Diethylstilbestrol was considered by previous Working Groups in November 1978 (volume 21, IARC, 1979a), and in March 1987 (Supplement 7, IARC, 1987a). Since that time, new data have become available, and these have been incorporated into the monograph, and taken into consideration in the present evaluation
1. Exposure Data a) Structural and molecular formulae, and relative molecular mass 1.1 Identi!cation and description of OH the agent CH3 Chem. Abstr. Serv. Reg. No.: 56–53–1 Chem. Abstr. Name: Phenol, 4,4'-[(1E)-1,2- diethyl-1,2-ethenediyl]bis-
IUPAC Systematic Name: 4-[(E)-4-(4-Hy- CH3 droxyphenyl)hex-en-3-yl]phenol HO Synonyms: (E)-3,4-Bis(4-hydroxyphenyl)-
3-hexene; (E)-4,4'-(1,2-diethyl-1,2- C18H20O2 ethenediyl)bisphenol; (E)-diethylstil- Relative molecular mass: 268.35 bestrol; α,α'-diethyl-4,4'-stilbenediol; α,α'-diethylstilbenediol; 4,4'-dihydroxy- 1.2 Use of the agent α,β-diethylstilbene; 4,4'-dihydroxydieth- ylstilbene; phenol, 4,4'-(1,2-diethyl-1,2- Information for Section 1.2 is taken from IARC ethenediyl)bis-, (E)-; 4,4'-stilbenediol, (1979a), McEvoy (2007), Royal Pharmaceutical α,α'-diethyl-, trans-; Society of Great Britain (2007), and Sweetman Description: white, odourless, crystalline (2008). powder (McEvoy, 2007) 1.2.1 Indications Diethylstilbestrol is a synthetic nonsteroidal estrogen that was historically widely used to pre- vent potential miscarriages by stimulating the synthesis of estrogen and progesterone in the pla- centa (in the United States of America, especially
!"# IARC MONOGRAPHS – 100A from the 1940s to the 1970s) (Rogers & Kavlock, given to treat prostate cancer in the form of its 2008). It was also used for the treatment of symp- diphosphate salts (Fosfestrol). toms arising during menopause and following When used as pessaries in the short term ovariectomy, and for senile (atrophic) vaginitis management of menopausal atrophic vaginitis, and vulvar dystrophy. Diethylstilbestrol was the daily dose was 1 mg (Royal Pharmaceutical employed as a postcoital emergency contracep- Society of Great Britain, 2007; Sweetman, 2008). tive (‘morning-a!er pill’). It has been used for the Diethylstilbestrol is available as 1 mg and prevention of postpartum breast engorgement, 5 mg tablets for oral administration in several for dysfunctional menstrual cycles, and for the countries (Royal Pharmaceutical Society of Great treatment of female hypogonadism. Britain, 2007). Diethylstilbestrol is now rarely used to treat Diethylstilbestrol is no longer commercially prostate cancer because of its side-e"ects. It is available in the USA (McEvoy, 2007). occasionally used in postmenopausal women with breast cancer. 1.2.3 Trends in use Diethylstilbestrol was also used as a livestock growth stimulant. Most reports about diethylstilbestrol use are from the USA. $e number of women 1.2.2 Dosages exposed prenatally to diethylstilbestrol world- wide is unknown. An estimated 5 to 10 million Historically, diethylstilbestrol was used for Americans received diethylstilbestrol during the treatment of symptoms arising during the pregnancy or were exposed to the drug in utero menopause (climacteric) and following ova- from the 1940s to the 1970s (Giusti et al., 1995). riectomy in an oral daily dose of 0.1–0.5 mg in A review of 51000 pregnancy records at 12 a cyclic regimen. For senile vaginitis and vul- hospitals in the USA during 1959–65 showed var dystrophy, it was given in an oral daily dose geographic and temporal variation in the per- of 1 mg, or, for vulvar dystrophies and atrophic centage of pregnant women exposed: 1.5% of vaginitis, in suppository form in a daily dose of pregnancies at the Boston Lying-In Hospital, and up to 1 mg. As a postcoital emergency contra- 0.8% at the Children’s Hospital in Bu"alo were ceptive (‘morning-a!er pill’), it was given as an exposed to diethylstilbestrol; at the remaining oral dose of 25 mg twice a day for 5 days starting ten hospitals, 0.06% of pregnant women were within 72 hours of insemination. An oral dose of exposed (Heinonen, 1973). At the Mayo Clinic 5 mg 1–3 times per day for a total of 30 mg was during 1943–59, 2–19% (mean, 7%) of pregnan- typically given in combination with methyltesto- cies per year were exposed (Lanier et al., 1973). sterone for the prevention of postpartum breast $e peak years of diethylstilbestrol use in the engorgement. For dysfunctional uterine bleed- USA varied from 1946–50 at the Mayo Clinic, ing, diethylstilbestrol was given in an oral dose of Minnesota, 1952–53 at the Massachusetts General 5 mg 3–5 times per day until bleeding stopped. It Hospital in Boston, and 1964 at the Gundersen was also used for the treatment of female hypog- Hospital in Wisconsin (Nash et al., 1983). onadism, in an oral dose of 1 mg per day (IARC, Over 40% of the women in the DESAD cohort 1979a; McEvoy, 2007). were exposed during the early 1950s (1950–55) $e typical dosage of diethylstilbestrol is (Herbst & Anderson, 1990). Among cases of clear 10–20 mg daily to treat breast cancer in post- cell adenocarcinoma of the cervix and vagina menopausal women, and 1–3 mg daily to treat recorded in the Central Netherlands Registry, prostate cancer. Diethylstilbestrol has also been born during 1947–73, the median year of birth
!"$ Diethylstilbestrol was 1960 (Hanselaar et al., 1997). In the Registry 2. Cancer in Humans for Research on Hormonal Transplacental Carcinogenesis, which registers cases of clear $e previous IARC monograph (IARC, cell adenocarcinoma of the vagina and cervix in 1987a) states that there is su&cient evidence of a the USA, Australia, Canada, Mexico and Europe, causal association between clear cell adenocarci- most of the exposed women from the USA were noma of the vagina/cervix and prenatal exposure born during 1948–65 (Herbst, 1981; Melnick to diethylstilbestrol. $at monograph also cited et al., 1987). clear evidence of an increased risk of testicular Diethylstilbestrol doses varied by hospital. cancer in prenatally diethylstilbestrol-exposed Based on the record review at 12 hospitals in the male o"spring, an association that is now uncer- USA, the highest doses were administered at the tain due to the publication of recent studies. $e Boston Lying-in, where 65% of treated pregnant association between diethylstilbestrol adminis- women received total doses higher than 10 g, up tered during pregnancy and breast cancer was to 46.6 g, for a duration of up to 9 months. At all considered established, but the latent period the other hospitals, most women (74%) received remained uncertain. Evidence was mixed for < 0.1 g (Heinonen, 1973). Data available from an association between diethylstilbestrol expo- the US National Cooperative Diethylstilbestrol sure during pregnancy and cancers of the uterus, Adenosis (DESAD) project indicate that median cervix, and ovary. Finally, the IARC monograph doses were 3650 mg (range 6–62100 mg) for states that there is su&cient evidence of a causal women identi%ed through the record review, relationship between uterine cancer and use of whereas the median dose exceeded 4000 mg for diethylstilbestrol as hormonal therapy for meno- women who entered the cohort through referral pausal symptoms. (self or physician), more of whom were a"ected by $e studies cited in this review represent diethylstilbestrol-related tissue changes (O’Brien key historical reports relevant to the association et al., 1979). Diethylstilbestrol doses may have between diethylstilbestrol and human cancer. varied over time, but this has not been reported. Only studies of key cancer end-points published $e use of diethylstilbestrol and other estro- since the most recent IARC monograph in 1987 gens during pregnancy is now proscribed in many are shown in the tables. countries (Anon, 2008), and diethylstilbestrol use is no longer widespread for other indications. Until the 1970s, it was common practice to 2.1 Women exposed to stimulate the fattening of beef cattle and chick- diethylstilbestrol during ens by mixing small amounts of diethylstilbestrol pregnancy into the animal feed or by implanting pellets of diethylstilbestrol under the skin of the ears of the 2.1.1 Breast cancer incidence animals. In the early 1970s, concern over trace Historically, nearly all of the studies assessing amounts of the hormone in meat led to bans on diethylstilbestrol in relation to invasive breast the use of diethylstilbestrol as a livestock growth cancer incidence or mortality involve the retro- stimulant (Anon, 2008). spective and/or prospective follow-up of women with veri%ed exposure to diethylstilbestrol during pregnancy. $e results of some early studies sug- gested modestly increased risk, with relative risks (RR) ranging from 1.37 to 1.47 (Clark & Portier,
!"% IARC MONOGRAPHS – 100A
1979; Greenberg et al., 1984; Hadjimichael et al., extended follow-up of the WHS cohort (by 1984). However, a standardized incidence ratio 5 years), and the Dieckmann clinical trial cohort (SIR) of 2.21 was reported from the Dieckmann (by 14 years). $e Dieckmann clinical trial was clinical trial cohort (Hubby et al., 1981), despite conducted in 1951–52 (Dieckmann et al., 1953) to null results from an earlier analysis of the same assess the e&cacy of diethylstilbestrol for prevent- cohort (Bibbo et al., 1978). Historically, null ing adverse pregnancy outcomes. Administered results were also reported from a small US cohort diethylstilbestrol doses were high, with a cumu- (eight cases) (Brian et al., 1980), and two small lative dose of 11–12 g (Bibbo et al., 1978). $e cohorts arising from separate clinical trials in combined WHS and Dieckmann cohorts pro- London, the United Kingdom (four and 13 cases, duced a modestly elevated relative risk of 1.25 for respectively) (Beral & Colwell, 1981; Vessey et al., breast cancer (Titus-Ernsto" et al., 2001). 1983). Based on data from the Dieckmann clini- Two reports published since the previous cal trial cohort (Hubby et al., 1981) and the IARC monograph are consistent with a modest NCI Combined Cohort Study (Titus-Ernsto" association between diethylstilbestrol exposure et al., 2001), the in'uence of diethylstilbestrol during pregnancy and breast cancer incidence on breast cancer risk did not di"er according (see Table 2.1 available et http://monographs. to family history of breast cancer, reproduc- iarc.fr/ENG/Monographs/vol100A/100A-11- tive history, prior breast diseases, or oral con- Table2.1.pdf). $e %rst of these (Colton et al., traceptive use. Although the %rst follow-up of 1993) was based on further follow-up of the the Dieckmann clinical trial cohort suggested Women’s Health Study (WHS) (Greenberg et al., breast cancer occurred sooner a!er trial partici- 1984). $e WHS cohort was originally assembled pation in the diethylstilbestrol-exposed women at three US medical centres (Mary Hitchcock (Bibbo et al., 1978), this was not seen in the sub- Memorial Hospital in Hanover; Boston Lying-in sequent follow-up (Hubby et al., 1981), in the Hospital in Boston; Mayo Clinic in Rochester) and WHS cohort (Greenberg et al., 1984; Colton a private practice in Portland (Greenberg et al., et al., 1993), in the NCI Combined Cohort Study 1984). At all participating WHS centres, diethyl- (Titus-Ernsto" et al., 2001), or the Connecticut stilbestrol exposure (or lack of exposure) during study (Hadjimichael et al., 1984). In both the NCI pregnancy was based on a review of obstetrics Combined Cohort Study (Titus-Ernsto" et al., records during 1940–60. Although exact diethyl- 2001) and the Connecticut study (Hadjimichael stilbestrol doses administered to women in the et al., 1984), the elevated risk associated with WHS are largely unknown, they are believed to diethylstilbestrol was not apparent 40 or more have been relatively low. In the 1989 WHS fol- years a!er exposure. low-up, health outcomes, including breast can- Data from the WHS (Greenberg et al., 1984) cer diagnosis and mortality, were retrospectively and the Dieckmann clinical trial cohort (Bibbo and prospectively ascertained in 2864 exposed et al., 1978; Hubby et al., 1981) did not show and 2760 unexposed women. $e data produced systematic di"erences in breast tumour size, a relative risk of 1.35 for breast cancer risk based histology or stage at diagnosis for the diethyl- on 185 exposed and 140 unexposed cases (Colton stilbestrol-exposed and -unexposed women. No et al., 1993), whereas the earlier study reported a di"erences between exposed and unexposed relative risk of 1.47 (Greenberg et al., 1984). women with regard to breast self-examination $e second report was based on the US or mammography screening were noted in fol- National Cancer Institute (NCI) Combined low-up data from the WHS (Colton et al., 1993) Cohort Study, which in 1994 combined and [$e Working Group noted it seemed unlikely
!"" Diethylstilbestrol the increased risk in diethylstilbestrol-exposed Diethylstilbestrol was also prescribed for the women was due to an increased surveillance of treatment of menopausal symptoms, but the use exposed women or to confounding by lifestyle of diethylstilbestrol in menopause has not been factors.] assessed systematically in relation to breast can- Historically, a few studies have suggested cer risk, and the association is unclear. an association between exposure to diethyl- stilbestrol during pregnancy and an increased 2.1.2 Other cancer sites risk of breast cancer mortality; these include an analysis based on the %rst follow-up report of An early study suggested a relationship women in the Dieckmann clinical trial (RR, 2.89; between the use of diethylstilbestrol to treat 95% CI: 0.99– 8.47) (Clark & Portier, 1979), and a gonadal dysgenesis and risk of endometrial can- study in Connecticut (RR, 1.89; 95% CI: 0.47–7.56) cer in young women (Cutler et al., 1972). An (Hadjimichael et al., 1984). More recent studies increased risk of endometrial cancer was also are consistent with a modest association, includ- reported in association with the use of diethyl- ing an analysis of fatal breast cancer in a large stilbestrol to treat symptoms of menopause American Cancer Society (ACS) cohort of gravid (Antunes et al. 1979). women (RR, 1.34; 95% CI: 1.06–1.69) (Calle et al., Two follow-up studies indicated (Hoover et al., 1996), the second follow-up of women in the 1977) or suggested (Hadjimichael et al., 1984) an WHS (RR, 1.27; 95% CI: 0.84–1.91) (Colton et al., increased risk of ovarian cancer among women 1993), and the NCI Combined Cohort Study, exposed to diethylstilbestrol during pregnancy, which for this analysis combined and extended but the number of exposed cases was small. the follow-up of the WHS women by 8 years and Similarly, early attempts to assess the risk of cer- the Dieckmann women by 17 years (hazard ratio vical and other cancers were limited by small case [HR] 1.38; 95% CI: 1.03–1.85) (Titus-Ernsto" numbers (Hadjimichael et al., 1984). $e large et al., 2006a). Similar to the NCI study of breast and more recent NCI Combined Cohort study cancer incidence (Titus-Ernsto" et al., 2001), the did not show an association between diethyl- ACS study showed that risk of breast cancer mor- stilbestrol exposure during pregnancy and the tality did not di"er by family history of breast incidence of cancer of the endometrium, ovary, cancer, reproductive history, or hormone use; or cervix (Titus-Ernsto" et al., 2001). also, the elevated risk was no longer evident 40 Although relative risks were elevated for or more years a!er exposure (Calle et al., 1996). brain and lymphatic cancers in the Connecticut In summary, evidence from large, recent study (Hadjimichael et al., 1984) and for stom- cohort studies suggests a modest association ach cancer in the NCI Combined Cohort Study between diethylstilbestrol exposure during (Titus-Ernsto" et al., 2001), con%dence intervals pregnancy and increased breast cancer inci- were wide. A recent report from the large ACS dence and mortality. Notably, these associa- study showed no association between diethyl- tions were apparent in women participating in stilbestrol taken during pregnancy and pan- the Dieckmann clinical trial cohort, minimizing creatic cancer mortality (1959 deaths in 387981 the possibility of distortion due to confounding women) (Teras et al., 2005). $e NCI Combined by the clinical indication for diethylstilbestrol Cohort study did not %nd associations between use. $e increased risk of breast cancer mortal- diethylstilbestrol exposure during pregnancy ity also argues against an artefactual association and death due to cancers other than breast can- stemming from the heightened surveillance of cer (Titus-Ernsto" et al., 2006a). diethylstilbestrol-exposed women.
