1346
SIR,-Like Dr Spiegel and colleagues I feel that adrenocortical secretion may be suppressed by exogenous corticosteroids, but other factors may also play a part. Dr Morgan (April 28, p. 932) argues that a direct endocrine effect of cytostatic agents cannot be excluded in all cases of anomalous adrenal behaviour. Spiegel’s patients were given oral prednisone with other drugs but we are not told whether prednisone was given for the same time as or for longer than the other cytostatic therapy. Patients were categorised on the basis of duration of steroid therapy but there is no information on other important variables (platelet-count, blast-counts in peripheral blood, hxmorrhagic manifestations, bactersmia, and eosinophils in peripheral blood-smears, both before and after the therapy) which might have influenced the duration of therapy.’ This could be important because transient and/or abortive forms of disseminated intravascular coagulation--(D.t.c.), together with a general propensity to hypercoagulation and thrombosis,2 could have led to microscopic haemorrhages and/or microembolisation within the tissues, including the adrenals.3 Prednisone itself may accelerate D.I.C.4 Furthermore neutropenia, which is common in acute lymphoblastic leukaemia (A.L.L.),5,6 often results in bacteramua (endotoxxmia), promoting D.I.C.7.8 Ten of the fourteen patients had A.L.L. yet no data on variants of A.L.L. or white-blood-cell counts and differentials are given. Adrenal infiltration with malignant lymphoblasts is a well-recognised, albeit rare, feature of A.L.L. It might have contributed to adrenal suppression. Lymphocytotoxic chemotherapy might have affected adrenal secretion via the factors liberated from lysed lymphoblasts. Exhaustion or clearance of these factors could explain why the cortex quickly (in 4-7 days) reverted to normal function. Cytotoxic therapy, given to all except patient 4, may cause systemic disturbances, resulting in autointoxication with products of necrosis of both normal and malignant cells. Inhibitory activity by these products could express itself by abolition of normal adrenal responses. Cytostatic regimens are stressful, but Spiegel et al. do not mention the common clinical complications which could drain adrenal reserves. Nor do they make much comment on the one patient who was on corticosteroids alone. The fact that neither the dose nor the duration of therapy correlated with adrenal suppression suggests that influences other than those of exogenous corticosteroids cannot be discounted in the aetiology of the adrenal suppression observed. In future studies of anomalous cortisol secretion profiles in patients on steroids other factors will have to be allowed for.
Plasma-cortisol before and
during
VAC combination chemo-
therapy. Dotted line indicates the lowest normal level of plasma-cortisol at 8 A.M. A=actinomycin D 0.5 mg/day for 5 days. V+C=vincristine 2 mg + cyclophosphamide 500 mg weekly.
given adjuvant chemotherapy according to a modified VAC regimen. Before and during chemotherapy plasma-cortisol and fasting blood-glucose levels were monitored on blood obtained at about 8 A.M. Plasma-cortisol fell below normal (see figure). The fasting blood-glucose was 5.9 mmol/1 (97 mg/dl) before chemotherapy began and fell successively to 3.3mmoVI 3 months later. After 1 month of treatment the patient complained of increasing fatigue and dizziness and about 1 month later an increasing skin pigmentation was noted. Serum potassium and sodium concentrations have been normal and the blood-pressure has not been reduced significantly. Anaemia, leukopenia, and thrombocytopenia have not been observed. The laboratory data strongly suggest a suppression of adrenocortical function due to the cytotoxic drugs. The clinical symptoms are also compatible with adrenocortical dysfunction. We conclude that therapy with cytotoxic drugs without the addition of steroids may cause clinically important adrenal in-
sufficiency. H. OLSSON L. BRANDT M. TELENIUS-BERG
Department of Oncology, University Hospital, S-221 85 Lund, Sweden
Hæmatological Department, Internal Clinic A, 11.000 Belgrade,
Yugoslavia
GRADIMIR M. JANKOVIĆ
that suppression of adrenocortical function during combination chemotherapy is probably due to exogenous steroids, while Dr Morgan (April 28, p. 932) referred to in-vitro studies indicating that cytotoxic agents per se may cause a profound reversible suppression of adrenal-steroid secretion at therapeutic doses. We have seen a patient in whom vincristine, actinomycin D, and cyclophosphamide (VAC) treatment caused a suppression of adrenocortical function which was clinically evident. A 21-year-old previously healthy man with an embryonal rhabdomyosarcoma in the proximal phalanx of the right middle finger, diagnosed and operated on in January, 1979, was
SIR,-Dr Spiegel
and
colleagues suggest
1. Stjernholm, R. L., and others. J. Reticuloendothel. Soc. 1970, 8, 446. 2. Brakman, P., and others. Br. J. Hœmat. 1970, 18, 135. 3. Cattan, A., and others. Rev. fr. Clin. Biol. 1966, 2, 155. 4. Blix, S., Jacobsen, C. D. Acta med. scand. 1966, 180, 723. 5. Stefanovic, S., Bericov, R. Kliniĉka Hematologija. Belgrade, 1968. 6. Raab, S. O., and others. Blood, 1960, 16, 1609. 7. Beller, F. K. in Disseminated Intravascular Coagulation (edited by E. F. Mamman). Stuttgart, 1969. 8. Metsuoka, M., and others. Acta med. biol. 1970, 17, 251.
