University Hospital, Stavanger, Rogaland, Norway; Rollins School of Public Health, Winship Cancer Institute, Emory University, Atlanta, GA; Radium Hospital, Oslo University Hospital, Oslo, Norway; Oslo University Hospital, Oslo, Norway; Stavanger University Hospital, Stavanger, Stavanger, Rogaland, Norway; University of Stavanger, Stavanger, Rogaland, Norway
| | - TL Lash
- Hormone Laboratory, Haukeland University Hospital, Bergen, Hordaland, Norway; University of Bergen, Bergen, Hordaland, Norway; Stavanger University Hospital, Stavanger, Rogaland, Norway; Rollins School of Public Health, Winship Cancer Institute, Emory University, Atlanta, GA; Radium Hospital, Oslo University Hospital, Oslo, Norway; Oslo University Hospital, Oslo, Norway; Stavanger University Hospital, Stavanger, Stavanger, Rogaland, Norway; University of Stavanger, Stavanger, Rogaland, Norway
| | - JT Kvaløy
- Hormone Laboratory, Haukeland University Hospital, Bergen, Hordaland, Norway; University of Bergen, Bergen, Hordaland, Norway; Stavanger University Hospital, Stavanger, Rogaland, Norway; Rollins School of Public Health, Winship Cancer Institute, Emory University, Atlanta, GA; Radium Hospital, Oslo University Hospital, Oslo, Norway; Oslo University Hospital, Oslo, Norway; Stavanger University Hospital, Stavanger, Stavanger, Rogaland, Norway; University of Stavanger, Stavanger, Rogaland, Norway
| | - A Renolen
- Hormone Laboratory, Haukeland University Hospital, Bergen, Hordaland, Norway; University of Bergen, Bergen, Hordaland, Norway; Stavanger University Hospital, Stavanger, Rogaland, Norway; Rollins School of Public Health, Winship Cancer Institute, Emory University, Atlanta, GA; Radium Hospital, Oslo University Hospital, Oslo, Norway; Oslo University Hospital, Oslo, Norway; Stavanger University Hospital, Stavanger, Stavanger, Rogaland, Norway; University of Stavanger, Stavanger, Rogaland, Norway
| | - E Borgen
- Hormone Laboratory, Haukeland University Hospital, Bergen, Hordaland, Norway; University of Bergen, Bergen, Hordaland, Norway; Stavanger University Hospital, Stavanger, Rogaland, Norway; Rollins School of Public Health, Winship Cancer Institute, Emory University, Atlanta, GA; Radium Hospital, Oslo University Hospital, Oslo, Norway; Oslo University Hospital, Oslo, Norway; Stavanger University Hospital, Stavanger, Stavanger, Rogaland, Norway; University of Stavanger, Stavanger, Rogaland, Norway
| | - E Bifulco
- Hormone Laboratory, Haukeland University Hospital, Bergen, Hordaland, Norway; University of Bergen, Bergen, Hordaland, Norway; Stavanger University Hospital, Stavanger, Rogaland, Norway; Rollins School of Public Health, Winship Cancer Institute, Emory University, Atlanta, GA; Radium Hospital, Oslo University Hospital, Oslo, Norway; Oslo University Hospital, Oslo, Norway; Stavanger University Hospital, Stavanger, Stavanger, Rogaland, Norway; University of Stavanger, Stavanger, Rogaland, Norway
| | - N Henne
- Hormone Laboratory, Haukeland University Hospital, Bergen, Hordaland, Norway; University of Bergen, Bergen, Hordaland, Norway; Stavanger University Hospital, Stavanger, Rogaland, Norway; Rollins School of Public Health, Winship Cancer Institute, Emory University, Atlanta, GA; Radium Hospital, Oslo University Hospital, Oslo, Norway; Oslo University Hospital, Oslo, Norway; Stavanger University Hospital, Stavanger, Stavanger, Rogaland, Norway; University of Stavanger, Stavanger, Rogaland, Norway
| | - EA Lien
- Hormone Laboratory, Haukeland University Hospital, Bergen, Hordaland, Norway; University of Bergen, Bergen, Hordaland, Norway; Stavanger University Hospital, Stavanger, Rogaland, Norway; Rollins School of Public Health, Winship Cancer Institute, Emory University, Atlanta, GA; Radium Hospital, Oslo University Hospital, Oslo, Norway; Oslo University Hospital, Oslo, Norway; Stavanger University Hospital, Stavanger, Stavanger, Rogaland, Norway; University of Stavanger, Stavanger, Rogaland, Norway
| | - G Mellgren
- Hormone Laboratory, Haukeland University Hospital, Bergen, Hordaland, Norway; University of Bergen, Bergen, Hordaland, Norway; Stavanger University Hospital, Stavanger, Rogaland, Norway; Rollins School of Public Health, Winship Cancer Institute, Emory University, Atlanta, GA; Radium Hospital, Oslo University Hospital, Oslo, Norway; Oslo University Hospital, Oslo, Norway; Stavanger University Hospital, Stavanger, Stavanger, Rogaland, Norway; University of Stavanger, Stavanger, Rogaland, Norway
| | - B Naume
- Hormone Laboratory, Haukeland University Hospital, Bergen, Hordaland, Norway; University of Bergen, Bergen, Hordaland, Norway; Stavanger University Hospital, Stavanger, Rogaland, Norway; Rollins School of Public Health, Winship Cancer Institute, Emory University, Atlanta, GA; Radium Hospital, Oslo University Hospital, Oslo, Norway; Oslo University Hospital, Oslo, Norway; Stavanger University Hospital, Stavanger, Stavanger, Rogaland, Norway; University of Stavanger, Stavanger, Rogaland, Norway
| | - EA Janssen
- Hormone Laboratory, Haukeland University Hospital, Bergen, Hordaland, Norway; University of Bergen, Bergen, Hordaland, Norway; Stavanger University Hospital, Stavanger, Rogaland, Norway; Rollins School of Public Health, Winship Cancer Institute, Emory University, Atlanta, GA; Radium Hospital, Oslo University Hospital, Oslo, Norway; Oslo University Hospital, Oslo, Norway; Stavanger University Hospital, Stavanger, Stavanger, Rogaland, Norway; University of Stavanger, Stavanger, Rogaland, Norway
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Helland T, Henne N, Bifulco E, Hustad SS, Kristensen VN, Lash T, Borgen E, Janssen EAM, Lien EA, Naume B, Mellgren G, Søiland H. Abstract P2-09-11: Metabolite-guided long-term prediction of outcome in tamoxifen treated breast cancer patients. Cancer Res 2017. [DOI: 10.1158/1538-7445.sabcs16-p2-09-11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background
The genetic polymorphisms of CYP2D6 determine its enzymatic activity thereby the pharmacokinetic velocity by which tamoxifen (tam) is converted into active metabolites. Combined analyses of tam metabolites compared to CYP2D6 type and long-term survival could allow prediction of tam response and personalization of therapies. The clinical importance of defining such subgroups in the era of the new long-term (10-year) tam treatment paradigm is actualized.
Material and Methods
From May 1995 to December 1998, patients were included in an observational micro-metastasis study in the Oslo region and treated according to the national guidelines at the time (1). Serum samples were drawn at 3-year follow-up from 356 relapse-free patients, 106 of these were treated with tamoxifen. The median follow up time for breast cancer death was 16.8 years (3.5-19.4).
Serum samples were processed using protein precipitation with acetonitrile. An Aquity UPLC system was used to chromatographically separate 10 tam metabolites using a BEH C18 Phenyl column (100 x 2.1 mm, 1.7 μm particle size) that was developed with a water-methanol gradient containing 0.1% formic acid. The LC system was coupled to a Xevo TQ-S tandem mass spectrometer equipped with an atmospheric pressure photoionization source. The method was validated with respect to linearity, imprecision, accuracy, and functional sensitivity according to FDA guidelines.
Results
The new LC-MS/MS method separated the active Z-isomers of 4OHtam and 4OHNDtam (endoxifen) from its inactive Z'-isomers and E-isomers. Imprecision (intra and inter-day CV %) was within 10 % for target concentrations for all metabolites and accuracies were in the range 95-106%. The method was validated with serum samples from 42 breast cancer patients using 20 mg of tamoxifen.
The endoxifen concentrations ranged from 0 to 90 nM, with a median value of 25 nM. The previous observed endoxifen level of 10 nM in poor metabolizers (2) was used as cut-off for the grouping of patients. The nil endoxifen (NE) group (< 0.1nM, n=14) or low-endoxifene (LE) group (0.1-10 nM, n=8) were grouped together. Univariate survival analysis did not show a significant association between breast cancer specific survival and endoxifen levels. (p=0.15; logrank and p=0.18;Breslow). However, for the period beyond 10-years of follow-up the breast cancer survival differed between the high endoxifene (HE) group and the NE+LE groups. For patients surviving the first 10 years the breast cancer specific survival was 94.2% vs. 77.8% for the HE and NE+LE groups respectively (p=0.020, logrank and p=0.017, Breslow, HR=4.5, CI 95=1.1-17.9). In the multivariate analysis endoxifen ≤/> 10 nM remained the only factor in the final model.
Discussion
We developed a new accurate and precise LC-MS/MS method for the measurement of 10 tamoxifen metabolites. Importantly, the method separates active and inactive isomers of 4OHtam and 4OHNDtam/endoxifen. Despite the low number of patients, we observed a poorer long-term survival beyond 10 years in patients with nil or low serum concentration of endoxifen. A comprehensive analysis is presented addressing the relationship between genotyped based and metabolite based prediction of long-term outcome in tamoxifen treated breast cancer patients.
Ref:
1. Wiedswang G, et al. Clin Ca Res; 2004
2. Mürdter TE, et al. Clin Pharmacol Ther; 2011.
Citation Format: Helland T, Henne N, Bifulco E, Hustad SS, Kristensen VN, Lash T, Borgen E, Janssen EAM, Lien EA, Naume B, Mellgren G, Søiland H. Metabolite-guided long-term prediction of outcome in tamoxifen treated breast cancer patients [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-09-11.
