840
advantages could possibly be outweighed by factors such as electrolyte disturbance due to diarrhoea, interference with the absorption and activity of other drugs, overgrowth of inadequately suppressed potential pathogens, or absorption of toxic antibiotics. In the present study the only variable between groups nursed in simple protective isolation in specially designed leukaemia units was the administration of FRACON to one of the groups. Very few patients were unable to tolerate the regimen. Diarrhoea was the only major sideeffect and it was controlled with codeine phosphate given intravenously because oral antidiarrhoeals proved unsatisfactory. The somewhat better survival-rate of the FRACON group demonstrates that there was little interference with other drugs or toxicity. The reduced incidence of infection indicated that disturbing the microbial flora had no detrimental effects. The absence of E. coli septicaemias in the FRACON group shows that sepsis was reduced by intestinal decontamination. The benefits of FRACON treatment were, first, fewer deaths from infection, giving a potentially longer period for the treatment of the primary disease. Secondly, a reduction in the number of febrile days and infectious episodes reduced the need for therapeutic use of systemic antibiotics. This improves the patient’s comfort and saves money. The absence of perianal sepsis in the FRACON group is especially important since this complication, unless treated by measures such as temporary colostomy and granulocyte transfusions, is often fatal in
neutropenic patients. We chose FRACON for decontamination, rather than the more commonly used combination of gentamicin, vancomycin, and nystatin (G.V.N.), because it costs about one tenth the price of G.V.N. and because we regard gentamicin as a valuable therapeutic agent and are loath to use it prophylactically and topically. The Baltimore team8 have already reported the development of gentamicin-resistant Ps. ceruginosa in some patients receiving oral gentamicin, whereas this problem was never encountered in any of our trial patients. Indeed, selection of organisms resistant to our most potent systemic antibiotics, particularly as the result of topical application, may outstrip the introduction of new antibiotics, and the prevention of infection will then assume even greater importance. These reservations do not apply to the antiseptic chlorhexidine, which was used to suppress the microflora of sites unaffected by the oral antibiotics. We found that FRACON combined with simple protective isolation in specially designed leukaemia units was useful in preventing infection in A.N.L.L. It allows antileukaemic therapy to proceed in patients who would otherwise die of infection and may well assist the introduction of more effective treatment to improve the ultimate prognosis in this almost invariably fatal disease. We thank all our clinical colleagues including Prof. D. A. G. GalJ. M. Goldman, and Dr D. Catovsky, for permission to study their patients; the nursing staff and patients for willing cooperation; our technical staff, especially Mr D. Adams, for valuable contributions to the microbiological methodology; Dr H. E. M. Kay, for his helpful advice; and Miss L. Gleave for her patient secretarial assistance. The Leukaemia Research Fund made this study possible by generous grants to H.G. and B.J. ton, Dr
Requests for reprints should be addressed to H.G., Department of Bacteriology, St. Mary’s Hospital Medical School, London W2 1PG.
PROLACTIN, ŒSTROGEN, AND LIPIDS IN BREAST FLUID P. HILL
E. L. WYNDER
Naylor Dana Institute for Disease Prevention, American Health Foundation, Valhalla, New York 10595, U.S.A.
Concentrations of prolactin, œstrogens, and lipids were measured in the plasma and breast-duct fluid of 8 non-lactating premenopausal women without a known history of breast disease. Concentrations of prolactin, œstrogen, and triglycerides were significantly higher in ductal fluid than in plasma, but there was little difference with cholesterol concentration. The high concentrations of prolactin and œstrogen found in the ductal fluid of Western women may be relevant to development of breast cancer.
