Does ifosfamide affect gonadal function?

BACKGROUND: Gonadal dysfunction and infertility are potential late effects of cancer therapy. Ifosfamide, an alkylating agent structurally related to cyclophosphamide, is thought to cause gonadal dysfunction, though there is little published evidence. PROCEDURE: Patients treated on sarcoma protocols containing ifosfamide as the only potential gonadotoxic agent, were evaluated, assessing pubertal development, menstrual history in the females and semen analysis in males. Biochemical evaluation included measurement of gonadotrophins, inhibin B and anti-mullerian hormone (AMH). RESULTS: All 32 males progressed normally through puberty. No gonadal dysfunction was seen at a total ifosfamide dose of <60 g/m(2). In those with a dose >60 g/m(2), two-thirds of those who underwent semen analysis were subfertile, 31% had elevated FSH and 50% showed decreased inhibin B supporting evidence of germ cell failure. All 13 females progressed through puberty normally and had regular menses. Biochemical results were in line with published data except for AMH levels, which were lower compared with an age-matched reference group. Nine patients not recruited into the study were known to have had 11 live births. CONCLUSIONS: Males appear more susceptible than females to ifosfamide gonadotoxicity. There may be a dose in males below which the risk of subfertility is low. In females there is preliminary evidence of reduction in ovarian reserve as measured by AMH levels, which may potentially lead to an early menopause and a reduction in the window of fertility.

Incidental radiological diagnosis of rickets.

Rickets fortunately remains rare in the United Kingdom, although its actual incidence is currently undetermined.1 Many still consider it to be a disease of poverty prevalent during the Victorian era. However, a number of recent articles have highlighted concern among British health professionals about the number of cases still being diagnosed in this country. These cases have nearly all involved non-Caucasian children who are considered to be at high risk due to skin colour, prolonged breast feeding, and low maternal vitamin D levels. Their presentations are variable ranging from failure to thrive, bone deformities, seizures, and even stridor. The diagnosis is usually made in babies and toddlers.We present a series of patients attending our accident and emergency (A&E) department, over a five month period, where the diagnosis of rickets was primarily a radiological diagnosis.

Nocturnal secretory dynamics of inhibin B and testosterone in pre- and peripubertal boys.

To investigate the secretory dynamics of testosterone and inhibin B, we collected samples every 20 min from 2000 h to 0800 h in 20 boys. Boys in group 1 (n = 5) were aged less than 8 yr, group 2 (n = 5) were aged more than 8 yr but 1.5 yr or more before pubertal onset, group 3 (n = 5) were studied 1.0 yr or less before pubertal onset, and group 4 (n = 5) were in early puberty. Testosterone increased after midnight in peripubertal boys, coinciding with the onset of LH pulsatility, and showed a pulsatile pattern in 6 of 10 of these boys. Cross-correlation analysis indicated significant temporal coupling between LH and testosterone. Inhibin B was higher in groups 3 and 4, compared with groups 1 and 2 (P < 0.01) and showed a downward trend overnight with no evidence of pulsatility and no evidence of short-term interactions with LH, FSH, or testosterone. Inhibin B and LH nocturnal means were both inversely correlated with time before pubertal onset (r(s) > or = -0.85, P < 0.01). Only LH nocturnal mean and amplitude, respectively, contributed independently to prediction of testosterone and inhibin B nocturnal means, explaining 71 and 65% of their variability. We conclude that both testosterone and inhibin B are related to nocturnal LH release in peripubertal boys but over different time scales.

Effects of intensive chemotherapy on bone and collagen turnover and the growth hormone axis in children with acute lymphoblastic leukemia.

