Monitoring different stages of breast cancer using tumour markers CA 15-3, CEA and TPA.

The ability of the tumour markers Cancer Antigen 15-3 (CA 15-3), Carcinoembryonic Antigen (CEA), and Tissue Polypeptide Antigen (TPA) to signal progression in breast cancer patients was investigated in this study. Marker interpretation considered the analytical variation, intra-individual biological variation, and the rate of increase. Patient cohorts were as follows: (A) 90 stage II breast cancer patients who were monitored postoperatively, (B) 204 recurrent breast cancer patients who were monitored during first-line chemotherapy, and (C) 112 patients who were monitored during the time period after first-line chemotherapy. The sensitivity for progression was 44% (cohort A), 69% (cohort B), and 68% (cohort C) without any false progression signals. Marker lead-times exceeded 3 months in 20% (cohort A) and 27% (cohort C) of patients. Marker lead-times were 1-6 months among 33% of the patients receiving first-line chemotherapy (cohort B). Trials are necessary to determine whether tumour marker-guided therapy has any prognostic impact. The data suggest that tumour marker information may be used to stop ineffective treatments and reduce unnecessary adverse effects.

Carbohydrate antigen 549 in metastatic breast cancer during cytostatic treatment and follow-up.

This study was designed to investigate whether the serum tumour marker CA 549 gave early and reliable information about disease activity among metastatic breast cancer patients during cytostatic treatment and follow-up. 50 females with metastatic breast cancer were monitored clinically and with the tumour marker CA 549. Response evaluation was based upon clinical (World Health Organization) and elaborated CA 549 criteria, respectively. In 113 blindly and matched evaluations, concordance appeared in 73/113 and discordance in 40/113 evaluations. In 27, discordance concerned degree of response, in 2 clinical progression followed marker progression after the end of the study, and in 11 progressive disease was established by clinical investigation alone. CA 549 response excluded clinical progression in bone or viscera and reversed. Clinical progression within 2 months in viscera and bone was predicted among 91% by marker progression. Clinical progression was excluded among 93% without marker progression. In conclusion, monitoring of metastatic breast cancer patients could include CA 549 if standardised criteria for marker evaluation are used.

Carcino-embryonic antigen in monitoring the growth of human colon adenocarcinoma tumour cells SK-CO-1 and HT-29 in vitro and in nude mice.

A set of experimental model systems were designed to investigate (a) the inter-relationship between growth of two human cancer cell lines (SK-CO-1, HT-29) and carcino-embryonic antigen (CEA) kinetics; and (b) whether neoplastic growth or CEA concentration is modulated by human growth hormone (hGH). We found that increasing CEA concentration depended on tumour burden. SK-CO-1 cells had the lowest growth rates but the highest rates of CEA production. The rate of CEA increase exceeded the growth rate of both SK-CO-1 and HT-29. hGH modulated neither neoplastic growth nor CEA production. In conclusion, our results suggest that experimental models may be useful for investigating the role of serological markers as monitors of increasing tumour burden. It will be of interest to investigate the performance of those model systems in examining the effect of cytotoxic agents in neoplastic growth.

Abnormal prolactin levels and pituitary-gonadal axis in the puerperium.

To investigate the influence of breast-feeding and prolactin secretion on the pituitary-gonadal function, 3 different groups of patients were studied during the first 8 weeks of the puerperium. Group A comprised patients with hyperprolactinemia and secondary amenorrhea who conceived while on a regimen of bromocriptine. Group B was composed of normal lactating women. Group C comprised nonlactating women treated with bromocriptine. Group A patients had a normal decline in serum prolactin levels during the early postpartum period, but serum prolactin remained completely unaltered after clearance of placental estradiol. In group B suckling increased serum prolactin and suppressed luteinizing hormone. This pattern was not seen in group A. Group C patients had a rapid postpartum normalization of the pituitary-gonadal axis. The results indicate that in relation to lactation the pituitary function is rather autonomous in hyperprolactinemic patients.

Elevated maternal serum alpha-fetoprotein caused by midtrimester amniocentesis: a prognostic factor.