!"& IARC MONOGRAPHS – 100A
2.2 Women exposed in utero the California Tumor Registry during 1950–69 showed an increase of vaginal tumours in girls 2.2.1 Clear cell adenocarcinoma of the aged 10–19 years (Linden & Henderson, 1972). vagina and cervix Subsequent case series, two of which were based in California, supported the link between prena- Substantial evidence indicates that women tal diethylstilbestrol exposure and CCA at both exposed in utero to diethylstilbestrol have a sites (Henderson et al., 1973; Hill, 1973). markedly increased risk of clear cell adenocarci- $e only follow-up study of prenatal diethyl- noma (CCA) of the vagina and cervix. $e ear- stilbestrol exposure in relation to risk of CCA is liest report, published in 1970, described seven the NCI Combined Cohort Study, which com- cases of adenocarcinoma (six CCA) in women bined pre-existing US cohorts with veri%ed of ages 15–22 who had been exposed prenatally diethylstilbestrol exposure (or lack of exposure) to diethylstilbestrol (Herbst & Scully, 1970). $e including: following year, a case–control study based on !"#$%&'()*+,*-+.'/*-%+*0"(&1210"&'!*1/*&%'*314 these seven cases plus an additional case (eight '25."//*261/12"6*&(1"6*731'25."//*'&*"689*:;<=>9 cases) and 32 matched controls showed a strong !"#$%&'()*+,*-+.'/*'/(+66'!*1/*&%'*?@A* statistical association between prenatal diethyl- 7B(''/C'($*'&*"689*:;DE>9 stilbestrol exposure and risk of vaginal CCA !"#$%&'()*+,*-+.'/*&('"&'!*-1&%*!1'&%F6)&164 based on seven exposed cases and zero exposed controls (P < 0.00001) (Herbst et al., 1971). A sec- C')&(+6*"&*"*G+)&+/*1/,'(&161&F*261/12*"/!*&%'1(* ond case–control study published the same year, #/'H0+)'!*)1)&'()*7&%'*@+(/'*2+%+(&>9*"/! involving %ve cases identi%ed through the New .+('*&%"/*
!&' Diethylstilbestrol non-cases in the DESAD study suggested that higher diethylstilbestrol doses (O’Brien et al., CCA risk is in'uenced by early gestational expo- 1979), women of young ages (aged 13–26 years in sure, but not by dose. Evidence was unclear for Mattingly & Sta'; 1976), and women who were an in'uence of prior miscarriage (Herbst et al., exposed early in gestation (de%ned variously as 1986). Another University of Chicago registry- before Week 16, before 19 or 20 weeks, or during based study published since the previous IARC the %rst trimester) (Herbst et al., 1975; Mattingly monograph found that maternal vaginal bleed- & Sta', 1976; Kaufman & Adam, 1978; O’Brien ing during pregnancy was not associated with et al., 1979). A decreasing prevalence with age case status, reducing the likelihood that preg- has been seen in case series (Kaufman et al., nancy complications confounded the association 1982), in the DESAD study (Robboy et al., 1981) between diethylstilbestrol and CCA (Sharp & and in prospective follow-up studies of diethyl- Cole, 1990). $e same study also found that CCA stilbestrol-exposed women, suggesting possible occurring in diethylstilbestrol-exposed women regression (Burke et al., 1981; Noller et al., 1983). was associated with earlier gestational expo- Although most women a"ected by adenosis do sure and with greater body weight and greater not develop CCA, adenosis is present in up to height at ages 14–15 years (Sharp & Cole, 1991) 100% of vaginal CCA (Herbst et al., 1972; Herbst [$e Working Group noted that, possibly, greater et al., 1974; Robboy et al., 1984a). body weight and height in the early teenage years was a proxy for early puberty, which may have 2.2.2 Squamous neoplasia of the cervix increased the time at risk.] A recent study com- paring diethylstilbestrol-exposed CCA cases to Around the time of puberty, the outer cervical diethylstilbestrol-controls did not identify post- epithelium undergoes a transition from the orig- natal factors that in'uenced risk of this cancer inal columnar epithelium to squamous epithe- (Palmer et al., 2000). lium. $e area a"ected by this change (squamous Vaginal adenosis is an established, although metaplasia), known as the cervical transforma- non-obligatory, precursor of CCA that a"ects tion zone (squamo-columnar junction), is at between 34–88% of diethylstilbestrol-exposed increased risk of malignancy. Early clinical women (Antonioli & Burke, 1975; Bibbo et al., series suggested the extended transformation 1975; Herbst et al., 1975; Kaufman & Adam, zone associated with prenatal diethylstilbestrol 1978; O’Brien et al., 1979) and fewer than 4% of exposure might increase susceptibility for squa- unexposed women (Bibbo et al., 1975; Herbst mous neoplasia/dysplasia in these women (Sta' et al., 1975). $e lower prevalence (34–35%) & Mattingly, 1974; Fetherston, 1975; Fowler et al., was found in diethylstilbestrol-exposed women 1981). A study comparing diethylstilbestrol- who were identi%ed through a medical record exposed and -unexposed women showed a review (Herbst et al., 1975; Robboy et al., 1979); higher percent of dysplastic squamous cells in the also, in these studies, tissues were biopsied only exposed (11%) than in the unexposed (7%) based when changes were seen upon clinical examina- on cytology; the prevalence was greater (27%) in tion or colposcopy. $e higher prevalence (88%) exposed women with pathologically con%rmed was reported in women many of whom had adenosis (Herbst et al., 1975). In a subsequent been referred for study because of other diethyl- study of 280 women exposed to diethylstilbestrol stilbestrol-related vaginal anomalies (Antonioli in the %rst trimester, 82% were a"ected by adeno- & Burke, 1975). Several studies suggested the sis and nearly all (96%) of these had abnormal likelihood of vaginal epithelial changes, includ- colposcopic %ndings (Mattingly & Sta', 1976). ing adenosis, is greater in women who received
!&! IARC MONOGRAPHS – 100A
$e baseline examination of the DESAD returned their questionnaires, participation bias study women who were identi%ed through med- may have in'ated the PrR.] ical record review did not %nd elevated rates of squamous dysplasia in the diethylstilbestrol- 2.2.3 Cancer of the breast exposed group (Robboy et al., 1981), but the 7-year follow-up of 1488 (744 exposed) women A study in the Netherlands based on 5421 noted higher rates of cervical squamous cell questionnaires returned to the NDIC found dysplasia and carcinoma in situ in the diethyl- a modestly elevated risk of breast cancer for stilbestrol-exposed compared to the unexposed diethylstilbestrol-exposed women, but the con%- women (15.7 versus 7.9 cases per 1000 person– dence intervals were wide (PrR, 1.5; 95% CI: 0.7– years) based on cytology or biopsy (Robboy et al., 2.9) (Verloop et al., 2000). Findings based on the 1984b). $e di"erence between exposed and 1994 and 2001 follow-up of the NCI Combined unexposed was more apparent when the analyses Cohort Study did not show an overall increase of were con%ned to cases identi%ed through biopsy breast cancer rates in prenatally exposed women (as opposed to cytology) (5.0 versus 0.4 cases (Hatch et al., 1998; Troisi et al., 2007) (see Table 2.3 per 1000 person–years) (Robboy et al., 1984b). available at http://monographs.iarc.fr/ENG/ [$e Working Group noted that studies relying Monographs/vol100A/100A-11-Table2.3.pdf). on selective biopsy may exaggerate the associa- Relative risks from the two reports were 1.18 tion between prenatal diethylstilbestrol exposure (95% CI: 0.56–2.49) (Hatch et al., 1998) and 1.35 and risk of cervical neoplasia.] A recent analy- (95% CI: 0.85–2.10) (Troisi et al., 2007). A more sis of the NCI Combined Cohort Study showed detailed analysis of the 2001 follow-up data gave a doubling of the risk of high-grade intraepithe- an incidence rate ratio (IRR) of 2.05 (95% CI: lial neoplasia (squamous cell dysplasia) in the 1.12–3.76) in women aged 40 years or more, and women exposed prenatally to diethylstilbestrol 0.57 (95% CI: 0.24–1.34) in women aged less than compared to the unexposed; the risk appeared 40 years. $e data also showed an elevated risk to be higher for those with intrauterine exposure for women aged 50 years or more (IRR, 3.85; 95% within 7 weeks of the last menstrual period (RR, CI: 1.06–14.0) (Palmer et al., 2006) [$e Working 2.8; 95% CI: 1.4–5.5) (Hatch et al., 2001). $ere Group noted that women aged 50 years or more were not enough con%rmed cases of invasive cer- contributed 3% of the person–years in these vical cancer for a meaningful analysis. analyses.] While speculative, women approach- A study of 5421 questionnaire respondents ing the age of 50 years in this cohort would have (representing 41% of 13350 queried) who had been exposed during the peak years (1952–3 for been enrolled previously in the Netherlands the Dieckmann clinical trial and DESAD cohort Diethylstilbestrol Information Centre (NDIC), members), which might have involved higher in which prenatal diethylstilbestrol exposure was doses. If the association is real, the increased validated using medical records, found evidence risk in older women might re'ect higher expo- of a 5-fold risk (prevalence ratio [PrR]: 5.4; 95% sure rather than age-related risk. In the same CI: 2.8–9.5) of con%rmed non-clear-cell-ade- study, risk appeared to be elevated for older nocarcinoma cervical cancer in comparison to women with high (versus low) diethylstilbestrol the number of cases expected based on age and exposure classi%ed using known dose (38%) or calendar year rates derived from a cancer regis- assumed dose based on geographic region. $ere try (Verloop et al., 2000) [$e Working Group was no evidence that the risk in women aged 40 noted that because a low proportion of women years or more was in'uenced by the timing of gestational exposure, which was known for 75%
!&( Diethylstilbestrol of the exposed subjects. Also, there was no indi- between prenatal exposure to diethylstilbestrol cation of e"ect modi%cation by known breast and tumours other than the established relation- cancer risk factors. Diethylstilbestrol expo- ship with clear cell adenocarcinoma a"ecting the sure did not in'uence the receptor status of the cervix and vagina. breast tumour or lymph node involvement, but the association was evident in women with larger 2.3 Men exposed to diethylstilbestrol tumours (≥ 2 cm), arguing against screening bias (Palmer et al., 2006). 2.3.1 Men exposed through cancer therapy
2.2.4 Other sites Early case reports of breast cancer occurring in prostate cancer patients treated with diethyl- $e study based on the NDIC produced a stilbestrol implied a possible link; however, the prevalence ratio of 2.9 (95% CI: 0.8–7.5) based extent to which some of these tumours repre- on four cases of ovarian cancer observed in sented metastatic prostate cancer is uncertain women prenatally exposed to diethylstilbestrol (Bülow et al., 1973). (1.36 cases expected) (Verloop et al., 2000). $e NCI Combined Cohort Study, however, showed 2.3.2 Men exposed in utero no evidence of an association between prenatal diethylstilbestrol exposure and ovarian cancer in (a) Cancer of the testes the 1994 or 2001 follow-up (Hatch et al., 1998; Several studies have examined prenatal Troisi et al., 2007). $e SIR was 0.88 (95% CI: diethylstilbestrol exposure in relation to testicu- 0.44–1.80) based on eight cases in the exposed lar cancer, but %ndings have been inconsistent. at the time of the 2001 follow-up (Troisi et al., Because the diethylstilbestrol-exposed men now 2007). have passed the age of highest risk for testicular Based on one case, the NDIC study sug- cancer, the question of an association is likely to gested an association between prenatal diethyl- remain unanswered. stilbestrol exposure and vulvar cancer (PrR, 8.8; Based on the %ndings from several case–con- 95% CI: 0.2–49.0) but con%dence intervals were trol studies examining this relationship, most of wide (Verloop et al., 2000). which relied completely (Henderson et al., 1979; $e NCI Combined Cohort Study found Schottenfeld et al., 1980; Depue et al., 1983; Brown no evidence of an association between prenatal et al., 1986) or partly (Moss et al., 1986) on self- diethylstilbestrol exposure and endometrial can- reported hormone use, the previous IARC mon- cer (SIR, 1.04; 95% CI: 0.52–2.10) based on eight ograph concluded there is su&cient evidence of cases in the exposed (Troisi et al., 2007). a relationship between prenatal diethylstilbestrol $e NCI Combined Cohort Study suggested exposure and testicular cancer. $ree of the con- possible increases of lymphoma, lung and brain/ tributing studies found possible evidence of an nervous system cancers in prenatally exposed association (; Henderson et al., 1979; Schottenfeld women, but the estimates were imprecise and et al., 1980; Depue et al., 1983) and two did not compatible with chance (Troisi et al., 2007). Sites (Brown et al., 1986; Moss et al., 1986). Of the three for which there was no indication of increased studies that found possible evidence, the asso- risk included the thyroid and colorectum (Troisi ciation was not of statistical signi%cance in two et al., 2007). (Henderson et al., 1979; Schottenfeld et al., 1980). Based on the present studies of women, $e strongest association arose from a study in there is scant evidence to support an association California that assessed hormone use during the
!&) IARC MONOGRAPHS – 100A