To investigate the effects of disease and intensive chemotherapy on bone turnover and growth in children with acute lymphoblastic leukemia (ALL), a longitudinal prospective study was carried out in 22 children, aged 1.2-13.5 yr, enrolled in the Medical Research Council-funded randomized trial of childhood ALL treatment in the UK. We measured lower leg length and markers of bone formation [bone alkaline phosphatase (ALP) and procollagen type I C-terminal propeptide (PICP)], bone resorption [pyridinoline, deoxypyridinoline, and carboxyl-terminal telopeptide of type I collagen (ICTP)], soft tissue turnover [procollagen type III N-terminal propeptide (P3NP)], and the GH axis [IGF-I, IGF-binding protein-3 (IGFBP-3), IGFBP-2, and urinary GH] at 1- to 4-week intervals from diagnosis to week 27 of treatment. In addition, GH-binding protein was measured at diagnosis. At diagnosis, mean SD scores were: bone ALP, -1.84; PICP -1.77; pyridinoline, -1.42; deoxypyridinoline, -1.66; ICTP, -0.42; P3NP, +1.45; GH, +24.4; IGF-I, -1.70; IGFBP-3, -0.88; IGFBP-2, +2.42; and GH-binding protein, -0.69. Bone ALP, PICP, and IGFBP-3 were all correlated (P < or = 0.03). During induction and intensification, there was shrinkage of the lower leg, with decreases in PICP, pyridinoline, ICTP, and P3NP (P < 0.05), whereas IGF-I and IGFBP-3 increased (P < 0.05). After prednisolone was discontinued, bone ALP and collagen markers increased markedly (P < 0.01), but there was no significant change in IGF-I and IGFBP-3. In 12 children who received high dose i.v. methotrexate, postglucocorticoid increases in bone ALP and PICP were less, whereas those in ICTP and P3NP were greater, compared to levels in children who did not receive methotrexate (P < 0.05). We conclude that ALL itself caused GH resistance and low bone turnover. During early intensive chemotherapy, further suppression of osteoblast proliferation and osteoclast activity occurred, not mediated through the systemic GH axis, probably by the direct action of prednisolone on bone. The postglucocorticoid increase in bone turnover was also independent of the GH axis and was modulated by high dose i.v. methotrexate, which depressed osteoblast recovery and enhanced osteoclast activity.

Effects of a third intensification block of chemotherapy on bone and collagen turnover, insulin-like growth factor I, its binding proteins and short-term growth in children with acute lymphoblastic leukaemia.

Children with acute lymphoblastic leukaemia (ALL) have reduced bone turnover caused by the disease itself and early intensive chemotherapy, but the effects of later chemotherapy using different drug combinations are uncertain. We report here a longitudinal study on 9 children with ALL randomised to receive an additional third intensification block of chemotherapy, compared with 9 children receiving continuing chemotherapy over the same period. During third intensification, bone alkaline phosphatase, procollagen type I C-terminal propeptide, the carboxyterminal propeptide of type I collagen, procollagen type III N-terminal propeptide and lower leg length all decreased in response to dexamethasone, then returned to (but not beyond) baseline levels after dexamethasone was stopped and other drugs started. These changes were unrelated to circulating insulin-like growth factor (IGF)-I, IGF binding protein (IGFBP)-3 or IGFBP-2. In all children, bone alkaline phosphatase remained below the population mean throughout. We conclude that dexamethasone decreased bone and soft tissue turnover, probably through direct effects on target tissues. The postdexamethasone phase of third intensification and continuing chemotherapy had no major deleterious effect on collagen turnover, but there was evidence of continuing suboptimal bone mineralisation.

Site of alkaline phosphatase attachment in alkaline phosphatase-immunoglobulin G complexes.

Sera containing the rare alkaline phosphatase-immunoglobulin G complex were studied to try to determine the type of interaction involved. Pepsin and papain digestion of immunoglobulin G showed that alkaline phosphatase was attached to the F(ab')2 region of the immunoglobulin molecule and not to the Fc region. Sialic acid did not play a role in this attachment. Attempts to generate the complex in vitro using polyclonal immunoglobulin, and attempts to dissociate the complex is an immune complex in vitro, were both unsuccessful. It is concluded that the complex is an immune complex formed by antibody-antigen reaction in the circulation, and consists of two molecules of monovalent alkaline phosphatase associated with one molecule of divalent immunoglobulin G.

An ion-exchange assay for high molecular weight alkaline phosphatase.

An ion-exchange method for the measurement of a high molecular weight form of alkaline phosphatase in serum is described. The method is simple, rapid, precise and suitable for processing small batches of samples. Other forms of alkaline phosphatase commonly encountered in serum do not interfere. The correlation between results obtained by this method and those obtained by Sephadex 6B chromatography is discussed. Electrophoretic methods of measurement were also investigated but were found to be both imprecise and inaccurate.

Alkaline phosphatase from human thyroid.

Alkaline phosphatase activity was found in human thyroid homogenate at a specific activity of about 0.01 units/mg protein. The enzyme responsible appears to be a membrane-bound sialoglycoprotein. The properties of thyroid membrane alkaline phosphatase were examined after extraction with non-ionic detergent or butanol. It was detected mainly as a single electrophoretic form with a mobility similar to that of the liver form of the enzyme. It was readily inhibited by homoarginine, but not by phenylalanine. It reacted in Ouchterlony double diffusion with antiserum raised against liver alkaline phosphatase, but not with antiserum to placental alkaline phosphatase. Heat treatment at 56 degree C for 10 min at pH 7.5 resulted in an approx. 50% loss of enzyme activity. Its relative molecular mass was estimated to be 320000 by gel filtration, and 300000 by gradient gel electrophoresis. It required magnesium for full activity, and had a pH optimum of 10.5 in Tris-borate buffers. It was concluded that thyroid alkaline phosphatase belongs to the liver/bone/kidney isoenzyme group, but may exist in a molecular form distinct from others previously described.