Summary
Introduction EPIDEMIOLOGICAL evidence suggests that dietary and endocrine factors alter the risk of breast cancer Hence, many attempts have been made to correlate specific changes in the hormonal environment in populations with increased or reduced risk of breast cancer, and with different patterns of food intake. The results of such studies have underlined the influence of diet and lifestyle on hormone production, metabolism, and excretion.3-s However, such studies have not contributed any direct information about the nature of the carcinogenic stimulus or on the mechanism by which various combinations of hormones might stimulate the development of a breast tumour. Aetiological agents were not identified when the excretory metabolites of oestrogens and androgens in high and low risk populations or from breast-cancer patients and normal controls were measured. Sensitive and specific radioimmunoassay have shifted attention to the plasma, the hormone profile of which physiologically affects the breast. However, the ductal fluid is in constant contact with the ductal epithelium, the site of development of most breast cancer. Ductal fluid contains lactose, lactalbumin, cholesterol, fatty acids, and peroxidised lipids.6 It may also contain 7agents which influence the development of breast cancer.’ Since oestrogen and prolactin are central to the induction and development of experimental breast cancer,’ we studied the hormonal content of this fluid in Caucasian women in whom the risk of breast cancer is high. We measured prolactin, oestrogens, and lipids in the breast
Levine, A. S., Schimpff, S. C., Graw, R. G., Jr., Young, R. C. Sem. hœmat 1974, 11, 141. 2. Bodey, G. P., Gehan, E. A., Freireich, E. J., Frei, E., III, Am. J. med. Sci 1971, 262, 138. 3. Levine, A. S., Siegel, S. E., Schreiber, A. D., Hauser, J., Preisler, H. D, Goldstein, I. M., Seidler, F., Simon, R., Perry, S., Bennett, J. E., Henderson, E. New Engl. J. Med. 1973, 288, 477. 4. Schimpff, S. C., Greene, W. H., Young, V. M., Fortner, C. L., Jepsen, L. Cusack, N., Block, J. B., Wiernik, P. H. Ann. intern. Med. 1975, 82, 351 5. Yates, J. W., Holland, J. F. Cancer, 1973, 32, 1490. 6. Klastersky, J., Debusscher, L., Weerts, D., Danneau, D. Path. Biol., Paris. 1974, 22, 5. 7. Jameson, B., Gamble, D. R., Lynch, J., Kay, H. E. M. Lancet, 1971, i, 1034. 8. Greene W. H., Moody, M., Schimpff, S. C., Young, V. M., Wiernik, P. H Ann. intern. Med. 1973, 79, 684. 1.
841
fluid of no
non-lactating premenopausal
women
who had
known history of breast disease.
Methods In
an
ongoing study
of 100
premenopausal
women,
we
obtained some ductal fluid from approximately 50% of the Caucasian women. Of these secretors, 50% secreted 50 N1 of fluid, and 10% secreted as much as 400 P of fluid. Women from the latter group were used in this study. Blood and breast fluid were obtained weekly in the morning from 8 healthy premenopausal non-puerperal women. 50-400 pd of fluid could be obtained at each weekly visit. Breast fluid was obtained by the nipple-aspiration method of Sartorius.7 Samples were run in duplicate and assayed at two different dilutions. The prolactin in the plasma and breast fluid was determined by radioimmunoassay (R.i.A.) by means of human prolactin (Lewis HPRL V-L-5 No. 2) as previously described,5 except that the lipids were extracted before prolactin assay. CEstradiol and cestrone were determined by the cytosol protein-binding method of Nagai and Longcope after separation on ’Sephadex’ LH 20.9 The sensitivity of this assay is 5 pg/ml with an intra-assay and inter-assay coefficient of variation of less than 5%. Cholesterol and cholesterol esters in the breast fluid were determined fluorometrically.1O Plasma cholesterol and triglyceride concentrations were determined by standard Technicon AutoAnalyzer methods.
Results
Prolactin, cestrogen (oestradiol and oestrone), cholesterol, and triglyceride concentrations in breast fluid and in plasma are shown in figs. 1 and 2. Prolactin and oestrogen concentrations
were
the breast fluid than in the
several times greater in
plasma. Breast-fluid prolac-
Fig.
I-Prolactin and cestrogen concentrations in breast fluid and plasma in eight premenopausal women sampled weekly for five weeks.
Results given as mean+s.E.M.
Fig.
2-Cholesterol and triglyceride concentrations in breast 8uid and plasma in eight premenopausal women sampled weekly for five weeks.
Results given as mean±s.E.M.
not vary during the menstrual in breast fluid and concentrations Cholesterol cycle. serum were comparable and much higher than in breast milk." In breast fluid, which was viscous in our subjects, the concentration of cholesterol esters (free/ esterified cholesterol ratio 3/2) was high and resembled that in the plasma. The concentration of triglyceride in breast fluid was also high.
