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--------------- -- ,v JUR09 RECD / -V Marstiiler J.: tA Spienomegaiic Liver ease 131 . Kelly, R. 2. 15"'. Viavi chloride and acroosttolj r Occupational Med. 15: 358. 1/75. Klatskin, G. 1969. Toxic and drug induced hi In Diseases of the Liver. L. Schtfr, Ed. 3rd edit. J. B. Lippincott iladelphia, Pa. t/^6. Xunge, 0. & H. W. Altmans. 1971. 5gie toxischer Hepatosen. Munch. Med. Wochschr. 113: 1529. 1/77. Kluge, T., H. Sommerschild & A. 1970. Sinusoidal portal hyperten- sion. Surgery 68: 294. 1/78. Kramer, C.G.&J.E. Mu The correlation of clinical and environ- mental measurements for worj ^sxposed to vinyl chloride. Am. Ind. Hyg. Assoc. J. 33: 19. 1/79. Lange, C.-E., S. JOhe, G. S' _ G. Veltman. 1974. Die sogenannte Vinyl- :hlorid-Krankheit--eine baflBbedingte Systemskierose? Intern. Arch. Arbeits- med. 32: 1. Leake, C. D. 1934. The jaBof pharmacology in the development of ideal anes thesia. J. Am. Med. A^Hrl02: 1. Lefaux, R. 1966. Ch^^Pund Toxikologie der Kunststoffe. Krausskopf. Mainz, &oo fc-- West Germany. LEFhvxE, M. 1. 197J^HternationaIes Symposion der Werksame der Chemischen Industrie, 27-29^Kil 1972, Ludwigshafen. As cited in Stein et al., 1973. Lehmann, K. 3Flury, Eds. 1938. Toxikologie und Hygiene der teehni- schen LSsunj^^tel. Julius SpringerL3eriin, Germany. l/84. Lester, D., ` Greenberg & W. R. Adams. 1963. Effects of single and re- peated ex: : of humans and rats to vinyl chloride. Am. Ind. Hyg. Assoc. J. 24:265. Lindner, 3. Laparoscopy in alcohol-induced liver disease. Gastroenterology! 64: 602465 Mac: , R. N. M., J. M. Vetters, S. K. Ross, J. Ferguson, J. M. John- A. T. Sandison. 1973. Haemangio-endothelial sarcoma of the liver. ,ol. 109: 39. ( DCiC- 87. K. . 4 R. L. Zielhuis. 1964. Industrial_Toxicology and Dermatology blishing Company. ode 88. Maltoni, (J., M. U85Pnff^^^WRH^8CT9n^nHtH!lational Symposium on Cancer Detection and Prevention, Bologna, April 9-12, 1973. Excerpta Medica InL Congr. Ser. No. 275. A., J- STRAires R B-JLqjM^L-t^JlLeaaE--3967. _ ________ ____________________ ise Seance du 18 janvier 1967). Rev. Rhumat. 34: S. S.t C. J. McDonald, W. Fethiere & M. S. Kerzner. 1972. Oc- cup^^aJacroosteolysis. Arch. Dermatol. 106:219. MarstejSHhlj., W. K. Lelbach, R. Muller, S. Juhe, C. E Lange, H..G. Rohner ^^HkuMAN. 1973. Chronisch-toxische Leberschaden bet Arbeitem in der PVC-Pr^MP|^Deut. Med. Wochschr. 98:2311. Mastkomatteo, E./^I^MjHp, H. Christie &. H. Danziger. 1960. Acute in halation toxicity of vinyNHbjde to laboratory animals. Am. Ind. Hyg. Assoc. J. 5:394; Bull. Hyg. 36: 244.1 Mayers, M. R. 1969. Occupationa^^Pkh. The Williams & Wilkins Company, i&ao K. Baltimore, Md. -L McCord, C. P. 1970. A new occupationan^^^s born. J. Occupational Med. 12:234. Mikkelsen, W. P., H. A. Edmondson, R. L. PeTH^^^^, Redexer' & T. B. Reynolds. 1965. Extra- and intrahepatic portal hypeH^^^^githout cirrhosis (hepatoportal sclerosis). Ann. Surg. 162: 602. Misceld, V., H. J. Stolpmann &. S. Schulte. 1973. Zur durch Vinylchlorid-Polymerisate und/oder deren Begleitstoffe. Z. Haut Ge^Vechtskr. BFG36332 _ Ck<inltli Thank you for choosing Advanced Information Consultants Vendor ------------ for your document delivery needs Ml Mail Tram Typo :---------- -- GEO02 Verification $. Ship Date Ct $ n $ 6.0.95 TO09T6E2T Advances in tumour prevention, detection and characterization Editor: C. Maltoni Vol.2 Cancer detection andprevention Proceedings of the Second international Symposium on Cancer Detection and Prevention Bologna, April 9-12, 1973 Editorial Board: Cesare Maltoni (President) Yves Fassin Edward C. Hammond Herbert E. Nieburgs Ivan Vodopija Massimo Crespi (Secretary) Linguistic Editors: M. S. Chesters P. R. J. Burch 1974 Excerpta Medica Amsterdam American Elsevier Publishing Co. Inc. New York BpG36333 h V itrieval photo- Second International Symposium on Cancer Detection and Prevention The Symposium was held under the High Patronage of: The President of the Italian Republic, Sen. Prof. Aw. Giovanni Leone Promoted by: Under the Auspices of: The International Agency for Research on Cancer and Union Internationale Contre le Cancer In Collaboration with: Istituto di Oncologia `F. Addarii' and Centro Tumori di Bologna President: Carlo Rizzoli International Advisory Scientific Committee: A. L. Abour Nasr N. Anchev Z. M. Bacq H. Bemdt D.A. Boyes G. Chavanne C. Craciun P. F. Denoix J. Hipyinmn : , M. Gaitan-Yanguas ! D. J. Yussawalla A. Uombart fife ' Z. Marinello L. Meinsma Meisels (Egypt) (Bulgaria) (Belgium) (DDR) (Canada) . (France) (Rumania) (France) (IARC) (Columbia) (India) (Spain) (Cuba) (Holland) (Canada) Secretary General: Cesare Maltoni D. Metcalf N. Montero