%rst trimester of pregnancy with a relative risk of (see Table 2.4 available at http://monographs. 8.00 (95% CI: 1.3–4.9); 2/9 case mothers (and none iarc.fr/ENG/Monographs/vol100A/100A-11- of the control mothers) speci%ed using diethyl- Table2.4.pdf). $e source of diethylstilbestrol stilbestrol (Depue et al., 1983). Data from some exposure status was unclear, but apparently was studies showed (Brown et al., 1986) or suggested not based on the medical record. $e analysis (Schottenfeld et al., 1980) an increased risk for did not show an association between prenatal the sons of women who had experienced spotting diethylstilbestrol exposure and testicular cancer. or bleeding during the index pregnancy, a possi- $e NCI Combined Cohort Study assessed 2759 ble marker for diethylstilbestrol use not recalled (1365 exposed, 1394 unexposed) sons born to by the mother. Four of the contributing studies women in the WHS study, the Dieckmann clinical relied partly (Schottenfeld et al., 1980) or entirely trial, and the Horne cohort, as well as sons identi- (Henderson et al., 1979; Depue et al., 1983; Moss %ed through the Mayo Clinic with retrospective et al., 1986) on neighbourhood controls [$e follow-up for an average of 16.9 years (1978–94) Working Group noted both of these approaches (Strohsnitter et al., 2001) (see Table 2.5 available may have resulted in overmatching and attenu- at http://monographs.iarc.fr/ENG/Monographs/ ation of a possible relationship between prenatal vol100A/100A-11-Table2.5.pdf). For all partici- diethylstilbestrol exposure and risk of testicular pants, diethylstilbestrol exposure (or lack of cancer]. In the setting of diethylstilbestrol, it is exposure) was veri%ed by the medical or clinical also possible the mothers’ reporting was inac- trial record. In this study, the SIR for prenatally curate, in part because of the amount of time exposed men was 2.04 (95% CI: 0.82–4.20) based that had passed since the pregnancy and in part on seven cases observed in the exposed and 3.4 because women of the diethylstilbestrol era were expected. $e relative risk was 3.05 (95% CI: 0.65– not always given complete information about 22.0) in the internal comparison (two unexposed their medical care [$e Working Group noted cases). None of the cases in the NCI Combined that errors of recall or recall bias may have in'u- Cohort study arose from the Dieckmann clinical enced the results of these studies.] trial cohort in which women were consistently Early cohort studies of men exposed in utero given high doses of diethylstilbestrol (cumula- to diethylstilbestrol also have been largely incon- tive dose of 11–12 g) during the %rst trimester, clusive. No testicular cancer cases were identi- although the subcohort was small in size (205 %ed in the sons of women exposed to high doses exposed, 187 unexposed). All of the elevated risk of diethylstilbestrol through participation in the was due to an excess of exposed cases arising in Dieckmann clinical trial (11–12 g) (Gill et al., the Mayo cohort (%ve cases in 660 exposed, one 1979), or a clinical trial involving diabetic women case in 592 unexposed). Among those for whom in the United Kingdom (mean of 17.9 g) (Beral & diethylstilbestrol dose was known, the mothers Colwell, 1980), although both cohorts were small. of cases and noncases received 12.5 and 10 mg/ One case of fatal teratoma was ascertained in the day, respectively, doses that are lower than those 138 exposed (no cases in the unexposed) sons of received by the Dieckmann clinical trial or women who participated in a separate high dose Horne cohorts (Strohsnitter et al., 2001). $e (mean of 11.5 g) clinical trial at the University relative risk was unchanged when the analyses College Hospital in London (Vessey et al., 1983). were con%ned to 138 men whose mothers were Two studies have been published since the given diethylstilbestrol during the %rst trimester previous IARC monograph. $e %rst study, a of pregnancy but increased to 5.91 (95% CI: 1.05– case–control design, matched controls to cases 46.1) a!er excluding from the analysis men who by obstetrician (Gershman & Stolley, 1988)
!&* Diethylstilbestrol were exposed prenatally to both diethylstilbestrol ovarian cancer occurred (diagnoses at ages 7 and progestogen. and 20 years) in the 2539 daughters of prenatally Cryptorchidism increases the risk for tes- exposed women. $e SIR in the exposed was 5.3 ticular cancer (Sarma et al., 2006). An increased (95% CI: 1.3–21) based on 0.38 cases expected. prevalence of cryptorchidism was not seen No cases were reported in the 1423 unexposed in the exposed men in either of the two small third generation daughters. cohort studies involving the sons of women who In 2001, the NCI Combined Cohort Study ini- received high doses through participation in tiated a follow-up study of the adult daughters of separate clinical trials in the United Kingdom (a women who either had or had not been exposed mean of 17.9 g in Beral & Colwell, 1980; mean to diethylstilbestrol in utero (Titus-Ernsto" of 11.5 g in Vessey et al., 1983). However, an et al., 2008). $e results of the baseline survey, increased prevalence of cryptorchidism (17/308 which enrolled 793 third generation women (463 exposed versus 1/307 unexposed; P < 0.005) was exposed, 330 unexposed), con%rmed two cases seen in the sons of women exposed to high doses of ovarian cancer in exposed women (diagno- of diethylstilbestrol through participation in sis ages of 20 and 22), including one of the cases the Dieckmann clinical trial (Gill et al., 1979), that had been reported by the mother. No cases suggesting a possible pathway linking diethyl- of ovarian cancer were observed in the daugh- stilbestrol and testicular cancer (no cases were ters of women who were not exposed to diethyl- noted). In the case–control study that addressed stilbestrol in utero. $e SIR was 14.68 (95% CI: this connection, only 1/22 testicular cancer cases 3.67–58.71) based on 0.14 expected cases. Because a"ected by cryptorchidism was also exposed to only half of the second generation women had diethylstilbestrol (Schottenfeld et al., 1980). allowed contact with their daughters, participa- tion bias was a possible explanation for this %nd- (b) Other sites ing. However, the SIR remained elevated (6.6; In the NCI Combined Cohort Study, %ndings 95% CI: 1.7–26) when based on all adult daugh- were suggestive for bone and thyroid cancer, but ters of prenatally exposed women, regardless of estimates were imprecise. whether they participated in the third generation study (0.30 cases expected). 2.4 O"spring (third generation) of Only one study involved clinical examina- tions of third generation women (Kaufman & women who were exposed to Adam, 2002). Most of the mothers had a his- diethylstilbestrol in utero tory of diethylstilbestrol-related changes, but no vaginal or cervical anomalies were noted upon 2.4.1 Third generation women colposcopic examination of 28 third-generation Follow-up of the prenatally exposed and daughters. Although the study was based on small unexposed second generation women par- numbers and did not include hysterosalpingog- ticipating in the NCI Combined Cohort in raphy, the absence of anomalies is inconsistent 1994, 1997, and 2001 included inquiries about with the high prevalence of diethylstilbestrol- cancers occurring in their o"spring (Titus- related vaginal epithelial changes a"ecting pre- Ernsto" et al., 2008) (see Table 2.6 available at natally exposed women. http://monographs.iarc.fr/ENG/Monographs/ vol100A/100A-11-Table2.6.pdf). Based on the mothers’ uncon%rmed reports, two cases of
!&# IARC MONOGRAPHS – 100A
2.4.2 Third generation men of dietary diethylstilbestrol was studied in p53± mice. Interstitial cell hyperplasia and tumours In the NCI Combined Cohort Study and based were observed in the testis, and pituitary hyper- on the mothers’ reports, the SIR provided no evi- plasia and adenomas were observed in females; dence of increased cancer risk in men born to however, the incidences of these lesions were women exposed prenatally to diethylstilbestrol. not statistically signi%cant (Storer et al., 2001). When, diethylstilbestrol was given to CB6F1- 2.5 Synthesis rasH2 transgenic mice, benign tumours and hyperplasia of the Leydig cells in the testes were A large body of evidence was evaluated for noted. $e incidence of Leydig cell tumours in several organ sites, among which the Working the rasH2 males at high dose was signi%cantly Group concluded that diethylstilbestrol is associ- higher than in vehicle control males (4/15 vs 0/15; ated with cancer of the breast in women who were P < 0.05) (Usui et al., 2001). Carcinogenicity of exposed while pregnant. Diethylstilbestrol also dietary diethylstilbestrol was investigated in two causes clear cell adenocarcinoma in the vagina mouse knockout models, the Xpa homozygous and cervix of women who were exposed in utero. knockout, and the combined Xpa homozygous Finally, a positive association has been observed and p53 heterozygous knockout. $e inci- between exposure to diethylstilbestrol and can- dence of osteosarcoma and testicular intersti- cer of the endometrium, and between in-utero tial cell adenomas was higher in male Xpa/p53 exposure to diethylstilbestrol and squamous-cell mice. One Xpa male had osteosarcoma, which carcinoma of the cervix, and cancer of the testis. was not observed in wild-type mice. Xpa mice were no more sensitive than wild-type mice for compounds like diethylstilbestrol. $e Xpa/p53 3. Cancer in Experimental Animals mouse model nevertheless showed an increased susceptibility to diethylstilbestrol in inducing 3.1 Oral administration osteosarcoma and testicular cell adenoma in males (McAnulty & Skydsgaard, 2005). 3.1.1 Mouse See Table 3.1. Dietary exposure of diethylstilbestrol induced tumours in many sites, such as the ovary, 3.2 Subcutaneous and/or endometrium and cervix of the uterus, and mes- intramuscular administration othelioma (origin not indicated) (Greenman et al., 1986). Mammary adenocarcinoma inci- 3.2.1 Mouse dence was increased in C3H/HeN-MTV+ female $e e"ects of diethylstilbestrol on ure- mice (Greenman et al., 1987). Dietary diethyl- than-induced mouse lung carcinogenesis were stilbestrol induced thyroid follicular cell ade- assessed. Results indicate that diethylstilbestrol noma in C57BL/6 mice (Greenman et al., 1990). promotes lung carcinogenesis (Jiang et al., 2000). Diethylstilbestrol was considered negative in See Table 3.2. the oral studies in Tg.AC mouse, which is one of the models selected for examination by topi- cal application of either mutagenic or non-muta- genic carcinogens with papilloma formation at the site of application (Eastin et al., 2001). E"ect
!&$ Diethylstilbestrol Age at the start of DES treatment was a major factor in susceptibility of mice to mammary carcinogenesis of C3H/ femaleHeN-MTV- mice C077%3+/
c b a f a d,e < 0.05] < 0.0001] < 0.0065] < 0.05] < 0.0001] < 0.0449] < 0.001 (negative < 0.001 (negative P P P P P P [ *[email protected]"32% [ [ [ [ [ Male P trend) Female P trend)
f
e
a
a ) (7%); 9/192 (7%); : d (5%); 8/192 (4%) 8/192 (5%); c (96%); 46/48 (96%); a
1 (94%) (98%) a a (12%) (32%) a b (5%) Pituitary (adenoma) Control: (1%) 1/67 (9%); 16/180 (6%); 10/180 (5%); DES: 8/173 21/179 A32.-%32%&01&+,70,4/ Uterus (endometrial carcinoma) Control : (0/77) 9/191 (3%); 6/189 DES : 0/182; Uterus (cervical carcinoma) Control : (0/77) 13/191 (3%); 5/189 DES : 0/182; Mesothelioma Control: (0/77) 29/192 (5%); 28/191 (7%); DES:13/189 0/182; Mammary gland (adenocarcinoma Control: (0/73) (2%) 3/182 (2%); 4/185 DES:0 189; 0/182; 68/72 (96%); (15%) (96%); 47/48 (96%); 640 ppb: 45/48 (94%); 64046/48 ppb: 45/48 (94%); Mammary adenocarcinoma Control: 234/295 (79%) 69/72 60/72 (83%); 320 (83%); ppb: 59/71 # yroid follicular cell adenomas Male – 6/51 (6%); 3/48 (2%); 1/47 0/51; 2/48 (4%); 0/43 (5%); 3/58 (50%); 27/51 (11%); Female – 10/55 (20%); 10/51 (20%); 11/56 (20%); 13/64 4/60 (7%); (29%); 14/48 (26%); 16/61 (18%); 0/50 Ovary (granulosa cell tumours) Control (21%) : 16/75 44/183 (24%); 24/180 (13%); (1%); DES : 1/181 59/183
>,7#%4?@40,6&"+&/+"4+<&-0/%& .3&-.%+<&-,4"+.03 48–72, controls 312 320 ppb DES in diet for 4, 8, 26 and wk 140 640 ppb DES in diet for 4, 8, 26, and wk 140 DES-free diet for controls for 61 wk 72 mice/sex/group DES 0, 20,5, 10, 40, 160, 320, 640 ppb wk or for (male) 153 wk (female) 143 DES-free diet for controls 144, 912 controls144, 912 640 ppb DES in diet 9 wkfrom of age 3, 5, 7, 2,(for 4, 6, 8, 12 wk 10, or until wk of133 age) DES-free diet for controls
. (1987) . (1990) . (1986)
& et al et al et al &
Mouse C3H/HeN-MTV(F Greenman Mouse C57BL/6 (M/F) Greenman !"#$%&'()&*+,-.%/&01&2"32%4&.3&%56%4.7%3+"$&"3.7"$/&%560/%-&+0&-.%+89$/+.$#%/+40$&:04"$&%560/,4%; *6%2.%/< /+4".3&:/%5; =%1%4%32% Mouse C3H/HeN-MTV(F) Greenman
!&% IARC MONOGRAPHS – 100A
C077%3+/ No table available because of negative data < 0.05 P
Incidences of interstitial cell and pituitary tumours were not statistically signi % cant *[email protected]"32% a
(27%), (27%), a
: 0/15; 0/15; 2/15 (13%), (13%), 2/15 0/15; : 0/15; (13%), 2/15 (13%); 2/15 : 0/15; ± ± Female, lung adenoma (14%), 2/14 (28%); 4/14 0/14; rasH2: (7%); 1/14 wild type: NR wild (14%) 2/15 type: (7%); 1/15 0/15; 0/15; wild type: 0/15 0/13; 0/15; wild type: 0/14 0/15; 0/15; A32.-%32%&01&+,70,4/ Male, testis (Interstitial cell tumour) p53 Female, pituitary adenoma p53 Male, Leydig cell tumour rasH2:4/15 0/15; 0/14; 0/15; No e " ect on the incidences of either forestomach papillomas or skin tumours in either sex.