tin concentration did
Discussion
70% of premenopausal Caucasian women and 24% of Chinese women secrete some ductal fluid.7 Petrakis et al. suggested that the ability to secrete breast fluid may be related to the different incidence-rates in breast cancer between Caucasian and Chinese women. In an ongoing study of 100 premenopausal women, we obtained some ductal fluid from approximately 50% of the Caucasian women. Of these secretors, 50% secreted 50 .1 of fluid and 10% secreted as much as 400 pi of fluid. Women from the latter group were used in this study. If agents which influence the development of breast cancer are present in the breast fluid, it is possible that high-volume secretors are at increased risk of breast cancer. The type of fatty acid in breast fluid has been reported to be directly related to the type of dietary fatty acids consumed.12 Thus, the composition of the ductal fluid seems to be affected by dietary and other environmental factors. Knowledge of the constituents of ductal fluid will be of value in determining the agents involved in both the induction and promotion phases of breast carcinogenesis. It remains to be demonstrated whether carcinogenic agents are present in these fluids. The breast-duct fluid may provide an environment in which breast epithelial cells may be exposed to relatively high local concentrations of carcinogens, co-carcinogens, or promoters over relatively long periods; this exposure may increase the probability of mutation or a carcinogenic event occurring in ductal cells. 12 In the rat model high fat intake is associated with both a high prolactin/oestrogen ratio in the plasma and enhanced breast-tumour development.13.14 In view of such observations and because plasma-prolactin has been shown to be altered by diet in man as well, 1 we propose that high fat intake, typical of the Western diet but not the Japanese diet, promotes the growth of preneoplastic lesions’6 by specifically altering the concentrations of prolactin and oestrogen in the ductal fluid. There are many published reports dealing with prolactin and breast cancer in both animal models and man.8.17-19 We do not know the extent to which the high incidence of invasive intraductal breast cancer in Caucasian (compared with Asian) women is related to the presence and/or composition of the breast fluid. Possible qualitative and quantitative differences in breast-fluid composition of high and low risk populations should be investigated. A comparison of breast fluid in the involved and uninvolved breasts of cancer patients, in patients with ductal hyperplasia, and in daughters of women with breast cancer would be of considerable interest. Requests for reprints should be addressed to E. L. W., American Health Foundation, 1370 Avenue of the Americas, New York, N.Y. 10019, U.S.A.
842
GROWTH-HORMONE DEFICIENCY IN CONGENITAL RUBELLA M. A. PREECE P. J. KEARNEY W. C. MARSHALL
Departments of Growth and Development and Microbiology, Institute of Child Health, University of London, and Royal Hospital for Sick Children, Bristol
boys with congenital rubella and concomitant growth-hormone deficiency responded to human-growth-hormone replacement and have already (over a period of 18 mo) achieved a significant increase in height. The association of these two diagnoses requires recognition so that treatable endocrine disorders, which are becoming recognised more often in congenital rubella, are always positively excluded when affected children with inexplicable short
Summary
Two
stature are seen.
Introduction
growth retardation is common in conrubella,1,2 although children affected in utero but genital without signs of damage at birth are usually of normal birth-weight.33 Postnatal growth retardation also occurs.4,5 Michaels and Kenny6 reported longitudinal growth studies for 15-33 mo in sixteen infants with congenital rubella. They described three growth patterns. Nine children remained small but grew at normal speed, five showed catch-up growth, and the remaining two showed a progressive deceleration in growth-rate. Investigations of thyroid, adrenal, and pituitary function in INTRAUTERINE
these children revealed no abnormalities. It has generally been held that growth retardation in congenital rubella is not due to a disturbance of endocrine function but rather to the direct effect of the virus on the rate of cell division. We now describe two patients in whom growth-hormone deficiency has been associated with congenital rubella. The response of both children to treatment with exogenous growth hormone for 18 mo is also described.
E. L., Bross, V., Hirayama, T. Cancer, 1960, 13, 559. Carroll, K. K., Khor, H. T. in Progress in Biochemical Pharmacology, Lipids and Tumors (edited by K. K. Carroll); p. 308. New York, 1975. 3. MacMahon, B. J. natn. Cancer Inst. 1973, 50, 21. 4. Dickinson, L. E., MacMahon, B., Cole, P., Brown, J. B. New Engl. J. Med. 1974, 219, 1211. 5. Hill, P., Wynder, E. L., Kumar, H., Helman, P., Rona, R., Kuno, K. Cancer Res. 1976, 35, 4102. 6. Petrakis, N. L. 1st Breast Cancer Task Force Working Conference, National Cancer Institute, Williamsburg, Virginia, February, 1973. 7. Petrakis, N. L., Mason, L., Lee, R., Sugimoto, B., Pawson, S., Catchpool, F. J. natn. Cancer Inst. 1975, 54, 829. 8. Pearson, O. H. in Current Research in Oncology (edited by C. B. Anfinson, M. Potter, and A. N. Schechter); p. 125, New York, 1972. 9. Nagai, N., Longcope, C. Steroids, 1971, 1, 631. 10. Alberts, R. W., Lowry, O. H. Analyt. Chem. 1955, 27, 1829. 11. Potter, J. M., Nestel, P. F. Am. J. clin. Nutr. 1976, 29, 54. 12. Petrakis, N. L., Mason, M. L., Doherty, M., Dupuy, M. D., Sadee, G., Wilson, C. S. Fedn Proc. 1977, 37, abstr. 4714. 13. Chan, P., Didato, F., Cohen, L. Proc. Soc. exp. Biol. Med. 1975, 149, 133. 14. Chan, P., Head, J. F., Cohen, L. A., Wynder, E. L. J. natn. Cancer Inst. (in the press). 15. Hill, P., Wynder, E. L. Lancet, 1976, ii, 806. 16. Wellings, S. R., Jensen, H. M., Marcum, R. G. J. natn. Cancer Inst. 1975, 55, 231. 17. Meites, J., Lu, K. H., Wuttke, W., Welsch, C. W., Nagasawa, H., Quadri, S. K. Rec. Prog. Hormone Res. 1973, 28, 471. 18. Welsch, E. W., Nagasawa, H. Cancer Res. 1977, 37, 951. 19. Robyn, C. Path. Biol., Paris, 1973, 23, 783. 1. 2.