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Affiliation(s)
- T Helland
- Haukeland University Hospital (HUS), Bergen, Hordaland, Norway; University of Bergen (UIB), Bergen, Hordaland, Norway; Stavanger University Hospital (SUS), Stavanger, Rogaland, Norway; Oslo University Hospital, Oslo, Norway; University of Oslo, Oslo, Norway; Emory University, Rollins School of Public Health, Atlanta, GA
| | - N Henne
- Haukeland University Hospital (HUS), Bergen, Hordaland, Norway; University of Bergen (UIB), Bergen, Hordaland, Norway; Stavanger University Hospital (SUS), Stavanger, Rogaland, Norway; Oslo University Hospital, Oslo, Norway; University of Oslo, Oslo, Norway; Emory University, Rollins School of Public Health, Atlanta, GA
| | - E Bifulco
- Haukeland University Hospital (HUS), Bergen, Hordaland, Norway; University of Bergen (UIB), Bergen, Hordaland, Norway; Stavanger University Hospital (SUS), Stavanger, Rogaland, Norway; Oslo University Hospital, Oslo, Norway; University of Oslo, Oslo, Norway; Emory University, Rollins School of Public Health, Atlanta, GA
| | - SS Hustad
- Haukeland University Hospital (HUS), Bergen, Hordaland, Norway; University of Bergen (UIB), Bergen, Hordaland, Norway; Stavanger University Hospital (SUS), Stavanger, Rogaland, Norway; Oslo University Hospital, Oslo, Norway; University of Oslo, Oslo, Norway; Emory University, Rollins School of Public Health, Atlanta, GA
| | - VN Kristensen
- Haukeland University Hospital (HUS), Bergen, Hordaland, Norway; University of Bergen (UIB), Bergen, Hordaland, Norway; Stavanger University Hospital (SUS), Stavanger, Rogaland, Norway; Oslo University Hospital, Oslo, Norway; University of Oslo, Oslo, Norway; Emory University, Rollins School of Public Health, Atlanta, GA
| | - T Lash
- Haukeland University Hospital (HUS), Bergen, Hordaland, Norway; University of Bergen (UIB), Bergen, Hordaland, Norway; Stavanger University Hospital (SUS), Stavanger, Rogaland, Norway; Oslo University Hospital, Oslo, Norway; University of Oslo, Oslo, Norway; Emory University, Rollins School of Public Health, Atlanta, GA
| | - E Borgen
- Haukeland University Hospital (HUS), Bergen, Hordaland, Norway; University of Bergen (UIB), Bergen, Hordaland, Norway; Stavanger University Hospital (SUS), Stavanger, Rogaland, Norway; Oslo University Hospital, Oslo, Norway; University of Oslo, Oslo, Norway; Emory University, Rollins School of Public Health, Atlanta, GA
| | - EAM Janssen
- Haukeland University Hospital (HUS), Bergen, Hordaland, Norway; University of Bergen (UIB), Bergen, Hordaland, Norway; Stavanger University Hospital (SUS), Stavanger, Rogaland, Norway; Oslo University Hospital, Oslo, Norway; University of Oslo, Oslo, Norway; Emory University, Rollins School of Public Health, Atlanta, GA
| | - EA Lien
- Haukeland University Hospital (HUS), Bergen, Hordaland, Norway; University of Bergen (UIB), Bergen, Hordaland, Norway; Stavanger University Hospital (SUS), Stavanger, Rogaland, Norway; Oslo University Hospital, Oslo, Norway; University of Oslo, Oslo, Norway; Emory University, Rollins School of Public Health, Atlanta, GA
| | - B Naume
- Haukeland University Hospital (HUS), Bergen, Hordaland, Norway; University of Bergen (UIB), Bergen, Hordaland, Norway; Stavanger University Hospital (SUS), Stavanger, Rogaland, Norway; Oslo University Hospital, Oslo, Norway; University of Oslo, Oslo, Norway; Emory University, Rollins School of Public Health, Atlanta, GA
| | - G Mellgren
- Haukeland University Hospital (HUS), Bergen, Hordaland, Norway; University of Bergen (UIB), Bergen, Hordaland, Norway; Stavanger University Hospital (SUS), Stavanger, Rogaland, Norway; Oslo University Hospital, Oslo, Norway; University of Oslo, Oslo, Norway; Emory University, Rollins School of Public Health, Atlanta, GA
| | - H Søiland
- Haukeland University Hospital (HUS), Bergen, Hordaland, Norway; University of Bergen (UIB), Bergen, Hordaland, Norway; Stavanger University Hospital (SUS), Stavanger, Rogaland, Norway; Oslo University Hospital, Oslo, Norway; University of Oslo, Oslo, Norway; Emory University, Rollins School of Public Health, Atlanta, GA
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Christensen MHE, Fenne IS, Nordbø Y, Varhaug JE, Nygård KO, Lien EA, Mellgren G. Novel inflammatory biomarkers in primary hyperparathyroidism. Eur J Endocrinol 2015; 173:9-17. [PMID: 25850829 DOI: 10.1530/eje-14-1038] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 04/07/2015] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Primary hyperparathyroidism (PHPT) has been associated with low-grade inflammation and increased risk of cardiovascular disease (CVD). The aim of the study was to investigate systemic levels of pro-inflammatory proteins that previously have not been examined in patients with PHPT. The selection of the pro-inflammatory biomarkers included in this study, MMP9, S100A4, S100A8/A9 and the receptors sCD14 and RAGE, was based on a previous microarray screen of mRNAs in adipose tissue from PHPT patients. DESIGN A prospective study was conducted on a total of 57 patients with PHPT and a control group of 20 healthy blood donors. METHODS PHPT patients with normalisation of serum calcium levels after parathyroidectomy were followed for 6 months. Forty-two patients participated in the longitudinal study, in which blood samples were taken at inclusion, and 1, 3 and 6 months after surgery. RESULTS We observed increased serum levels of MMP9 (P=0.029), S100A4 (P<0.001) and sCD14 (P=0.002) in the 57 patients with PHPT compared to the control-group. During 6 months of follow up, S100A4 (P=0.022) and sCD14 (0.002) decreased significantly, while serum levels of MMP9 increased (P=0.025). CONCLUSIONS The results demonstrate an increased inflammatory response in PHPT patients shown by elevated MMP9, S100A4 and sCD14 at inclusion. During the 6 months of follow-up, MMP9 increased further, possibly due to the tissue repair process after parathyroidectomy. S100A4 and sCD14 decreased after surgery demonstrating a partial reversal of the systemic inflammation.
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Affiliation(s)
- M H E Christensen
- Department of Clinical ScienceUniversity of Bergen, Bergen, NorwayHormone LaboratoryDepartment of SurgeryHaukeland University Hospital, 5021 Bergen, NorwayDepartment of Surgical ScienceUniversity of Bergen, Bergen, NorwayKG Jebsen Center for Diabetes ResearchBergen, NorwayDepartment of Heart DiseaseHaukeland University Hospital, Bergen, Norway Department of Clinical ScienceUniversity of Bergen, Bergen, NorwayHormone LaboratoryDepartment of SurgeryHaukeland University Hospital, 5021 Bergen, NorwayDepartment of Surgical ScienceUniversity of Bergen, Bergen, NorwayKG Jebsen Center for Diabetes ResearchBergen, NorwayDepartment of Heart DiseaseHaukeland University Hospital, Bergen, Norway
| | - I S Fenne
- Department of Clinical ScienceUniversity of Bergen, Bergen, NorwayHormone LaboratoryDepartment of SurgeryHaukeland University Hospital, 5021 Bergen, NorwayDepartment of Surgical ScienceUniversity of Bergen, Bergen, NorwayKG Jebsen Center for Diabetes ResearchBergen, NorwayDepartment of Heart DiseaseHaukeland University Hospital, Bergen, Norway Department of Clinical ScienceUniversity of Bergen, Bergen, NorwayHormone LaboratoryDepartment of SurgeryHaukeland University Hospital, 5021 Bergen, NorwayDepartment of Surgical ScienceUniversity of Bergen, Bergen, NorwayKG Jebsen Center for Diabetes ResearchBergen, NorwayDepartment of Heart DiseaseHaukeland University Hospital, Bergen, Norway
| | - Y Nordbø
- Department of Clinical ScienceUniversity of Bergen, Bergen, NorwayHormone LaboratoryDepartment of SurgeryHaukeland University Hospital, 5021 Bergen, NorwayDepartment of Surgical ScienceUniversity of Bergen, Bergen, NorwayKG Jebsen Center for Diabetes ResearchBergen, NorwayDepartment of Heart DiseaseHaukeland University Hospital, Bergen, Norway
| | - J E Varhaug
- Department of Clinical ScienceUniversity of Bergen, Bergen, NorwayHormone LaboratoryDepartment of SurgeryHaukeland University Hospital, 5021 Bergen, NorwayDepartment of Surgical ScienceUniversity of Bergen, Bergen, NorwayKG Jebsen Center for Diabetes ResearchBergen, NorwayDepartment of Heart DiseaseHaukeland University Hospital, Bergen, Norway Department of Clinical ScienceUniversity of Bergen, Bergen, NorwayHormone LaboratoryDepartment of SurgeryHaukeland University Hospital, 5021 Bergen, NorwayDepartment of Surgical ScienceUniversity of Bergen, Bergen, NorwayKG Jebsen Center for Diabetes ResearchBergen, NorwayDepartment of Heart DiseaseHaukeland University Hospital, Bergen, Norway
| | - K O Nygård
- Department of Clinical ScienceUniversity of Bergen, Bergen, NorwayHormone LaboratoryDepartment of SurgeryHaukeland University Hospital, 5021 Bergen, NorwayDepartment of Surgical ScienceUniversity of Bergen, Bergen, NorwayKG Jebsen Center for Diabetes ResearchBergen, NorwayDepartment of Heart DiseaseHaukeland University Hospital, Bergen, Norway Department of Clinical ScienceUniversity of Bergen, Bergen, NorwayHormone LaboratoryDepartment of SurgeryHaukeland University Hospital, 5021 Bergen, NorwayDepartment of Surgical ScienceUniversity of Bergen, Bergen, NorwayKG Jebsen Center for Diabetes ResearchBergen, NorwayDepartment of Heart DiseaseHaukeland University Hospital, Bergen, Norway Department of Clinical ScienceUniversity of Bergen, Bergen, NorwayHormone LaboratoryDepartment of SurgeryHaukeland University Hospital, 5021 Bergen, NorwayDepartment of Surgical ScienceUniversity of Bergen, Bergen, NorwayKG Jebsen Center for Diabetes ResearchBergen, NorwayDepartment of Heart DiseaseHaukeland University Hospital, Bergen, Norway
| | - E A Lien
- Department of Clinical ScienceUniversity of Bergen, Bergen, NorwayHormone LaboratoryDepartment of SurgeryHaukeland University Hospital, 5021 Bergen, NorwayDepartment of Surgical ScienceUniversity of Bergen, Bergen, NorwayKG Jebsen Center for Diabetes ResearchBergen, NorwayDepartment of Heart DiseaseHaukeland University Hospital, Bergen, Norway Department of Clinical ScienceUniversity of Bergen, Bergen, NorwayHormone LaboratoryDepartment of SurgeryHaukeland University Hospital, 5021 Bergen, NorwayDepartment of Surgical ScienceUniversity of Bergen, Bergen, NorwayKG Jebsen Center for Diabetes ResearchBergen, NorwayDepartment of Heart DiseaseHaukeland University Hospital, Bergen, Norway
| | - G Mellgren
- Department of Clinical ScienceUniversity of Bergen, Bergen, NorwayHormone LaboratoryDepartment of SurgeryHaukeland University Hospital, 5021 Bergen, NorwayDepartment of Surgical ScienceUniversity of Bergen, Bergen, NorwayKG Jebsen Center for Diabetes ResearchBergen, NorwayDepartment of Heart DiseaseHaukeland University Hospital, Bergen, Norway Department of Clinical ScienceUniversity of Bergen, Bergen, NorwayHormone LaboratoryDepartment of SurgeryHaukeland University Hospital, 5021 Bergen, NorwayDepartment of Surgical ScienceUniversity of Bergen, Bergen, NorwayKG Jebsen Center for Diabetes ResearchBergen, NorwayDepartment of Heart DiseaseHaukeland University Hospital, Bergen, Norway Department of Clinical ScienceUniversity of Bergen, Bergen, NorwayHormone LaboratoryDepartment of SurgeryHaukeland University Hospital, 5021 Bergen, NorwayDepartment of Surgical ScienceUniversity of Bergen, Bergen, NorwayKG Jebsen Center for Diabetes ResearchBergen, NorwayDepartment of Heart DiseaseHaukeland University Hospital, Bergen, Norway
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Lien EA, Helland T, Gjerde J, Mellgren G, Søiland H. 4-Hydroxy-N-Demethyltamoxifen (4OHNDTAM, Endoxifen) down-regulates Cytokeratin 6 (CK6) IN MCF-7 breast cancer cells. Exp Clin Endocrinol Diabetes 2015. [DOI: 10.1055/s-0035-1547629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Lien EA, Mellgren G, Christensen MHE. The vitamin D receptor gene polymorphism Apa1 influences bone mineral density in patients with primary hyperparathyroidism. Exp Clin Endocrinol Diabetes 2014. [DOI: 10.1055/s-0034-1372056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Hoang T, Fenne IS, Madsen A, Bozickovic O, Johannessen M, Bergsvåg M, Lien EA, Stallcup MR, Sagen JV, Moens U, Mellgren G. cAMP response element-binding protein interacts with and stimulates the proteasomal degradation of the nuclear receptor coactivator GRIP1. Endocrinology 2013; 154:1513-27. [PMID: 23462962 PMCID: PMC5393311 DOI: 10.1210/en.2012-2049] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The glucocorticoid receptor interacting protein (GRIP1) belongs to the p160 steroid receptor coactivator family that plays essential roles in nuclear receptor-dependent transcriptional regulation. Previously, we reported that the cAMP-dependent protein kinase (PKA) induces ubiquitination leading to degradation of GRIP1. Here we show that the cAMP response element-binding protein (CREB) downregulates GRIP1 and is necessary for the PKA-stimulated degradation of GRIP1, which leads to changes in the expression of a subset of genes regulated by estrogen receptor-α in MCF-7 breast cancer cells. Our data of domain-mapping and ubiquitination analyses suggest that CREB promotes the proteasomal breakdown of ubiquitinated GRIP1 through 2 functionally independent protein domains containing amino acids 347 to 758 and 1121 to 1462. We provide evidence that CREB interacts directly with GRIP1 and that CREB Ser-133 phosphorylation or transcriptional activity is not required for GRIP1 interaction and degradation. The basic leucine zipper domain (bZIP) of CREB is important for the interaction with GRIP1, and deletion of this domain led to an inability to downregulate GRIP1. We propose that CREB mediates the PKA-stimulated degradation of GRIP1 through protein-protein interaction and stimulation of proteasomal degradation of ubiquitinated GRIP1.
