Aust N.Z. J. Med. (1978), 8, pp 628-630
Low Dose Lithium-Carbimazole in the Treatment of Thyrotoxicosis , J. M. Hedley", J. G. Turnert, B. E. W. Brownlief and W. A. Sadler**
From the Department of Nuclear Medicine, Christohurch Hospital, Christchurch, New Zealand
Summary: Low dose lithium-carbimazole in the treatment of thyrotoxicosis. J. M. Hedley, J . G. Turner, B. E. W. Brownlie and W. A. Sadler. Aust. N.Z.J. Med., 1978, 8, pp. 628-630.
carbimazole treatment in the management of thyrotoxicosis. Patients and Methods
Fifteen patients with thyrotoxicosh were treated with l o w dose sustained release lithium carbonate 400 mg, combined with carbimazole 40 mg daily, and the therapeutic response was followed over a t w o week period. This response was cbmpared with that obtained in a similar group of patient treated with carbimazole alone. Licarbimazole treatment brought about a fall in the mean total serum T 4 of 57.4% compared with a drop of 32.8% in patients treated with carbimazole alone. The mean serum T 3 fell by 69.4%in the Li-carbimazole group compared with 47.3% in the group treated with carbimazole only. No lithium adverse effects were encountered.
Antithyroid drug treatment with carbimazole alone relies on the depletion of intrathyroidal hormone stores and is unable to render an acutely thyrotoxic patient euthyroid before several weeks.' Lithium exerts its antithyroid effect primarily by blocking the release of preformed thyroid hormone2 and has been found to be effective when used alone3s4 in the treatment of thyrotoxicosis. The doses used in this manner have been similar to those used in manic depressive illness and side effects were frequent? This had led to disenchantment with the use of lithium as an antithyroid drug.' In this study low dose lithium carbonate (sustained release preparation-Priadel, Delandale/TVL) was evaluated as an adjunct to *Registrar. +Senior Registrar. :Physician in Charge. "Radiochemist. Correspondence; Dr. B. E. W. Brownlie, Physician in Charge, Department of Nuclear Medicine, Christchurch Hospital, Christchurch, New Zealand Accepted for publication: 24 July. 1978
Thirty thyrotoxic patients were studied, all had diffuse hyperplasia on 99n1Tcthyroid scan and it was the first episode of thyrotoxicosis in all patients. The patients were moderate to severely thyrotoxic on clinical and biochemical grounds. Two treatment groups were studied. Group I (Li-carbimazole) Fifteen patients were treated with carbimazole, I0 mg qid plus lithium carbonate (sustained release) 400 mg mane for 14 days. All patients treated with lithium had normal serum electrolytes prior to entering the trial. No, patients with untreated heart failure or serious metabolic problems were studied. Venous blood was drawn for thyroid function assessment prior to the initiation of treatment and again at two weeks. Venous blood samples were taken for serum lithium estimations after seven and 14 days treatment. Group 2 (Carbimazole) A comparable group of 15 patients were treated with carbimazole alone in a dose of 10 mg qid. These patients were matched with those of Group 1 for the initial serum thyroxine (T4) values, in a retrospective manner, without knowledge of patients' names. Where possibie the patients were also matched for serum tri-iodothyronine (T3) values. Radioimmunoassav techniques were. used to obtain total T4 estimations (normal range 55-140 nmolil) and total T36 (1.2-2.7 nmol/l). Serum lithium estimations were performed by atomic absorption spectrophotometry. Statistical analysis was carried out using the student /-test for unpaired variates, and covariance analysis. Results
Thyroid function results are summarised in Table I . The pretreatment mean T4 levels for the two groups were not different. After two weeks' treatment the mean T4 level in the Licarbimazole group was, significantly lower than that for the carbimazole alone group ( P < 0.001). The mean pretreatment T3 level was statistically higher in the Li-carbimazole group, but the post-treatment T3 mean was significantly lower ( P < 0.001). Six of the 15 patients in the Li-carbimazole group (Group 1) had normal serum T4 and T3 levels after two weeks' treatment, but no patients in Group 2 had normal biochemistry at the end