Wynder,
Methods All the physical measurements quoted were carried out in the growth-disorder clinic of the Hospital for Sick Children, Great Ormond Street, by methods previously described.’ The biochemical investigations were done at the Royal Hospital for Sick Children, Bristol, in the first case and at the Hospital for Sick Children, Great Ormond Street, in the second. Serumgrowth-hormone was measured during an insulin-tolerance test and was assayed by radioimmunoassay (1st i.R.p. as standard). Serum-thyroxine and serum-cortisol were measured bv competitiye-protein-binding assay. In the second case, the insu lin-tolerance test was combined with an injection of thyrotrophin-releasing hormone (T.R.H.), 200 jig, and luteinising-hormone-releasing hormone (L.H.R.H.), 100 µg. Thyrotrophin (T.S.H.), luteinising hormone (L.H.), and follicle-stimulating hormone (F.S.H.) were assayed by radioimmunoassay against their respective 1st I.R.P. standards.
Case-reports Case1 This boy was born after a normal term third pregnancy. The mother had no illness or history of contact with rubella during the pregnancy. Birth-weight was 2.9 kg. At age 8 mo he presented to hospital with failure to thrive. Feeding was poor, but there were no other specific symptoms. Sensorineural deafness was detected, and fundal examination revealed typical changes of rubella retinopathy. A rubella hsemagglutination-inhibiting (H.I.) antibody titre of 1/16 000 was demonstrated in his serum. As he was already considerably below the 3rd centile for height and was continuing to grow at a subnormal rate, he was further investigated at age 3 yr. On that occasion an inadequate growth-hormone response to insulin hypoglycaemia was demonstrated, but no other endocrine abnormalities were present. These investigations were repeated 3 yr later when, once again, growth-hormone production was abnormal, with a peak of 1.mi.u./l. He was first seen in the growth-disorder clinic at the Hospital for Sick Children, Great Ormond Street, when he was 6.16 yr of age, at which time his height was 6.6 standard deviations below the mean. He had all the clinical features of growth-hormone deficiency, with high skinfold thickness (reflecting an excess of subcutaneous fat) and hypoplastic genitalia, previously described in association with growth-hormone deficiency.s He had bilateral sensorineural deafness and the retinal changes of congenital rubella. Over the subsequent months his growth was assessed at 3-monthly intervals (see figure), and his stature velocity was 3.4 cm/yr—2.8 standard deviations below the mean for his age. At 705 yr he was started on human-growth-hormone replacement at a dose of 5 LU. three times weekly, and over the next 12 mo his growth velocity increased to 146 cm/yr, which is 11.0standard deviations above the mean for his age. During the same period his subcutaneous fat, as indicated by skinfold thickness at the triceps and subscapular sites, fell from a mean of +07 to -09 standarddeviation units. This is a typical response in severe growthhormone deficiency. After 18 mo treatment his stature (104.1 cm) is 4.3 standard deviations below the mean. Case 2 This boy was born after a 37 wk, but otherwise uneventful second pregnancy. Birth-weight was 2-66 kg. There was no history of rubella or contact with rubella in pregnancy. At age 21 mo he was admitted to the Hospital for Sick Children. Great Ormond Street, for investigation of mental retardation. At this time he was found to have bilateral sensorineural deafness and a mild hypochromic anaemia. At 6 yr he was reported to have the retinal pigmentation typical of congenital rubella. but there were no other clinical features of this condition. apart from severe bilateral deafness. Serological tests revealed