Regan variant alkaline phosphatase in gastrointestinal carcinoma.

A fast-moving alkaline phosphatase band on polyacrylamide gel electrophoresis has been found in 6 patients with carcinoma of the liver and gastrointestinal tract. This isoenzyme resembled the placental isoenzyme in its inhibition by L-phenylalanine, its resistance to L-homoarginine inhibition and its molecular weight. However, it differed from the placental and Regan isoenzymes in its sensitivity to L-leucine and ethylenediaminetetra-acetic acid, its lower retardation by neuraminidase, its electrophoretic mobility and its decreased heat stability. The latter two properties also distinguished it from the Nagao isoenzyme. It was identified as the Regan Variant. The Regan Variant has hitherto been reported largely in hepatocellular carcinoma. In the presented paper we report its appearance in the sera of patients who have neoplasms in a variety of primary sites in the gastrointestinal tract. It is emphasized that, while the presence of the Regan Variant in serum may be taken as evidence of carcinoma, no conclusions can be drawn as to the site of the disease.

The properties and clinical significance of some electrophoretically slow forms of alkaline phosphatase.

Sera from 8 patients with a marked slow-moving alkaline phosphatase band on electrophoresis were investigated. Inhibitor studies and treatment with neuraminidase showed that all the patients had slow bands with alkaline phosphatase properties resembling those of the liver or bone isoenzyme. In no case did the slow band resemble the intestinal isoenzyme. Immunoelectrophoretic and molecular weight studies indicated that the slow band consisted of an IgG-alkaline phosphatase complex of molecular weight 540 000. Serum from a patient with the slow band was able to bind liver or bone, but not intestinal, alkaline phosphatase from other patients to form the slow band. Serum from patients with the slow band probably contains an abnormal IgG molecule which can bind alkaline phosphatase in the ratio 2:1. No clinical condition was common to all 8 patients although most of them had either intestinal or lung disease.

Complexes in serum between alkaline phosphatase and immunoglobulin G: immunological and clinical aspects.

A retrospective study was performed on 31 patients in whose sera an immune complex between alkaline phosphatase and immunoglobulin G had been detected. The average age of these patients was 64 years and the sexes were equally represented. Twenty-three patients (74%) had a disease with either an autoimmune aetiology or associated with circulating immune complexes or autoantibodies. Sera from 16 patients were tested for the presence of circulating immune complexes in addition to the alkaline phosphatase immune complex, and these complexes were detected in 14 cases (88%). Sera from 17 patients were tested for the presence of specific autoantibodies and these were detected in 9 cases (53%). Twelve patients were followed up for a mean period of 11.6 months (range 0.5 to 39 month). At the end of the follow-up period, 10 patients (83%) showed persistence of the immunoglobulin-G-alkaline phosphatase complex.

High molecular weight alkaline phosphatase: a clinical study.

High molecular weight alkaline phosphatase activities have been measured in the sera of 72 patients with a variety of forms of liver disease, 14 patients with bone disease and 8 healthy volunteers. These measurements have been compared with measurements of other indices of hepatic function in order to establish the place of this enzyme in the diagnosis of liver disease. High molecular weight alkaline phosphatase proved to be a sensitive and specific tests for detecting liver disease, particularly obstructive liver disease. It was better than all the other liver function tests in distinguishing liver metastases from other hepatobiliary diseases. It may therefore prove especially useful in the early detection of liver metastases.

Short-term changes in lower leg length in children treated for acute lymphoblastic leukaemia.

The lower leg length velocity (LLLV) of 14 children with a median age of 4.5 yr who were undergoing chemotherapy (CT) for acute lymphoblastic leukaemia (ALL) was studied for a median duration of 56 weeks (range 14-112). Nine children were studied over the first 6 months, six over the first year, four over the full 2-year course and nine children over the 3 months before and after the end of CT. Over the first month of CT, during induction, median LLLV was 0 mm/wk (P5, P95: -1.6, 0.11); during the fourth month of CT, at the end of CNS-directed therapy, there was a significant rise to 0.38 mm/wk (P5, P95: -0.04, 0.81; p = 0.01, WSR). In the children measured following the end of CT, median LLLV rose from 0.46 mm/wk (P5, P95: -0.02, 0.79) in month 23 to 0.84 mm/wk (P5, P95: 0.72, 1.12) (p = 0.03). There was a positive relationship between neutrophil count and LLLV during continuation chemotherapy (r = 0.4, p = 0.0002); median LLLV was 0.2 mm/ wk (P5, P95: -0.15, 0.5) when the neutrophil count was less than 1 x 10(9)/l and 0.65 mm/wk (P5, P95: 0.1, 1.0) (p = 0.01) when the count was above 1 x 10(9)/l. No significant differences in LLLV were observed between children randomised to different UKALLXI regimens. Intensive chemotherapy for ALL adversely affects lower leg growth. Growth was subnormal during the first few weeks of chemotherapy, but was comparable to healthy children during CNS directed and continuation therapy. There was a significant relationship between growth velocity and neutrophil count during continuation chemotherapy. On discontinuation of chemotherapy there was a further acceleration in lower leg length velocity to supranormal levels ("catch-up" growth).