In a prospective investigation, 247 patients underwent ultrasonically guided midtrimester amniocentesis. Maternal serum alpha-fetoprotein (AFP) was measured before and after the procedure. In 229 patients, preamniocentesis AFP exceeded 19 micrograms/liter. Forty-eight (21.0%) of these displayed a significant elevation of AFP induced by the procedure, indicating fetal-maternal bleeding. This event was correlated with anterior placental location (P less than .025) and was followed by a significantly reduced mean fetal birth weight (3143 versus 3385 g, P less than .05). In addition, a nonsignificant (.10 less than P less than .20) doubling of the risk of giving birth to a child small for gestational age was observed. These findings suggest that amniocentesis represents a potential hazard to the fetus. The implications in relation to the widening indications for amniocentesis are discussed.

Comparison of urinary human follicle-stimulating hormone and human menopausal gonadotropin for ovarian stimulation in polycystic ovarian syndrome.

A randomized, double-blind, crossover study was carried out to compare purified urinary follicle-stimulating hormone (FSH) and human menopausal gonadotropin (hMG) for ovarian stimulation in polycystic ovarian syndrome (PCOS). Twelve patients were stimulated with FSH and hMG in three alternate cycles. FSH, luteinizing hormone (LH), estradiol, dihydroepiandrosterone sulphate, free and total testosterone, delta 5-androstenedione, sex hormone binding globulin, and ovarian volume were monitored during the stimulation. There was no difference between the dose of FSH and hMG necessary to induce preovulatory follicles in the individual patients. The mean increase of ovarian volume during stimulation with FSH and hMG was 120% and 129% respectively (no significant difference). Two patients became pregnant in the first cycle. Two other patients had delayed bleeding and positive serum-human chorionic gonadotropin. No significant difference was found in the endocrine changes during the two different stimulation methods. The LH/FSH ratio was normalized after a few days of treatment regardless of the type of stimulation. The size of the material does not permit a comparison of the efficacy of the two treatment schedules. Our clinical and ultrasonic observations do not support the theory that treatment of infertility in PCOS with FSH is more safe than with hMG.

Serial measurements of serum human placental lactogen (hPL) and serial ultrasound examinations in the evaluation of fetal growth.

Serial serum hPL measurements and serial ultrasound fetometry were compared in the evaluation of fetal growth by relating these two parameters to size at birth and to clinical factors known to influence size at birth. The data were from a prospective study of 1000 consecutive pregnant women considered to be at risk for fetal growth retardation with retrospective analysis. Serum hPL was measured by radioimmunoassay and fetal weight estimated by ultrasound every 3 weeks during the last trimester. hPL values were expressed as multiples of the median (MoM) and linear regression analysis of the hPL MoM values was carried out for each pregnancy to find the slope of the line (hPL-slope); at least 3 serum hPL values were required. The estimated fetal weight and weight-for-age at birth was expressed in Z-scores. The individual intrauterine growth velocity was calculated by regression analysis and expressed as change in Z-score for 12 weeks. At least two ultrasound measurements over an interval of at least 42 days were used to estimate the fetal growth velocity. In 588 women the file was complete. The main outcome measures were the individual mean hPL, hPL-slope, fetal growth velocity, birth weight deviation, smoking in pregnancy and diagnosis of preeclampsia. A significant correlation was found between the hPL-slope and the intrauterine fetal growth velocity (r=0.34), and between hPL-slope and birth weight deviation (r=0.32). Mean hPL was correlated to birth weight deviation (r=0.27), but only very weakly to intrauterine growth velocity (r=0.08). hPL-slope and intrauterine growth velocity independently predicted birth weight deviation. Heavy smoking which was stopped before the third trimester was not associated with low intrauterine growth velocity, but with a low hPL-slope. Preeclampsia was associated with a trend towards low and decreasing hPL and with an increasing intrauterine growth velocity and birth weight deviation. In conclusion the rate of change of serial hPL measurements correlated well to intrauterine fetal growth velocity in the third trimester as estimated by ultrasound and to the deviation in birth weight, but hPL seems to have a separate physiological significance, since it did not pick up when smoking was stopped and growth velocity was normalised and it did not at all detect the increased growth associated with preeclampsia.

Internal quality control of radioimmunoassays.