advantages could possibly be outweighed by factors such as electrolyte disturbance due to diarrhoea, interference with the absorption and activity of other drugs, overgrowth of inadequately suppressed potential pathogens, or absorption of toxic antibiotics. In the present study the only variable between groups nursed in simple protective isolation in specially designed leukaemia units was the administration of FRACON to one of the groups. Very few patients were unable to tolerate the regimen. Diarrhoea was the only major sideeffect and it was controlled with codeine phosphate given intravenously because oral antidiarrhoeals proved unsatisfactory. The somewhat better survival-rate of the FRACON group demonstrates that there was little interference with other drugs or toxicity. The reduced incidence of infection indicated that disturbing the microbial flora had no detrimental effects. The absence of E. coli septicaemias in the FRACON group shows that sepsis was reduced by intestinal decontamination. The benefits of FRACON treatment were, first, fewer deaths from infection, giving a potentially longer period for the treatment of the primary disease. Secondly, a reduction in the number of febrile days and infectious episodes reduced the need for therapeutic use of systemic antibiotics. This improves the patient’s comfort and saves money. The absence of perianal sepsis in the FRACON group is especially important since this complication, unless treated by measures such as temporary colostomy and granulocyte transfusions, is often fatal in
neutropenic patients. We chose FRACON for decontamination, rather than the more commonly used combination of gentamicin, vancomycin, and nystatin (G.V.N.), because it costs about one tenth the price of G.V.N. and because we regard gentamicin as a valuable therapeutic agent and are loath to use it prophylactically and topically. The Baltimore team8 have already reported the development of gentamicin-resistant Ps. ceruginosa in some patients receiving oral gentamicin, whereas this problem was never encountered in any of our trial patients. Indeed, selection of organisms resistant to our most potent systemic antibiotics, particularly as the result of topical application, may outstrip the introduction of new antibiotics, and the prevention of infection will then assume even greater importance. These reservations do not apply to the antiseptic chlorhexidine, which was used to suppress the microflora of sites unaffected by the oral antibiotics. We found that FRACON combined with simple protective isolation in specially designed leukaemia units was useful in preventing infection in A.N.L.L. It allows antileukaemic therapy to proceed in patients who would otherwise die of infection and may well assist the introduction of more effective treatment to improve the ultimate prognosis in this almost invariably fatal disease. We thank all our clinical colleagues including Prof. D. A. G. GalJ. M. Goldman, and Dr D. Catovsky, for permission to study their patients; the nursing staff and patients for willing cooperation; our technical staff, especially Mr D. Adams, for valuable contributions to the microbiological methodology; Dr H. E. M. Kay, for his helpful advice; and Miss L. Gleave for her patient secretarial assistance. The Leukaemia Research Fund made this study possible by generous grants to H.G. and B.J. ton, Dr
Requests for reprints should be addressed to H.G., Department of Bacteriology, St. Mary’s Hospital Medical School, London W2 1PG.
PROLACTIN, ŒSTROGEN, AND LIPIDS IN BREAST FLUID P. HILL
E. L. WYNDER
Naylor Dana Institute for Disease Prevention, American Health Foundation, Valhalla, New York 10595, U.S.A.
Concentrations of prolactin, œstrogens, and lipids were measured in the plasma and breast-duct fluid of 8 non-lactating premenopausal women without a known history of breast disease. Concentrations of prolactin, œstrogen, and triglycerides were significantly higher in ductal fluid than in plasma, but there was little difference with cholesterol concentration. The high concentrations of prolactin and œstrogen found in the ductal fluid of Western women may be relevant to development of breast cancer.