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Affiliation(s)
- Tuyen Hoang
- Department of Clinical Science, University of Bergen, N-5021 Bergen, Norway
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9
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Lien EA, Søiland H, Gjerde J. Associations between tamoxifen and age during steady state tamoxifen treatment of postmenopausal women with breast cancer. Exp Clin Endocrinol Diabetes 2013. [DOI: 10.1055/s-0033-1336763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Christensen MHE, Pedersen EKR, Nordbø Y, Varhaug JE, Midttun Ø, Ueland PM, Nygård OK, Mellgren G, Lien EA. Vitamin B6 status and interferon-γ-mediated immune activation in primary hyperparathyroidism. J Intern Med 2012; 272:583-91. [PMID: 22757621 DOI: 10.1111/j.1365-2796.2012.02570.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Primary hyperparathyroidism (PHPT) has been associated with low-grade inflammation and elevated risk of cardiovascular disease (CVD). In inflammatory conditions, interferon-γ (IFN-γ) activity is enhanced and a decreased circulating concentration of vitamin B6 is often observed. Such changes in IFN-γ activity or vitamin B6 levels have been associated with increased incidence of CVD. The aim of the study was to investigate systemic markers of IFN-γ-mediated immune activation, such as neopterin, the kynurenine-to-tryptophan ratio (KTR) and kynurenine pathway metabolites, as well as B6 vitamers in patients with PHPT. DESIGN/SUBJECTS A total of 57 patients with PHPT and a control group of 20 healthy blood donors were included in this study. PHPT patients who responded positively to parathyroidectomy were followed for 6 months. Forty-three patients participated in the longitudinal study in which blood samples were taken at inclusion and 1, 3 and 6 months after surgery. RESULTS Plasma concentrations of the B6 vitamers pyridoxal 5'-phosphate (PLP) (P = 0.007) and pyridoxal (P = 0.013) were significantly lower in the patient group compared to healthy control subjects. An increase in the KTR indicated that the kynurenine pathway of tryptophan metabolism was altered in PHPT patients (P = 0.015). During the initial 6 months after surgery, levels of PLP (P < 0.001) and anthranilic acid (P < 0.001) increased significantly, whereas neopterin decreased (P = 0.018). CONCLUSIONS The results of this study demonstrate altered levels of vitamin B6 and the KTR in PHPT patients, both of which may reflect cellular immune activation. These abnormalities should be considered in relation to the increased risk of CVD previously observed in patients with PHPT.
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DeCensi A, Guerrieri-Gonzaga A, Gandini S, Serrano D, Cazzaniga M, Mora S, Johansson H, Lien EA, Pruneri G, Viale G, Bonanni B. Prognostic significance of Ki-67 labeling index after short-term presurgical tamoxifen in women with ER-positive breast cancer. Ann Oncol 2010; 22:582-587. [PMID: 20716629 DOI: 10.1093/annonc/mdq427] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Studies have shown that Ki-67 response after short-term neoadjuvant aromatase inhibitors may predict recurrence in postmenopausal breast cancer, whereas its prognostic effect in premenopausal women is unknown. PATIENTS AND METHODS We compared the prognostic and predictive value of baseline and post-treatment Ki-67 in 120 pre- and postmenopausal women with early-stage estrogen receptor-positive breast cancer who participated in a 4-week presurgical trial of tamoxifen. RESULTS After 7.2 years of follow-up, women with post-treatment Ki-67 in the second (14%-19%), third (20%-29%) and top (≥30%) quartiles had a recurrence hazard ratio of 2.92 [95% confidence interval (CI) 0.95-8.96], 4.37 (1.56-12.25) and 6.05 (2.07-17.65), respectively, as compared with those in the bottom quartile (<14%) (P-trend = 0.001). The risk of invasive disease recurrence was 2.2% (95% CI 0.9-5.0) per point increase in baseline Ki-67 (P-trend = 0.076) and 5.0% (95% CI 2.3-7.7) per point increase in post-tamoxifen Ki-67 (P-trend < 0.001). The risk of death was 5.5 (95% CI 1.26-23.16) times higher in patients with post-drug Ki-67 ≥20% than in those with Ki-67 <20% (P-trend = 0.006). CONCLUSIONS Ki-67 response after short-term neoadjuvant tamoxifen is a good predictor of recurrence-free survival and overall survival, further supporting its use as surrogate biomarker to personalize adjuvant treatment and to screen novel drugs cost-effectively.
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Affiliation(s)
- A DeCensi
- Division of Cancer Prevention and Genetics, European Institute of Oncology, Milan; Medical Oncology Unit, E.O. Ospedali Galliera, Genoa.
| | - A Guerrieri-Gonzaga
- Division of Cancer Prevention and Genetics, European Institute of Oncology, Milan
| | - S Gandini
- Division of Epidemiology and Biostatistics, European Institute of Oncology, Milan, Italy
| | - D Serrano
- Division of Cancer Prevention and Genetics, European Institute of Oncology, Milan
| | - M Cazzaniga
- Division of Cancer Prevention and Genetics, European Institute of Oncology, Milan
| | - S Mora
- Division of Cancer Prevention and Genetics, European Institute of Oncology, Milan
| | - H Johansson
- Division of Cancer Prevention and Genetics, European Institute of Oncology, Milan
| | - E A Lien
- Hormone Laboratory, Haukeland University Hospital; Section for Endocrinology, Institute of Medicine, University of Bergen, Bergen, Norway
| | - G Pruneri
- Division of Pathology, European Institute of Oncology; University of Milan School of Medicine, Milan, Italy
| | - G Viale
- Division of Pathology, European Institute of Oncology; University of Milan School of Medicine, Milan, Italy
| | - B Bonanni
- Division of Cancer Prevention and Genetics, European Institute of Oncology, Milan
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Flågeng MH, Moi LLH, Dixon JM, Geisler J, Lien EA, Miller WR, Lønning PE, Mellgren G. Nuclear receptor co-activators and HER-2/neu are upregulated in breast cancer patients during neo-adjuvant treatment with aromatase inhibitors. Br J Cancer 2009; 101:1253-60. [PMID: 19755984 PMCID: PMC2768454 DOI: 10.1038/sj.bjc.6605324] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Acquired resistance to endocrine therapy in breast cancer is poorly understood. Characterisation of the molecular response to aromatase inhibitors in breast cancer tissue may provide important information regarding development of oestrogen hypersensitivity. METHODS We examined the expression levels of nuclear receptor co-regulators, the orphan nuclear receptor liver receptor homologue-1 and HER-2/neu growth factor receptor using real-time RT-PCR before and after 13-16 weeks of primary medical treatment with the aromatase inhibitors anastrozole or letrozole. RESULTS mRNA expression of the steroid receptor co-activator 1 (SRC-1) and peroxisome-proliferator-activated receptor gamma co-activator-1alpha (PGC-1alpha) was correlated (P=0.002), and both co-activators increased during treatment in the patient group as a whole (P=0.008 and P=0.032, respectively), as well as in the subgroup of patients achieving an objective treatment response (P=0.002 and P=0.006). Although we recorded no significant change in SRC-3/amplified in breast cancer 1 level, the expression correlated positively to the change of SRC-1 (P=0.002). Notably, we recorded an increase in HER-2/neu levels during therapy in the total patient group (18 out of 26; P=0.016), but in particular among responders (15 out of 21; P=0.008). CONCLUSION Our results show an upregulation of co-activator mRNA and HER-2/neu during treatment with aromatase inhibitors. These mechanisms may represent an early adaption of the breast cancer cells to oestrogen deprivation in vivo.
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Gjerde J, Hauglid M, Breilid H, Lundgren S, Varhaug JE, Kisanga ER, Mellgren G, Steen VM, Lien EA. Effects of CYP2D6 and SULT1A1 genotypes including SULT1A1 gene copy number on tamoxifen metabolism. Ann Oncol 2007; 19:56-61. [PMID: 17947222 DOI: 10.1093/annonc/mdm434] [Citation(s) in RCA: 117] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Tamoxifen is hydroxylated by cytochrome P450 (CYP) 2D6 to the potent metabolites 4-hydroxytamoxifen (4OHtam) and 4-hydroxy-N-demethyltamoxifen (4OHNDtam), which are both conjugated by sulphotransferase (SULT)1A1. Clinical studies indicate that CYP2D6 and SULT1A1 genotypes are predictors for treatment response to tamoxifen. Therefore, we examined the relationship between CYP2D6 genotype, SULT1A1 genotype, SULT1A1 copy number and the pharmacokinetics of tamoxifen. PATIENTS AND METHODS The serum levels of tamoxifen and metabolites of 151 breast cancer patients were measured by high-pressure liquid chromatography-tandem mass spectrometry. The CYP2D6 and SULT1A1 polymorphisms and SULT1A1 copy number were determined by long PCR, PCR-based restriction fragment length polymorphism, DNA sequencing and fluorescence-based PCR. RESULTS The levels of 4OHtam, 4OHNDtam and N-demethyltamoxifen were associated with CYP2D6 predicted enzymatic activity (P < 0.05). The SULT1A1 genotype or copy number did not influence the levels of tamoxifen and its metabolites. However, the ratios of N-demethyltamoxifen/tamoxifen and N-dedimethyltamoxifen/N-demethyltamoxifen were related to SULT1A1 genotype. CONCLUSION CYP2D6 and SULT1A1 genotypes may partly explain the wide inter-individual variations in the serum levels of tamoxifen and its metabolites. We propose that therapeutic drug monitoring should be included in studies linking CYP2D6 and SULT1A1 genotypes to clinical outcome.