(0, 500, (0, 1 000 ppm), (0, 50, (0, 250 ppm), ± ± Female rasH2 0.3, 0.1, (0, 1.0 ppm), wild type 0.3, 0.1, (0, 1.0 ppm), 26 wk Female p53 >,7#%4?@40,6&"+&/+"4+<&-0/%& .3&-.%+<&-,4"+.03 wild type 50, (0, 250 ppm), 26 wk wild type 500, (0, 1 000 ppm), 26 wk 15 mice/sex/group15 Male p53 15 mice/sex/group15 Male rasH2 0.3, 0.1, (0, 1.0 ppm), wild type 0.3, 0.1, (0, 1.0 ppm), 26 wk 15 mice/sex/group15 DES 0, 30, 240, or 480 µg/kg bw in corn oil i.g. twice weekly for 26 wk then once during Week control27; corn oil, 27 wk
& . (2001) . (2001) & . (2001) (M/F) et al
et al 2 et al transgenic (M/F) ± !"#$%&'()&:203+.3,%-; *6%2.%/< /+4".3&:/%5; =%1%4%32% Mouse Tg.AC Mouse p53 Mouse CB6F1-rasH2 transgenic Usui Storer Eastin
!&" Diethylstilbestrol C077%3+/ CB6F1-rasH2 transgenic mice 3
a b < 0.05 < 0.05 P *[email protected]"32% P
(67%) (83%) b a Male, osteosarcoma (17%) 1/6 0/13; Xpa: 0/14; 0/15; wild type: 0/15 0/15; Xpa/p53: 5/6 0/13; A32.-%32%&01&+,70,4/ Male, testicular interstitial cell adenoma (17%) 1/6 (23%); 3/13 Xpa: 0/14; 0/15; wild type: (7%) 1/15 0/15; Xpa/p53: 4/6 0/13; Female, osteosarcoma 0/2 Xpa: 0/15; 0/15; 0/15; wild type: 0/15 0/15; Xpa/p53: 2/2 (100%) 0/13; Female, mammary carcinoma 0/2 Xpa: 0/15; 0/15; 0/15; wild type: 0/15 0/15; 0/2 (8%); Xpa/p53 1/13
Xpa homozygous and heterozygous p53 de % cient condition 4
15 mice/sex/group15 Male Xpa 100, (0, 300, 1500 ppb), wild type 1500 (0, ppb) Xpa/p53 1500 (0, ppb) 39 wk Female Xpa 100, (0, 300, 1 500 ppb), wild type 1 500(0, ppb) Xpa/p53 1 500(0, ppb) 39 wk >,7#%4?@40,6&"+&/+"4+<&-0/%& .3&-.%+<&-,4"+.03 e Tg.AC genetically$ e Tg.AC engineered mouse, carrying a v-Ha-ras oncogene fused to the promoter of the gamma-globin gene 2
& & (M/F) 4
Origin was not described McAnulty & Skydsgaard (2005) !"#$%&'()&:203+.3,%-; *6%2.%/< /+4".3&:/%5; =%1%4%32% Mouse Xpa/p53
with human c-Ha-ras proto-oncogene d, day or days; DES, diethylstilbestrol; female; F, i.g., intragastric; M, male; NR, not reported; wk, week or weeks 1
!&& IARC MONOGRAPHS – 100A
3.3 Subcutaneous implantation exposure to diethylstilbestrol with a high-fat diet increased the incidence of uterine glandular 3.3.1 Rat tumours but not of mammary tumours (Walker, Diethylstilbestrol pellets were implanted 1990). Prenatal diethylstilbestrol induced pitui- in lactating Wistar-MS rats a!er irradiation tary tumours in female CD-1 mice (Walker & (260 cGy). A signi%cantly higher incidence of Kurth, 1993). mammary tumours was observed in the 260 cGy In the CBA female descendants of mothers plus diethylstilbestrol group compared with the treated with prenatal diethylstilbestrol exposure, 260 cGy-alone group. $e latency period was described as F2m, the incidence of uterine sarco- shortest in the diethylstilbestrol-treated group mas, lymphomas, and ovarian tumours was sig- irradiated during the late lactation period. ni%cantly higher than in controls (Turusov et al., Diethylstilbestrol treatment alone in virgin rats, 1992). $e persistence of diethylstilbestrol e"ects without irradiation (n = 20), did not produce any was studied further one generation (diethyl- tumours (Suzuki et al., 1994). stilbestrol-lineage-2 mice). Diethylstilbestrol- Implanted diethylstilbestrol silastic tubes lineage-2 mice, exposed to low- or high-fat induced signi%cantly larger and highly haemor- maternal diets, had signi%cantly more tumours rhagic pituitary tumours in female F344 rats but in their reproductive system and liver than con- not in Brown Norway (BN) rats. $e female F1 trol mice with the same dietary fat exposure (F344 x BN) rats exhibited signi%cantly increased (Walker & Haven, 1997). $e incidence of uter- pituitary growth a!er 10 weeks of diethyl- ine adenocarcinomas in F2 females with prena- stilbestrol treatment, but the pituitary was not tal diethylstilbestrol exposure was signi%cantly haemorrhagic. $e haemorrhagic pituitaries in higher than controls, whereas the incidence of F2 rats were mostly massive, indicating that some tumours of the liver, lung or other organs exam- genes regulate both phenotypes (Wendell et al., ined in this study was not signi%cantly di"erent 1996). Diethylstilbestrol increased pituitary mass from that in control animals (Newbold et al., to 10.6-fold in male ACI rats, and only to 4.4-fold 1998). In F2 males, a signi%cant increase in the in male Copenhagen (COP) rats. $e pituitary incidences of proliferative lesions of the rete tes- growth response of the diethylstilbestrol-treated tis (hyperplasia and tumours) was observed, (5 mg at 63 ± 4 days until 12 weeks of age) in suggesting that the rete testis is a target for the F1 (COPxACI) rats was intermediate (6.9-fold) transgenerational e"ects of diethylstilbestrol in to that exhibited by the parental ACI and COP males (Newbold et al., 2000). strains (Strecker et al., 2005). Prenatal diethylstilbestrol treatment of See Table 3.3. female CBA mice increased the incidence of DMH-induced colon carcinoma (Turusov et al., 1997). E"ects of perinatal diethylstilbestrol expo- 3.4 Perinatal exposure sure on mammary tumorigenesis were stud- ied in female C3H/HeN/MTV+ mice. Neonatal 3.4.1 Mouse treatment with a low dose of diethylstilbestrol Methylcholanthrene treatment induced vag- increased the probability of mammary tumour inal tumours (squamous cell carcinoma and formation (Lopez et al., 1988). E"ects of perina- mixed (squamous cell carcinoma plus adeno- tal exposure to estrogens during the developing carcinoma) carcinoma) with signi%cantly higher stage of reproductive tract organs were studied incidence in the CD-1 mice a!er prenatal expo- in CD-1 mice. Uterine adenocarcinomas were sure to diethylstilbestrol (Walker, 1988). Prenatal induced in a time- and dose-related manner
('' Diethylstilbestrol
C077%3+/ DES is a promoter of lung carcinogenesis. Age at start NR, animal g weight 17–20 < 0.01 P , a, b < 0.05 P *[email protected]"32% vs U alone group, respectively
) b ) b
1 ± 2.833.81 (77%), ) (65%) b b (61%), 1.80 ± 1.79 (61%), a
U + DES 50 mg (20/26 A32.-%32%&01&+,70,4/<&7,$+.6$.2.+9 Lung macroscopic tumours 0.69 ± 1.04) U alone(33%), (9/27 U + DES 5 mg (17/28 U alone (5/27) U(18%) alone (5/27) (32%) U + DES 5 mg (9/28) U + DES 50 mg (17/26 Lung malignant tumour
>,7#%4?@40,6&"+&/+"4+<&-0/%<& -,4"+.03 26–28, 58 controls Single i.p. injection of U in saline mg/kg)(50 + DES, i.m. injections one wk later 5 or 50 mg/kg bw once every wk wk for 18 Control: saline and DMSO + saline
& & . (2000)
et al Malignant tumours were combinations of adenocarcinoma, papillocarcinoma translation), (author’s and mixed type cancer !"#$%&'(D&*+,-.%/&01&2"32%4&.3&%56%4.7%3+"$&"3.7"$/&%560/%-&+0&-.%+89$/+.$#%/+40$&:.3+4"7,/2,$"4&.3E%2+.03; *6%2.%/< /+4".3&:/%5; =%1%4%32% Mouse Kunming (F) Jiang
1 DES, diethylstilbestrol; i.m., intramuscular; i.p., intraperitoneal; NR, not reported; urethane; U, wk, week or weeks
('! IARC MONOGRAPHS – 100A C077%3+/ DES promoted radiation-induced mammary tumorigenesis
< 0.001 in the < 0.001 in the *[email protected]"32% P incidence and latency period, 260 cGy + DES vs 260 cGy + CHOL P incidence and latency period 260 cGy + DES vs DES alone
)
) A32.-%32%&01&+,70,4/<&7,$+.6$.2.+9 Mammary tumours histological (no information Incidence, latency period (month 10.5 ± 0.2); (35%), 260 cGy + CHOL (6/17 10.0 ± 1.2); (27%), O cGy + DES (3/11 ± 0.5); 7.4 260 (96%), cGy + DES (27/28 Virgin rats: 0 cGy + DES (0/20) 1 & remained 2
$ e release of DES from the pellet was estimated to be 1 μg/day 2
>,7#%4?@40,6&"+&/+"4+< -0/%<&-,4"+.03 + CHOL pellets containing 5 mg DES were implanted 1 mo a ! er lactation. DES pellets for 1 yr and were replaced every 8 wk 17–28 rats/group 17–28 Irradiatedwith 260 cGy gammaof rays d a on 21 ! er parturition
& . (1994) & et al
Detailed location was not described !"#$%&'('&*+,-.%/&01&2"32%4&.3&%56%4.7%3+"$&"3.7"$/&%560/%-&+0&-.%+89$/+.$#%/+40$&:/,#2,+"3%0,/&.76$"3+"+.03; *6%2.%/< /+4".3&:/%5; =%1%4%32% Rat Wistar-MS (F) Suzuki
CHOL, cholesterol; d, day or days; DES, diethylstilbestrol; female; F, mo, month or months; wk, week or weeks 1
('( Diethylstilbestrol a!er diethylstilbestrol treatment (Newbold et al., 3.4.2 Rat 1990). Male o"spring of CD-1 mice with trans- placental exposure to arsenite were treated with Mammary tumours are induced in female diethylstilbestrol neonatally. Total liver tumour ACI rats by either prenatal injections or by post- incidence, the number of mice with multiple natal pellet implantation of diethylstilbestrol. liver tumours, and urinary bladder proliferative $e combination of both yielded signi%cantly lesions was higher in the arsenite plus diethyl- greater tumour multiplicity, and decreased stilbestrol mice compared to the arsenite-alone tumour latency (Rothschild et al., 1987). Vaginal group (Waalkes et al., 2006b). In female o"spring epithelial tumours were induced in a dose-related CD-1, the incidence of carcinoma of the cervix manner in female Wistar rat following in-utero and of urinary bladder total proliferative lesions diethylstilbestrol exposure (Baggs et al., 1991). (hyperplasia plus papilloma plus carcinoma) in Prenatal exposure to diethylstilbestrol produced the arsenite plus diethylstilbestrol group was uterine adenocarcinomas and pituitary adeno- signi%cantly higher than in the arsenite-alone mas in female Donryu rats, as reported in an group (Waalkes et al., 2006a). earlier study in mice (Kitamura et al., 1999). In CD-1 and diethylstilbestrol induced-TGFα Sprague Dawley rats, neonatal diethylstilbestrol transgenic mice were neonatally treated with exposure at a relatively low dose (1 µg/kg bw) diethylstilbestrol. $e presence of the TGFα caused an increase in the incidence of mammary transgene signi%cantly increased the incidence carcinomas induced by 1,2-dimethylbenz[a] of endometrial hyperplasia and benign ovarian anthracene (Ninomiya et al., 2007). Female rats Ek/+) adminis- cysts, whereas it did not promote uterine adeno- carrying the Eker mutation (Tsc-2 tered diethylstilbestrol neonatally had a signi%- carcinoma (Gray et al., 1996). Transgenic MT-mER cantly greater multiplicity of leiomyoma in the mice, which overexpress the estrogen receptor, uterus (Cook et al., 2005). driven by the mouse metallothionein I promoter, were neonatally treated with diethylstilbestrol. $e diethylstilbestrol-treated MT-mER mice 3.4.3 Hamster demonstrated a signi%cantly higher incidence $e subcutaneous implantation of diethyl- of uterine adenocarcinomas (Couse et al., 1997). stilbestrol pellets caused renal tumours in young Diethylstilbestrol-treated wild-type mice exhib- Syrian hamsters (Liehr & Wheeler, 1983), and ited a relatively high frequency of uterus endome- diethylstilbestrol pellets, implanted a!er orchiec- trial hyperplasia and granulosa cell tumours in tomy, induced kidney tumours in the same species the ovary, while αERKO mice (estrogen receptor (Goldfarb & Pugh, 1990). Diethylstilbestrol- α knockout mice) showed a complete lack of these treated castrated hamsters exhibited interstitial lesions (Couse et al., 2001). Lymphoma-prone lesions in the kidney as well as kidney tumours Mlh1 or Msh2 knockout mice were treated with (Oberley et al., 1991). In male and female diethylstilbestrol. Combination of Mlh1 de%- Armenian hamsters, diethylstilbestrol pellets ciency condition with diethylstilbestrol expo- applied subcutaneously induced hepatocellular sure was shown to accelerate lymphomagenesis carcinomas (Coe et al., 1990). (Kabbarah et al., 2005). Murine PTEN (mPTEN) See Table 3.4. heterozygous mutant mice demonstrated that neonatal diethylstilbestrol treatments exerted an inhibitory, rather than an enhancing, e"ect on PTEN-associated endometrial carcinogenesis via stromal alterations (Begum et al., 2006).