T. Mork A. Nagy T. Nakayama N. Napalkov G. Notter R.A.Q. O'Meara I. Padovan A. J. Phillips F. J. C. Roe C. G. Schmidt Ph. Shubik G. Terzano V. Thurzo (Australia) """ (Chile) (Norway) (Hungary) (Japan) (WHO) (Sweden) (Eire) (Yugoslavia) (UICC) (UK) (BRD) (USA) (Argentina) (CCSR) . <( BFG36334 C009T6f'Z Contents IX Lectures Developments in cancer prevention through environmental control J. Higginson Occupational carcinogenesis C.Maltoni Aspects of experimental carcinogenesis related to cancer prevention in children N. P. Napalkov Cardnogenetic hazards from drugsD. Schmahl The possible importance of nitrosamines as carcinogens in humans P. N. Magee Recent advances and perspectives of automation in cytology O. A. N. Husain The evaluation of cancer control measures A. J. Phillips Problems in the detection of early malignant tumors of the locomotor system M. Campanacci 3 19 27 34 41 48 56 63 Panels 1. Gastric cancer Chairmen: N. Zamcheck, U. S. A. and G. Marcozzi, Italy Introduction to the panel on gastric cancer N. Zamcheck Epidemiology of gastric cancer E. C. Hammond and H. Seidman Prevention and detection of gastric cancer M. Crespi Roentgen diagnosis of gastric cancer T. Yamada, H. Ichikawa and H. Doi Foetal sulphoglycoprotein antigen (FSA) as a possible precursor of alimentary canal cancers I. P. T. Hakkinen Skin testing with soluble membrane antigens obtained from fetal stomach and normal and malignant gastric cells A. Hollinshead and R. B. Herberman Role of skin responses to tumour-associated macromolecules in the diagnosis of neoplasia D. E. H. Tee 2. Cancer of the colon and rectum Chairmen: W. J. Burdette, U. S. A. and L. Barbara, Italy The etiology of cancer of the large bowel E. L. Wynder and B. S. Reddy Proliferation and differentiation of colonic epithelial cells in lesions of man and rodent M. Lipkin Precancerous changes in ulcerative colitis and its association with carcinoma of the colon Chr. Ahren, L. Hulten and J. Kewenter CEA in cancer of the colon N. Zamcheck Cancer of the colon and rectum: Diagnostic methods A. Franchini Carcinoma of the colon and rectum. Discussion 3. Cancer of the lung Chairmen: R. Doll, United Kingdom and D. Campanacci, Italy 69 70 81 88 94 102 105 111 116 118 124 132 136 138 142 146 .' BFG36335 24916004 Higginson -iternational ;arch, Num- tries. No. 6 ific Publica- rical Report ce on `Hostsearch'. PritdI.lA.Vo- r, Lyon. Occupational carcinogenesis 19 Cesare Maltoni Istituto di Ortcologia 'F. Addarii'and Centro Tumori, Bologna, Italy Occupational carcinogenesis is one of the most interesting, tragic, important and difficult fields in oncology. It is interesting from the scientific point of view because it represents, dramatically, an experiment in carcinogenesis made on humans and it may teach us a lot about the natural history of tumours. It is tragic from a human point of view, because work which is per se a natural necessity of life, should not, at least, cause cancer. It is socially important because oncogenic factors increasingly are produced and diffused in occupational environ ments. Moreover from the factories they spread to the general environment, so that they come to be an ecological problem. Finally, occupational carcinogenesis is a difficult field to approach, because the care of the workers' health is often in conflict with the product ive interests of the factories. Industry has done a lot for experimental carcinogenesis, related to occupational can cer; often however the result is merely to prove the carcinogenic effect in animals of agents which have already proved to be carcinogenic for man: this is equivalent to saying that many people die of cancer but some make their living from cancer. On the other hand emotional arguments should be avoided. Thus I am aware that speaking on occupa tional carcinogenesis is a complex and difficult task. Experimental carcinogenesis did not start with the experiment of Yamagiwa and Ichi kawa in 1915, but rather in the 16th century with the observation of the so-called `mountain disease' in miners of Joachimsthal. This disease was recognized at the end of the last century as pulmonary carcinoma, which we now know is due to radio-active pollution, present in those mines. In 1775 Percival Pott in `Chirurgical Observations' de scribed a cancer of the scrotum in chimney sweepers and he correlated it with the black soot. In 1894 Unna repented on the frequency of skin cancer found in maritime workers, and he considered it due to excessive exposure to sun light. In 1895 Rehn, a surgeon from Frankfurt, reported at the congress of the German Society of Surgeons, 3 cases of bladder tumours found among 45 workers from a factory