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Affiliation(s)
- J Gjerde
- The Hormone Laboratory, Haukeland University Hospital, N-5021 Bergen
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Geisler J, Lønning PE, Krag LE, Løkkevik E, Risberg T, Hagen AI, Schlichting E, Lien EA, Ofjord ES, Eide GE, Polli A, di Salle E, Paolini J. Changes in bone and lipid metabolism in postmenopausal women with early breast cancer after terminating 2-year treatment with exemestane: a randomised, placebo-controlled study. Eur J Cancer 2006; 42:2968-75. [PMID: 16963261 DOI: 10.1016/j.ejca.2006.07.005] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2006] [Revised: 06/28/2006] [Accepted: 07/11/2006] [Indexed: 11/21/2022]
Abstract
Aromatase inhibitors improve relapse-free survival in early breast cancer, but there is concern about possible detrimental effects on bone mineral density (BMD) and plasma lipids. This paper presents the results of a 2-year study evaluating the effects of exemestane versus placebo on BMD, bone markers, plasma lipids and coagulation factors, including a 1-year follow-up after termination of treatment in 147 patients. During treatment, the mean annual rate of loss of BMD in the lumbar spine was 2.17% in the exemestane group versus 1.84% in the placebo group (n.s.) and 2.72% versus 1.48%, respectively, in the femoral neck (P=0.024). A loss of BMD above that expected in both arms of this study could be due to low vitamin D status (88% of all patients had vitamin D levels <30 ng/ml). The changes observed with exemestane were partially reversed during a 1-year follow-up, with no significant difference between the two arms. Similarly, the moderate decrease in high-density lipoprotein (HDL)-cholesterol was reversed. The bone marker values decreased, although a difference at 6 months of follow-up was still recorded, in particular for the markers of bone synthesis.
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Affiliation(s)
- J Geisler
- Section of Oncology, Department of Medicine, Haukeland University Hospital, University of Bergen, NO-5021, Bergen, Norway
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Gjerde J, Kisanga ER, Hauglid M, Holm PI, Mellgren G, Lien EA. Identification and quantification of tamoxifen and four metabolites in serum by liquid chromatography-tandem mass spectrometry. J Chromatogr A 2005; 1082:6-14. [PMID: 16038189 DOI: 10.1016/j.chroma.2005.01.004] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
We have developed a method for the determination of tamoxifen (tam) and its metabolites 4-hydroxytamoxifen (4OHtam), N-demethyltamoxifen (NDtam), N-dedimethyltamoxifen (NDDtam), tamoxifen-N-oxide (tamNox), and 4-hydroxy-N-demethyltamoxifen (4OHNDtam) in 50 microl human serum. Serum proteins were precipitated with acetonitrile. Deuterated-tamoxifen (D5 tam) was added as internal standard. Sample supernatant was injected into an on-line reversed-phase extraction column coupled with a C18 analytical column and analytes were detected by tandem mass spectrometry. The lower limits of quantification were 0.25 ng/mL for 4OHtam, NDtam and tam, 1.0 ng/mL for NDDtam and tamNox. Ranges of within- and between-day variation were 2.9-15.4% and 4.4-12.9%, respectively.
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Affiliation(s)
- J Gjerde
- Hormone Laboratory, Haukeland University Hospital, N-5021 Bergen, Norway
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Hoang T, Fenne IS, Cook C, Børud B, Bakke M, Lien EA, Mellgren G. cAMP-dependent protein kinase regulates ubiquitin-proteasome-mediated degradation and subcellular localization of the nuclear receptor coactivator GRIP1. J Biol Chem 2004; 279:49120-30. [PMID: 15347661 DOI: 10.1074/jbc.m409746200] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Nuclear receptors and their coactivators are key regulators of numerous physiological functions. GRIP1 (glucocorticoid receptor-interacting protein) is a member of the steroid receptor coactivator family. Here, we show that GRIP1 is regulated by cAMP-dependent protein kinase (PKA) that induces its degradation through the ubiquitin-proteasome pathway. GRIP1 was down-regulated in transiently transfected COS-1 cells after treatment with 8-para-chlorophenylthio-cAMP or forskolin and 3-isobutyl-1-methylxanthine and in adrenocortical Y1 cells after incubation with adrenocorticotropic hormone. Pulse-chase experiments with transiently transfected COS-1 cells demonstrated that the half-life of GRIP1 was markedly reduced in cells overexpressing the PKA catalytic subunit, suggesting that activation of PKA increases the turnover of GRIP1 protein. The proteasome inhibitors MG132 and lactacystin abolished the PKA-mediated degradation of GRIP1. Using ts20 cells, a temperature-sensitive cell line that contains a thermolabile ubiquitin-activating E1 enzyme, it was confirmed that PKA-mediated degradation of GRIP1 is dependent upon the ubiquitin-proteasome pathway. Coimmunoprecipitation studies of COS-1 cells transfected with expression vectors encoding GRIP1 and ubiquitin using anti-GRIP1 and anti-ubiquitin antibodies showed that the ubiquitination of GRIP1 was increased by overexpression of PKA. Finally, we show that PKA regulates the intracellular distribution pattern of green fluorescent protein-GRIP1 and stimulates recruitment of GRIP1 to subnuclear foci that are colocalized with the proteasome. Taken together, these data demonstrate that GRIP1 is ubiquitinated and degraded through activation of the PKA pathway. This may represent a novel regulatory mechanism whereby hormones down-regulate a nuclear receptor coactivator.
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Affiliation(s)
- Tuyen Hoang
- Hormone Laboratory, Section of Endocrinology, Institute of Medicine, Division of Anatomy and Cell Biology, Department of Biomedicine, University of Bergen and Haukeland University Hospital, Bergen N-5021, Norway
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Nedrebø BG, Hustad S, Schneede J, Ueland PM, Vollset SE, Holm PI, Aanderud S, Lien EA. Homocysteine and its relation to B-vitamins in Graves' disease before and after treatment: effect modification by smoking. J Intern Med 2003; 254:504-12. [PMID: 14535973 DOI: 10.1046/j.1365-2796.2003.01222.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To investigate plasma total homocysteine levels and its relation to B-vitamins and smoking in Graves' disease before and after antithyroid therapy. DESIGN A longitudinal study taking place at four hospitals in Norway. METHODS AND SUBJECTS Plasma total homocysteine, serum folate, serum cobalamin and riboflavin, flavin mononucleotide and flavin adenine dinucleotide in plasma were investigated in 182 patients with hyperthyroidism before treatment. The same parameters were reinvestigated in 112 of these patients after attaining euthyroid state. RESULTS In hyperthyroidism, plasma total homocysteine was low, and inversely related to folate, cobalamin and riboflavin, and positively related to serum creatinine and age. Following antithyroid therapy, total homocysteine increased and the concentration of folate, cobalamin, riboflavin, flavin mononucleotide and flavin adenine dinucleotide decreased significantly. The most pronounced reduction (35%) was observed for flavin mononucleotide. In the hyperthyroid state, smokers had lower levels of folate and flavin mononucleotide than non-smokers. After restoration of euthyroidism, both folate and riboflavin were significantly lower in smokers than non-smokers. Plasma total homocysteine increased according to decreasing quartiles of B-vitamins. For riboflavin, this relation was confined to smokers. CONCLUSION Plasma total homocysteine changes according to thyroid status. These changes may be partly attributable to altered folate, cobalamin but also riboflavin status, particularly in smokers.
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Affiliation(s)
- B G Nedrebø
- LOCUS for Homocysteine and Related Vitamins, University of Bergen, Haukeland University Hospital, Bergen, Norway.
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18
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Bonanni B, Johansson H, Gandini S, Guerrieri-Gonzaga A, Sandri MT, Mariette F, Lien EA, Decensi A. Effect of tamoxifen at low doses on ultrasensitive C-reactive protein in healthy women. J Thromb Haemost 2003; 1:2149-52. [PMID: 14521597 DOI: 10.1046/j.1538-7836.2003.00392.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The use of tamoxifen as a breast cancer preventive agent may be contraindicated by an increased risk of endometrial cancer and venous thromboembolic events, particularly in postmenopausal women. Since these estrogenic effects may be dose-related, a dose reduction may reduce toxicity. We have recently shown a comparable activity of lower doses of tamoxifen on putative surrogate biomarkers of cardiovascular disease and breast cancer. To provide further insight into the effect of tamoxifen at low doses on the cardiovascular system, we compared the effect of three different doses on circulating levels of C-reactive protein (CRP), an independent risk marker for cardiovascular disease (CVD), which was lowered by tamoxifen at the standard dose of 20 mg day-1 in previous studies. We compared the changes in CRP after 2 months of either placebo (n = 24), or tamoxifen 10 mg alternate daily (n = 26), or 10 mg day-1 (n = 22), or 20 mg day-1 (n = 19) in healthy women aged 35-70 years. The median percent change was -2.2% (95% CI, -23.3 to 42.8) with placebo, -39.1 (95% CI, -59.9 to -28.7) with 10 mg alternate daily, -56.9% (95% CI, -68.6 to -38.4) with 10 mg day-1 and -42.9% (95% CI, -62.6 to 1.6) with 20 mg day-1 (P = 0.291 for the linear dose-response trend). Similar results were obtained when the data were classified according to blood tamoxifen concentrations, with a median reduction of 47% (95% CI, 65.5-36.3) for women with low tamoxifen concentrations (< 30 ng mL-1). We conclude that tamoxifen at low doses is able to lower ultrasensitive CRP and that this might be associated with a beneficial effect on CVD.
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Affiliation(s)
- B Bonanni
- Division of Chemoprevention, European Institute of Oncology, via Ripamonti 435, 20141 Milan, Italy
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19
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Mellgren G, Børud B, Hoang T, Yri OE, Fladeby C, Lien EA, Lund J. Characterization of receptor-interacting protein RIP140 in the regulation of SF-1 responsive target genes. Mol Cell Endocrinol 2003; 203:91-103. [PMID: 12782406 DOI: 10.1016/s0303-7207(03)00097-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Receptor-interacting protein (RIP) 140 interacts with several nuclear receptors, but its function in regulation of nuclear receptor action has been debated. Here we have examined the role of RIP140 in regulation of Steroidogenic factor-1 (SF-1)-dependent transcription. SF-1 interacts with RIP140 through its activation function-2 (AF-2) domain. Several domains of RIP140 interact directly with SF-1, but the carboxyl-terminal region containing 4 of its 9 LXXLL motifs showed the strongest SF-1 interaction. Coexpression of RIP140 and SF-1 in different cell types demonstrated that RIP140 acts as a potent corepressor of transcription from the SF-1 responsive cAMP regulatory sequence 2 (CRS2) element of the CYP17 gene and a variety of SF-1 responsive promoter genes. RIP140 also counteracted the stimulatory action of p160/SRC coactivators. The inhibitory effect of RIP140 was partially reversed by Trichostatin A, suggesting a role of histone deacetylase (HDAC) activity in RIP140-mediated repression of SF-1. Quantitation of endogenous coregulator mRNA levels revealed cell type specific differences that could affect the repressor action by overexpressed RIP140.
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Affiliation(s)
- Gunnar Mellgren
- Department of Clinical Biochemistry, The Hormone Laboratory, Haukeland University Hospital, University of Bergen, N-5021 Bergen, Norway.