(') IARC MONOGRAPHS – 100A
3.5 Synthesis Whole animal autoradiography experiments showed that radiolabelled diethylstilbestrol $e oral administration of diethylstilbestrol injected intravenously into rats is accumulated in induced tumours of the ovary, endometrium the liver and small intestine within 4 hours, and and cervix, and mammary adenocarcinomas radioactivity can still be detected in these organs in female mice. Osteosarcomas and Leydig cell a!er 4 days (Bengtsson, 1963). Peak plasma lev- tumours were induced in rasH2 and Xpa/p53 els of radioactivity were found within 16 hours male mice, respectively. in sheep given radiolabelled diethylstilbestrol Subcutaneous implantation of diethyl- at single oral doses. Radioactivity disappeared stilbestrol induced mammary tumours in female almost completely a!er 120 hours (Aschbacher, Wistar rats. 1972). Ten days a!er a single oral dose of radiola- Perinatal exposure to diethylstilbestrol belled diethylstilbestrol to steers, residues could induced lymphomas, uterine sarcomas, adeno- be detected in the small intestine, the faeces, and carcinomas and pituitary, vaginal, and ovarian the urine (Aschbacher & $acker, 1974). In the tumours in female mice. Uterine adenocarcino- rat, it was demonstrated that a!er intestinal intu- mas and mammary and vaginal tumours were bation of diethylstilbestrol or diethylstilbestrol- also induced in female rats. In hamsters, diethyl- glucuronide, free diethylstilbestrol is readily stilbestrol perinatal exposure induced kid- absorbed through the epithelium, whereas the ney tumours. In castrated hamsters, kideney conjugated form requires prior hydrolysis by the tumours were also induced following implanta- intestinal micro'ora (Fischer et al., 1973). tion of diethylstilbestrol. Studies on diethylstilbestrol transfer across the placenta in mice have shown that it accumu- lates in the fetal genital tract, where it reaches lev- 4. Other Relevant Data els 3 times higher than found in the fetal plasma (Shah & McLachlan, 1976). 4.1 Absorption, distribution, $e kinetics of a single oral dose of radiola- metabolism, and excretion belled diethylstilbestrol (10 mg) in cattle fol- lowed a biphasic depletion curve, attributed to $e toxicokinetics and metabolism of diethyl- hepatic clearance. An initial steeper slope repre- stilbestrol (diethylstilbestrol) were reviewed in sented a biological half-life of 17 hours, while the 1979 (IARC, 1979b), and by Metzler & Fischer half-life for the later phase was 5.5 days (Rumsey (1981). et al. 1975a). Furthermore, pellets of 24–36 mg Diethylstilbestrol is readily absorbed and dis- diethylstilbestrol implanted subcutaneously tributed in the whole organism a!er oral admin- in cattle or steers liberated about 56–74 μg of istration (Marselos & Tomatis, 1992). In animal diethylstilbestrol per day into the circulation; the models used for the pharmacokinetics of diethyl- half-life was 80–90 days (Rumsey et al. 1975b). stilbestrol (with the exception of primates), it Subsequently, the oxidative quinone metab- is apparent that the drug is almost exclusively olite of diethylstilbestrol (4',4''-diethystilbestrol eliminated through biliary excretion into the quinone) was found to be reactive in vitro, bind- intestine, where it undergoes extensive entero- ing to DNA (Liehr et al., 1983; 1985a). $e forma- hepatic circulation before being excreted in the tion of the quinone is mediated by microsomal faeces (Marselos & Tomatis, 1992). Only traces monooxygenase (Degen et al., 1986; Roy et al., of diethylstilbestrol can be detected in urine 1991a), in particular cytochrome P450(CYP)1A1 (McMartin et al., 1978). (Roy et al., 1992), by prostaglandin synthase
('* Diethylstilbestrol C077%3+/ = 0.0022 = 0.037 = 0.004 < 0.05 DES+MCA vs < 0.01 P P P *[email protected]"32% P Vehicle+MCA P
2 Uterine sarcomas: control F2m6%) 20%), female (6/108, (17/84, Lymphomas: F2m female (17/84, 20%), control (10/108, 9%) controlF2m 20%), female (10/108, (17/84, Benign ovarian tumours: 8%) controlF2m female (9/108, 19%), (16/84, A32.-%32%&01&+,70,4/ Vaginal tumours: (SCC and mixed (SCC + adenocarcinoma) carcinoma) 29%) DES + MCA (10/35, + MCAVehicle (2/28, 7%) DES + beeswax 8%) (1/12, + beeswaxVehicle 0%) (0/8, Pituitary tumours: 2%) Control (1/57, DES 56%) 1 µg (19/34, DES100%) 2 µg (3/3,
1
&
the descendants of DES-treated grandmothers were used in this study) For life >,7#%4?@40,6&"+&/+"4+ =0,+%<&-0/%<&-,4"+.03 Number/group at start NR Prenatal: s.c. injection 1 µg/g bw DES in olive oil + 2% ethanol of atpregnancy Day 17 + Postnatal: sponges impregnated with MCA in beeswax were lodged against the cervix and vaginal fornices of the mice at 6 months of age Controls received olive oil mo toUp 14 132; 64 controls i.p. injection 1 or 2 µg/g bw days postconceptionat 16–17 For life Number/group at start NR Prenatal: i.p. injection 1 µg/g bw DES in olive oil + 2% ethanol of atpregnancy Day 17 (F2m, &
. & et al
!"#$%&'(F&*+,-.%/&01&2"32%4&.3&%56%4.7%3+"$&"3.7"$/&%560/%-&+0&-.%+89$/+.$#%/+40$&:6%4.3"+"$&%560/,4%; *6%2.%/< /+4".3&:/%5;<&"@% =%1%4%32% Mouse (F), CD-1 gestation Day 17 Walker (1988) Mouse (F), CD-1 gestation Day 16 Walker & Kurth (1993) Mouse CBA gestation(F), Day 17 Turusov (1992)
('# IARC MONOGRAPHS – 100A $ e multigenerational e " ect of DES was observed in mice Pups, g 1–3.5 C077%3+/ 5 6 < 0.001 < 0.001 < 0.001 P P P < 0.05; 0.01; < 0.01; < 0.05; < 0.05 = 0.03 < 0.001 P NS; NS NS; NS P P – ; P P NS P vs. historical controls *[email protected]"32% vs. concurrent controls; 5/65 (8%) 5/65 1/48 (2%) 1/48 0/40 8/72 (11%) 5/64 (8%) 0/55 total 4/36 (11%) 1/15 (7%) 1/15 0/24 6/37 (16%) 6/37 3/35 (9%) 3/35 0/23 at 22–24 mo 1/29 1/29 (3%) 0/33 0/16 2/35 2/35 (6%) 2/29 (7%) 0/32 at 17– mo 19 G3 G2 g 10 G1 G1 5 g G1 G1 G1 2.5 g Control Liver tumours: LF 48%) (32/66, 28%), DES+LF (17/61, HF 30%), (22/68, 32%) DES+HF (16/54, Reproductive system tumours: Combination of ovarian, uterine, cervical (adenocarcinoma) and mammary tumours (adenocarcinoma + sarcoma) 17%) LF (11/66, 51%), DES+LF (31/61, 26%) HFDES+HF(25/54, (18/68, 46%), Groups A32.-%32%&01&+,70,4/ Uterine adenocarcinomas in F2:
&
were examined 4
mice were exposed 3
to low- (LF, 2.6%) or high-fat2.6%) to (LF, low- diets 29%) (HF, For life >,7#%4?@40,6&"+&/+"4+ =0,+%<&-0/%<&-,4"+.03 Number/group at start NR 1 µg/g bw of DES in olive oil + ethanol0.1% of atpregnancy. Day 17 DES-lineage2 in this study. Animals or were held for 17–19 22–24 mo Number at start NR s.c. injection 2.5,G1: µg/kg 5, 10 bw ofon gestationDays 9–16 G2: 1000 µg/kg bw of ongestation Day 18 G3: 0.002 µg/pup/day on Days a 1–5 ! er birth Female F2 mice &
. & et al
!"#$%&'(F&:203+.3,%-; *6%2.%/< /+4".3&:/%5;<&"@% =%1%4%32% Mouse (F), CD-1 gestation Day 17 Walker & Haven (1997) Mouse Day(F), CD-1 1 for F2 Newbold (1998)
('$ Diethylstilbestrol
Pups, g 1–3.5 C077%3+/ < 0.01 < 0.01 < 0.05 < 0.01 = 0.0026 at 12 mo, = 0.0002 mo at 18 NS NS P<0.01 (0.3–DES+DMH)P<0.01 NS P NS P – P P *[email protected]"32% P P 16/27 (59%) 16/27 0/32 10/27 (37%) 10/27 4/32 (12%) 0.3-DES+DMH 29/54 (53%) 29/54 4/45 (9%) 10/54 (18%) 10/54 6/45 (13%) 6/45 0.1-DES+DMH 21/38 21/38 (55%) 0/37 2/38 (5%) 9/37 9/37 (24%) DMH CBA Uterus sarcomas: C3H CBA C3H G2 (5/52, 10%) (1 tumour) (1 10%) G2 (5/52, 30%) G3 (7/23, Rete testis proliferative lesions (hyperplasia or tumours) in testis of DES-lineage (F2) male mice: 6%) Control (3/53, 2.5 21%) G1 μg (15/73, tumour) (1 32%) 5 μG1 g (27/83, 35%) μ 10 g (17/49, G1 Colon carcinomas: A32.-%32%&01&+,70,4/ Uterus adenocarcinomas of 2 µg group at2, 1, 4, 6, 8, 12,mo: 18 (90%) 9/10 (47%), 8/17 0/12, 0/5, 0/10, DES: 0/10, 0/18, 0/10 0/17, 0/12,Controls: 0/5, 0/10, 0/10, 0/15, 8
&
examined in this 7
study were killed mo at 17–24 Killed 50 at Week a ! er the beginning of DMH >,7#%4?@40,6&"+&/+"4+ =0,+%<&-0/%<&-,4"+.03 Number at start NR s.c. injection 2.5,G1: g/kg 5, 10 bw on Days of gestation9–16 G2: 1000 µg/kg of bw on Day 18 gestation G3: 0.002 µg/pup/d on Days a 1–5 ! er birth DES was dissolved in corn oil Male F2 mice 35–50; controls/group 84–101 s.c. injection 0.30, 0.1, mg/kg bw DES in olive ethanoloil + 0.1% of atpregnancy Day 17 and then descendants were treated with 1,2-dimethyl hydrazine (DMH) Number at start NR s.c. injection of 0.002 or 2 µg/ DES inpup/d corn oil for Days of age 1–5 Controls received corn oil Killed 2, 1, 4, 6, 8, 12, mo of 18 age &
. . .
&
et al et al
et al
!"#$%&'(F&:203+.3,%-; *6%2.%/< /+4".3&:/%5;<&"@% =%1%4%32% Mouse (M) CD-1 Day 1 for F2 Newbold Mouse, C3H(F) CBA(F) 2–3 months for F1 Turusov Mouse (F) CD-1 Day 1 of life Newbold (2000) (1997) (1990)
('% IARC MONOGRAPHS – 100A Sodium arsenite in the drinking-water C077%3+/
< 0.05 vs Vehicle/DES < 0.05 vs Vehicle/DES = (DES0.01 vs control) < 0.05 (ARS+DES vs < 0.05 (ARS+DES vs < 0.001 response) (dose < 0.05 at 8 months < 0.05 at 8, 12, mo 18 <0.01 <0.01 P P
a b P P ARS) P ARS) P *[email protected]"32% – – P P vs Wild(MT-mER+DES type+DES) P (Wild type+DES vs wild type) P
10
b
14
, 4.3 a , 3.0 a
High DES/DES: 15.2 wk Cervix (carcinoma): ARS Control (0/34), (0/33), ARS+DES 24%) (8/33, 18%), DES (6/33, Urinary bladder proliferative(total lesions): Mean time to appearance of $ rst mammary tumour, mean No. of palpable mammary tumours/rat: Vehicle/DES: 22.2 wk, 2.2 Low DES/DES: wk 19.4 Control (1/33, 3%), ARS-alone 3%), Control 15%), (1/33, (5/34, 38%) ARS+DESDES-alone 3%), (13/33, (1/33, (27%) 3/11 (2%), 1/63 4/80 (5%), (4%), 2/49 (1%), 2/147 A32.-%32%&01&+,70,4/ Vaginal epithelial tumours: Uterus (adenocarcinoma): in (0/26) Vehicle CD-1, inVehicle TGF α (0/25) 44%) DES in (7/16, CD-1 Uterus adenocarcinomas at 4, 8, 12,mo: 18 12/13 (87%), 13/15 (73%), 19/26 +DES: MT-mER 0/19, (92%) 13/14 (73%), Wild 11/15 type+DES: (46%), 11/24 0/19, (93%) (5%) 1/19 0/15, control:MT-mER 0/10, 0/14, Wild type 0/19 0/15, control: 0/11, 0/15, (7/15, 47%) DES in TGF α (7/15,
&
9
13
85 ppm from of Days 8–18 gestation + s.c. injection 2 µg/pup/d DES Days of age 1–5 Killed at 90 wk 2.5 mg DES pellet at 12 wk Control: sesame oil (vehicle/DES) Killed 7 mo post pellet >,7#%4?@40,6&"+&/+"4+ =0,+%<&-0/%<&-,4"+.03 animals/group35 " spring) (o Transplacental exposure to arsenite (ARS) controls32 32–47, Prenatal: s.c. injection of 0.8 µg (Low) or 8.0 µg (High) DES in sesame oil on Days and 15 of gestation 18 Postnatal: controls 147 11–80, i.p. injection 0.5,0, 0.1, 25, 50 mg/kg bw andon Days 19, 2018, of gestation > 120 days Number/group at start NR s.c. injection 2 µg/pup/d DES in sesame oil on Days 1 – 5 of age Control remained untreated maintained wk 52 or for life 39, Number/group at start NR s.c. injection 2 µg/pup/d DES in corn oil on Days 1 – 5 of age Control: untreated Killed at 4, 8, 12, and mo of 18 age &
. .
et al . (1997) (F) . (1991)
& . (1996) 12 et al
(F)
et al
et al 11 et al
!"#$%&'(F&:203+.3,%-; *6%2.%/< /+4".3&:/%5;<&"@% =%1%4%32% Mouse (F) CD-1 Day 1 of life (female o " spring) Waalkes (2006a) Mouse CD-1(F) TGF α Mouse, Wild type fvb/N (F) MT-mER Rat, (F) ACI gestation Day 15 Rothschild Rat, Wistar (F) gestation Day 18 Baggs (1987) Day 1 of life Gray Day 1 of life Couse
('" Diethylstilbestrol C077%3+/
< vs0.01 control < 0.05 vs control < 0.02 in multiplicity, mg 0.1 vs < 0.01, control < 0.05, mg 0.1 vs control < 0.05 P P P
and size in Eker rats (DES vs vehicle) a b a P *[email protected]"32% P P
a
b a
, 10.50 ± 2.70 a a
+/+ Ek/+ Tsc-2 Tsc-2 (100%), 3.00 ± 1.22 (100%), a 1 µg: 21/21 2.54 ± 1.66 (85%), µg:10 11/13 1.63 ± 1.45 100 (75%), µg: 12/16 0.82 2.30 ± 0.15, (64%), 18/28 Vehicle: ± 1.10 ±1.33 0.17 DES: 22/24 (92%), In wild type 0/34,Vehicle: 0, 0 DES: 0/34, 0, 0 A32.-%32%&01&+,70,4/ Uterus tumours: (endometrial adenocarcinoma) (31%) 9/29 4/39 (10%), 1/20 (5%), Pituitary adenomas: 6/29 (20%) 0/39, 1/20 (5%), Mammary tumour incidence and multiplicity (Mammary adenocarcinoma) at 300 d a %er birth: 1.50 ± 1.19 0.0 (77%), µg: 17/22 2.80 (86%), ± µg:1.61 0.1 13/15 Uterus (leiomyoma): Incidence, multiplicity and size In Ekar rats Renal tumours: Control (0/9) 85%) DES (11/13,
&
>,7#%4?@40,6&"+&/+"4+ =0,+%<&-0/%<&-,4"+.03 35–72, 23 controls s.c. injection mg/kg 0.1 0, 0.01, bw DES on Days and 17 of gestation 19 Control: olive oil months18 22 controls13–21, s.c injection 100 10, µg/kg 1, 0, 0.1, bw DES in sesame oil at birth. 50 days a !er birth all rats received 1 mg DMBA in 1 mL sesame oil by gastric intubation Killed 50–300 d a ! er birth Number at start NR s.c. injections µg/rat/d10 DES in sesame oil on Days 3, 4, and 5 a ! er birth Controls: 50 μl sesame oil Killed mo of upage. to 16 animals/group15 40 mg pelletsTwo containing 90% DES cholesterol+ 10% were implanted at Day 27 and one more (same composition) 3 mo later d 172 &
. .
et al et al . (2005) &
et al
!"#$%&'(F&:203+.3,%-; *6%2.%/< /+4".3&:/%5;<&"@% =%1%4%32% Rat, Donryu (F) gestation Day 17 Kitamura (1999) Rat, Sprague Dawley (F) Day 1 of life Ninomiya (2007) Rat Eker Rats carrying a germ-line defect in the tuberous sclerosis complex tumour2 (Tsc-2) suppressor gene (F) Day 3 of life Cook Hamster Syrian 4 wk(M), Liehr & Wheeler (1983)
('& IARC MONOGRAPHS – 100A
8
DES-exposed female Age NR, Animal weight 90–100 g C077%3+/ Pregnant CD-1 7 9
$ e types of epithelial tumours 14
Homozygous TGF α transgenic 11
versus concurrent controls; relative to 5
< 0.05, DES vs control NS *[email protected]"32% P at 6.2 Female mice in each (F1) group were raised to sexual maturity and bred with 4
$ e descendants of DES-treated mothers, described as DES-lineage were mated with control 3
]anthracene; female; F, i.p., intraperitoneal; M, male; MCA, methylcholanthrene; mo, month or 13 a Total proliferative lesion (hyperplasia+ papilloma+ carcinoma). 10
DES 2, at 1, 8,3, 4, 9 mo 5, 6, 7, 4/6 NR; 2/3 (67%); (37%); 3/8 0/12; 0/7; 0/7; 0/7; 0/7; (67%) Controls: at 9 mo 0/4 A32.-%32%&01&+,70,4/ Renal tumours: Controls at 2.5–3; 5–6.2 mo 0/8; 0/12 DES at 2.5; 4.6; 5.6; 6.2 mo (78%) 7/9 (67%); 8/12 (17%); 2/12 0/13; Interstitial foci in the kidney: DES 2, at 1, 8,3, 4, 9 mo 5, 6, 7, NR; 2/3 (66%); (62%); 5/8 4/12 (33%); 0/7; 0/7; 0/7; 0/7; (17%) 1/6 Kidney tumours: &
$ e transgenic construct consisted of a fragment of the mouse ER cDNA encoding the full-length ER protein driven by the mouse metallothionein I 12
versus historical controls; relative to historical control rate of month in0.4% (2/482) 21–24 old female Charles River CD-1 mice. 6
>,7#%4?@40,6&"+&/+"4+ =0,+%<&-0/%<&-,4"+.03 controls 8–12 9–13; Orchiectomy and 4 wk later 20 mg DES pellets every 3 mo, 2.5–6.2 mo 57, 4 controls 57, Castrated and 20 mg of DES pellet every 2.5 mo mo, for 1–9 &
.