DECEMBER,
1978
LOW DOSE LI-CARBIMAZOLE IN THYROTOXICOSIS
TABLE 1 Biochemical response after 2 weeks' treatment ~
~~~
Pretreatment . -
(Li-carbnnazole)
_
--
"
drop
~
T4 249 i 4 4 7 ( 1 SD) (nmolll) (185-324)
Group I
14 Days
l06+39 9 ( I SD) (18-183)
_
7 3 9 4 2 k 3 757 (nmol I ) ( 7 10-15 54)
2 8 8 k 0 968
T4 259+53 5 (nmol I ) (194-376)
174+30 4
57 4
~ 69 4
(1 67-4 43)
~-
Group 2 (Cdrbimarole)
-
~
~~
T3 7 9 0 k 2 821 (nmolil) (7 74-12 94)
32 8
(130-261) ~
~
4 1 6 2 1 385
47 3
(2 44-7 42)
of this period. Patients were specifically questioned about their major symptoms but a diagnostic index suitable for later analysis was not used. Many patients in Group 1 felt considerably better after two weeks' treatment but this was an infrequent observation from Group 2. The mean serum lithium level at the end of the two week treatment period was 0.42 mmol/l (range 0.15-0.65 mmol/l). No toxic serum lithium levels were obtained and no patients in either treatment group complained of any adverse drug effects. Discussion
The most rational approach to the initial management of severe thyrotoxicosis is to reduce the level of circulating thyroid hormone rapidly. Thionamide (carbimazole or propylthiouracil) treatment alone is sufficient for the mildly thyrotoxic patient but in severe thyrotoxicosis control may not be achieved for some 4-8 weeks.'. This study demonstrates the rapid fall in thyroid hormone levels that may be achieved by using low dose lithium as an adjunct to carbimazole treatment. Possible subsequent radioiodine treatment is not delayed as it may be after the use of potassium iodide with thionamide to obtain rapid control. The mean percentage fall in serum T3 and T4 levels (69.4% and 57.4% respectively) in patients treated with low dose Li-carbimazole is comparable to that obtained using a combination of carbimazole and potassium iodide7, or a combination of carbimazole and a higher dose of
629
lithium.' Earlier workers suggested that it was important to obtain a significant serum lithium level8, comparable to that aimed for in the treatment of manic depressive illness, and lithium side-effects were frequent4 The serum lithium levels that were obtained in our study did not ~ approach the _ therapeutic range for psych~ iatric illness. This suggests that the generally accepted therapeutic serum lithium level is not appropriate when lithium is used as an adjunct to carbimazole treatment, and it is possible that even a lower dose of lithium could be effective (e.g. 200 mg of lithium carbonate daily). Although no adverse effects were encountered, weekly serum lithium determination should be performed even on the low dose regimen. Lithium is perhaps best avoided in patients with complicating metabolic disease, e.g. renal failure, untreated cardiac failure or unstable diabetes because of the increased risk of lithium toxicity. After two weeks of lithium-carbimazole treatment, six of the 15 patients had normal serum T4 and T3 levels. Perhaps the remaining nine patients could have benefited from a third week of lithium. After the lithium was discontinued, carbimazole was continued at 40 mg daily. When patients were reviewed 2-4 weeks afterwards the thyroid function tests were frequently in the hypothyroid range, and the dose of carbimazole had to be curtailed to a 5-10 mg maintenance dose. None of the patients became clinically hypothyroid, but it would seem likely that this may have occurred if the lithium had been continued for longer than the initial two weeks. This study has shown that low dose Licarbimazole is a safe and effective method of obtaining rapid control of severe thyrotoxicosis. On theoretical grounds Li-propylthiouracil may offer a more potent combination of antisecretory drugs, as propylthiouracil also blocks the peripheral conversion of thyroxine to tri-iodothyronine.' Although we have found ldw dose lithium to be safe, it is suggested that its use should be reserved for the grossly thyrotoxic patient when rapid control is desirable. Acknowledgements
This study was supported by the New Zealand Medical Research Council to whom we are grateful. We wish to acknowledge the invaluable technical assistance of the staff of the Nuclear Medicine Department, Christchurch Hospital
630
HEDLEY ET AL.