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20
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Abstract
We investigated the kinetics of tamoxifen (tam) in immunodeficient mice and rats after oral treatment and compared drug and metabolite profile in nude rat serum and tissues after oral and subcutaneous (s.c.) routes of administration. The serum levels were compared to those observed in man. After oral dosing in mice, tam and the potent metabolite 4-hydroxytamoxifen (4-hydroxytam), were detectable in liver and lung tissue, but not in serum. The levels of 4-hydroxytam in these tissues were significantly higher than those of tam, a profile opposite to that observed in rat and man. In rats and man, the 4-hydroxytam/tam serum concentration ratios were 0.16 and 0.02, respectively. Compared to oral route, the s.c. pellets yielded only trace amounts of the demethylated derivatives of tam in rats. Thus, the kinetics of tam observed in the present study suggest that the nude rat may represent a preferable animal model in studying the pharmacokinetics of tam and that, the oral route yielded higher serum and tissue levels of tam and metabolites than equivalent s.c. pellet implants.
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Affiliation(s)
- E R Kisanga
- The Hormone Laboratory, Department of Clinical Biochemistry, Haukeland University Hospital, University of Bergen, Norway.
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21
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Mellgren G, Holm PI, Lien EA, Bleskestad IH, Aanderud S, Bindoff L. [Thyrotoxic periodic paralysis--an unusual complication of hyperthyroidism]. Tidsskr Nor Laegeforen 2002; 122:1029-31. [PMID: 12082695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND Thyrotoxic periodic paralysis (TPP) is a complication of hyperthyroidism. MATERIALS AND METHODS We describe two patients with TPP. RESULTS A 26-year-old man from Vietnam had weight loss, tachycardia, palpitations and heat intolerance for five months. Episodic leg and arm weakness developed three months after debut of symptoms. The second patient, a 23-year old woman from the Philippines, had had episodic leg weakness in the evenings after dinner for three weeks. Her attacks resolved spontaneously overnight. Physical examination of both patients revealed tachycardia and symmetrical proximal weakness involving both arms and legs. ECG and electrolyte analysis indicated a severe hypokalaemia; thyroid function tests showed hyperthyroidism. Both patients were diagnosed as having Graves' thyrotoxicosis and TPP. They were initially treated with propranolol and subsequently with carbimazole. The first patient had recurrence of thyrotoxicosis and paralysis after 16 months, whereas the second patient has remained symptom-free. INTERPRETATION TPP is most common in Asian males, very few cases are reported in females. In Western countries TPP is rare, but with increasing immigration, TPP is likely to occur more frequently.
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22
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Nedrebø BG, Nygård O, Ueland PM, Lien EA. Plasma total homocysteine in hyper- and hypothyroid patients before and during 12 months of treatment. Clin Chem 2001; 47:1738-41. [PMID: 11514424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Affiliation(s)
- B G Nedrebø
- LOCUS for Homocysteine and Related Vitamins, University of Bergen, 5021 Bergen, Norway.
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23
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Bonanni B, Johansson H, Gandini S, Guerrieri-Gonzaga A, Torrisi R, Sandri MT, Cazzaniga M, Mora S, Robertson C, Lien EA, Decensi A. Effect of low dose tamoxifen on the insulin-like growth factor system in healthy women. Breast Cancer Res Treat 2001; 69:21-7. [PMID: 11759825 DOI: 10.1023/a:1012241505717] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The use of tamoxifen as a preventive agent may be limited by the increased risk of endometrial cancer and venous thromboembolic events observed in postmenopausal women. We have recently shown a comparable activity of lower doses of tamoxifen on several surrogate biomarkers of cardiovascular disease and breast cancer, including Insulin-like Growth Factor-I (IGF-I). To provide further insight into the effect of tamoxifen at low doses on the IGF system, we have correlated the drug serum levels attained after 2 months of either placebo (n = 32), tamoxifen 20 mg/day (n = 26), 10 mg/day (n = 23) or 10 mg/every other day (n = 29) with the changes in IGF-I, Insulin-like Growth Factor-II (IGF-II), Insulin-like Growth Factor Binding Protein-1 (IGFBP-1), Insulin-like Growth Factor Binding Protein-3 (IGFBP-3), and IGF-I/IGFBP-3 ratio. Compared with placebo, tamoxifen induced a mean +/- standard error (SE) reduction of IGF-I of 16.9 +/- 7.8%, p < 0.05, a non-significant increase of 22.9 +/- 12.2% in IGF-II, an increase in IGFBP-1 of 49.3 +/- 22.7%, p < 0.05, and a non-significant change of IGFBP-3 (-4.0% +/- 9.2). No significant concentration-response relationship was observed between serum tamoxifen concentrations and the biomarker changes except for the ratio of IGF-I/IGFBP-3, which decreased by 1.53 +/- 0.68% for any increase by 10 ng/ml of serum tamoxifen concentration (p = 0.02). Although low tamoxifen concentrations induce a comparable modulation of the IGF family relative to the conventional dose, the lower decrements in the IGF-I/IGFBP-3 ratio observed at low drug concentrations might be associated with a reduced preventive activity. Further studies on the search of the minimal active dose of tamoxifen are warranted.
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Affiliation(s)
- B Bonanni
- Division of Chemoprevention, European Institute of Oncology, Milan, Italy
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24
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Guerrieri-Gonzaga A, Baglietto L, Johansson H, Bonanni B, Robertson C, Sandri MT, Canigiula L, Lampreda C, Diani S, Lien EA, Decensi A. Correlation between tamoxifen elimination and biomarker recovery in a primary prevention trial. Cancer Epidemiol Biomarkers Prev 2001; 10:967-70. [PMID: 11535549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023] Open
Abstract
We have shown previously that a reduction from the conventional dose of tamoxifen is associated with a comparable modulation of circulating biomarkers, including insulin-like growth factor-I and cholesterol. In the present study, we have correlated serum tamoxifen elimination with biomarker recovery in healthy subjects completing a 5-year intervention period. Tamoxifen, N-desmethyltamoxifen, and biomarker levels were measured at 0 (baseline), 2, 4, and 6 weeks after completion of treatment in 23 healthy postmenopausal women allocated to tamoxifen 20 mg/day and in 6 women allocated to placebo. Mean (+/-SD) serum tamoxifen and N-desmethyltamoxifen concentrations were, respectively, 141 +/- 50 and 226 +/- 77 ng/ml at baseline, 36 +/- 19 and 99 +/- 46 at 2 weeks, 20 +/- 15 and 61 +/- 37 at 4 weeks, and 12 +/- 9 and 36 +/- 26 at 6 weeks. Serum tamoxifen and N-desmethyltamoxifen half-lives were 9 and 13 days, respectively. Body mass index was associated positively with drug's serum half-life. Compared with baseline values, the percentage increase in total cholesterol, low-density lipoprotein cholesterol, and insulin-like growth factor-I 4 weeks after treatment completion was 5, 9, and 14%, respectively. No change during the 6-week period was observed in the placebo arm. Our findings indicate that the biomarker recovery is slower than serum tamoxifen elimination, suggesting that low tamoxifen concentrations may still exert a biological effect. In addition, the prolonged half-life of tamoxifen and metabolite provides the rationale for a weekly administration of the drug in a preventive context. However, the clinical implications of our findings remain to be defined.
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Affiliation(s)
- A Guerrieri-Gonzaga
- Division of Chemoprevention, European Institute of Oncology, 20141 Milan, Italy
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25
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Ulvik A, Evensen ET, Lien EA, Hoff G, Vollset SE, Majak BM, Ueland PM. Smoking, folate and methylenetetrahydrofolate reductase status as interactive determinants of adenomatous and hyperplastic polyps of colorectum. Am J Med Genet 2001; 101:246-54. [PMID: 11424140 DOI: 10.1002/ajmg.1370] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Most studies demonstrate increased risk of colorectal cancer (CRC) and adenomas in folate-deficient subjects or that high folate intake may afford some protection. Smoking increases such risk in some but not all studies. We investigated whether smoking, folate status and methylenetetrahydrofolate reductase (MTHFR) genotype predict the risk of adenomatous and hyperplastic polyps of colorectum. By colonoscopy, the type, number, size and extent of dysplasia of colorectal polyps were assessed in 443 subjects aged 63-72 years. We also determined RBC folate and the C667T polymorphism of the methylenetetrahydrofolate reductase (MTHFR) gene. Smoking, folate status and the C677T MTHFR polymorphism were strong, interactive determinants of high-risk adenomas (HRAs, defined as adenomas > or =10 mm in diameter, adenomas with villous components or with severe dysplasia). The risk was particularly high in smokers with low folate and the CT/TT genotype (risk category T) and in smokers with high folate and the CC genotype (risk category C). With non-smokers with low folate and the CC genotype as reference, the odds ratios (OR, 95% CI) were 8.7 (2.5-29.7) in category T and 9.9 (2.6-38.4) in category C. Notably, this risk pattern was also observed for hyperplastic polyps. In conclusion, in smokers, high folate status may confer increased or decreased risk for HRAs, depending on the MTHFR genotype. These data demonstrate the strong gene-nutrition interaction involving the C677T MTHFR polymorphism.
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Affiliation(s)
- A Ulvik
- LOCUS for Homocysteine and Related Vitamins, Armauer Hansens hus, University of Bergen, Bergen, Norway
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26
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Abstract
Antioestrogen therapy is currently receiving renewed interest for several reasons. Tamoxifen was introduced in the treatment of metastatic breast cancer more than three decades ago. The drug significantly reduces long term mortality and also reduces the risk of contralateral tumours when administered in early breast cancer. Five years of tamoxifen is now standard in adjuvant endocrine therapy, and the drug is currently being evaluated for breast cancer prevention. Despite this, several aspects regarding the pharmacology of the drug are still unclear, and the scientific rationale for dose selection has recently been challenged. Several novel antioestrogen compounds, called selective oestrogen receptor modifiers (SERMs), express selective oestrogen agonistic or antagonistic properties depending on the organ or test system evaluated. Some of these drugs, like raloxifene, do not seem to promote the development of endometrial cancer, although they still have selected oestrogen-like beneficial effects. This paper reviews the pharmacologic and the pharmacokinetic aspects of the different SERMs with particular emphasis on their potential use in therapy and prevention of breast cancer.
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Affiliation(s)
- E A Lien
- Department of Biochemical Endocrinology, Section of Oncology, Haukeland University Hospital, Bergens, N-5021, Norway
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27
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Abstract
Hypothyroidism is associated with increased cardiovascular morbidity, which cannot be fully explained by the atherogenic lipid profile observed in these patients. We have previously found elevated levels of the cardiovascular risk factor, plasma total homocysteine (tHcy), in hypothyroidism. We conducted a longitudinal study on 17 patients who had undergone total thyroidectomy for thyroid cancer. During 6 weeks of discontinued T4 substitution before radioscintigraphy (phase I), they attained a hypothyroid state, which was reversed by resupplementation (phase II). Plasma tHcy, serum creatinine, serum and red blood cell folate, serum cobalamin, and serum cholesterol were determined at 2-week intervals throughout phases I and II. There was a progressive and parallel increase in tHcy (mean, 27%), serum creatinine (37%), and serum cholesterol (100%) during phase I, and these values returned to the original level within 4-6 weeks after reinitiating T4 therapy. Serum and red blood cell folate levels showed only minor, but statistically significant, changes. In a bivariate model, serum creatinine and serum cholesterol were strongly associated with the changes observed in tHcy during short term hypothyroidism. In conclusion, we found a transient increase in both plasma tHcy and serum cholesterol during short term iatrogenic hypothyroidism, and the tHcy response is probably mainly explained by concurrent changes in renal function. The increase in both plasma tHcy and serum cholesterol may confer increased cardiovascular risk in hypothyroid patients.