which produced fuchsine. He thought that the tumours were caused by aniline, but in fact it was shown, several decades later, that they were due to other aromatic amines. In 1902 at a meeting of the Medical Society'' of Hamburg, Frieben presented a case of a cutaneous tumour found on the hand of an employee of a factory producing X-ray apparatus. This employee used his hand for radiological demonstrations. The frequency of reports on occupational cancer has been increasing with the increase of industrialization, mainly due to the progress of chemistry. The most important thing to do in occupational carcinogenesis is to try to recognize occupations which may re present an oncogenic risk, and to identify the agent or agents which cause the risk, and also to try to assess the degree of risk. If the risk is related to an agent already known to be oncogenic for man, its detection in the occupational environment should be considered sufficient for undertaking preventive measures. On the other hand if the risk is related to agents, whose effects on workers have not yet been studied and are therefore not yet known, then we have to evaluate the risk they represent for workers. This can be done by means ofepidemiological investigations and experimental testing. Most oncogenic occupa tional agents have been identified on the basis of retrospective epidemiological studies. The progress in and the development of this branch of oncology should facilitate* systematic experimental testing of agents heavily released in the occupational environ- BFG36336 24916005 20 C. Maltoni ment In other words the need of epidemiological evidence in man should be avoided. Be* peoriental tests on animals are the more relevant to man, the more they reproduce the conditions of human exposure and eventually induce in animals the same tumours that they induce in man. In this case, the results of experimental tests may be considered largely equivalent to epidemiological evidence in man. On the other hand if an agent causes any kind of tumour in animals, in whatever experimental conditions, it should be considered potentially carcinogenic for man. To consider an agent definitely carcinogenic for man on such a basis, would be an excess, but no time should be lost before retesting it in more appropriate conditions. To reproduce experimentally the conditions of occupational exposure is often difficult and costly. Furthermore we have to consider that the number of agents in the occupational environ ment is large and increasing. Thus, new agents to which workers may be exposed should be submitted first to the easiest and quickest tests, however incomplete those tests may be. Then, for those agents inducing tumours in the experimental animals in these conditions, more precise and sophisticated experimental tests should be devised. The validity of experimental testing and the prerequisites for validity have been a matter of long discussions in international TABLE 1 Incidence of subcutaneous sarcomas in rats, following local injection of some inorganic pigments Treatment No. of animals Chromium yellow (lead chromate) Chromium orange (lead chromate) Molybdenum orange (lead chromate and molybdenum chromate) Cadmium yellow (cadmium sulphide) Iron red (iron oxide) Iron yellow (iron oxide) Controls 40 40 40 40 40 40 60 No. of tumours 26 26 36 15 1 0 0 1. a * ; a- FIG. 1 Apparatus for inhalation of controlled doses of gaseous compounds, in the Experimental Unit of the Istituto di Oncologia di Bologna. Occupational < meetings and exposure conti rat of compot some idea of L In Table 1, the subcutane< that chromiur From what h conditions, sh availability of apparatus is q able to find a inhalation of experimental i With this chloride mono first) of great resin, as a co] mediate, and results on thes Zymbal gla observed as oc Only 3 cas< Dawley) have t and liver angic nephroblastoir. angiosarcomas Although 1 tumours have sidered in our i Zymbal gla often multiphc Epidemiolo workers. Woul given the rarit indication of t of environmen such bioassays scale. Another mt working popu' cancer precurscytology amo. among worker posed to chroi groups of work To evaluate agents, we mus 1. a direct plastic response 2. the once develop whe f* 3. the onco Jjjeir effects. gZ According t< (a) definite BFG36337 .fOSB C. Maltoni >e avoided. Ex reproduce the ; tumours that be considered Is, in whateverc for man. To an excess, but To reproduce ilt and costly, tional environted first to the >r those agents re precise and mental testing 1 international some inorganic Jo. of tumours Experimental Occupational carcinogenesis 21 meetings and commissions, but of course, in the meantime the