Summary
Introduction EPIDEMIOLOGICAL evidence suggests that dietary and endocrine factors alter the risk of breast cancer Hence, many attempts have been made to correlate specific changes in the hormonal environment in populations with increased or reduced risk of breast cancer, and with different patterns of food intake. The results of such studies have underlined the influence of diet and lifestyle on hormone production, metabolism, and excretion.3-s However, such studies have not contributed any direct information about the nature of the carcinogenic stimulus or on the mechanism by which various combinations of hormones might stimulate the development of a breast tumour. Aetiological agents were not identified when the excretory metabolites of oestrogens and androgens in high and low risk populations or from breast-cancer patients and normal controls were measured. Sensitive and specific radioimmunoassay have shifted attention to the plasma, the hormone profile of which physiologically affects the breast. However, the ductal fluid is in constant contact with the ductal epithelium, the site of development of most breast cancer. Ductal fluid contains lactose, lactalbumin, cholesterol, fatty acids, and peroxidised lipids.6 It may also contain 7agents which influence the development of breast cancer.’ Since oestrogen and prolactin are central to the induction and development of experimental breast cancer,’ we studied the hormonal content of this fluid in Caucasian women in whom the risk of breast cancer is high. We measured prolactin, oestrogens, and lipids in the breast
Levine, A. S., Schimpff, S. C., Graw, R. G., Jr., Young, R. C. Sem. hœmat 1974, 11, 141. 2. Bodey, G. P., Gehan, E. A., Freireich, E. J., Frei, E., III, Am. J. med. Sci 1971, 262, 138. 3. Levine, A. S., Siegel, S. E., Schreiber, A. D., Hauser, J., Preisler, H. D, Goldstein, I. M., Seidler, F., Simon, R., Perry, S., Bennett, J. E., Henderson, E. New Engl. J. Med. 1973, 288, 477. 4. Schimpff, S. C., Greene, W. H., Young, V. M., Fortner, C. L., Jepsen, L. Cusack, N., Block, J. B., Wiernik, P. H. Ann. intern. Med. 1975, 82, 351 5. Yates, J. W., Holland, J. F. Cancer, 1973, 32, 1490. 6. Klastersky, J., Debusscher, L., Weerts, D., Danneau, D. Path. Biol., Paris. 1974, 22, 5. 7. Jameson, B., Gamble, D. R., Lynch, J., Kay, H. E. M. Lancet, 1971, i, 1034. 8. Greene W. H., Moody, M., Schimpff, S. C., Young, V. M., Wiernik, P. H Ann. intern. Med. 1973, 79, 684. 1.
841
fluid of no
non-lactating premenopausal
women
who had
known history of breast disease.
Methods In
an
ongoing study
of 100
premenopausal
women,
we
obtained some ductal fluid from approximately 50% of the Caucasian women. Of these secretors, 50% secreted 50 N1 of fluid, and 10% secreted as much as 400 P of fluid. Women from the latter group were used in this study. Blood and breast fluid were obtained weekly in the morning from 8 healthy premenopausal non-puerperal women. 50-400 pd of fluid could be obtained at each weekly visit. Breast fluid was obtained by the nipple-aspiration method of Sartorius.7 Samples were run in duplicate and assayed at two different dilutions. The prolactin in the plasma and breast fluid was determined by radioimmunoassay (R.i.A.) by means of human prolactin (Lewis HPRL V-L-5 No. 2) as previously described,5 except that the lipids were extracted before prolactin assay. CEstradiol and cestrone were determined by the cytosol protein-binding method of Nagai and Longcope after separation on ’Sephadex’ LH 20.9 The sensitivity of this assay is 5 pg/ml with an intra-assay and inter-assay coefficient of variation of less than 5%. Cholesterol and cholesterol esters in the breast fluid were determined fluorometrically.1O Plasma cholesterol and triglyceride concentrations were determined by standard Technicon AutoAnalyzer methods.
Results
Prolactin, cestrogen (oestradiol and oestrone), cholesterol, and triglyceride concentrations in breast fluid and in plasma are shown in figs. 1 and 2. Prolactin and oestrogen concentrations
were
the breast fluid than in the
several times greater in
plasma. Breast-fluid prolac-
Fig.
I-Prolactin and cestrogen concentrations in breast fluid and plasma in eight premenopausal women sampled weekly for five weeks.
Results given as mean+s.E.M.
Fig.
2-Cholesterol and triglyceride concentrations in breast 8uid and plasma in eight premenopausal women sampled weekly for five weeks.
Results given as mean±s.E.M.
not vary during the menstrual in breast fluid and concentrations Cholesterol cycle. serum were comparable and much higher than in breast milk." In breast fluid, which was viscous in our subjects, the concentration of cholesterol esters (free/ esterified cholesterol ratio 3/2) was high and resembled that in the plasma. The concentration of triglyceride in breast fluid was also high.