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Affiliation(s)
- E A Lien
- Division of Pharmacology, University Hospital of Bergen, Norway.
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28
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Love RR, Anker G, Yang Y, Refsum H, Ueland PM, Lønning PE, Lien EA. Serum homocysteine levels in postmenopausal breast cancer patients treated with tamoxifen. Cancer Lett 1999; 145:73-7. [PMID: 10530772 DOI: 10.1016/s0304-3835(99)00233-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Adjuvant treatment of breast cancer with tamoxifen may be associated with reduced risk of cardiovascular disease. Serum homocysteine level has been suggested to be a risk factor for cardiovascular disease influenced by estrogenic hormones. We evaluated a subset of postmenopausal women who had participated in a longitudinal, double-blind, randomized, placebo-controlled toxicity study of tamoxifen 10 mg orally, twice daily. Twenty-seven treated subjects and 37 placebo subjects had measurements of serum homocysteine levels made on previously frozen samples obtained at baseline and after 12 months. After treatment with tamoxifen, we found lower levels of serum homocysteine of borderline statistical significance.
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Affiliation(s)
- R R Love
- Department of Medicine, University of Wisconsin Medical School, Madison 53706, USA.
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29
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Decensi A, Gandini S, Guerrieri-Gonzaga A, Johansson H, Manetti L, Bonanni B, Sandri MT, Barreca A, Costa A, Robertson C, Lien EA. Effect of blood tamoxifen concentrations on surrogate biomarkers in a trial of dose reduction in healthy women. J Clin Oncol 1999; 17:2633-8. [PMID: 10561336 DOI: 10.1200/jco.1999.17.9.2633] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Tamoxifen administered at 20 mg/d has been shown to decrease breast cancer incidence in at-risk women by 50%, but toxicity may limit its broad use, particularly in postmenopausal women. Because toxicity may be dose-dependent, we studied the biologic activity of low concentrations of tamoxifen to determine the plausibility of a dose reduction. PATIENTS AND METHODS We measured the blood concentrations of tamoxifen and its main metabolites in a dose titration study in 105 healthy women (placebo, tamoxifen 10 mg on alternate days, tamoxifen 10 mg/d, and tamoxifen 20 mg/d). Drug levels measured after 2 months of treatment were correlated with the changes in surrogate biomarkers of different diseases, including lipid profile, blood cell count, fibrinogen, antithrombin III, osteocalcin, and insulin-like growth factor I, a promising surrogate biomarker of breast cancer. RESULTS The means (+/- SD) for tamoxifen and N-desmethyltamoxifen (metabolite X) concentrations (ng/mL) were dose-related, being, respectively, 0 and 0 with placebo, 26.8 +/- 15.1 and 43.7 +/- 22.5 with 10 mg every other day, 51.2 +/- 24.1 and 90.7 +/- 48.0 with 10 mg/d, and 136.0 +/- 52.7 and 230.6 +/- 75.0 with 20 mg/d of tamoxifen. At variance, the biomarker changes were of comparable magnitude at any drug concentration except for platelet count and triglycerides levels, the latter showing a trend to an increase with increasing tamoxifen concentrations. CONCLUSION An 80% reduction in blood concentrations does not seem to affect the activity of tamoxifen on biomarkers of cardiovascular or breast cancer risk and may in fact have a more favorable safety profile. Additional studies are warranted to determine the most appropriate dose of this agent.
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Affiliation(s)
- A Decensi
- Chemoprevention Unit, the Division of Epidemiology and Biostatistics, and the Division of Laboratory Medicine, European Institute of Oncology, Milan, Italy.
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30
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Anker GB, Refsum H, Ueland PM, Johannessen DC, Lien EA, Lonning PE. Influence of aromatase inhibitors on plasma total homocysteine in postmenopausal breast cancer patients. Clin Chem 1999; 45:252-6. [PMID: 9931048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
In this study, we evaluated the effect of estrogen suppression with three aromatase inhibitors, aminoglutethimide (n = 30), formestane (n = 12), and exemestane (n = 10), and the progestin megestrol acetate (n = 21) on plasma total homocysteine (tHcy) in patients suffering from advanced breast cancer. Treatment with 1 g/day aminoglutethimide for 2 and 3-5 months increased plasma tHcy by a mean value of 24.5% [95% confidence interval, 10.5-40.4%] at 2 months and 35.8% (95% confidence interval, 18.2-55.9%) at 3-5 months, corresponding to increases in the mean plasma tHcy of 1.90 and 3.67 micromol/L, respectively. In contrast, none of the other treatment options influenced plasma tHcy concentrations. The finding that aminoglutethimide, but none of the other aromatase inhibitors or megestrol acetate, influenced plasma tHcy suggests that this effect is achieved by mechanisms not related to suppression of plasma estrogens or to the glucocorticoids administered in concert.
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Affiliation(s)
- G B Anker
- Department of Oncology, Haukeland University Hospital, N-5021 Bergen, Norway
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31
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Abstract
Thyroid function was evaluation in 26 postmenopausal women with breast cancer before and at various time intervals during treatment with tamoxifen. Tamoxifen treatment suppressed plasma levels of FT3 and FT4 (p < 0.005 for both) and elevated plasma concentrations of TBG (p < 0.005 and TG (p < 0.025). In general, these changes became significant after 6 months of treatment. Plasma TSH increased significantly after 1 y of treatment (p < 0.025). A fall in FT4 and FT3 combined with increase in TSH suggests a reduced bioavailability of T4 and T3 during tamoxifen treatment. The increase in TG may reflect a reduced synthesis or liberation of T4 resulting in a reduced plasma level of FT4. Our findings suggest that tamoxifen influences the thyroid hormone levels, not only by modulating plasma TBG, but also by interfering with hormone synthesis or secretion in the thyroid gland.
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Affiliation(s)
- G B Anker
- Department of Oncology, Haukeland University Hospital, Bergen, Norway
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32
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Abstract
We found a higher plasma concentration of total homocysteine (tHcy), an independent risk factor for cardiovascular disease, in patients with hypothyroidism (mean, 16.3 micromol/L; 95% confidence interval [CI], 14.7 to 17.9 micromol/L) than in healthy controls (mean, 10.5 micromol/L; 95% CI, 10.1 to 10.9 micromol/L). The tHcy level of hyperthyroid patients did not differ significantly from that of the controls. Serum creatinine was higher in hypothyroid patients and lower in hyperthyroid patients than in controls, whereas serum folate was higher in hyperthyroid patients compared with the two other groups. In multivariate analysis, these differences did not explain the higher tHcy concentration in hypothyroidism. We confirmed the observation of elevated serum cholesterol in hypothyroidism, which together with the hyperhomocysteinemia may contribute to an accelerated atherogenesis in these patients.
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Affiliation(s)
- B G Nedrebø
- Department of Internal Medicine, University Hospital of Bergen, Norway
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Geisler J, Lien EA, Ekse D, Lønning PE. Influence of aminoglutethimide on plasma levels of estrone sulphate and dehydroepiandrosterone sulphate in postmenopausal breast cancer patients. J Steroid Biochem Mol Biol 1997; 63:53-8. [PMID: 9449206 DOI: 10.1016/s0960-0760(97)00071-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The aromatase inhibitor aminoglutethimide (AG) is widely used in the treatment of advanced breast cancer in postmenopausal women. Apart from the inhibition of estrogen synthesis, previous studies by our group have shown that AG selectively enhances plasma clearance of the estrogen conjugate estrone sulphate (E1S). In the present study we used a novel, highly sensitive radioimmunoassay to measure plasma E1S during treatment with AG. Treatment with AG decreased plasma levels of E1S from a mean pretreatment value of 372.4 to 50.6 pmol/l (mean suppression to 14.5% of pretreatment values) whereas plasma levels of E1 and E2 were suppressed to 40.7 and 32.8% of pretreatment values, respectively. Dehydroepiandrosterone sulphate levels decreased from a mean value of 0.8 to 0.5 micromol/l (mean suppression to 59.6% of pretreatment values), whereas the ratios of E1S/E1 and DHEAS/DHEA decreased to 30.8% (P < 0.001) and 55.5% (P < 0.005) of pretreatment values, respectively. In conclusion, we found that AG suppressed plasma levels of E1S more extensively compared to previous studies. The simultaneous suppression of the DHEAS/DHEA ratio suggests that AG may influence the disposition of steroid sulphates in general.
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Affiliation(s)
- J Geisler
- Department of Oncology, Haukeland University Hospital, Bergen, Norway
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34
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Lien EA, Anker G, Lønning PE, Refsum H, Ueland PM. Effects of hormones on the plasma levels of the atherogenic amino acid homocysteine. Biochem Soc Trans 1997; 25:33-5. [PMID: 9056838 DOI: 10.1042/bst0250033] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- E A Lien
- Department of Clinical Biology, University of Bergen, Norway
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35
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Abstract
We measured the serum levels of tamoxifen and 5 of its metabolites in serum from 7 premenopausal and 9 postmenopausal women during the first 56 days of treatment. The serum levels of N-desdimethyltamoxifen were higher in postmenopausal women compared to premenopausal women (P < 0.02). A similar trend was observed for N-desmethyltamoxifen (P = 0.06).
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Affiliation(s)
- E A Lien
- Department of Clinical Biology, Haukeland University Hospital, Bergen, Norway
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36
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Abstract
Endocrine treatment plays an important role in the therapy of breast cancer. While the basic mechanisms are understood, additional mechanisms may be of importance to their action and they may also contribute to the mechanism(s) of acquired resistance. Currently, several novel drugs are entering into clinical trials. Observations of the absence or presence of cross resistance to novel 'pure' steroidal antiestrogens and the non-steroidal tamoxifen may add important information to our understanding of the mechanisms of action of both classes of drugs. Similarly, exploration of different aromatase inhibitors in sequence or concert, as well as the combining of different endocrine treatment options may be warranted. Additionally, alterations in different biochemical parameters such as growth factors should not only be carefully explored in relation to treatment options but should also be followed during the course of treatment to asess alterations over time and in relation to the development of drug resistance.