and Mrs. R. Fisher who helped prepare the manuscript. We also thank Tasman Vaccine Laboratories, NZ for the supply of Priadel, Mrs. D Hinton for the serum lithium measurements and the physicians of the Christchurch area who referred their patients. References 1. DANOWSKI, T. S , MAN,E. B. and WINKLER, A S (1946).Additive effects of rodine and thiourea In the treatment of hyperthyroidism, J . clm Invesr. 25, 597. 2. SPAUI-DING. S. W., BURROW, G . N.. BERMUUEZ, F. and HIMMEI.HOCH, J M (1972):The inhibitory effect of lithium on thyroid hormone release in both euthyroid and thyrotoxic patients, J . d i n Endocr 35, YOS
Aust. N.Z. J. Med. 119781. 8.
1
VOL.
8,
NO.
6
3. LAZARUS, J. H., RICHARDS. A R , AOOlWX, G M and OwrN. G. M. (1974) Treatment of thyrotoxicosis with lithium carbonate, Lunwr 2, I I60 4. K R I S T ~ N S 0 O ~. ,HARRtSTRUP ANDERSON, H. and PALLISGAARO.G. (1976). Lithium carbonate in the treatment of thyrotoxicosis, ~ I I L C I1, 603. 5. H A I L . R . ~ ~ ~ E V E R E O . DLithiuminthyrotoxicos,s, .C.(I~~~): Lanccr2,1521 6 SADLER,W. A. and BROWNLIE, B. E. W. (1975): 'Tri-iodothyronine radioimmunoassayin theassessment ofthyroid function, N.Z. med. J. 81,328. 7 . TLIRNSK, J. G . , BROWNLIE, 9. E. W., SADLEK, W A. and JENSPY, C. H (1976). An evaluation of lithium as an adjunct to carblmazole treatment in acute thyrotoxicosis, Acra endocr. (Kbh) 83, 86. 8 TFMPLE, R.,BEKMAN, M , CARLSON, H . E. and ROBBINS, J (1972):The use of lithium in Graves' disease, Muyo Clin. Proc. 47, 872 9. Asbin. J and LARSFN,P. R (1974):Tri-iodothyronine and thyroxine in hyperthyroidism, J . clin Invest. 54,201
00.630-638
Progesterone and Oestrogen Receptors in Human Breast Cancer 1. M. Holdaway" and K. 6 . Mountjoyf
From the Section of Endocrinology, Department Qf Medicine, Auckland Hospital, New Zealand
SUmmary: Progesterone and oestrogen receptors in human breast cancer. I. M. Holdaway and K. G. Mountjoy, Aust. N.Z. J. Med.. 1978, 8, pp. 630-638. Receptors for progesterone were found in
27% of 98 human breast tumours, and for oestrogen in 57% of 791 tumours. With one exception, progesterone receptors were found only in tumours which also contained oestrogen receptors. levels of oestrogen receptor in positive tumours rose significantly with patient age whereas progesterone receptors were unchanged. Progesterone receptor levels were lower i n lymph node metastases than in primary tumours, and oestrogen receptor levels were lower in large tumours (> 5 cm diameter) compared to small lesions. Receptor levels were not significantly correlated with cir culating concentrations of either oestrogen or prolactin. The implications of receptor measurements in assessing hormone responsiveness of breast tumours are discussed.