POSSIBLE ASSOCIATION BETWEEN HLA-AW24 AND METASTATIC TESTICULAR GERM-CELL TUMOURS
SiR,—The discovery of the HLA system of human histocompatibility antigens led to a search for associations between these and human diseases. Unlike diseases such as ankylosing spondylitis, which have a high association with an HLA antigen, most malignancies studied have shown, at the most, surprisingly weak associations.’-3 Prompted by the significant associations between H-2 and some kinds of leukaemia in inbred mice, Amiel4 described an association between HLA and Hodgkin’s disease in humans. Nasopharyngeal cancer (BW46)5 1. Sverjgaard, A., and others. Transpl. Rev. 1975, 22, 3. 2. Terasaki, P. I., Perdue, S. T., Mickey, M. R. in Genetics of Human Cancer (edited by J. J. Mulvihill, R. W. Miller, and J. F. Fraumeni, Jr.); p. 321. New York, 1977. 3. Dausset, J. in HLA and Malignancy (edited by G. P. Murphy); p. 13. New 4. 5.
York, 1977. Amiel, J. F. in Histocompatibility Testing; p. 79. Copenhagen, 1967. Simons, M. J., Wee, G. B., Dey, N. E., Morris, P. J., Shanmugaratnam, K., de Thé, G. B. Int. J. Cancer, 1974, 13, 122.
1347 and oesophageal cancer (B40)6 have shown to be associated with specific HLA types but these malignancies have rather restricted racial distribution. Several aspects of testicular germ-cell tumours suggest genetic regulatory factors. First, the ethnic incidence varies widely: European and North American Whites have an incidence of approximately 2 per 1000 000,7 while the disease is very rare in American and African Blacks and in Japanese.8.9 Secondly, approximately 1% of the male mice of inbred strain 129 have spontaneous testicular teratomas,10 while in a subline of the strain, 32% of the males have teratomas.11 These tumours apparently arise from the primordial germ cells. Testicular tumours constitute the commonest epithelial solid malignancy after melanoma in North American males aged 20-30 years.8 Possible involvement of major-histocompatibility-complex encoded antigens in the differentiated events that take place in embryonal cells of mouse teratocarcinoma is suggested by the lack of the H-2 antigen (the mouse major histocompatibility complex), and possession instead of the foetal antigen, F9. The H-2 antigen is acquired when these cells undergo differentiation to teratomas.12 This prompted us to examine our patients with testicular teratocarcinoma for a possible association with an HLA antigen. 5 of our 20 patients (25%) possess the HLA-A locus antigen W24. All 5 had metastatic disease out of a total of 9 patients with distant involvement (55%). All the patients were of European descent. The frequency of AW24 antigen in the group as a whole is not significantly different from the normal frequency (16%) of this antigen in North American Whites.13 However, the frequency of antigen AW24 in patients with metastatic tumour was significantly increased (Fisher exact test, p=0.0075). The frequency of AW24 antigen in the metastatic group (5/9) is also greater than the frequency in the non-
metastatic group (0/11) (r=0-008). Our series is a small one and our interpretations must be preliminary. Furthermore, correction of the p value for the number of HLA antigens studied (20) eliminates the significance of the difference between the normal frequency and that found in patients with metastases. The comparison between metastatic and non-metastatic populations would not require correction for the number of antigens studied, although a conservative analysis might require a much lesser correction; the p (0-008) would probably still be significant. The concept of the association between HLA antigens and disease may help in the subdivision of what are considered single entities clinically. A possibly increased frequency of HLA-AW24 in patients with metastatic, non-seminomatous, testicular, germ-cell tumours requires further studies because of the small numbers studied. If our studies are confirmed it could be that in a patient with this form of tumour, the presence of the AW24 antigen might indicate an increased likelihood of distant involvement.