existing occupational exposure continues. Also, imperfect testing, for example the subcutaneous injection in the rat of compounds, to which man is exposed mainly by the respiratory route, may give some idea of their potential oncogenic risk. In Table 1, data are reported on the induction of tumours (sarcomas) at the site of the subcutaneous injection of some inorganic pigments. From these data it clearly appears that chromium and cadmium pigments should be considered riskier than iron pigments. From what has been said before, the compounds shown to be carcinogenic in these conditions, should now be tested by inhalation. The latter way of exposure implies the availability of a complex apparatus for continuous inhalation of controlled doses. The apparatus is quite rare, as we discovered when we wanted to build one and we were not able to find any model in our own or any neighbouring country. Now an apparatus for inhalation of gaseous compounds has been functioning for more than two years in the experimental unit of our institute (Fig. 1). With this apparatus we are now performing a carcinogenicity bioassay of vinyl chloride monomer (VC) and of vinyl acetate monomer (VA), which are (particularly the first) of great industrial importance. VC is used in the preparation of polyvinyl chloride resin, as a copolymer in saran and other plastics, as a solvent and as a chemical inter mediate, and it is at present produced at a rate of 12,000,000 tons per year. Early results on these bioassays are shown in Table 2. Zymbal glands carcinomas, nephroblastomas and liver angiosarcomas have never been observed as occurring spontaneously in our breed of Sprague-Dawley rata Only 3 cases of spontaneously occurring Zymbal glands carcinomas in rats (SpragueDawley) have been recorded in 1962. To our knowledge, no spontaneous nephroblastomas and liver angiosarcomas of rats have been reported in the literature. As far as we know, nephroblastomas have never been reported to be experimentally induced is rats; liver angiosarcomas have been induced in this species by dicthylnitrosamine. Although liver is the preferential site for onset of angiosarcomas, such kind of tumours have been observed in other tissues and organs: therefore VC should be con sidered in our experimental conditions generally cancerogenic for endothelia. Zymbal glands tumours and nephroblastomas may be bilateral; liver angiosarcomas are often multiphocal. Epidemiological investigations and medical controls should be undertaken on exposed workers. Would such neoplastic lesions of kidney and liver unhappily be found in man, given the rarity of these tumours in both animals and humans, it would be a precise indication of the high value of experimental testing in predicting the oncogenic potential of environmental agents and would strengthen the recommendation on the necessity of such bioassays before any new industrial compound is produced and widespread in large scale. Another means of revealing the oncogenic risk of an agent is to examine the exposed working populations with methods which make it possible to assess the incidence of cancer precursors. The incidence of such precursors has been studied by us by exfoliative cytology among asymptomatic, apparently healthy workers exposed to risk, namely among workers exposed to aromatic amines (urine cytology), and among workers'ex posed to chromates (sputum cytology). The incidence of cellular atypias in these two groups of workers is shown in Tables 3 and 4. It far exceeds the expected incidence. To evaluate in medical and legal terms the risks represented by occupational oncogenic agents, we must consider that: 1. a direct relation exists between dose (amount and length of exposure) and neo plastic response; 2. the oncogenic agents produce mainly non-reversible changes, which may continue to develop when the exposure is interrupted; 3. the oncogenic agents (occupational or generally environmental) may be additive in their effects. According to our knowledge the occupational carcinogenic agents may be classified as: (a) definite carcinogens, when epidemiological evidence exists. BFg36338 . * 2491600? 