A proportion of human breast tumours are known to regress following hormonal manipulation and this observation has been applied clinically in the treatment of patients with disseminated disease. The mechanism by which endocrine treatment acts is still uncertain. It has been shown that steroid hormones stimulate _____ Endocrinologist tscientific Officer Correspondence. Dr. I . M. Holdaway. Section of Endocrinology, Auckland Hospital, Auckland I , New Zealand Accepted for publication: 13 July, 1978
target tissues such as the breast through initial binding to a cytosol receptor protein, translocation of the steroid-receptor complex to the cell nucleus, and stimulation of DNA-directed, RNA-mediated protein synthesis.' It is therefore of interest that cytosol receptors for oestrogen' and progesterone3 have been detected in human breast tumours, and claims have been made that the presence or absence of these receptors allows the clinician to predict the likelihood of response to endocrine manipulation of patients with breast The present paper reports the detection of progesterone (PR) and oestrogen (ER) receptors in human breast tumours and the relationship of receptor levels to a number of clinical factors. Methods Tumour collection: After removal from the patient, tumour tissue was placed in a dry container on ice and transferred to
the pathology department where the pathologist allotted separate portions for histological study and receptor determination. The sample was then wrapped in foil. snap-frozen and stored at - 70 C until assay, The total time on ice until the specimen was frozen was about 30 min. Storage for a minimum of two to three days before assay allowed time for the pathologist to recall the sample in case the histological aliquot was unsatisfactory. Where there was doubt about the neoplastic nature of the specimen received for receptor assay, a small piece of tissue from the centre of the sample was sent for independent histological examination. Preparation of' receptor: The tumour was thawed, surrounding fat tissue was removed and the sample was weighed and minced finely with scissors. Five volumes (voliwt) of cold buffer (0.01 M tris HCL, 0.0015M EDTA, 0.0025M dithiothreitol, pH 7 . 4 ) were added and the sample homogenised with a Polytron homogeniser for 30 sec keeping the container surrounded by crushed ice at all times. The crude homo-
Low Dose Lithium-Carbimazole in the Treatment of Thyrotoxicosis , J. M. Hedley", J. G. Turnert, B. E. W. Brownlief and W. A. Sadler**
From the Department of Nuclear Medicine, Christohurch Hospital, Christchurch, New Zealand
Summary: Low dose lithium-carbimazole in the treatment of thyrotoxicosis. J. M. Hedley, J . G. Turner, B. E. W. Brownlie and W. A. Sadler. Aust. N.Z.J. Med., 1978, 8, pp. 628-630.
carbimazole treatment in the management of thyrotoxicosis. Patients and Methods
Fifteen patients with thyrotoxicosh were treated with l o w dose sustained release lithium carbonate 400 mg, combined with carbimazole 40 mg daily, and the therapeutic response was followed over a t w o week period. This response was cbmpared with that obtained in a similar group of patient treated with carbimazole alone. Licarbimazole treatment brought about a fall in the mean total serum T 4 of 57.4% compared with a drop of 32.8% in patients treated with carbimazole alone. The mean serum T 3 fell by 69.4%in the Li-carbimazole group compared with 47.3% in the group treated with carbimazole only. No lithium adverse effects were encountered.