ABSENCE OF LYMPHOCYTOTOXIC ANTIBODIES IN SPOUSES OF MULTIPLE-SCLEROSIS PATIENTS
SIR, The report by Schocket and BX’einer1 that cold-reacting lymphocytotoxic antibodies (L.C.A.S) were as prevalent in 9 spouses of multiple sclerosis (M.S.) patients as in the patients themselves, is of considerable importance to the hypothesis that M.S. is associated with a transmissible agent. However, we have been unable to confirm Schocket and Weiner’s finding in a larger series. Sera from 62 Australian patients with definite M.S. (as defined by McAlpine’s criteria2 on clinical examination, including visual evoked responses), from 45 spouses of M.S. patients, and from 125 Canberra blood-donors, were screened for presence of L.C.A.Sby the microdroplet technique3 modified for 15°C conditions. Target cells were peripheral B lymphocytes from twelve normal donors. Most cold-reactive lymphocytotoxic sera recognise determinants on both B and T cells,4 but since a proportion of sera are selectively B or T-cell specific4 target cells were restricted to B-cell enriched preparations of known HLA DRw, A, and B specificities. The distribution of cytotoxicity was clearly bimodal in M.S. patients. The proportion of target cells killed in each microlymphocytotoxic test was scored on a five-point scale from 0-4 (less than 20% of target cells killed, 20-50%, 50-75%, 75-90%, or 90-100%). Mean cytotoxicity scores were determined from the simple mean of 12 cell reactions, and a score greater than 0.40 was considered evidence for the presence of L.C.A.S.
In
from
patients, the prevalence of L.c.A.s was comparable with an earlier figure of 34% L.C.A.S in a series of 400 M.S. patients but significantly lower (p
SIR,-Like Dr Spiegel and colleagues I feel that adrenocortical secretion may be suppressed by exogenous corticosteroids, but other factors may also play a part. Dr Morgan (April 28, p. 932) argues that a direct endocrine effect of cytostatic agents cannot be excluded in all cases of anomalous adrenal behaviour. Spiegel’s patients were given oral prednisone with other drugs but we are not told whether prednisone was given for the same time as or for longer than the other cytostatic therapy. Patients were categorised on the basis of duration of steroid therapy but there is no information on other important variables (platelet-count, blast-counts in peripheral blood, hxmorrhagic manifestations, bactersmia, and eosinophils in peripheral blood-smears, both before and after the therapy) which might have influenced the duration of therapy.’ This could be important because transient and/or abortive forms of disseminated intravascular coagulation--(D.t.c.), together with a general propensity to hypercoagulation and thrombosis,2 could have led to microscopic haemorrhages and/or microembolisation within the tissues, including the adrenals.3 Prednisone itself may accelerate D.I.C.4 Furthermore neutropenia, which is common in acute lymphoblastic leukaemia (A.L.L.),5,6 often results in bacteramua (endotoxxmia), promoting D.I.C.7.8 Ten of the fourteen patients had A.L.L. yet no data on variants of A.L.L. or white-blood-cell counts and differentials are given. Adrenal infiltration with malignant lymphoblasts is a well-recognised, albeit rare, feature of A.L.L. It might have contributed to adrenal suppression. Lymphocytotoxic chemotherapy might have affected adrenal secretion via the factors liberated from lysed lymphoblasts. Exhaustion or clearance of these factors could explain why the cortex quickly (in 4-7 days) reverted to normal function. Cytotoxic therapy, given to all except patient 4, may cause systemic disturbances, resulting in autointoxication with products of necrosis of both normal and malignant cells. Inhibitory activity by these products could express itself by abolition of normal adrenal responses. Cytostatic regimens are stressful, but Spiegel et al. do not mention the common clinical complications which could drain adrenal reserves. Nor do they make much comment on the one patient who was on corticosteroids alone. The fact that neither the dose nor the duration of therapy correlated with adrenal suppression suggests that influences other than those of exogenous corticosteroids cannot be discounted in the aetiology of the adrenal suppression observed. In future studies of anomalous cortisol secretion profiles in patients on steroids other factors will have to be allowed for.