24 C. Maltoni (b) highly suspected carcinogens, when strong experimental and/or some epidemio logical evidence is present, (c) potential carcinogens, when experimental data give some indication of carcino genic action of a compound on an experimental animaL According to their effects, the carcinogenic agents may be classified as strong or medium. The agents, which have been definitively proved or are suspected to be oncogenic for man on an epidemiological basis, are listed in Table 5, together with the target tissues and the degree of evidence. The list of the agents present in the occupational environment, which, on an experimental basis should be considered highly suspect or potentially carci nogenic for man, is reported in Table 6. TABLE 5 Agents proved or suspected to be oncogenic for workers on an epidemiological basis Agents U.V. radiations X-rays Uranium ore Arsenic Evidence + + + (+> Asbestos + Chromium Nickel Iron ore Bis-chloromethyl ether Benzene Isopropylic oil Soot, tars, mineral oils, cutting oils Carbon black Mustard gas Aromatic amines + + (+) + + (+) + + + + Tumours Skin carcinomas Skin carcinomas Leukaemias Pulmonary carcinomas Skin carcinomas (lung carcinomas) (liver tumours) Lung carcinomas Pleural mesotheliomas (abdominal malignancies) Lung carcinomas Lung carcinomas Carcinomas of nasal and paranasal cavities Lung carcinomas Lung carcinomas Leukaemias Carcinomas of paranasal cavities Skin carcinomas Lung carcinomas Laryngeal carcinomas Bladder and upper urinary tract carcinomas TABLE 6 Agents suspected to be carcinogenic for workers on an experimental basis Beryllium Cadmium Cobalt Lead Selenium Zinc Carbon tetrachloride Chloroform Vinyl chloride Pesticides (DDT, aldrin, dieldrin, Aramite, DMDT, Amizol, Thiuram) Thiourea and related compounds Tannins Detergents Alkylating agents Nitrosamines Azo-dyes Oestrogens . * Occupational ci In Italy care (a) exposei produced; (b) exposei (c) exposet workers in fact< (d) in facte (e) in facto (f) in the d In our coun tioned workers chromate facto workers in asbe who were heat Province and 1 among workers workers had be fudndne, 3,3'-dj and benzidine 1 carcinogenesis it TABLE 7 Freq. torie. Factory Total b A B C D E Total * In 1 case bladder The methods t 1. correct ex] 2. up to dati risk; 3. legislative have been shown especially if the sr 4. measures c be produced or e Public Health Insp 5. specific me preneoplastic lesii risks through the i It is my opinic epidemiological. I mainly located in We know that the: some way affected C. Maltoni Oll-- epidemioion of carcinod as strong or s oncogenic for rget tissues and 1 environment, Jtentially carcilogical basis ties Aramite, DMDT, Occupational carcinogenesis 25 In Italy carcinogenic occupational risk exists for workers who are: (a) exposed to chromates, mainly the ones working in factories where chromates are produced; (b) exposed to nickel, mainly the ones exposed to nickel-carbonyl; (cj exposed to asbestos, mainly the ones who extract it from its natural source, or workers in factories where asbestos is used for manufacturing; (d) in factories making shoes, purses and raincoats, exposed to benzene; (e) in factories producing carbon black from mineral oils; and (f) in the dye and rubber industries, exposed to aromatic amines. In our country occupational tumours have been observed in many of the above men tioned workers. 21 lung carcinomas have been found among less than 200 workers in a chromate factory in Northern Italy. Pleural mesotheliomas have been discovered among workers in asbestos mines. A number of leukaemias have been found among shoe-makers, who were heavily exposed to benzene, in factories in Lombardy (Vigevano), Bologna Province and Tuscany. The incidence of bladder and other urinary tract carcinomas among workers in 5 Italian dye-stuff factories are shown in Table 7. In these factories workers had been exposed to /5-naphthylamine, benzidine, ac-naphthylamine, Auramine, fuchsiae, 3,3'-dichlorobenzidine. Now in our country the production of 0-naphthylamine and benzidine has been withdrawn. One may conclude that prevention of occupational carcinogenesis Ls a very urgent problem. TABLE 7 Frequency of carcinomas of the urinary tract among workers of 5 Italian dye-stufffac tories exposed to aromatic amines Factory Total No. of exposed workers A B C D E Total 286 386 213 135 135 1,155 No. of workers with carcinoma Bladder Renal pelves and ureters 17 1 87 5 44 4- 71 159 7 Total 18 92* 44 4 8 166 * In 1 case bladder and upper urinary tract tumours were coexistent. The methods of prevention may be summarized as follows; 1. correct experimental testing of all newly used agents; 2. up to date epidemiological data from various categories of workers exposed to risk; 3. legislative measures forbidding the production and the utilization of agents which have been shown to be oncogenic on an epidemiological and/or an experimental basis, especially if the said agents are strong carcinogens; 4. measures of technical protection, when weak or doubtful carcinogens continue to be produced or employed; these protective measures should be periodically examined by Public Health Inspectors; 5. specific medical checks to make possible, on