tin concentration did
Discussion
70% of premenopausal Caucasian women and 24% of Chinese women secrete some ductal fluid.7 Petrakis et al. suggested that the ability to secrete breast fluid may be related to the different incidence-rates in breast cancer between Caucasian and Chinese women. In an ongoing study of 100 premenopausal women, we obtained some ductal fluid from approximately 50% of the Caucasian women. Of these secretors, 50% secreted 50 .1 of fluid and 10% secreted as much as 400 pi of fluid. Women from the latter group were used in this study. If agents which influence the development of breast cancer are present in the breast fluid, it is possible that high-volume secretors are at increased risk of breast cancer. The type of fatty acid in breast fluid has been reported to be directly related to the type of dietary fatty acids consumed.12 Thus, the composition of the ductal fluid seems to be affected by dietary and other environmental factors. Knowledge of the constituents of ductal fluid will be of value in determining the agents involved in both the induction and promotion phases of breast carcinogenesis. It remains to be demonstrated whether carcinogenic agents are present in these fluids. The breast-duct fluid may provide an environment in which breast epithelial cells may be exposed to relatively high local concentrations of carcinogens, co-carcinogens, or promoters over relatively long periods; this exposure may increase the probability of mutation or a carcinogenic event occurring in ductal cells. 12 In the rat model high fat intake is associated with both a high prolactin/oestrogen ratio in the plasma and enhanced breast-tumour development.13.14 In view of such observations and because plasma-prolactin has been shown to be altered by diet in man as well, 1 we propose that high fat intake, typical of the Western diet but not the Japanese diet, promotes the growth of preneoplastic lesions’6 by specifically altering the concentrations of prolactin and oestrogen in the ductal fluid. There are many published reports dealing with prolactin and breast cancer in both animal models and man.8.17-19 We do not know the extent to which the high incidence of invasive intraductal breast cancer in Caucasian (compared with Asian) women is related to the presence and/or composition of the breast fluid. Possible qualitative and quantitative differences in breast-fluid composition of high and low risk populations should be investigated. A comparison of breast fluid in the involved and uninvolved breasts of cancer patients, in patients with ductal hyperplasia, and in daughters of women with breast cancer would be of considerable interest. Requests for reprints should be addressed to E. L. W., American Health Foundation, 1370 Avenue of the Americas, New York, N.Y. 10019, U.S.A.
842
GROWTH-HORMONE DEFICIENCY IN CONGENITAL RUBELLA M. A. PREECE P. J. KEARNEY W. C. MARSHALL
Departments of Growth and Development and Microbiology, Institute of Child Health, University of London, and Royal Hospital for Sick Children, Bristol
boys with congenital rubella and concomitant growth-hormone deficiency responded to human-growth-hormone replacement and have already (over a period of 18 mo) achieved a significant increase in height. The association of these two diagnoses requires recognition so that treatable endocrine disorders, which are becoming recognised more often in congenital rubella, are always positively excluded when affected children with inexplicable short
Summary
Two
stature are seen.
Introduction
growth retardation is common in conrubella,1,2 although children affected in utero but genital without signs of damage at birth are usually of normal birth-weight.33 Postnatal growth retardation also occurs.4,5 Michaels and Kenny6 reported longitudinal growth studies for 15-33 mo in sixteen infants with congenital rubella. They described three growth patterns. Nine children remained small but grew at normal speed, five showed catch-up growth, and the remaining two showed a progressive deceleration in growth-rate. Investigations of thyroid, adrenal, and pituitary function in INTRAUTERINE
these children revealed no abnormalities. It has generally been held that growth retardation in congenital rubella is not due to a disturbance of endocrine function but rather to the direct effect of the virus on the rate of cell division. We now describe two patients in whom growth-hormone deficiency has been associated with congenital rubella. The response of both children to treatment with exogenous growth hormone for 18 mo is also described.
E. L., Bross, V., Hirayama, T. Cancer, 1960, 13, 559. Carroll, K. K., Khor, H. T. in Progress in Biochemical Pharmacology, Lipids and Tumors (edited by K. K. Carroll); p. 308. New York, 1975. 3. MacMahon, B. J. natn. Cancer Inst. 1973, 50, 21. 4. Dickinson, L. E., MacMahon, B., Cole, P., Brown, J. B. New Engl. J. Med. 1974, 219, 1211. 5. Hill, P., Wynder, E. L., Kumar, H., Helman, P., Rona, R., Kuno, K. Cancer Res. 1976, 35, 4102. 6. Petrakis, N. L. 1st Breast Cancer Task Force Working Conference, National Cancer Institute, Williamsburg, Virginia, February, 1973. 7. Petrakis, N. L., Mason, L., Lee, R., Sugimoto, B., Pawson, S., Catchpool, F. J. natn. Cancer Inst. 1975, 54, 829. 8. Pearson, O. H. in Current Research in Oncology (edited by C. B. Anfinson, M. Potter, and A. N. Schechter); p. 125, New York, 1972. 9. Nagai, N., Longcope, C. Steroids, 1971, 1, 631. 10. Alberts, R. W., Lowry, O. H. Analyt. Chem. 1955, 27, 1829. 11. Potter, J. M., Nestel, P. F. Am. J. clin. Nutr. 1976, 29, 54. 12. Petrakis, N. L., Mason, M. L., Doherty, M., Dupuy, M. D., Sadee, G., Wilson, C. S. Fedn Proc. 1977, 37, abstr. 4714. 13. Chan, P., Didato, F., Cohen, L. Proc. Soc. exp. Biol. Med. 1975, 149, 133. 14. Chan, P., Head, J. F., Cohen, L. A., Wynder, E. L. J. natn. Cancer Inst. (in the press). 15. Hill, P., Wynder, E. L. Lancet, 1976, ii, 806. 16. Wellings, S. R., Jensen, H. M., Marcum, R. G. J. natn. Cancer Inst. 1975, 55, 231. 17. Meites, J., Lu, K. H., Wuttke, W., Welsch, C. W., Nagasawa, H., Quadri, S. K. Rec. Prog. Hormone Res. 1973, 28, 471. 18. Welsch, E. W., Nagasawa, H. Cancer Res. 1977, 37, 951. 19. Robyn, C. Path. Biol., Paris, 1973, 23, 783. 1. 2.