Plasma-cortisol before and
during
VAC combination chemo-
therapy. Dotted line indicates the lowest normal level of plasma-cortisol at 8 A.M. A=actinomycin D 0.5 mg/day for 5 days. V+C=vincristine 2 mg + cyclophosphamide 500 mg weekly.
given adjuvant chemotherapy according to a modified VAC regimen. Before and during chemotherapy plasma-cortisol and fasting blood-glucose levels were monitored on blood obtained at about 8 A.M. Plasma-cortisol fell below normal (see figure). The fasting blood-glucose was 5.9 mmol/1 (97 mg/dl) before chemotherapy began and fell successively to 3.3mmoVI 3 months later. After 1 month of treatment the patient complained of increasing fatigue and dizziness and about 1 month later an increasing skin pigmentation was noted. Serum potassium and sodium concentrations have been normal and the blood-pressure has not been reduced significantly. Anaemia, leukopenia, and thrombocytopenia have not been observed. The laboratory data strongly suggest a suppression of adrenocortical function due to the cytotoxic drugs. The clinical symptoms are also compatible with adrenocortical dysfunction. We conclude that therapy with cytotoxic drugs without the addition of steroids may cause clinically important adrenal in-
sufficiency. H. OLSSON L. BRANDT M. TELENIUS-BERG
Department of Oncology, University Hospital, S-221 85 Lund, Sweden
Hæmatological Department, Internal Clinic A, 11.000 Belgrade,
Yugoslavia
GRADIMIR M. JANKOVIĆ
that suppression of adrenocortical function during combination chemotherapy is probably due to exogenous steroids, while Dr Morgan (April 28, p. 932) referred to in-vitro studies indicating that cytotoxic agents per se may cause a profound reversible suppression of adrenal-steroid secretion at therapeutic doses. We have seen a patient in whom vincristine, actinomycin D, and cyclophosphamide (VAC) treatment caused a suppression of adrenocortical function which was clinically evident. A 21-year-old previously healthy man with an embryonal rhabdomyosarcoma in the proximal phalanx of the right middle finger, diagnosed and operated on in January, 1979, was
SIR,-Dr Spiegel
and
colleagues suggest
1. Stjernholm, R. L., and others. J. Reticuloendothel. Soc. 1970, 8, 446. 2. Brakman, P., and others. Br. J. Hœmat. 1970, 18, 135. 3. Cattan, A., and others. Rev. fr. Clin. Biol. 1966, 2, 155. 4. Blix, S., Jacobsen, C. D. Acta med. scand. 1966, 180, 723. 5. Stefanovic, S., Bericov, R. Kliniĉka Hematologija. Belgrade, 1968. 6. Raab, S. O., and others. Blood, 1960, 16, 1609. 7. Beller, F. K. in Disseminated Intravascular Coagulation (edited by E. F. Mamman). Stuttgart, 1969. 8. Metsuoka, M., and others. Acta med. biol. 1970, 17, 251.
POSSIBLE ASSOCIATION BETWEEN HLA-AW24 AND METASTATIC TESTICULAR GERM-CELL TUMOURS
SiR,—The discovery of the HLA system of human histocompatibility antigens led to a search for associations between these and human diseases. Unlike diseases such as ankylosing spondylitis, which have a high association with an HLA antigen, most malignancies studied have shown, at the most, surprisingly weak associations.’-3 Prompted by the significant associations between H-2 and some kinds of leukaemia in inbred mice, Amiel4 described an association between HLA and Hodgkin’s disease in humans. Nasopharyngeal cancer (BW46)5 1. Sverjgaard, A., and others. Transpl. Rev. 1975, 22, 3. 2. Terasaki, P. I., Perdue, S. T., Mickey, M. R. in Genetics of Human Cancer (edited by J. J. Mulvihill, R. W. Miller, and J. F. Fraumeni, Jr.); p. 321. New York, 1977. 3. Dausset, J. in HLA and Malignancy (edited by G. P. Murphy); p. 13. New 4. 5.