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MESH Headings
- Adrenal Cortex/drug effects
- Adrenal Cortex/physiopathology
- Adult
- Aged
- Animals
- Antineoplastic Agents, Hormonal/classification
- Antineoplastic Agents, Hormonal/pharmacology
- Antineoplastic Agents, Hormonal/therapeutic use
- Aromatase Inhibitors
- Breast Neoplasms/drug therapy
- Breast Neoplasms/genetics
- Breast Neoplasms/physiopathology
- Breast Neoplasms/therapy
- Chemotherapy, Adjuvant
- Combined Modality Therapy
- Drug Resistance, Multiple
- Enzyme Inhibitors/pharmacology
- Enzyme Inhibitors/therapeutic use
- Estrogen Antagonists/adverse effects
- Estrogen Antagonists/pharmacology
- Estrogen Antagonists/therapeutic use
- Estrogens/blood
- Estrogens/physiology
- Female
- Gene Expression Regulation, Neoplastic/drug effects
- Gonadotropin-Releasing Hormone/agonists
- Humans
- Insulin-Like Growth Factor I/antagonists & inhibitors
- Insulin-Like Growth Factor I/physiology
- Mammary Neoplasms, Experimental/drug therapy
- Mammary Neoplasms, Experimental/physiopathology
- Menopause
- Mice
- Middle Aged
- Neoplasm Proteins/antagonists & inhibitors
- Neoplasms, Hormone-Dependent/drug therapy
- Neoplasms, Hormone-Dependent/genetics
- Neoplasms, Hormone-Dependent/physiopathology
- Neoplasms, Hormone-Dependent/therapy
- Progesterone/antagonists & inhibitors
- Progesterone/physiology
- Progestins/antagonists & inhibitors
- Progestins/pharmacology
- Progestins/therapeutic use
- Receptors, Estrogen/drug effects
- Receptors, Estrogen/physiology
- Signal Transduction/drug effects
- Steroids/metabolism
- Tamoxifen/adverse effects
- Tamoxifen/pharmacology
- Tamoxifen/therapeutic use
- Tumor Cells, Cultured/drug effects
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Affiliation(s)
- E Lønning
- Department of Oncology, Haukeland University Hospital, Bergen, Norway
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37
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Abstract
In this assay of the nonsteroidal antiestrogen droloxifene and two metabolites in human serum, the serum samples were deproteinized with an equal volume of acetonitrile and then injected into an analytical octadecylsilane column. The analytical column was equilibrated with acetonitrile/water (1/1, vol/vol) containing acetic acid and diethyl amine and eluted isocratically with 66% acetonitrile in the same buffer. Droloxifene, N-desmethyldroloxifene, and 4-methoxdroloxifene were post-column converted to fluorophors by ultraviolet illumination while passing through a 10-m transparent knitted polytetrafluorethylene reaction coil. Analytical recovery was close to 100%. Within- and between-day precision corresponded to a coefficient of variation (CV) of 2-5% at serum concentrations of > or 25 ng/ml, except for 4-methoxydroloxifene (CV 7-10% at a concentration of 25 ng/ml). By increasing the injection volume from 50 to 250 microliters, the detection limits could be decreased from approximately 5 to 1 ng/ml. Conjugated droloxifene could be estimated in a second run after treatment of sample with an enzyme preparation containing beta-glucuronidase plus sulphatase. The recovery of droloxifene glucuronide was close to 100%. Sulphate conjugates have not been identified and were not accounted for.
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Affiliation(s)
- E A Lien
- Division of Pharmacology, Bergen University Hospital, Norway
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38
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Lønning PE, Johannessen DC, Lien EA, Ekse D, Fotsis T, Adlercreutz H. Influence of tamoxifen on sex hormones, gonadotrophins and sex hormone binding globulin in postmenopausal breast cancer patients. J Steroid Biochem Mol Biol 1995; 52:491-6. [PMID: 7748814 DOI: 10.1016/0960-0760(94)00189-s] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Estrone sulphate (E1S) may be an important estrogen source in breast cancers, particularly in postmenopausal women. Recent studies have shown that tamoxifen inhibits the uptake and metabolism of E1S to estradiol (E2) in cell cultures. To evaluate a possible influence of tamoxifen on E1S disposition in vivo, we measured plasma levels of E1S together with unconjugated estrogens (E1 and E2), androgens (T, A, DHEA and DHEAS), SHBG, FSH and LH in 32 postmenopausal breast cancer patients before and during tamoxifen treatment. In a subgroup of 10 patients, we measured 24 h urinary excretion of estrogen metabolites to evaluate the influence of tamoxifen treatment on estrogen metabolism and total estrogen production. Tamoxifen increased plasma levels of E1S (mean increase of 18.1%, P < 0.05) and the ratio of E1S/E1 (mean increase of 25.7%, P < 0.01) and E1S/E2 (mean increase of 34.7%, P < 0.0005). No significant change in plasma E1 was seen, but plasma E2 was reduced (mean reduction of 12.1%, P < 0.005). The fall in plasma E2 was probably secondary to a fall in plasma T (mean reduction of 11.9%, P < 0.05) due to a reduced ovarian excretion of this androgen. The mechanisms may be a reduced gonadotrophin stimulation of the ovary, as plasma FSH and LH fell by mean values of 45.5 and 48.1%, respectively (P < 0.0001 for both). The increase in plasma E1S was accompanied by a reduced ratio of 2OHE1/E1 in urine (mean reduction of 38.2%, P < 0.025) indicating reduced 2-hydroxylation. Possible mechanisms for these alterations are discussed.
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Affiliation(s)
- P E Lønning
- Department of Oncology, Haukeland University Hospital, Bergen, Norway
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39
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Anker G, Lønning PE, Ueland PM, Refsum H, Lien EA. Plasma levels of the atherogenic amino acid homocysteine in post-menopausal women with breast cancer treated with tamoxifen. Int J Cancer 1995; 60:365-8. [PMID: 7829246 DOI: 10.1002/ijc.2910600316] [Citation(s) in RCA: 74] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Long-term treatment of breast-cancer patients with the anti-oestrogen tamoxifen has been found to be associated with reduced cardiovascular mortality. Plasma homocysteine is an independent risk factor for atherosclerotic disease, and its level is determined by folate and cobalamin status, and possibly also by oestrogen status. We measured the effect of tamoxifen on plasma homocysteine, serum cholesterol, serum cobalamin and serum and erythrocyte folate in 31 post-menopausal women with breast cancer. The plasma homocysteine level was decreased by a mean value of 29.8% after 9-12 months and by 24.5% after 13-18 months of treatment. Tamoxifen suppressed serum cholesterol by mean values varying between 7.2% and 17.6% after 3 to 19 months of treatment. There was no correlation between changes in plasma homocysteine and serum cholesterol. These findings suggest that the homocysteine-lowering effect of tamoxifen may contribute to the reduction of cardiovascular mortality observed in patients on adjuvant therapy with tamoxifen.
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Affiliation(s)
- G Anker
- Department of Oncology, University Hospital of Bergen, Norway
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40
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Lønning PE, Helle SI, Johannessen DC, Adlercreutz H, Lien EA, Tally M, Ekse D, Fotsis T, Anker GB, Hall K. Relations between sex hormones, sex hormone binding globulin, insulin-like growth factor-I and insulin-like growth factor binding protein-1 in post-menopausal breast cancer patients. Clin Endocrinol (Oxf) 1995; 42:23-30. [PMID: 7534218 DOI: 10.1111/j.1365-2265.1995.tb02594.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Oestrogens, androgens and anti-endocrine drugs such as tamoxifen and aminoglutethimide influence plasma insulin-like growth factor-I (IGF-I). IGF-I, in turn, has been found to stimulate the peripheral aromatase in vitro. The aim of this study was to examine relations between sex hormones, IGF-I and insulin-like growth factor binding protein-1 (IGFBP-1) in post-menopausal women with breast cancer. DESIGN To measure plasma sex steroids, sex hormone binding globulin (SHBG), IGF-I, IGFBP-1, insulin and urinary oestrogen metabolites in post-menopausal women with breast cancer not receiving any endocrine therapy. PATIENTS Thirty-two patients had fasting blood samples obtained between 0800 and 1000 h. A sub-group of 10 patients had 24-hour urine oestrogen metabolites determined. MEASUREMENTS Plasma steroids and proteins were measured by radioimmunoassays. Urinary oestrogens were measured by GC-MS. RESULTS SHBG correlated negatively with plasma androstenedione (P < 0.001), insulin (P < 0.001), IGF-I, height and plasma oestrone sulphate (P < 0.025 for all), but positively with plasma IGFBP-1 (P < 0.025). IGFBP-1 correlated negatively with IGF-I (P < 0.001) and the testosterone/SHBG ratio (P < 0.05). Neither IGF-I nor IGFBP-1 correlated with any of the plasma or urinary sex hormones or with the oestrone/androstenedione and oestradiol/testosterone ratios. Multivariate analysis revealed plasma SHBG to correlate positively with IGFBP-1 (P = 0.029) and negatively with insulin (P = 0.031). Plasma IGFBP-1 correlated negatively with IGF-I (P < 0.0001) but not with insulin. CONCLUSION Our results do not suggest any influence of plasma sex steroids in physiological concentrations on IGF-I or IGFBP-1 in post-menopausal breast cancer patients, nor do they indicate IGF-I at physiological concentrations influences the ratios between plasma oestrogens and their androgen precursors.
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Affiliation(s)
- P E Lønning
- Department of Oncology, Haukeland University Hospital, Bergen, Norway
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41
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Millward MJ, Lien EA, Robinson A, Cantwell BM. High-dose (480 mg/day) tamoxifen with etoposide: a study of a potential multi-drug resistance modulator. Oncology 1994; 51:79-83. [PMID: 8265108 DOI: 10.1159/000227315] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Tamoxifen and its principle metabolite N-desmethyltamoxifen can modulate multi-drug resistance in vitro. Tamoxifen 480 mg/day was given for 6 days with oral etoposide on days 4-6 to 17 patients with advanced solid tumours. Venous thrombosis (2 patients), reversible neurological toxicity (1 patient), and WHO grade III nausea/vomiting (3 patients) related to tamoxifen were observed but overall toxicity was manageable. One partial response occurred in 15 assessable patients. Mean plasma concentrations of tamoxifen and N-desmethyltamoxifen increased to 4.3 mumol/l and 2.7 mumol/l, respectively, by day 6. Plasma concentrations corresponding to active in vitro levels were attained by most patients.
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Affiliation(s)
- M J Millward
- University Department of Clinical Oncology, Newcastle General Hospital, Newcastle Upon Tyne, England
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42
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Stuart NS, Philip P, Harris AL, Tonkin K, Houlbrook S, Kirk J, Lien EA, Carmichael J. High-dose tamoxifen as an enhancer of etoposide cytotoxicity. Clinical effects and in vitro assessment in p-glycoprotein expressing cell lines. Br J Cancer 1992; 66:833-9. [PMID: 1358168 PMCID: PMC1977984 DOI: 10.1038/bjc.1992.369] [Citation(s) in RCA: 51] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Twenty-six patients with relapsed or drug-resistant cancer were treated with a combination of oral etoposide (300 mg day-1 for 3 days) and high-dose oral tamoxifen as a potential modulator of drug resistance (480 or 720 mg day-1 for 6 days beginning 3 days before etoposide). One patient with relapsed high-grade lymphoma and one with adenocarcinoma of unknown primary site has a partial response. Toxicity consisting of nausea, vomiting and subjective dizziness, unsteadiness of gait and malaise occurred during tamoxifen treatment. Serum levels of tamoxifen averaged 3-3.5 microM on day 4 of all courses of treatment at both 480 and 720 mg day-1. N-desmethyltamoxifen levels were lower than tamoxifen during the first course (2 microM) but increased to equal tamoxifen levels during the second course. Didesmethyltamoxifen levels remained below 1 microM. In vitro, both tamoxifen and the standard modulator of multidrug resistance, verapamil, produced minor enhancement of etoposide cytotoxicity in the MCF-7 wt cell line but produced no enhancement with any other cell line. High, intermittent doses of tamoxifen can be given with acceptable toxicity and produce serum levels that have been shown to modulate drug resistance in vitro. In vitro, however, such levels have no significant effect on etoposide cytotoxicity towards a range of wild-type and MDR cell lines.