Macroorchidism in two unrelated prepubertal boys with a normal FSH receptor.

BACKGROUND: Macroorchidism in prepuberty is an uncommon condition which we hypothesised might reflect constitutive activation of the FSH receptor (FSHR). PATIENTS AND METHODS: Patient 1 was found to have macroorchidism (15 ml testicular volume) at the time of orchidopexy when 3.7 years of age. A gonadal biopsy was obtained at the time of surgery. Patient 2 developed macroorchidism (5 ml) when 8.8 years old. Despite a testicular volume >4 ml, morning testosterone levels were unrecordable with no measurable gonadotrophin production in either patient. Patient 2 had prepubertal gonadotrophin levels 3 years later despite a testicular volume that was 8 ml bilaterally. Inhibin B was measured and the FSHR sequenced in both patients. RESULTS: Inhibin B levels were age and pubertal stage appropriate. Gonadal biopsy (patient 1) demonstrated areas of Sertoli cell hyperplasia. Sequence analysis of all 10 exons of the FSHR was normal. There was significant, presumed gonadotrophin-dependent testosterone production in both boys by 15 years of age. CONCLUSIONS: The cause of prepubertal macroorchidism in our patients is unclear but the pronounced difference in phenotype suggests that there may be more than one underlying mechanism. This mechanism was not constitutive activation of a mutated FSHR.

Properties of alkaline phosphatase isoenzymes in plasma of preterm and term neonates.

The isoenzymes of alkaline phosphatase (EC 3.1.3.1) in plasma of 37 preterm and 21 term neonates two weeks postpartum have been studied with regard to electrophoretic mobility, sialic acid content, inhibition properties, heat lability, molecular mass, and binding to lectins. Term infants generally had a single form of alkaline phosphatase present in significant amounts, identified by the above criteria as originating in bone. All the preterm neonates had two alkaline phosphatase isoenzymes in plasma, namely, bone- and fetal-type intestinal alkaline phosphatase. Liver-, placental-, and adult-type intestinal alkaline phosphatase were not detected in any of the plasma samples.

What is the cause of benign transient hyperphosphatasemia? A study of 35 cases.

In a study of 35 children with benign transient hyperphosphatasemia, I found a marked seasonal clustering of cases after the summer months. Furthermore, plasma 25-hydroxyvitamin D concentrations were almost twice those of controls matched for age and time of year. Many children had evidence of weight loss and one had idiopathic hypercalcemia of infancy. Activities both of liver and bone isoenzymes of alkaline phosphatase (EC 3.1.3.1) in plasma were increased. The liver and (to a lesser extent) bone isoenzymes had enhanced electrophoretic mobility, and both showed increased binding to wheat-germ lectin by affinity electrophoresis. For the liver (and probably also the bone) isoenzyme, these changes were due to an increased content of sialic acid. A possible etiology for the condition is proposed involving (a) increased synthesis of alkaline phosphatase, mediated by vitamin D metabolites, and (b) decreased hepatic clearance caused by the high sialic acid content and exacerbated in some cases by the effects of some drugs on the liver.

Wheat-germ lectin affinity electrophoresis for alkaline phosphatase isoforms in children: age-dependent reference ranges and changes in liver and bone disease.

This modified lectin affinity electrophoresis method is suitable for simultaneous measurement of liver, bone, and high-molecular-mass (high-Mr) isoforms of alkaline phosphatase (ALP; EC 3.1.3.1) in children. Age-related isoform reference ranges were derived for 247 children, ages 0-13 years. Liver ALP did not appear in plasma until after six months of age, and remained constant after one year of age. Bone ALP was highest in the youngest age group, and declined to relatively constant activities thereafter. High-MrALP was not detected in normal children. In bone disease, the bone isoform was increased in all age groups. In liver disease, only 5 of 30 infants younger than six months had detectable liver ALP, although half had increased bone ALP. Among children older than six months, 5 patients with biliary atresia and 15 patients with hepatitis A all had increased liver isoform activity. Liver ALP was also a sensitive index of early hepatobiliary complications in 27 nonjaundiced children with cystic fibrosis. Measurement of ALP isoforms therefore yields useful clinical information in children older than six months but is of doubtful value in younger infants.