A quality control system for radioimmunoassays is described. The system is designed to give a high probability for error detection and a low probability for false rejection by use of a combination of three control samples with different ligand concentration levels. Intra-assay precision profile is also calculated on the basis of deviations between the sample and the standard duplicates.

Six direct radioimmunoassays of estradiol evaluated.

We evaluated the analytical performance of six commercial direct radioimmunoassays of 17 beta-estradiol, those from Radioassay Systems Laboratories, IRE Medgenix, Biotecx Laboratories, Farmos Spectria, International CIS, and Diagnostic Products Corp. The mean value for estradiol (E2) and the within- and between-run CVs were determined for serum pools and control materials, measured in seven to 10 runs with each method. Mean values for E2 in pooled sera deviated by 75% to 350% from the means measured with our routinely used extraction method. Between-run CVs ranged from 4% to 14% for the direct assays as compared with 10% for the extraction assay. We also investigated, for two of the direct assays, the effect of extraction with diethyl ether before radioimmunoassay, with respect to improvement in the agreement with our extraction method. All of the assays were easy to perform and results were obtained within 4-5 h, but we conclude that matrix effects may be expected in direct assays of estradiol.

Description of a computer program to assess cancer antigen 15.3, carcinoembryonic antigen, and tissue polypeptide antigen information during monitoring of metastatic breast cancer.

It is time-consuming to process and compare the clinical and marker information registered during monitoring of breast cancer patients. To facilitate the assessment, we developed a computer program for interpreting consecutive measurements. The intraindividual biological variation, the analytical precision profile, the cutoff limit, and the detection limit for each marker are entered and stored in the program. The assessment procedure for marker signals considers the analytical and biological variation of the applied markers. The software package contains a database that can store the interpretation of the measurements as evaluation codes together with patient demographics, information about treatment type, dates for treatment periods, control periods, and evaluation codes for clinical activity of disease. The consecutive concentrations for a patient are imported temporarily into the program from outside sources and presented graphically. Marker concentrations to be compared are selected with the computer mouse and the significance of the difference is calculated by the program. The program has an option for calculating the lead time of marker signals vs clinical information. The program facilitates the monitoring of individual breast cancer patients with tumor marker measurements. It may also be implemented in trials investigating the utility of potential new markers in breast cancer as well as in other malignancies.

Ratio of human placental lactogenic hormone (hPL) in amniotic fluid/maternal serum.

The predictive value of the ratio of hPL concentrations in amniotic fluid/maternal serum has been investigated in 24 complicated pregnancies. A correct prediction of the fetal outcome with respect to low birth weight and/or dysmaturity was found in 75 per cent of the pregnancies compared to 67 per cent for total estriol in serum. Serum hPL alone did not seem to have a satisfactory predictive value in this small study.

Influence of breast-feeding pattern on pituitary-ovarian axis of women in an industrialized community.

A longitudinal study of 48 postpartum women showed that during the first 6 months the daily frequency of infant feedings remained between six and seven. The lower threshold of the ratio breast-feedings/supplementary feedings that sustained both hyperprolactinemia and anovulation was 4.5/1. The duration and the 24-hour distribution, but not the intensity, of breast-feedings were significantly altered during prolonged lactation and when supplementary feeding was used. However, neither differences in the levels of prolactin (PRL) no gonadal status could be correlated with qualitative differences in the breast-feeding pattern. Postpartum maternal body weight was not related to serum PRL, gonadotropins, or resumption of ovulation, but mothers who smoked cigarettes had significantly lower serum levels of PRL during the third and fourth months, and weaned their babies earlier, than did mothers who were nonsmokers. Our data showed that minor quantitative differences in the feeding pattern have a significant impact on the pituitary-gonadal axis, and that the decline in the levels of PRL during continued lactation is due mainly to a decreased frequency of breast-feeding but may be due also to a shorter duration and more heterogeneous 24-hour distribution of nursings but not to a reduced intensity of sucking.

Performance characteristics of creatine kinase-MB isoenzyme measured with an immunoenzymometric and an immunoinhibition assay in acute myocardial infarction with and without thrombolytic therapy.