the one hand, the early detection of preneoplastic lesions and tumours, and on the other, the quantitative evaluation of the risks through the incidence of these changes. It is my opinion that the value of medical checks is mainly to evaluate the risk that is epidemiologies. Early detection of occupational tumours which, as already shown, are mainly located in the respiratory and urinary tract, has been, I think, over-emphasized. We know that these tumours are multicentric. In other words all the target apparatus is in some way affected by the carcinogenic process. v tm x & b z BFG36342 26 C. Maltoni Concerning the urinary tract, in a systematic histological study, I have seen that in patients with bladder tumours, dysplastic and cancerous foci may be detected from renal pelvis to urethra. Therefore it is obvious that in such conditions early diagnosis can achieve very little. We may diagnose some tumours quite early, but on the basis of 15 years' experience with periodic checks of workers exposed to high risk, I doubt that periodical medical examination has a real bearing in saving people with occupational cancer although detected early,~or in prolonging their life span. Thus my position is in sharp contrast with those who claim to `protect' (!) workers exposed to carcinogenic risk with medical examinations. I do believe that the potentialities of medical examinations should be evaluated at an international level In conclusion, I would like to emphasize the need of a close collaboration among scientists, public health services, workers unions and industries, to evaluate the risks and to devise preventive measures for avoiding or minimizing occupational tumours. References Frieben (1902): Fortschr. Rontgenstr., 6, 106. Pott, P. (1775): In: Chirurgical Observations, relative to the Cataract, the Polypus of the Nose, the Cancer of the Scrotum, the Different Kinds of Ruptures, and the Modification on the Toes and Feet Hower, Clarke and Pollms, London. Rehn, L. (1895): Arch. klin. Chir., 50,588. Unna, P. G. (1894): In: Histopathologic der Hautkrankheiten, p. 719. Hirschwaid, Berlin. Yamagiwa, K. and Ichikawa, K. (1915): Mitt med. Fak. Tokyo, 15,295. *0 C Aspects related N. F. Napalk Petrov Resean Until recent y so-called tran: diate and late more than th genesis and bl chemical agei observations < genesis becon factors and kov, 1971). Malignant ren under 1 f Marsden and in children's for children s nant tumour: established p epidemiologii The prob! searchers, cli stage of inte; which have ri as well as by children, hav> with means f logical obsen growth dyna blastoma, rh might be inc ever, seem t< from exposu clinico-epide to the work administratk cell vaginal apparently c humans of tl substances d Fragment nant animal: considerably ~ inducing tui experiments BFG36343 E. Sega et al. . higher than 0 in carcino>atients with xmtroversial igenic deteiissue of the Jtion of the 1 the related ay be worth an that may der to avoid is, it will be n. It will be the antigen ie before we conclusions uickly from immunoassay istry, 9, 28S. Surg., 123/2, Serum alpha-fetoproteins in chronic liver diseases and primary cancer of the liver in children and adults 627 J. Milosavljevic, M. Stajic, D. Filipovic, N. Vilhar and J. Teodorovic Mother and Child Health Institute, and Department ofMedicine, General Hospital in Zemun, Belgrade, Yugoslavia The synthesis of alpha-fetoprotein (AFP) which takes place in proliferating liver cells, probably hepatoblasts, starts very early: its presence can be demonstrated in the fetal serum as early as the sixth week of intrauterine life. With further development of the fetus, the AFP concentration increases to reach its highest level between the twelfth and sixteenth week (Houstek et al., 1968; Van Furth and Adinolfi, 1969). Two to four weeks before birth, this protein fraction shows a rapid decrease and at birth its concentration is 1-3% of the highest value reached during fetal life. AFP synthesis stops after birth and AFP therefore disappears from the serum of the newborn baby at the end of the first month of life. Outside the embryonal phase, AFP was first observed in experimentally induced liver cancer in mice (Abelev et al., 1963) and rats (Stanislawski-Birenswaig et al., 1967). In view of the fact that the presence of AFP was also demonstrated in the sera of adults with primary liver cancer (Tatarinov, 1964), this finding has been considered to be a reliable test in the diagnosis of hepatocellular cancer (Leblanc et al., 1967; Abelev et aL, 1967). However, the presence of AFP was also demonstrated in the sera of patients with malig nant undifferentiated teratomas, liver cancer of the mixed