&
Pellets containing 2.5 mg cholesterol mg DES+17.5 (DES pellet) or 20 mg cholesterol were implanted s.c. into 12-week-old female o " springs. et al 13
Both grossly visible tumours and microscopic cancers included in this category. 2
$ e descendants of DES-treated mothers, described as F1DES, were mated among each other or with untreated animals. F1DES males were successfully mated with untreated females !"#$%&'(F&:203+.3,%-; *6%2.%/< /+4".3&:/%5;<&"@% =%1%4%32% Hamster, Syrian 7 wk(M), Goldfarb & Pugh (1990) Hamster, Syrian (M) 2 mo Oberley (1991)
$ e descendants, starting from the age of 2–3 months, received weekly s.c. injections of 1,2-dimethylhydrazine (DMH) mg/kg (8 for a bw), total of 20 injections. concurrent control rate of 0/55. animals. DES-lineage2 mice were generated by mating DES-lineage female mice with control males. 1 promoter. of the vagina were adenocarcinomas, squamous cell carcinomas, and mixed carcinomas bodybw, weight; d, day or days; DES, diethylstilbestrol; dimethylbenz[ DMBA, 7,12 months; NR, not reported; NS, not signi % cant; s.c., subcutaneous; wk, week or weeks mice received 85 ppm arsenite in the drinking-water from gestation Days 8 to 18 mice (F(1)) were raisedmice (F(1)) to maturity and bred with control males to generate DES-lineage descendants. (F(2)) males $ e F(2) obtained from these matings are the subjects of this report. (F2m). female mice from the MT42 line. control males. Female o" spring (DES lineage or F2) from these matings were raised to maturity and housed with control males for 20 weeks.
(!' Diethylstilbestrol
(Ross et al., 1985; Degen, 1993), and by peroxi- superoxide dismutase (Segura-Aguilar et al., dases (Metzler, 1984; Liehr et al., 1983; 1985a). 1990). In the mammary gland tissue of female $e quinone metabolite is reduced by P450 rats, expression of Cyp1A1 gene was increased by reductase and xanthine oxidase, via the semiqui- diethylstilbestrol treatment, whereas the expres- none and non-enzymatically, directly to diethyl- sion of the genes encoding glutathione-S-trans- stilbestrol (Roy & Liehr, 1988; Roy et al., 1991b). ferase and superoxide dismutase were depressed Diethylstilbestrol quinone is also formed in vivo, (Green et al., 2007). in the kidney of diethylstilbestrol-treated male $e oxidative metabolism of diethylstilbestrol Syrian hamsters (Roy & Liehr, 1988), in the mam- almost certainly plays a central role in the induc- mary gland tissue of diethylstilbestrol-treated tion of kidney tumours in Syrian hamsters, of ACI rats ($omas et al., 2004), and in the liver of genetic changes in various in-vitro assays, and diethylstilbestrol-treated rats (Green et al., 2003). probably also of other tumours in animals peri- Diethylstilbestrol quinone is formed in the liver, natally exposed to diethylstilbestrol in utero. kidney, uterus, and placenta of pregnant diethyl- Whether these events occur in target tissues of stilbestrol-treated Syrian hamsters, and in the transplacental exposure to diethylstilbestrol in liver and kidney of their fetuses (Roy & Liehr, humans has not been determined. 1989). Diethylstilbestrol metabolites are also found in the female genital tract of adult mice 4.2 Genetic and related e"ects and pregnant mice, and in tissues of their fetuses (Gottschlich & Metzler, 1984; Maydl et al., 1985). 4.2.1 Direct genotoxicity $e quinone metabolite was found to undergo a CYP-mediated process of redox cycling (Liehr (a) Humans et al., 1985a), via a semiquinone intermediate No changes in DNA ploidy pattern and no (Kalyanaraman et al., 1989). mutations were found in speci%c cancer-related During redox cycling of diethylstilbestrol, genes (H-RAS and K-RAS proto-oncogenes, TP53 superoxide radicals are formed in vitro (Epe and the Wilms’ tumour (WT-1) tumour suppres- et al., 1986; Roy and Liehr, 1988). In the kid- sor genes) or in the coding region of the estrogen ney of diethylstilbestrol-treated hamsters, ele- receptor-α (ERα) gene (Welch et al., 1983; Boyd vated levels of 8-hydroxy-deoxyguanosine were et al., 1996; Waggoner et al., 1996). $e frequency found, indicating that diethylstilbestrol can of some known polymorphisms (exon 1, 3, and induce oxidative DNA damage in vivo (Roy 8) in the ERα gene was not di"erent from that et al., 1991c). Furthermore, increased levels of expected in the general population (Boyd et al., lipid hydroperoxides and of malondialdehyde- 1996). DNA adducts were also detected (Wang & Liehr, In cervico-vaginal biopsies and smears from 1995a). Lipid hydroperoxides were also found 19 women who had been exposed to diethyl- to be increased in the mammary gland tissue of stilbestrol in utero and 19 controls, the frequen- diethylstilbestrol-treated ACI rats (Gued et al., cies of trisomy of chromosomes 1, 7, 11, and 17 2003). $ese lipid hydroperoxides co-activate the were evaluated by the FISH technique. $e tri- CYP1A1-mediated oxidation of diethylstilbestrol somy frequencies were elevated in 4/19 (21%) to its quinone metabolite (Wang & Liehr, 1994). diethylstilbestrol-exposed women. Trisomy of Diethylstilbestrol treatment reduced the activ- chromosomes 1, 7, and/or 11 was found, which ity of enzymes that protect against diethyl- frequently occurs in gynaecological tumours, stilbestrol-induced oxidative stress, such as but trisomy of chromosome 17 did not occur. No glutathione peroxidase, quinone reductase, and
(!! IARC MONOGRAPHS – 100A chromosomal trisomy was observed in samples et al., 1972; Herbst et al., 1974; Robboy et al., from the control women (Hajek et al., 2006). 1984a). In neoplastic and preneoplastic lesions of the Other e"ects of in-utero exposure to diethyl- breast, loss of heterozygosity and allelic imbal- stilbestrol include infertility in female o"spring, ance at 20 microsatellite markers on nine chro- as reported in most but not all studies (Palmer mosomal arms was comparable between women et al., 2001), and possibly in males (Perez et al., exposed in utero to diethylstilbestrol and control 2005). women (Larson et al., 2006). In most studies, changes in menstrual activ- $ere are no data on the e"ects of diethyl- ity by decreasing the duration of menstrual stilbestrol on cell proliferation or apoptosis bleeding were observed in comparison with con- in human target tissues of diethylstilbestrol- trol women (Hornsby et al.,1994). Young women induced carcinogenicity. whose mothers had been exposed to diethyl- Women with documented in-utero exposure stilbestrol in utero had a 1.5- to 2-fold increased to diethylstilbestrol had a higher mitogen-induced risk for self-reported menstrual irregularities and proliferation of peripheral blood lymphocytes fertility problems (Titus-Ernsto" et al., 2006b). compared to age- and menstrual-cycle phase- In a meta-analysis (Martin et al., 2008) of matched control women (Ways et al., 1987; Burke three studies (Klip et al., 2002; Palmer et al., et al., 2001), suggestive of an increased cellu- 2005; Pons et al., 2005), in-utero exposure to lar immune response. A hyperactive immune diethylstilbestrol was associated with a 3.7-fold system may be related to the reported higher increased risk for hypospadias in men. frequency of autoimmune disease, and immune- related in'ammatory disorders such as arthritis (b) Experimental systems following in-utero exposure to diethylstilbestrol, (i) In vivo compared with control women (Wingard & Diethylstilbestrol induced chromosomal Turiel, 1988; Noller et al., 1988). However, natu- aberrations in bone-marrow cells of mice treated ral killer-cell activity was not found to be altered in vivo, but data on in-vivo induction of sister in women exposed to diethylstilbestrol in utero chromatid exchange and micronuclei were equiv- (Ford et al., 1983). ocal (IARC, 1987b); it induced sister chromatid $e developmental abnormalities and the exchange in one study in rats (Gloser & Cerni, disturbance of menstrual activity found in sons 1984). Diethylstilbestrol induced micronuclei in and daughters, respectively, of diethylstilbestrol early haploid mouse spermatids 17 days a!er a daughters suggest that third generation (F2) single subcutaneous injection (Pylkkänen et al., e"ects of human prenatal diethylstilbestrol 1991a); chromosomal aberrations in cells of the exposure, including cancer development, are renal cortex in male Syrian golden hamsters (the conceivable. However, there are no mechanistic target tissue of diethylstilbestrol-induced carci- data on this point in animal models, nor data nogenicity) (Banerjee et al., 1994); sister chro- about germ-line mutations or other heritable matid exchange (but no changes in chromosome alterations. number) in uterine cervical epithelial cells, but Vaginal adenosis is an established, although not in the epithelium of the uterus or kidneys non-obligatory, precursor of clear cell adeno- (Forsberg, 1991), and sister chromatid exchange, carcinoma. Although most women a"ected by but no aneuploidy in mouse bone-marrow cells vaginal adenosis do not develop clear cell adeno- (Zijno et al., 1989). Markedly increased aneu- carcinoma, adenosis is present in up to 100% of ploidy was found in proximal tubular kidney women with clear cell adenocarcinoma (Herbst
(!( Diethylstilbestrol cells of male Syrian hamsters with subcutane- of diethylstilbestrol-treated adult female rats ously implanted diethylstilbestrol pellets (Li (Green et al., 2005), and in hamster fetal tissues et al., 1993; 1999). a!er injection of their mothers with diethyl- In hamsters, diethylstilbestrol-induced kid- stilbestrol, but the major adduct found was dif- ney tumours point mutations were detected ferent from that identi%ed in the kidneys of in the catalylic domain of DNA polymerase β adult diethylstilbestrol-treated hamsters (Gladek gene compared to control normal tissue (Yan & & Liehr, 1991). $e precise structures of the Roy 1995), and at 44/365 random loci, seven of diethylstilbestrol-induced DNA adducts have which were also present in non-tumorous kid- not been elucidated, but it is probable that some ney tissue (Singh & Roy, 2004). $e expression are oxidative-stress-generated lipid-hydroperox- of DNA polymerase β and a novel gene, Etrg- ide- and malondialdehyde-DNA adducts (Wang 1, was reduced in tumorous and non-tumor- & Liehr, 1995a; 1995b). Although feeding of vita- ous kidney tissues of diethylstilbestrol-treated min C reduced the incidence of kidney tumours, hamsters compared to controls (Singh & Roy, the generation of diethylstilbestrol quinone, 2008). Microsatellite instability was increased in and the formation of adducts in the kidney of early lesions induced by neonatal treatment of diethylstilbestrol-treated male Syrian hamsters mice (Kabbarah et al., 2003). In host-mediated (Liehr et al., 1989) the biological signi%cance of assays using mice, no DNA-repair response was the diethylstilbestrol-generated adducts has not detected in E. coli strains (Kerklaan et al., 1986). been determined, and speci%c mutations gener- Using [32P]-postlabelling, adducted nucle- ated by exposure to diethylstilbestrol have not otides were found in the kidney DNA of ham- been identi%ed thus far. sters chronically treated with diethylstilbestrol (ii) In vitro but not in the kidneys of untreated animals (Liehr et al., 1985b). Some adducts were chro- Diethylstilbestrol induces aneuploidy and matographically identical to those induced by DNA strand breaks in human cells in vitro estradiol and other estrogenic compounds, sug- (IARC, 1987a,b; Rupa et al., 1997; Schuler et al., gesting that some of these adducts may not be 1998; Quick et al., 2008). Data on in-vitro induc- diethylstilbestrol-derived (Liehr et al., 1986). tion of sister chromatid exchange, chromosomal $e major diethylstilbestrol adduct formed in aberrations, and mutations in human cells were vivo in the hamster kidney and liver DNA was inconclusive (IARC, 1987a,b). More recent studies chromatographically identical to that observed found additional evidence of diethylstilbestrol- a!er in-vitro reaction of DNA with 4',4''-diethys- induced sister chromatid exchange in cultured tilbestrol quinone in the presence of microsomes human lymphocytes, but at cytotoxic diethyl- and hydroperoxide cofactors, suggesting that stilbestrol concentrations (Lundgren et al., 1988; this metabolite is responsible for DNA dam- Konac et al., 2005). Data on induction of micronu- age by diethylstilbestrol in vivo, and that oxida- clei by diethylstilbestrol remain equivocal (Fauth tive metabolism of diethylstilbestrol is required et al., 2000; Clare et al., 2006;), while studies on for its formation (Bhat et al., 1994; Gladek & the induction of unscheduled DNA synthesis in Liehr, 1989). $e adduct was unstable with an human cells in vitro were mostly negative (IARC, in-vitro half-life of 4–5 days at 37°C, and an 1987a,b). Diethylstilbestrol inhibited the polym- estimated in-vivo half-life of 14 hours, which erization of microtubules in human %broblasts is suggestive of in-vivo repair (Gladek & Liehr, and prostate cancer cells, inducing metaphase 1989). Importantly, diethylstilbestrol adducts arrest (Hartley-Asp et al., 1985; Parry et al., were also found in the mammary gland tissue
(!) IARC MONOGRAPHS – 100A