Antithyroid drug treatment with carbimazole alone relies on the depletion of intrathyroidal hormone stores and is unable to render an acutely thyrotoxic patient euthyroid before several weeks.' Lithium exerts its antithyroid effect primarily by blocking the release of preformed thyroid hormone2 and has been found to be effective when used alone3s4 in the treatment of thyrotoxicosis. The doses used in this manner have been similar to those used in manic depressive illness and side effects were frequent? This had led to disenchantment with the use of lithium as an antithyroid drug.' In this study low dose lithium carbonate (sustained release preparation-Priadel, Delandale/TVL) was evaluated as an adjunct to *Registrar. +Senior Registrar. :Physician in Charge. "Radiochemist. Correspondence; Dr. B. E. W. Brownlie, Physician in Charge, Department of Nuclear Medicine, Christchurch Hospital, Christchurch, New Zealand Accepted for publication: 24 July. 1978
Thirty thyrotoxic patients were studied, all had diffuse hyperplasia on 99n1Tcthyroid scan and it was the first episode of thyrotoxicosis in all patients. The patients were moderate to severely thyrotoxic on clinical and biochemical grounds. Two treatment groups were studied. Group I (Li-carbimazole) Fifteen patients were treated with carbimazole, I0 mg qid plus lithium carbonate (sustained release) 400 mg mane for 14 days. All patients treated with lithium had normal serum electrolytes prior to entering the trial. No, patients with untreated heart failure or serious metabolic problems were studied. Venous blood was drawn for thyroid function assessment prior to the initiation of treatment and again at two weeks. Venous blood samples were taken for serum lithium estimations after seven and 14 days treatment. Group 2 (Carbimazole) A comparable group of 15 patients were treated with carbimazole alone in a dose of 10 mg qid. These patients were matched with those of Group 1 for the initial serum thyroxine (T4) values, in a retrospective manner, without knowledge of patients' names. Where possibie the patients were also matched for serum tri-iodothyronine (T3) values. Radioimmunoassav techniques were. used to obtain total T4 estimations (normal range 55-140 nmolil) and total T36 (1.2-2.7 nmol/l). Serum lithium estimations were performed by atomic absorption spectrophotometry. Statistical analysis was carried out using the student /-test for unpaired variates, and covariance analysis. Results
Thyroid function results are summarised in Table I . The pretreatment mean T4 levels for the two groups were not different. After two weeks' treatment the mean T4 level in the Licarbimazole group was, significantly lower than that for the carbimazole alone group ( P < 0.001). The mean pretreatment T3 level was statistically higher in the Li-carbimazole group, but the post-treatment T3 mean was significantly lower ( P < 0.001). Six of the 15 patients in the Li-carbimazole group (Group 1) had normal serum T4 and T3 levels after two weeks' treatment, but no patients in Group 2 had normal biochemistry at the end
DECEMBER,
1978
LOW DOSE LI-CARBIMAZOLE IN THYROTOXICOSIS
TABLE 1 Biochemical response after 2 weeks' treatment ~
~~~
Pretreatment . -
(Li-carbnnazole)
_
--
"
drop
~
T4 249 i 4 4 7 ( 1 SD) (nmolll) (185-324)
Group I
14 Days
l06+39 9 ( I SD) (18-183)
_
7 3 9 4 2 k 3 757 (nmol I ) ( 7 10-15 54)
2 8 8 k 0 968
T4 259+53 5 (nmol I ) (194-376)
174+30 4
57 4
~ 69 4
(1 67-4 43)
~-
Group 2 (Cdrbimarole)
-
~
~~
T3 7 9 0 k 2 821 (nmolil) (7 74-12 94)
32 8
(130-261) ~
~
4 1 6 2 1 385
47 3
(2 44-7 42)
of this period. Patients were specifically questioned about their major symptoms but a diagnostic index suitable for later analysis was not used. Many patients in Group 1 felt considerably better after two weeks' treatment but this was an infrequent observation from Group 2. The mean serum lithium level at the end of the two week treatment period was 0.42 mmol/l (range 0.15-0.65 mmol/l). No toxic serum lithium levels were obtained and no patients in either treatment group complained of any adverse drug effects. Discussion