Wynder,
Methods All the physical measurements quoted were carried out in the growth-disorder clinic of the Hospital for Sick Children, Great Ormond Street, by methods previously described.’ The biochemical investigations were done at the Royal Hospital for Sick Children, Bristol, in the first case and at the Hospital for Sick Children, Great Ormond Street, in the second. Serumgrowth-hormone was measured during an insulin-tolerance test and was assayed by radioimmunoassay (1st i.R.p. as standard). Serum-thyroxine and serum-cortisol were measured bv competitiye-protein-binding assay. In the second case, the insu lin-tolerance test was combined with an injection of thyrotrophin-releasing hormone (T.R.H.), 200 jig, and luteinising-hormone-releasing hormone (L.H.R.H.), 100 µg. Thyrotrophin (T.S.H.), luteinising hormone (L.H.), and follicle-stimulating hormone (F.S.H.) were assayed by radioimmunoassay against their respective 1st I.R.P. standards.
Case-reports Case1 This boy was born after a normal term third pregnancy. The mother had no illness or history of contact with rubella during the pregnancy. Birth-weight was 2.9 kg. At age 8 mo he presented to hospital with failure to thrive. Feeding was poor, but there were no other specific symptoms. Sensorineural deafness was detected, and fundal examination revealed typical changes of rubella retinopathy. A rubella hsemagglutination-inhibiting (H.I.) antibody titre of 1/16 000 was demonstrated in his serum. As he was already considerably below the 3rd centile for height and was continuing to grow at a subnormal rate, he was further investigated at age 3 yr. On that occasion an inadequate growth-hormone response to insulin hypoglycaemia was demonstrated, but no other endocrine abnormalities were present. These investigations were repeated 3 yr later when, once again, growth-hormone production was abnormal, with a peak of 1.mi.u./l. He was first seen in the growth-disorder clinic at the Hospital for Sick Children, Great Ormond Street, when he was 6.16 yr of age, at which time his height was 6.6 standard deviations below the mean. He had all the clinical features of growth-hormone deficiency, with high skinfold thickness (reflecting an excess of subcutaneous fat) and hypoplastic genitalia, previously described in association with growth-hormone deficiency.s He had bilateral sensorineural deafness and the retinal changes of congenital rubella. Over the subsequent months his growth was assessed at 3-monthly intervals (see figure), and his stature velocity was 3.4 cm/yr—2.8 standard deviations below the mean for his age. At 705 yr he was started on human-growth-hormone replacement at a dose of 5 LU. three times weekly, and over the next 12 mo his growth velocity increased to 146 cm/yr, which is 11.0standard deviations above the mean for his age. During the same period his subcutaneous fat, as indicated by skinfold thickness at the triceps and subscapular sites, fell from a mean of +07 to -09 standarddeviation units. This is a typical response in severe growthhormone deficiency. After 18 mo treatment his stature (104.1 cm) is 4.3 standard deviations below the mean. Case 2 This boy was born after a 37 wk, but otherwise uneventful second pregnancy. Birth-weight was 2-66 kg. There was no history of rubella or contact with rubella in pregnancy. At age 21 mo he was admitted to the Hospital for Sick Children. Great Ormond Street, for investigation of mental retardation. At this time he was found to have bilateral sensorineural deafness and a mild hypochromic anaemia. At 6 yr he was reported to have the retinal pigmentation typical of congenital rubella. but there were no other clinical features of this condition. apart from severe bilateral deafness. Serological tests revealed