type and in patients with cancer metastases in the liver from a primary cancer in the pancreas, or from gastric adenocarcinoma (Tatarinov and Nogaller, 1966; Houstek et al., 1968; Bourreille et al., 1970; Geffroy et aL, 1970a; Geffroy et al., 19706; Alpert et al., 1968; Bernades et aL, 1971). By means of very sensitive radio-immunological methods it has been possible to demonstrate the presence of AFP also in a small number of pregnant women (Foy et aL, 1970), in patients with regenerative processes in the liver and in healthy individuals. In all these cases, AFP was present in very small concentrations which were undetectable by the usual immunological methods. Although it has been proved that this protein is synthesiz ed in proliferating liver cells (Abelov, 1970; Gitlin and Boesman, 1967), their biological properties are not yet known. The results obtained in the existing studies on the inci dence of positive findings in patients with primary liver cancer are very variable and range' between 27 and 87%. However, Masopust and co-workers (Masopust et al., 1968) have found AFP in children up to the age of 12 months if they have had hepatitis or other liver lesions. Material and methods Sera were examined from 666 persons aged between 4 days and 73 years. Controls con sisted of 100 sera of which SO were obtained from pregnant women in the second half of pregnancy and SO from school children 17-18 years old. The remaining S66 sera were divided into two groups. The first group included sera from adults with a chronic liver disease, or liver cancer (Table 1), and the second group included sera from children with a chronic liver disease or other illnesses (Tables 2 and 3). Diagnosis was established on the BFG36344 628 J. Milosavljevic et al. TABLE I Alpha-fetoprotein in sera ofexamined patients Diagnosis Normal persons Pregnant women Cirrhosis 1 compensated Hepatis f uncompensated Hepatitis acuta Hepatitis '1 agressiva Chronica ( persistens Steatosis hepatis Hepatopathia secundaria Icterus obstructivus Echinococcus hepatis Carcinoma hepatis metastasis Carcinoma hepatis primaria patients 50 50 5 17 2 5 5 10 4 3 1 1 5 AFP No. of positive cases - 2 % 40 basis of clinical and biochemical criteria, and in the majority, liver biopsy was also performed, except in adult cases with uncompensated liver cirrhosis in whom laparoscopy was carried out. Unless the analyses were done immediately the sera were stored at -20C. Three immunological techniques were used for the demonstration of AFP: Kohn's modification of Pesendorfer's method of immuno-precipitation (Kohn, 1970), immunodiffusion after TABLE 2 Alpha-fetoprotein in sera ofchildren with a chronic liver disease or other illnesses Diagnosis Orrhosis hepatis Hepatitis acuta Hepatitis chronica Icterus neonatorum Icterus prolongatus Other liver diseases Leucosis lymphoblastomata acuta Lymphogranulomatosis Collagenosis Neuroblastoma Reticulosarcomatosis Anemia Sepsis; Status febrilis Total 33 18 13 9 12 7 77 5 64 4 3 32 225 No. of patients Less than 1 year 1 6 9 12 3 1 6 74 1 year and above 32 12 13 4 76 5 64 4 3 26 151 No. of alpha-fetoprotein positive cases Less than 1 year 1 year and above 11-73 3- -----15- Serum alph TABLE 3 Diagnosis Orrhosis he Hepatitis ac Icterus neoi Icterus prol Other liver < Leucosis lyi Anemia Sepsis: St. f Ouchterlo titative de Results Of the toi the contrc Of 56< (Table 1) in the un chronic h persistent steatosis < belonged tients suf: tients: in 1 female these path Of the positive f: hepatis p; centration The st belonged liver cirrh- Negati' ing cases: 1. C* 72-year-ol fV 2. Ca. h^M7-year-ol ( 3. Ly The gr (JjfJofage.Thi >12 month BFG36345 Diagnosis No. of _____________ Patientsposits oases Total Less than 1 month 1 month1 year Grrhosis hepatis Hepatitis acuta Icterus neonatorum Icterus prolongatus 1 -1 6 -6 9912 5 7 Other liver diseases 312 Leucosis lymphoblastomata acuta Anemia Sepsis: SL febrihis 1 6 74 -1 33 8 66 No. of alpha-fetoprotein Less than 1 month 7 2 1 1 5 1 month1 year 1 1 1 2 - - Ouchterlony, and commercially available Partigen plates (Behringwerke AG) for the quan titative determination of this fraction. Results Of the total number of 666 sera which were analyzed, 100 sera represented samples from the control group in which AFP was not found. Of 566 patients under study, 64 were adults and 502 children. Among the adults (Table 1) 22 patients had liver cirrhosis, and of these 5 were in the compensated and 17 in the uncompensated phase of disease. Two patients had acute hepatitis and 10 had chronic hepatitis. Among the latter, 5 persons had the aggressive form and the other 5 the persistent form of chronic hepatitis. The next