In a time study we compared the analytical and clinical performance of the Tandem Icon QSR CK-MB enzyme-immunoassay (Hybritech) (creatine kinase-MB) and a creatine kinase-MB immunoinhibition method (Boehringer Mannheim GmbH) (creatine kinase-B). Two hundred and ninety-nine serum samples from 38 patients suspected of acute myocardial infarction were collected at regular intervals during 48 hours. Twenty-nine patients were diagnosed as having acute myocardial infarction, of whom 19 received thrombolytic therapy. Although highly correlated, the large scatter around the regression line at low values indicated a different clinical performance of the two methods. We evaluated and compared test performance at different decision levels by means of frequency distributions and predictive values of positive and negative results. For early diagnosis of acute myocardial infarction (4 hours after onset of pain) the Hybritech creatine kinase-MB method gives acceptable predictive values. In thrombolytic treated acute myocardial infarction patients, the peak creatine kinase-MB and creatine kinase-B concentrations were reached after 13.0 h and 13.6 h after the onset of pain, compared with 19.8 h and 17.8 h for patients without thrombolytic therapy.

Alpha-1 fetoprotein in cord serum correlated to gestational age.

Measurement of alpha1-fetoprotein by rocket immuno-electrophoresis in cord serum from a consecutive series of 422 newborn infants showed a negative correlation with gestational age. The coefficient of correlation was divided by 0.70 for girls and divided by 0.74 for boys. For a given alpha1-fetoprotein concentration in cord blood the confidence limits for prediction of gestational age for both sexes were calculated to +/- 24 days. It is concluded that determination of alpha1-fetoprotein in cord serum is of limited help in the evaluation of maturity.

Interpretation of results for tumor markers on the basis of analytical imprecision and biological variation.

Interpretation of results for CA 15.3, carcinoembryonic antigen (CEA), and tissue polypeptide antigen (TPA) during breast cancer monitoring requires data on intra- (CVP) and inter- (CVG) individual biological variation, analytical imprecision (CVA), and indices of individuality. The average CVP and CVG obtained from 22 healthy women were, respectively, 6.2% and 62.9% (CA 15.3), 9.3% and 86.8% (CEA), and 28.3% and 133% (TPA). The indices of individuality were all < 0.6: 0.2 (CA 15.3), 0.15 (CEA), and 0.2 (TPA). CVA depended on the concentration of the analytes. CVP and CVA determine what constitutes a significant difference between sequential results. Assuming a CVA of 11.2% (CA 15.3), 9.5% (CEA), or 11.9% (TPA), results must differ by 30%, 31%, or 72%, respectively, for P < or = 0.05. We found that CVP and CVA contribute considerably to the variation during breast cancer monitoring. Consequently, both CVP and CVA should be considered in criteria for marker evaluation. Because of low indices of individuality, conventional cutoff limits are inappropriate both for initial identification and for follow-up of breast cancer.

Anencephaly in trisomy 18 associated with elevated alpha-1-fetoprotein in amniotic fluid.

Elevated levels of alpha-1-fetoprotein (AFP) were found in the amniotic fluid of a 36-year-old woman in the 15th week of gestation. Because of this and the results of repeated ultrasonography, abortion was induced. An anencephalic fetus with trisomy 18 was delivered. The possible correlation among neural-tube defects, chromosomal abnormalities, and level of AFP is discussed.

Assessment of biological variation and analytical imprecision of CA 125, CEA, and TPA in relation to monitoring of ovarian cancer.

OBJECTIVES: Changes in serial tumor marker results during monitoring of patients with ovarian cancer are due not only to deterioration or amelioration of the patient's condition, but also to preanalytical sources of variation (CPP), total random analytical error, and within-subject normal biological variation. The aim of the study was to assess (i) the analytical imprecision (CVA) and the average inherent intra- and interindividual biological variation (CVTI and CVG, respectively) for CA 125, CEA, and TPA in a group of healthy women; (ii) the significance of changes in serial results of each marker; and (iii) the index of individuality. METHODS: The study group consisted of 31 healthy women. Sixteen blood samples from each subject were collected in four series over a period of approximately 1 year. Data analysis was based on ANOVA. The index of individuality was calculated as ((CV2A + CV2TI)/CV2G)1/2 and the critical difference for a change between two consecutive concentrations as radical2xZx(CV2P + CV2A + CV2TI)1/2 (Z = 1.65 for unidirectional and 1.96 for bidirectional changes, P