The most rational approach to the initial management of severe thyrotoxicosis is to reduce the level of circulating thyroid hormone rapidly. Thionamide (carbimazole or propylthiouracil) treatment alone is sufficient for the mildly thyrotoxic patient but in severe thyrotoxicosis control may not be achieved for some 4-8 weeks.'. This study demonstrates the rapid fall in thyroid hormone levels that may be achieved by using low dose lithium as an adjunct to carbimazole treatment. Possible subsequent radioiodine treatment is not delayed as it may be after the use of potassium iodide with thionamide to obtain rapid control. The mean percentage fall in serum T3 and T4 levels (69.4% and 57.4% respectively) in patients treated with low dose Li-carbimazole is comparable to that obtained using a combination of carbimazole and potassium iodide7, or a combination of carbimazole and a higher dose of
629
lithium.' Earlier workers suggested that it was important to obtain a significant serum lithium level8, comparable to that aimed for in the treatment of manic depressive illness, and lithium side-effects were frequent4 The serum lithium levels that were obtained in our study did not ~ approach the _ therapeutic range for psych~ iatric illness. This suggests that the generally accepted therapeutic serum lithium level is not appropriate when lithium is used as an adjunct to carbimazole treatment, and it is possible that even a lower dose of lithium could be effective (e.g. 200 mg of lithium carbonate daily). Although no adverse effects were encountered, weekly serum lithium determination should be performed even on the low dose regimen. Lithium is perhaps best avoided in patients with complicating metabolic disease, e.g. renal failure, untreated cardiac failure or unstable diabetes because of the increased risk of lithium toxicity. After two weeks of lithium-carbimazole treatment, six of the 15 patients had normal serum T4 and T3 levels. Perhaps the remaining nine patients could have benefited from a third week of lithium. After the lithium was discontinued, carbimazole was continued at 40 mg daily. When patients were reviewed 2-4 weeks afterwards the thyroid function tests were frequently in the hypothyroid range, and the dose of carbimazole had to be curtailed to a 5-10 mg maintenance dose. None of the patients became clinically hypothyroid, but it would seem likely that this may have occurred if the lithium had been continued for longer than the initial two weeks. This study has shown that low dose Licarbimazole is a safe and effective method of obtaining rapid control of severe thyrotoxicosis. On theoretical grounds Li-propylthiouracil may offer a more potent combination of antisecretory drugs, as propylthiouracil also blocks the peripheral conversion of thyroxine to tri-iodothyronine.' Although we have found ldw dose lithium to be safe, it is suggested that its use should be reserved for the grossly thyrotoxic patient when rapid control is desirable. Acknowledgements
This study was supported by the New Zealand Medical Research Council to whom we are grateful. We wish to acknowledge the invaluable technical assistance of the staff of the Nuclear Medicine Department, Christchurch Hospital
630
HEDLEY ET AL.
and Mrs. R. Fisher who helped prepare the manuscript. We also thank Tasman Vaccine Laboratories, NZ for the supply of Priadel, Mrs. D Hinton for the serum lithium measurements and the physicians of the Christchurch area who referred their patients. References 1. DANOWSKI, T. S , MAN,E. B. and WINKLER, A S (1946).Additive effects of rodine and thiourea In the treatment of hyperthyroidism, J . clm Invesr. 25, 597. 2. SPAUI-DING. S. W., BURROW, G . N.. BERMUUEZ, F. and HIMMEI.HOCH, J M (1972):The inhibitory effect of lithium on thyroid hormone release in both euthyroid and thyrotoxic patients, J . d i n Endocr 35, YOS
Aust. N.Z. J. Med. 119781. 8.
1
VOL.
8,
NO.