1982), an e"ect that may underlie the induction cells transformed by diethylstilbestrol (Fitzgerald of aneuploidy. et al., 1989). Diethylstilbestrol inhibited the in-vitro Aneuploidy and DNA strand breaks were growth of human primary cervical cell strains, induced in rodent cells in vitro (IARC, 1987b), as and inhibited colony formation at high concen- con%rmed in additional studies (Hayashi et al., trations (Johnstone et al., 1984; Stanley et al., 1996; Tsutsui & Barrett, 1997; Tsutsui et al., 1985). Short-term exposure to diethylstilbestrol 1997). Results for chromosomal aberrations, stimulated the growth of SV40-immortalized micronuclei, and sister chromatid exchange were human endometrial stromal cells in so! agar, equivocal (IARC, 1987b), but in more recent an e"ect that was inhibited by the anti-estrogen studies, chromosomal aberrations, micronuclei, tamoxifen (Xu et al., 1995). Chronic exposure and sister chromatid exchange, as well as aneu- of these cells to low concentrations of diethyl- ploidy were found in a variety of rodent cell lines stilbestrol markedly increased growth in so! (de Stoppelaar et al., 2000; Aardema et al., 2006; agar (Siegfried et al., 1984; Rinehart et al., 1996). Wakata et al., 2006; Tayama et al., 2008). $us, diethylstilbestrol caused the transforma- In a comparison of diethylstilbestrol-induced tion of human endometrial stromal cells. aneuploidy in human foreskin %broblasts and Repeated treatment with low doses of diethyl- Syrian Hamster embryo %broblasts, the hamster stilbestrol of MCF-10F immortalized, non-tum- cells appeared signi%cantly more sensitive than origenic, human epithelial breast cells increased the human cells (Tsutsui et al., 1990). colony formation in a so! agar assay at diethyl- $e ability of diethylstilbestrol to bind cova- stilbestrol concentrations ranging from 0.007– lently to tubulin in cell-free systems in the pres- 70 nM (Russo et al., 2001, 2003). Growth of these ence of an activating system (Sharp & Parry, cells in collagen changed from di"erentiated 1985; Epe et al., 1987), and to inhibit the polym- ductular growth to solid spherical masses with erization of microtubules in vitro (Sharp & Parry, the same dose–response relationship. Invasive 1985; Sato et al., 1987; Albertini et al., 1993; growth in a Boyden chamber assay was increased Metzler & Pfei"er, 1995), in Chinese hamster V79 more than 10-fold at a diethylstilbestrol con- cells and in Syrian hamster embryo cells (Tucker centration of 70 nM (Russo et al. 2001, 2003). & Barrett, 1986; Sakakibara et al., 1991; Ochi, Di"erent e"ects are seen with high doses of 1999) may underlie the induction of aneuploidy. diethylstilbestrol. ER+ MCF-7 human breast $is microtubule-damaging property appears to cancer cells growth in so! agar was inhibited by be unique to diethylstilbestrol because it is not diethylstilbestrol at concentrations of 2 μM and shared with estradiol or 17α-ethinyl estradiol, higher (Brandes & Hermonat, 1983). which are otherwise equally strong estrogens, Block et al. (2000) found e"ects of exposure to and can be similarly genotoxic in some systems diethylstilbestrol in Ishikawa (endometrial car- (Metzler & Pfei"er, 1995). cinoma) cells, HeLa (cervical carcinoma) cells, Exposure to diethylstilbestrol did not induce and SKOV-3 (ovarian carcinoma) cells on mRNA mutations or unscheduled DNA synthesis expression of homeobox (HOX) genes that are (IARC, 1987b), except in a single study in Syrian involved in the development of the reproductive hamster embryo cells, and in the presence of tract and other tissues. liver postmitochondrial supernatant from male Tests for in-vitro transformation in rat and rats pretreated with aroclor (Tsutsui et al., 1984). Syrian hamster embryo cells gave positive results, Diethylstilbestrol did not inhibit intercellular while results in mouse cells were negative (IARC, communication and most studies did not %nd 1987b). No mutations were found in BALB/C 3T3 positive results for diethylstilbestrol in the mouse
(!* Diethylstilbestrol lymphoma assay using L5178 tk+/+ cells (IARC, 4.2.2 Indirect e!ects related to genotoxicity 1987b; Sofuni et al., 1996). Exposure of phage (a) Cell proliferation and apoptosis and plasmid DNA to diethylstilbestrol quinone resulted in a variety of mutations and, under Diethylstilbestrol increased mitotic rate in certain conditions, recombinations in LacZ(α) Chinese hamster embryo cells, and in primary following transfection into E. coli (Korah & male hamster kidney tubular epithelial cells in Humayun, 1993). vitro (Stopper et al., 1994; Li et al., 1995; Chen Diethylstilbestrol did not induce mutation in et al., 1996). Chronic diethylstilbestrol treatment a variety of bacterial and insect systems, but it increased DNA synthesis in renal tubular cells was mutagenic in plants (IARC, 1987b). In assays isolated from male Syrian hamsters (Li et al., with Saccharomyces cervisiae and other yeasts, 1993); this e"ect was blocked by co-treatment diethylstilbestrol caused aneuploidy (IARC, with a pure anti-estrogen (ICI 182780) (Chen 1987b), but it had mixed e"ects on induction et al., 1996). of chromosomal losses (Albertini et al., 1993), In-utero treatment of rats resulted in and, in most studies, it did not induce muta- increased DNA synthesis in both the epithe- tion, recombinations, or gene conversion (IARC, lium and stroma of the proximal portion of the 1987b; Carls & Schiestl, 1994). DNA damage was Müllerian duct (which di"erentiate into oviduct) not induced in fungi (yeasts) or bacteria, but on the last day of gestation, but not in the caudal diethylstilbestrol induced single-strand breaks portion (which di"erentiate into upper vagina) in bacteriophage DNA in the presence of a horse- where epithelial cell proliferation was actually radish peroxidase activation system (IARC, depressed (Okada et al., 2001). Neonatal exposure 1987b). of mice to diethylstilbestrol resulted in markedly In vitro, rat liver and mammary gland mito- elevated DNA synthesis in epithelial, but not chondria were able to oxidatively metabolize stromal cells of the vagina, whereas it increased diethylstilbestrol to 4',4''-diethylstilbestrol qui- the percentage of apoptotic stromal cells, but none and to reduce diethylstilbestrol quinone not epithelial cells at 90 days of age (Sato et al., to diethylstilbestrol ($omas & Roy, 1995; 2004). Following diethylstilbestrol treatment of $omas et al., 2004). Treatment of Syrian ham- pre-pubertal mice, DNA synthesis was markedly sters with diethylstilbestrol resulted in the for- increased in the uterine and vaginal epithelium mation of adducts in kidney mitochondrial a!er 16–42 hours (Takahashi et al., 1994). $is DNA by [32P]-postlabelling detected ($omas e"ect was %rst apparent at 5 days of age and was & Roy, 2001a), and diethylstilbestrol treatment still observed at 70 days (Suzuki et al., 2006). of rats induced similar adducts in liver mito- (b) Immune modulatory e!ects chondrial DNA at higher levels than in nuclear DNA ($omas & Roy, 2001b). In addition, both $ere are several studies in mice that indi- functional ERα and ERβ have been identi%ed in cate some immune modulatory e"ects of diethyl- mitochondria (Yager & Chen, 2007). $us, mito- stilbestrol treatment. $ese appear to target the chondria may be a target of diethylstilbestrol, thymus, are highly dose-dependent, and di"er in and its mitochondrial e"ects conceivably play a male and female animals (Calemine et al., 2002; role in its carcinogenic activity. Utsuyama et al., 2002; Brown et al., 2006).
(!# IARC MONOGRAPHS – 100A
(c) Estrogen receptor-mediated e!ects In-utero diethylstilbestrol exposure caused (i) Female animals persistent Müllerian duct structures resulting in a range of male and female genital tract abnor- Diethylstilbestrol exposure in utero reduced malities in mice, which are remarkably simi- the response of the mouse uterus weight and lar to those found in diethylstilbestrol-exposed morphology to estrogenic stimulation by humans (IARC, 1979a). Besides alterations in the diethylstilbestrol on Days 22–25 of life, but not uterus, cervix, and vagina, diethylstilbestrol also on Day 21 (Maier et al., 1985). Neonatal diethyl- caused ovarian abnormalities in mice aged 3–14 stilbestrol treatment reduced the responsiveness months, exposed in utero (on Days 9–16 of ges- of uterus weight to ovariectomy, with or without tation), and markedly increased ex-vivo ovarian subsequent estrogen stimulation in young adult production of progesterone, estradiol, and testo- mice (Medlock et al., 1992), and reduced vaginal sterone (Haney et al., 1984). weight (Suzuki et al., 1996). $e morphological appearance of the mam- (ii) Male animals mary glands of 2- to 11-month-old mice neo- Neonatal diethylstilbestrol treatment of mice natally treated with diethylstilbestrol (0.1 μg caused persistent decreases in weight of the male daily for 5 days) was not di"erent from that of accessory sex glands at 12 months of age and untreated controls, but they developed hyper- the development of in'ammation and dysplas- plasia more o!en in response to stimulation tic lesions in the posterior periurethral region with estradiol. $ey showed the same response of the accessory sex gland complex at 2, 12, to stimulation with estradiol plus progesterone. and 18 months of age (Pylkkänen et al., 1991b; $e severity of the hyperplasia was increased in 1993). A!er 12 and 18 months, there were also diethylstilbestrol-treated mice in response to morphological changes in the testes (Pylkkänen both hormonal stimuli (Bern et al., 1992). et al., 1991a; 1993). Treatment of these diethyl- Overexpression of ERα accelerated the onset stilbestrol-exposed mice at 2 months of age with of squamous metaplasia, atypical hyperplasia estradiol caused squamous metaplasia in the and adenocarcinoma of the uterus induced by periurethral prostatic ducts (Pylkkänen et al., neonatal diethylstilbestrol exposure by at least 1991b), and adult treatment with estradiol and 4 months (Couse et al., 1997). In αERKO mice, 5α-dihydrotestosterone (via silastic implants) no uterine abnormalities, persistent vaginal from 9–12 months of age exacerbated the in'am- corni%cation, or oviduct lesions were found fol- mation and dysplasia at 12 months (Pylkkänen lowing neonatal diethylstilbestrol treatment, and et al., 1993). In contrast, prenatal diethyl- uterine weight was the same as in vehicle-treated stilbestrol treatment did not have any lasting αERKO mice (Couse et al., 2001). $is %nding e"ects on the male accessory sex glands, except strongly suggests that the ERα is the mediator for occasional dysplasia in the ventral prostate of the e"ects of neonatal diethylstilbestrol expo- lobe (Pylkkänen et al., 1993). $e prostatic weight sure in the female mouse genital tract (Couse decrease and lesion development were also found & Korach, 2004). ERβ knockout mice (βERKO in mice exposed neonatally to diethylstilbestrol mice) had a normal morphological response to (Edery et al., 1990). Neonatal exposure of rats to neonatal diethylstilbestrol treatment (Couse & diethylstilbestrol enhanced the induction of pro- Korach, 1999), related to the very low to absent static dysplasia and cancer by subsequent chronic expression of ERβ in the female mouse genital adult treatment with estradiol and testosterone tract (Je"erson et al., 2000). (Yuen et al., 2005). Diethylstilbestrol treatment of rats for 16 weeks with or without concomitant
(!$ Diethylstilbestrol testosterone treatment resulted in increased lev- genes in the vagina and uterus (Klotz et al., 2000; els of lipid peroxidation products, and altered Miyagawa et al., 2004a; Suzuki et al., 2006). antioxidant activity in the ventral and dorsola- $e persistently increased expression of lacto- teral prostate (Tam et al., 2003). ferrin, c-fos, and Nsbp1 in mice that were treated Neonatal diethylstilbestrol treatment of male neonatally with diethylstilbestrol was associated mice also resulted in decreased size of male acces- with the persistent hypomethylation of CpG sory sex glands, particularly the seminal vesicles. sequences in the promoter regions of these genes In'ammation and dysplastic lesions developed (Li et al., 1997, 2003a; Tang et al., 2008). Other in the glands of the ventral and dorsolateral pros- mechanisms may also be involved in gene expres- tate between 6–18 months of age and increased sion (Miyagawa et al., 2004a, Tang et al., 2008). in severity with time (Prins et al., 2001). When $e persistently decreased expression of Hox the same treatment was given to αERKO mice, genes found in the uterus a!er 5 days of neona- no morphological e"ects were found a!er 6–18 tal treatment with diethylstilbestrol (Couse et al., months, whereas the neonatal diethylstilbestrol 2001) was not associated with changes in meth- e"ects in βERKO mice were indistinguishable ylation status of these genes (Li et al., 2001). $e from those in wild-type mice (Prins et al., 2001). decreased expression of most but not all develop- mental Hox and Wnt genes required the presence (d) E!ects on gene expression (hormonal of ERα, because the expression of these genes is imprinting) not a"ected when mice that lacked this estro- (i) Female animals gen receptor subtype are neonatally exposed to In-utero treatment with diethylstilbestrol diethylstilbestrol (Couse et al., 2001). $e dose caused changes in the expression of several genes, of diethylstilbestrol may be a major determinant including the estrogen-responsive lactoferrin of the size and direction of the e"ects on DNA gene and the developmental Hox and Wnt genes, methylation in the mouse uterus (Alworth et al., in the Müllerian duct/uterus of the developing 2002). murine fetus and of mice on the %rst days of life $e mRNA expression of nucleosomal bind- (Newbold et al., 1997; Ma et al., 1998; Miller et al., ing protein-1 (Nsbp1), which plays a role in chro- 1998; Okada et al., 2001). matin remodelling, was permanently increased $e expression of a range of genes in the in mice treated neonatally with diethylstilbestrol mouse uterus and/or vagina was permanently for up to 18 months in a dose-related fashion altered by neonatal exposure to diethylstilbestrol (Tang et al., 2008). A low-dose treatment resulted on the %rst 4–5 days of life up to postnatal Days in a response in the expression and methylation 60–90, and included alterations in developmen- pattern of the uterine Nsbp1 gene to the estro- tal Hox and Wnt genes (Miller et al., 1998; Block gen surge at puberty that was the opposite of et al., 2000; Couse et al., 2001; Li et al., 2003a; that in control mice, but this phenomenon was Miyagawa et al., 2004a, b; Sato et al., 2004; dose-speci%c because a high diethylstilbestrol Huang et al., 2005; Newbold et al., 2007; Tang dose did not have this e"ect (Tang et al., 2008). et al., 2008). Ovarian hormones are important in the induc- A single injection of diethylstilbestrol in pre- tion of uterine adenocarcinomas in mice treated pubertal mice acutely altered the expression of neonatally with diethylstilbestrol, because pre- genes coding for 3 TGFß isoforms in the uterus pubertally ovariectomized mice did not develop (Takahashi et al., 1994). Treatment of young these tumours (Newbold et al., 1990). adult mice also altered the expression of several
(!% IARC MONOGRAPHS – 100A