group of 10 consisted of patients with liver steatosis of different etiology. Only one patient had echinococcus of the liver. Three sera belonged to persons with obstructive jaundice subsequent to choledocholithiasis. Four pa tients suffered from secondary hepatopathy. Metastatic liver cancer was present in 7 pa tients: in 4, the primary was in the stomach, 2 had primary cancer of the colon, and 1 female patient had cancer of the ovaries. AFP was not found in the serum of any of these patients. Of the 5 patients with primary liver cancer AFP was found in 2 cases. The first positive finding of AFP was in the serum of a 23-year-old patient with hypernephroma hepatis prim. -- adrenal rest carcinoma (verified surgically and by autopsy). The con centrations of AFP ranged between 26.4 and 88.0 mg/100 ml. The second serum with the positive finding, at a concentration of 6.6 mg/100 ml, belonged to a 68-year-old patient with a primary hepatocellular cancer of the liver and liver cirrhosis. Negative findings in the sera of patients with liver cancer were obtained in the follow ing cases: 1. Carcinoma hepatis prim, hepatocellulare (verified by laparoscopy and biopsy) in a 72-year-old patient. 2. Carcinoma hepatis prim, hepatocellulare (verified by surgery and autopsy) in a 47-year-old female patient. 3. Lymphosarcoma hepatis in a 65-year-old patient. The group of children under study included 502 patients between 4 days and 14 years of age. This group was further divided into two sub-groups: children below, and those over 12 months of age. The following pathological findings were recorded in these children; BFG36346 . >1 al.' quately ), acute states, tie total sera of >st child -monthnths, in d with a FP was vho was din the i under ive AFP ice were normal- ewbom esent in patients h cancer -.ells, . the entiated tits with which is ibryonic P in the 970). 30 days AFP is idicated ificance s of the h severe Serum alpha-fetoproteins in liver diseases and cancer 631 following diseases: liver cirrhosis, acute and chronic hepatitis, liver steatosis, secondary hepatopathies and metastatic cancer of the liver. Of S patients with primary cancer of the liver, AFP was found to be present in 2 patients. Alpha-fetoprotein was found in concentrations from 26.4 to 88.0 mg% in a patient with hypernephroma hepatis prim. -- adrenal rest carcinoma. The other positive finding of AFP in the concentration of 6.6 mg% was in a patient with carcinoma hepatis prim, et cirrhosis hepatis. Among 86 newborn babies, AFP was found to be present in the sera of 5 (thyroxinemia, acute hepatitis, prolonged jaundice, congenital abnormality of the biliary tract and hemorrhagic disease of the newborn). AFP was found in 16 of 26 newborn babies (neonatal and prolonged jaundice and abnormalities of the biliary tract). References Abelev, G. L (1970): In: Protides of the Biological Fluids. Proceedings of the XVIlIth Ann. Collo quium, Bruges. Elsevier PubL Co., Amsterdam. Abelev, G. L, Perova, S. D., Kharamkova, N. I., Postnikova, Z. A and Irlin, I. S. (1963): Transplanta tion, 1,174. Abelev, G. L, Assecritova, L. V., Kraevsky, N. A, Perova, S. D. and Perevodchikova, N. L (1967): Int J. Cancer, 2, SSI. Alpert, M. E, Pirm, V. W. and Isselbacher, K. J. (1971): New EngL J. Med., 285,1058. Alpert, M. E., Unci, J. and Nechand, B. (1968): New EngL J. Med., 278, 984. Beraades, P-, Smadja, M., Rueff, B., Bonnefond, A, Tursz, T., Martin, E., Bognel, C., Barge, J. and Uriel,}. (1971): Presse m6d.,79,1585. Bouneille, J-, Metayes, P. and Sanger, F. (1970): Presse med,78,1277. Foy, H., Kcmdi, A, Parker, A M., Stanley, R. and Venning, C. D. (1970): Lancet, 2, 1336. Geffroy, Y., Denis, P. and Colin, R. (1970a): Presse m&L, 78,1107. Geffroy, Y., Metayer, P. and Denis, P. (1970b): Presse mid., 78,1096. Gitlin, D. and Boesman, M. (1966): J. clin. Invest., 45,1826. Gitlin, D. and Boesman, M. (1967): Comp. Biochem. PhysioL, 21, 327. Houstek, I., Masopust, J., Kithier, K. and Radi, J. (1968): J. Ptdiat., 72, 186. Kohn, J. (1970): J. clin. Path., 23,733. Leblanc, L., Quenum, C., Loisiflier, F. and Grabar, P. (1967): CR-Aca<LScL(Paris), 265,75. Masopust, J., Kithier, K., RidL J., Kontecky, J. and Kotal, L. (1968): InL ). Cancer, 3, 364. Stanislawski-Btrenswaig, M., Uriel, J. and Grabar, P. (1967): Cancer Res., 27,1990. Tatarinov, L S. (1964): VopjnedJChim., 10,90. Tatarinov, S. Y. and NogaOer, M. A (1966): Vop.OnkoL, 12,26. Uriel, J. (1970): In: Protides of the Biological Fluids. Proceedings of the XVIlIth Ann. Colloquium, Bruges. Elsevier PubL Co., Amsterdam. Van Furth, R. and Adinoifi, M. (1969): Nature (Lond.), 222,1296. days to jsendorld comuree me- 50 from a. rom the 24916017 BFG36347