6
3. LAZARUS, J. H., RICHARDS. A R , AOOlWX, G M and OwrN. G. M. (1974) Treatment of thyrotoxicosis with lithium carbonate, Lunwr 2, I I60 4. K R I S T ~ N S 0 O ~. ,HARRtSTRUP ANDERSON, H. and PALLISGAARO.G. (1976). Lithium carbonate in the treatment of thyrotoxicosis, ~ I I L C I1, 603. 5. H A I L . R . ~ ~ ~ E V E R E O . DLithiuminthyrotoxicos,s, .C.(I~~~): Lanccr2,1521 6 SADLER,W. A. and BROWNLIE, B. E. W. (1975): 'Tri-iodothyronine radioimmunoassayin theassessment ofthyroid function, N.Z. med. J. 81,328. 7 . TLIRNSK, J. G . , BROWNLIE, 9. E. W., SADLEK, W A. and JENSPY, C. H (1976). An evaluation of lithium as an adjunct to carblmazole treatment in acute thyrotoxicosis, Acra endocr. (Kbh) 83, 86. 8 TFMPLE, R.,BEKMAN, M , CARLSON, H . E. and ROBBINS, J (1972):The use of lithium in Graves' disease, Muyo Clin. Proc. 47, 872 9. Asbin. J and LARSFN,P. R (1974):Tri-iodothyronine and thyroxine in hyperthyroidism, J . clin Invest. 54,201
00.630-638
Progesterone and Oestrogen Receptors in Human Breast Cancer 1. M. Holdaway" and K. 6 . Mountjoyf
From the Section of Endocrinology, Department Qf Medicine, Auckland Hospital, New Zealand
SUmmary: Progesterone and oestrogen receptors in human breast cancer. I. M. Holdaway and K. G. Mountjoy, Aust. N.Z. J. Med.. 1978, 8, pp. 630-638. Receptors for progesterone were found in
27% of 98 human breast tumours, and for oestrogen in 57% of 791 tumours. With one exception, progesterone receptors were found only in tumours which also contained oestrogen receptors. levels of oestrogen receptor in positive tumours rose significantly with patient age whereas progesterone receptors were unchanged. Progesterone receptor levels were lower i n lymph node metastases than in primary tumours, and oestrogen receptor levels were lower in large tumours (> 5 cm diameter) compared to small lesions. Receptor levels were not significantly correlated with cir culating concentrations of either oestrogen or prolactin. The implications of receptor measurements in assessing hormone responsiveness of breast tumours are discussed.
A proportion of human breast tumours are known to regress following hormonal manipulation and this observation has been applied clinically in the treatment of patients with disseminated disease. The mechanism by which endocrine treatment acts is still uncertain. It has been shown that steroid hormones stimulate _____ Endocrinologist tscientific Officer Correspondence. Dr. I . M. Holdaway. Section of Endocrinology, Auckland Hospital, Auckland I , New Zealand Accepted for publication: 13 July, 1978
target tissues such as the breast through initial binding to a cytosol receptor protein, translocation of the steroid-receptor complex to the cell nucleus, and stimulation of DNA-directed, RNA-mediated protein synthesis.' It is therefore of interest that cytosol receptors for oestrogen' and progesterone3 have been detected in human breast tumours, and claims have been made that the presence or absence of these receptors allows the clinician to predict the likelihood of response to endocrine manipulation of patients with breast The present paper reports the detection of progesterone (PR) and oestrogen (ER) receptors in human breast tumours and the relationship of receptor levels to a number of clinical factors. Methods Tumour collection: After removal from the patient, tumour tissue was placed in a dry container on ice and transferred to
the pathology department where the pathologist allotted separate portions for histological study and receptor determination. The sample was then wrapped in foil. snap-frozen and stored at - 70 C until assay, The total time on ice until the specimen was frozen was about 30 min. Storage for a minimum of two to three days before assay allowed time for the pathologist to recall the sample in case the histological aliquot was unsatisfactory. Where there was doubt about the neoplastic nature of the specimen received for receptor assay, a small piece of tissue from the centre of the sample was sent for independent histological examination. Preparation of' receptor: The tumour was thawed, surrounding fat tissue was removed and the sample was weighed and minced finely with scissors. Five volumes (voliwt) of cold buffer (0.01 M tris HCL, 0.0015M EDTA, 0.0025M dithiothreitol, pH 7 . 4 ) were added and the sample homogenised with a Polytron homogeniser for 30 sec keeping the container surrounded by crushed ice at all times. The crude homo-