York, 1977. Amiel, J. F. in Histocompatibility Testing; p. 79. Copenhagen, 1967. Simons, M. J., Wee, G. B., Dey, N. E., Morris, P. J., Shanmugaratnam, K., de Thé, G. B. Int. J. Cancer, 1974, 13, 122.
1347 and oesophageal cancer (B40)6 have shown to be associated with specific HLA types but these malignancies have rather restricted racial distribution. Several aspects of testicular germ-cell tumours suggest genetic regulatory factors. First, the ethnic incidence varies widely: European and North American Whites have an incidence of approximately 2 per 1000 000,7 while the disease is very rare in American and African Blacks and in Japanese.8.9 Secondly, approximately 1% of the male mice of inbred strain 129 have spontaneous testicular teratomas,10 while in a subline of the strain, 32% of the males have teratomas.11 These tumours apparently arise from the primordial germ cells. Testicular tumours constitute the commonest epithelial solid malignancy after melanoma in North American males aged 20-30 years.8 Possible involvement of major-histocompatibility-complex encoded antigens in the differentiated events that take place in embryonal cells of mouse teratocarcinoma is suggested by the lack of the H-2 antigen (the mouse major histocompatibility complex), and possession instead of the foetal antigen, F9. The H-2 antigen is acquired when these cells undergo differentiation to teratomas.12 This prompted us to examine our patients with testicular teratocarcinoma for a possible association with an HLA antigen. 5 of our 20 patients (25%) possess the HLA-A locus antigen W24. All 5 had metastatic disease out of a total of 9 patients with distant involvement (55%). All the patients were of European descent. The frequency of AW24 antigen in the group as a whole is not significantly different from the normal frequency (16%) of this antigen in North American Whites.13 However, the frequency of antigen AW24 in patients with metastatic tumour was significantly increased (Fisher exact test, p=0.0075). The frequency of AW24 antigen in the metastatic group (5/9) is also greater than the frequency in the non-
metastatic group (0/11) (r=0-008). Our series is a small one and our interpretations must be preliminary. Furthermore, correction of the p value for the number of HLA antigens studied (20) eliminates the significance of the difference between the normal frequency and that found in patients with metastases. The comparison between metastatic and non-metastatic populations would not require correction for the number of antigens studied, although a conservative analysis might require a much lesser correction; the p (0-008) would probably still be significant. The concept of the association between HLA antigens and disease may help in the subdivision of what are considered single entities clinically. A possibly increased frequency of HLA-AW24 in patients with metastatic, non-seminomatous, testicular, germ-cell tumours requires further studies because of the small numbers studied. If our studies are confirmed it could be that in a patient with this form of tumour, the presence of the AW24 antigen might indicate an increased likelihood of distant involvement.
ABSENCE OF LYMPHOCYTOTOXIC ANTIBODIES IN SPOUSES OF MULTIPLE-SCLEROSIS PATIENTS
SIR, The report by Schocket and BX’einer1 that cold-reacting lymphocytotoxic antibodies (L.C.A.S) were as prevalent in 9 spouses of multiple sclerosis (M.S.) patients as in the patients themselves, is of considerable importance to the hypothesis that M.S. is associated with a transmissible agent. However, we have been unable to confirm Schocket and Weiner’s finding in a larger series. Sera from 62 Australian patients with definite M.S. (as defined by McAlpine’s criteria2 on clinical examination, including visual evoked responses), from 45 spouses of M.S. patients, and from 125 Canberra blood-donors, were screened for presence of L.C.A.Sby the microdroplet technique3 modified for 15°C conditions. Target cells were peripheral B lymphocytes from twelve normal donors. Most cold-reactive lymphocytotoxic sera recognise determinants on both B and T cells,4 but since a proportion of sera are selectively B or T-cell specific4 target cells were restricted to B-cell enriched preparations of known HLA DRw, A, and B specificities. The distribution of cytotoxicity was clearly bimodal in M.S. patients. The proportion of target cells killed in each microlymphocytotoxic test was scored on a five-point scale from 0-4 (less than 20% of target cells killed, 20-50%, 50-75%, 75-90%, or 90-100%). Mean cytotoxicity scores were determined from the simple mean of 12 cell reactions, and a score greater than 0.40 was considered evidence for the presence of L.C.A.S.
In
from
patients, the prevalence of L.c.A.s was comparable with an earlier figure of 34% L.C.A.S in a series of 400 M.S. patients but significantly lower (p