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Affiliation(s)
- N S Stuart
- ICRF Clinical Oncology Unit, Churchill Hospital, Oxford
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43
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Lønning PE, Hall K, Aakvaag A, Lien EA. Influence of tamoxifen on plasma levels of insulin-like growth factor I and insulin-like growth factor binding protein I in breast cancer patients. Cancer Res 1992; 52:4719-23. [PMID: 1380889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Plasma levels of insulin-like growth factor I (IGF-I) and insulin-like growth factor binding protein I (IGFBP-I) were measured in fasting blood samples obtained from 16 postmenopausal breast cancer patients before and during tamoxifen treatment for 1 to 6 months. Tamoxifen suppressed total plasma IGF-I by a mean of 28.5% (P less than 0.001) but elevated plasma IGFBP-I by a mean value of 78% (P less than 0.001). Changes in plasma levels of growth hormone, insulin, or insulin C-peptide were not observed. These findings suggest that tamoxifen exerts its influence on plasma IGF-I and IGFBP-I by mechanisms other than those known to regulate the plasma levels of these peptides, primarily growth hormone and insulin, respectively. A dual effect suppressing plasma IGF-I and elevating plasma IGFBP-I suggests that tamoxifen may have a significant influence on endocrine and possibly paracrine delivery of IGF-I to breast cancer cells in vivo.
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Affiliation(s)
- P E Lønning
- Department of Oncology, Haukeland University Hospital, Bergen, Norway
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44
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Abstract
Endocrine therapy is important in the treatment of advanced breast cancer. The prototype antiestrogen tamoxifen and the prototype aromatase inhibitor aminoglutethimide have been in clinical use for more than 2 decades, as have synthetic progestin derivatives. Currently, several novel antiestrogens and aromatase inhibitors are used to treat breast cancer. This paper reviews the present knowledge of the clinical pharmacokinetics of these drugs. Drug monitoring in plasma and other body fluids has been improved over recent years by the introduction of sensitive and specific high performance liquid chromatography and gas chromatography-mass spectrometry methods. However, we still lack information on such basic pharmacokinetic parameters as the bioavailability of several of these drugs. It is important to study not only plasma but also tissue drug concentrations.
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Affiliation(s)
- P E Lønning
- Department of Oncology, Haukeland University Hospital, Bergen, Norway
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45
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Abstract
In vitro tamoxifen reverses multidrug resistance (MDR). To evaluate the clinical potential of using tamoxifen in this way, intermittent high-dose tamoxifen was combined with oral etoposide in 86 patients. At 320 mg/day tamoxifen for 6 days, mean plasma levels of tamoxifen in 11 patients increased from 453 ng/ml (range 269-664) on day 2 to 984 ng/ml (578-1336) on day 6. Of 31 patients who had plasma tamoxifen measured during the time of etoposide administration (days 4-6), 13(43%) were over 1111 ng/ml (3 mumol/l), an active in vitro level. Potentially active levels of the principal metabolite, N-desmethyl tamoxifen, were also obtained but accumulation was slower. Emesis and thromboembolism were toxicities. Tamoxifen is a modifier of MDR, a role that warrants further clinical studies.
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Affiliation(s)
- M J Millward
- University Department of Clinical Oncology, Newcastle General Hospital, Newcastle Upon Tyne, U.K
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46
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Lien EA, Johannessen DC, Aakvaag A, Lønning PE. Influence of tamoxifen, aminoglutethimide and goserelin on human plasma IGF-I levels in breast cancer patients. J Steroid Biochem Mol Biol 1992; 41:541-3. [PMID: 1532904 DOI: 10.1016/0960-0760(92)90380-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Plasma insulin-like growth factor-I (IGF-I) was measured in breast cancer patients before and during treatment with tamoxifen, goserelin or aminoglutethimide. 24 out of 27 postmenopausal women treated with tamoxifen 20 or 30 mg daily experienced a decrease in plasma IGF-I levels (mean levels before treatment 14.8 nM, during treatment 10.2 nM, P less than 0.001). In 8 out of 12 premenopausal breast cancer patients there was a reduction in plasma IGF-I during treatment with goserelin (mean levels before treatment 23.3 nM, during treatment 19.4 nM, P = 0.052). Contrary, 15 out of 17 postmenopausal women treated with the aromatase inhibitor aminoglutethimide had an increase in plasma IGF-I level (mean level before treatment 17.0 nM, during treatment 21.1 nM, P less than 0.01). These preliminary results indicate that different forms of endocrine treatment of breast cancer may influence plasma IGF-I levels in different directions.
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Affiliation(s)
- E A Lien
- Medical Department, Haukeland University Hospital, Bergen, Norway
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47
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Lien EA, Solheim E, Ueland PM. Distribution of tamoxifen and its metabolites in rat and human tissues during steady-state treatment. Cancer Res 1991; 51:4837-44. [PMID: 1893376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
A procedure for the extraction of tamoxifen and metabolites from various rat and human tissues was developed and verified. With this method, we determined the drug and metabolite concentrations during one dosing interval in various tissues (brain, fat, liver, heart, lung, kidney, uterus, and testes) of rats given tamoxifen once daily for 3 or 14 days, and in various normal and malignant tissues obtained during surgery or at autopsy from patients with breast cancer treated with tamoxifen. In the rat, the concentrations of tamoxifen and metabolites in most tissues were 8- to 70-fold higher than in serum. The highest levels were observed in lung and liver; substantial amounts were also recovered from kidney and fat. Fluctuations of metabolites and tamoxifen content in most tissues were observed during one dosing interval, corresponding to a ratio of 4:8 between Cmax and Cmin, except in fat and testicular tissues, where the drug concentrations were relatively stable. In addition to tamoxifen, N-desmethyltamoxifen, followed by 4-hydroxytamoxifen, 4-hydroxy-N-desmethyltamoxifen, and N-desdimethyltamoxifen, were abundant in most tissues. In contrast, adipose tissue contained only small amounts of these metabolites. The concentrations of tamoxifen and metabolites found in human normal and malignant tissues confirmed and extended the conclusions made in the experiments with rats. In humans, levels were 10- to 60-fold higher in tissues than in serum, and relatively high concentrations were detected in liver and lung. Additionally, pancreas, pancreatic tumor, and brain metastases from breast cancer and primary breast cancer retained large amounts of drug. Again, the amounts of demethylated and hydroxylated metabolites were high in most tissues, except in fat. Tamoxifen and some metabolites were also present in specimens of skin and bone tissue. In one patient, significant amounts of drugs could be detected in lung, heart, ovary, and intestinal wall 14 months after withdrawal of tamoxifen, demonstrating efficient retention and slow washout of these compounds in human tissue.
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Affiliation(s)
- E A Lien
- Department of Pharmacology and Toxicology, University of Bergen, Norway
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48
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Lien EA, Wester K, Lønning PE, Solheim E, Ueland PM. Distribution of tamoxifen and metabolites into brain tissue and brain metastases in breast cancer patients. Br J Cancer 1991; 63:641-5. [PMID: 2021551 PMCID: PMC1972343 DOI: 10.1038/bjc.1991.147] [Citation(s) in RCA: 125] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
We determined the amount of tamoxifen, N-desmethyltamoxifen (metabolite X), N-desdimethyltamoxifen (metabolite Z), and hydroxylated metabolites (Y, B, BX) in brain metastases from breast cancer and in the surrounding brain tissues. Specimens were collected from the breast cancer patients who received tamoxifen for 7-180 days and with the last dose taken within 28 h before surgical removal of the tumour. The concentrations of tamoxifen and its metabolites were up to 46-fold higher in the brain metastatic tumour and brain tissue than in serum. Metabolite X was the most abundant species followed by tamoxifen and metabolite Z. Small but significant amounts of the hydroxylated metabolites, trans-1(4-beta-hydroxyethoxyphenyl)-1,2-diphenylbut-1-ene (metabolite Y), 4-hydroxytamoxifen (metabolite B) and 4-hydroxy-N-desmethyltamoxifen (metabolite BX) were detected in most specimens. The ratios between the concentrations of tamoxifen and various metabolites were similar in tumour, brain and serum. This is the first report on the distribution of tamoxifen and metabolites into human brain and brain tumour, and the data form a basis for further investigation into the therapeutic effects of tamoxifen on brain metastases from breast cancer.
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Affiliation(s)
- E A Lien
- Department of Pharmacology and Toxicology, University of Bergen, Norway
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49
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Lien EA, Anker G, Lønning PE, Solheim E, Ueland PM. Decreased serum concentrations of tamoxifen and its metabolites induced by aminoglutethimide. Cancer Res 1990; 50:5851-7. [PMID: 2393854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The antiestrogen tamoxifen and the aromatase inhibitor aminoglutethimide show similar response rates when used in the endocrine management of advanced breast cancer. However, numerous clinical trials have demonstrated no increase in response rate from treatment with the drug combination of tamoxifen plus aminoglutethimide. We investigated the possibility of a pharmacokinetic interaction between these two drugs in six menopausal woman with breast cancer. All patients were investigated under three different conditions (termed phases A, B, and C). The steady state kinetics of tamoxifen were determined when administered alone (phase A) and after coadministration of aminoglutethimide for 6 weeks (phase B). In phase B, the pharmacokinetics for aminoglutethimide were determined and compared with these parameters after a tamoxifen washout of 6 weeks (phase C). The serum concentration of tamoxifen and most of its metabolites ([trans-1(4-beta-hydroxy-ethoxyphenyl)-1,2-diphenylbut-1-ene], 4-hydroxytamoxifen, 4-hydroxy-N-desmethyltamoxifen, N-desmethyltamoxifen, and N-desdimethyltamoxifen) were markedly reduced following aminoglutethimide administration, corresponding to an increase in tamoxifen clearance from 189-608 ml/min. The amount of most metabolites in serum increased relative to the amount of parent tamoxifen. These data are consistent with induction of tamoxifen metabolism during aminoglutethimide exposure. We found no effect of tamoxifen on aminoglutethimide pharmacokinetics or acetylation. We conclude that this aminoglutethimide-tamoxifen interaction should be taken into account when evaluating the clinical effect of this drug combination relative to monotherapy.
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Affiliation(s)
- E A Lien
- Department of Pharmacology and Toxicology, University of Bergen, Norway
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50
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Lien EA, Graue M, Iversen TH, Nordrehaug JE. [Prognosis of diabetes mellitus type 1. A follow-up study]. Tidsskr Nor Laegeforen 1989; 109:1145-9. [PMID: 2734738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
A follow-up of 92 patients with diabetes mellitus, who were hospitalized at the Department of Pediatrics, University of Bergen, during the years 1950-63, was conducted in June 1986. The mean age of the 76 living patients was 38 years, and the mean duration of diabetes 30 years. Sixteen patients had died. According to the death certificates the causes of death were as follows: Myocardial infarction, uremia, pneumonia, diabetes not further specified, suicide, sudden death not further specified, ketoacidosis, accident to the head, and convulsions (epilepsy). The 39 patients living in the county of Hordaland (including Bergen) were invited to a clinical examination. Twenty-nine patients (mean age 37 years, mean duration of diabetes 29 years) accepted. In eleven, the disease had influenced the choice of occupation. Twelve experienced professional difficulties due to diabetes, and thirteen had major complaints due to the disease. Three used antianginal drugs, and a further three were receiving antihypertensive treatment. Four women had hypothyreosis. Twelve had proteinuria or pathologic microalbuminuria. Only two of 27 patients examined by means of fluorescein-angiography showed no retinopathy. Evidence of cardiovascular autonomic neuropathy was observed in ten patients. Since only three patients had used fast-acting insulin regularly during the last ten years, it should be possible to give patients with type 1 diabetes better treatment in the future.
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