(ii) Male animals $ere is some evidence that diethylstilbestrol Neonatal treatment with diethylstilbestrol alters the expression of enzymes involved in of mice caused a persistent upregulation of diethylstilbestrol metabolism in rat. the c-fos and c-myc proto-oncogenes in all Diethylstilbestrol causes aneuploidy in male accessory sex glands (Pylkkänen et al., human and animal cells, most likely because of 1993; Salo et al., 1997), and a marked increase interference with microtubules, which requires in the response of c-fos expression to estradiol oxidative metabolic activation. Diethylstilbestrol injection at 3–5 months (Salo et al., 1997). In also induces chromosomal breaks and other 30-days-old F344 rats treated neonatally with chromosomal aberrations; this is likely to be a diethylstilbestrol, the expression of both ERα major mechanism of diethylstilbestrol-induced and ERβ was increased as well as circulating carcinogenicity. prolactin (Khurana et al., 2000). Neonatal treat- Diethylstilbestrol can immortalize primary ment of mice caused changes in the expression animal embryo cells in vitro and transform of several other genes and in DNA methylation human breast cell lines. Diethylstilbestrol also patterns (Sato et al., 2006). increases the proliferation of human and ani- Neonatal exposure of mice to diethyl- mal cervical and uterine cells, and increases cell stilbestrol resulted in a persistent reduction of proliferation in diethylstilbestrol target tissues androgen-receptor-protein expression in the (uterus) in animals following neonatal and pre- ventral and dorsolateral prostate, ERβ expres- pubertal exposure. sion was persistently decreased, and ERα expres- Neonatal exposure to diethylstilbestrol sion (in stromal cells around prostatic ducts) causes persistent changes in gene expression and was upregulated at postnatal Day 10 but not DNA methylation patterns in diethylstilbestrol later in life (Prins et al., 2001). $is treatment target tissues (prostate and uterus), and there is also resulted in a persistent downregulation of a some evidence that hormone responsiveness is permanently altered in the mammary and pros- secretory protein, DLP2, in the dorsolateral pros- tate. $ese e"ects of neonatal treatment with tate tissue of exposed mice. diethylstilbestrol were not seen in αERKO mice, In'ammatory and dysplastic prostate lesions whereas they were identical to those in wild-type are also observed in mice a!er neonatal exposure mice in βERKO mice (Prins et al., 2001). to diethylstilbestrol. Several of the above e"ects of diethyl- stilbestrol, including mitogenic, gene expres- 4.3 Synthesis sion, and prostatic e"ects, are mediated at least Following exposure in utero, the oxidative in large part by ERα. metabolism of diethylstilbestrol can occur in $ere is some evidence of modulatory e"ects fetal mouse tissues. $ere is some evidence that of perinatal exposure to diethylstilbestrol on the diethylstilbestrol binds covalently to DNA in immune system in animals and humans. fetal target tissue (uterus). In animal cells and tis- It is likely that two or more of these factors in sues, diethylstilbestrol binds covalently to DNA combination are responsible for the carcinogenic and causes oxidative damage to DNA and lip- e"ects of diethylstilbestrol; estrogen receptor- ids; some of these tissues are known targets of mediated e"ects and genotoxicity conceivably diethylstilbestrol-induced cancer in animals. both being involved, while other factors may be contributory. $e early developmental changes in the female and male genital tract caused by exposure to diethylstilbestrol in utero or – in
(!" Diethylstilbestrol rodents – neonatally, may result in epigenetic versus high doses. Toxicol Appl Pharmacol, 183: 10–22. events that create a tissue and cellular environ- doi:10.1006/taap.2002.9459 PMID:12217638 Anon (2008) Diethylstilbestrol. Encyclopædia Britannica ment conducive for the mechanisms responsi- Online ble for the transplacental carcinogenic e"ects of Anon (1972). Selected item from the FDA drug bulletin- diethylstilbestrol in humans and animals. november 1971: diethylstilbestrol contraindicated in pregnancy. Calif Med, 116: 85–86. PMID:18730697 Antonioli DA & Burke L (1975). Vaginal adenosis. Analysis of 325 biopsy specimens from 100 patients. Am J Clin 5. Evaluation Pathol, 64: 625–638. PMID:1190123 Antunes CMF, Strolley PD, Rosenshein NB et al. (1979). Endometrial cancer and estrogen use. Report of a large $ere is su&cient evidence in humans case-control study. N Engl J Med, 300: 9–13. doi:10.1056/ for the carcinogenicity of diethylstilbestrol. NEJM197901043000103 PMID:213722 Diethylstilbestrol causes cancer of the breast Aschbacher PW (1972). Metabolism of 14 C-diethylstilbestrol in sheep. J Anim Sci, 35: 1031–1035. in women who were exposed while pregnant. PMID:5085294 Diethylstilbestrol also causes clear cell adenocar- Aschbacher PW & $acker EJ (1974). Metabolic fate of cinoma in the vagina and cervix of women who oral diethylstilbestrol in steers. J Anim Sci, 39: 1185– 1192. PMID:4443319 were exposed in utero. Also, a positive association Baggs RB, Miller RK, Odoro" CL (1991). Carcinogenicity has been observed between exposure to diethyl- of diethylstilbestrol in the Wistar rat: e"ect of postna- stilbestrol and cancer of the endometrium, and tal oral contraceptive steroids. Cancer Res, 51: 3311– between in-utero exposure to diethylstilbestrol 3315. PMID:2040004 Banerjee SK, Banerjee S, Li SA, Li JJ (1994). Induction of and squamous cell-carcinoma of the cervix, and chromosome aberrations in Syrian hamster renal cor- cancer of the testis. tical cells by various estrogens. Mutat Res, 311: 191–197. $ere is su&cient evidence in experi- PMID:7526183 mental animals for the carcinogenicity of Begum M, Tashiro H, Katabuchi H et al. (2006). Neonatal estrogenic exposure suppresses PTEN-related diethylstilbestrol. endometrial carcinogenesis in recombinant mice. Lab Invest, 86: 286–296. doi:10.1038/labinvest.3700380 PMID:16402032 Overall evaluation Bengtsson G (1963). Autoradiographic distribution stud- ies of injected 32p-labelled polydiethylstilboestrol Diethylstilbestrol is carcinogenic to humans phosphate. Acta Endocrinol (Copenh), 43: 581–586. (Group 1). PMID:14055731 Beral V & Colwell L (1980). Randomised trial of high doses of stilboestrol and ethisterone in pregnancy: +,-,.,/0,1 long-term follow-up of mothers. BMJ, 281: 1098–1101. doi:10.1136/bmj.281.6248.1098 PMID:7000292 Aardema MJ, Snyder RD, Spicer C et al. (2006). SFTG Beral V & Colwell L (1981). Randomised trial of high international collaborative study on in vitro micronu- doses of stilboestrol and ethisterone therapy in preg- cleus test III. Using CHO cells. Mutat Res, 607: 61–87. nancy: long-term follow-up of the children. J Epidemiol PMID:16797224 Community Health, 35: 155–160. doi:10.1136/ Albertini S, Brunner M, Würgler FE (1993). Analysis jech.35.3.155 PMID:7035598 of the six additional chemicals for in vitro assays of Bern HA, Mills KT, Hatch DL et al. (1992). Altered mam- the European Economic Communities’ EEC aneu- mary responsiveness to estradiol and progesterone in ploidy programme using Saccharomyces cerevisiae mice exposed neonatally to diethylstilbestrol. Cancer D61.M and the in vitro porcine brain tubulin assembly Lett, 63: 117–124. doi:10.1016/0304-3835(92)90061-Y assay. Environ Mol Mutagen, 21: 180–192. doi:10.1002/ PMID:1562988 em.2850210211 PMID:8444145 Bhat HK, Han X, Gladek A, Liehr JG (1994). Regulation Alworth LC, Howdeshell KL, Ruhlen RL et al. (2002). of the formation of the major diethylstilbestrol- Uterine responsiveness to estradiol and DNA methyla- DNA adduct and some evidence of its struc- tion are altered by fetal exposure to diethylstilbestrol ture. Carcinogenesis, 15: 2137–2142. doi:10.1093/ and methoxychlor in CD-1 mice: e"ects of low carcin/15.10.2137 PMID:7955045
(!& IARC MONOGRAPHS – 100A
Bibbo M, Ali I, Al-Naqeeb M et al. (1975). Cytologic %nd- term tests for carcinogens. Mutat Res, 320: 293–303. ings in female and male o"spring of DES treated moth- doi:10.1016/0165-1218(94)90082-5 PMID:7508555 ers. Acta Cytol, 19: 568–572. PMID:1061475 Chen CW, Oberley TD, Roy D (1996). Inhibition of stilbene Bibbo M, Haenszel WM, Wied GL et al. (1978). A twenty- estrogen-induced cell proliferation of renal epithelial %ve-year follow-up study of women exposed to diethyl- cells through the modulation of insulin-like growth stilbestrol during pregnancy. N Engl J Med, 298: 763–767. factor-I receptor expression. Cancer Lett, 105: 51–59. doi:10.1056/NEJM197804062981403 PMID:628409 doi:10.1016/0304-3835(96)04263-2 PMID:8689633 Block K, Kardana A, Igarashi P, Taylor HS (2000). In Clare MG, Lorenzon G, Akhurst LC et al. (2006). SFTG utero diethylstilbestrol (DES) exposure alters Hox gene international collaborative study on in vitro micronu- expression in the developing müllerian system. FASEB cleus test II. Using human lymphocytes. Mutat Res, J, 14: 1101–1108. PMID:10834931 607: 37–60. PMID:16765631 Boyd J, Takahashi H, Waggoner SE et al. (1996). Molecular Clark LC & Portier KM (1979). Diethylstilbestrol and the genetic analysis of clear cell adenocarcinomas of the risk of cancer. N Engl J Med, 300: 263–264. doi:10.1056/ vagina and cervix associated and unassociated with NEJM197902013000519 PMID:759877 diethylstilbestrol exposure in utero. Cancer, 77: 507–513. Coe JE, Ishak KG, Ross MJ (1990). Estrogen induction doi:10.1002/(SICI)1097-0142(19960201)77:3<507::AID- of hepatocellular carcinomas in Armenian hamsters. CNCR12>3.0.CO;2-8 PMID:8630958 Hepatology, 11: 570–577. doi:10.1002/hep.1840110408 Brandes LJ & Hermonat MW (1983). Receptor status and PMID:2328952 subsequent sensitivity of subclones of MCF-7 human Colton T, Greenberg ER, Noller K et al. (1993). Breast breast cancer cells surviving exposure to diethyl- cancer in mothers prescribed diethylstilbestrol in stilbestrol. Cancer Res, 43: 2831–2835. PMID:6850594 pregnancy. Further follow-up. JAMA, 269: 2096–2100. Brian DD, Tilley BC, Labarthe DR et al. (1980). Breast doi:10.1001/jama.269.16.2096 PMID:8468763 cancer in DES-exposed mothers: absence of associa- Cook JD, Davis BJ, Cai SL et al. (2005). Interaction tion. Mayo Clin Proc, 55: 89–93. PMID:7354650 between genetic susceptibility and early-life environ- Brown LM, Pottern LM, Hoover RN (1986). Prenatal and mental exposure determines tumor-suppressor-gene perinatal risk factors for testicular cancer. Cancer Res, penetrance. Proc Natl Acad Sci USA, 102: 8644–8649. 46: 4812–4816. PMID:3731127 doi:10.1073/pnas.0503218102 PMID:15937110 Brown N, Nagarkatti M, Nagarkatti PS (2006). Couse JF, Davis VL, Hanson RB et al. (1997). Accelerated Diethylstilbestrol alters positive and negative selection onset of uterine tumors in transgenic mice with aberrant of T cells in the thymus and modulates T-cell repertoire expression of the estrogen receptor a!er neonatal expo- in the periphery. Toxicol Appl Pharmacol, 212: 119–126. sure to diethylstilbestrol. Mol Carcinog, 19: 236–242. doi:10.1016/j.taap.2005.07.012 PMID:16122773 doi:10.1002/(SICI)1098-2744(199708)19:4<236::AID- Bülow H, Wullstein HK, Böttger G, Schröder FH (1973). MC4>3.0.CO;2-A PMID:9290700 Mamma-carinom bei oestrogenbehandeltem prostata- Couse JF, Dixon D, Yates M et al. (2001). Estrogen receptor- carcinom. Urologe A, 12: 249–253. PMID:4357698 alpha knockout mice exhibit resistance to the develop- Burke L, Antonioli D, Friedman EA (1981). Evolution mental e"ects of neonatal diethylstilbestrol exposure of diethylstilbestrol-associated genital tract lesions. on the female reproductive tract. Dev Biol, 238: 224– Obstet Gynecol, 57: 79–84. PMID:7454179 238. doi:10.1006/dbio.2001.0413 PMID:11784006 Burke L, Segall-Blank M, Lorenzo C et al. (2001). Altered Couse JF & Korach KS (1999). Estrogen receptor null immune response in adult women exposed to diethyl- mice: what have we learned and where will they lead us? stilbestrol in utero. Am J Obstet Gynecol, 185: 78–81. [Erratum in: Endocr Rev 1999 Aug;20] [4]Endocr Rev, doi:10.1067/mob.2001.113873 PMID:11483908 20: 358–417. doi:10.1210/er.20.3.358 PMID:10368776 Calemine JB, Gogal RM Jr, Lengi A et al. (2002). Couse JF & Korach KS (2004). Estrogen receptor-alpha Immunomodulation by diethylstilbestrol is dose mediates the detrimental e"ects of neonatal diethyl- and gender related: e"ects on thymocyte apopto- stilbestrol (DES) exposure in the murine repro- sis and mitogen-induced proliferation. Toxicology, ductive tract. Toxicology, 205: 55–63. doi:10.1016/j. 178: 101–118. doi:10.1016/S0300-483X(02)00201-9 tox.2004.06.046 PMID:15458790 PMID:12160618 Cutler BS, Forbes AP, Ingersoll FM, Scully RE (1972). Calle EE, Mervis CA, $un MJ et al. (1996). Endometrial carcinoma a!er stilbestrol therapy in Diethylstilbestrol and risk of fatal breast cancer in a gonadal dysgenesis. N Engl J Med, 287: 628–631. prospective cohort of US women. Am J Epidemiol, 144: doi:10.1056/NEJM197209282871302 PMID:5076457 645–652. PMID:8823060 de Stoppelaar JM, Faessen P, Zwart E et al. (2000). Isolation Carls N & Schiestl RH (1994). Evaluation of the yeast DEL of DNA probes speci%c for rat chromosomal regions assay with 10 compounds selected by the International 19p, 19q and 4q and their application for the analysis Program on Chemical Safety for the evaluation of short- of diethylstilbestrol-induced aneuploidy in binucleated
((' Diethylstilbestrol
rat %broblasts. Mutagenesis, 15: 165–175. doi:10.1093/ epithelial cells and kidney cells from neonatal mice. mutage/15.2.165 PMID:10719043 Teratog Carcinog Mutagen, 11: 135–146. doi:10.1002/ Degen GH (1993). SEMV cell cultures: a model for stud- tcm.1770110303 PMID:1686821 ies of prostaglandin-H synthase-mediated metabolism Fowler WC Jr, Schmidt G, Edelman DA et al. (1981). Risks of and genotoxicity of xenobiotics. Toxicol Lett, 67: 187– cervical intraepithelial neoplasia among DES-exposed 200. doi:10.1016/0378-4274(93)90055-3 PMID:8451760 women. Obstet Gynecol, 58: 720–724. PMID:7312237 Degen GH, Metzler M, Sivarajah KS (1986). Co-oxidation Gershman ST & Stolley PD (1988). A case-control study of diethylstilbestrol and structural analogs by pros- of testicular cancer using Connecticut tumour reg- taglandin synthase. Carcinogenesis, 7: 137–142. istry data. Int J Epidemiol, 17: 738–742. doi:10.1093/ doi:10.1093/carcin/7.1.137 PMID:3080250 ije/17.4.738 PMID:3225080 Depue RH, Pike MC, Henderson BE (1983). Estrogen Gill WB, Schumacher GF, Bibbo M et al. (1979). exposure during gestation and risk of testicular can- Association of diethylstilbestrol exposure in utero cer. J Natl Cancer Inst, 71: 1151–1155. PMID:6140323 with cryptorchidism, testicular hypoplasia and semen Dieckmann WJ, Davis ME, Rynkiewicz LM, Pottinger RE abnormalities. J Urol, 122: 36–39. PMID:37351 (1953). Does the administration of diethylstilbestrol Giusti RM, Iwamoto K, Hatch EE (1995). Diethylstilbestrol during pregnancy have therapeutic value? Am J Obstet revisited: a review of the long-term health e"ects. Ann Gynecol, 66: 1062–1081. PMID:13104505 Intern Med, 122: 778–788. PMID:7717601 Eastin WC, Mennear JH, Tennant RW et al. (2001). Tg.AC Gladek A & Liehr JG (1989). Mechanism of genotoxicity genetically altered mouse: assay working group over- of diethylstilbestrol in vivo. J Biol Chem, 264: 16847– view of available data. Toxicol Pathol, 29: Suppl60–80. 16852. PMID:2777810 doi:10.1080/019262301753178483 PMID:11695563 Gladek A & Liehr JG (1991). Transplacental genotoxic- Edery M, Turner T, Dauder S et al. (1990). In'uence of ity of diethylstilbestrol. Carcinogenesis, 12: 773–776. neonatal diethylstilbestrol treatment on prolactin doi:10.1093/carcin/12.5.773 PMID:2029740 receptor levels in the mouse male reproductive system. Gloser H & Cerni C (1984). Increase of sister chroma- Proc Soc Exp Biol Med, 194: 289–292. PMID:2388902 tid exchange formation induced by diethylstilbestrol. Epe B, Hegler J, Metzler M (1987). Site-speci%c cova- Oncology, 41: 285–288. doi:10.1159/000225839 lent binding of stilbene-type and steroidal estro- PMID:6462605 gens to tubulin following metabolic activation in Goldfarb S & Pugh TD (1990). Morphology and anatomic vitro. Carcinogenesis, 8: 1271–1275. doi:10.1093/ localization of renal microneoplasms and proximal carcin/8.9.1271 PMID:3304691 tubule dysplasias induced by four di"erent estrogens Epe B, Schi"mann D, Metzler M (1986). Possible role in the hamster. Cancer Res, 50: 113–119. PMID:2152770 of oxygen radicals in cell transformation by diethyl- Gottschlich R & Metzler M (1984). Oxidative metabolites stilbestrol and related compounds. Carcinogenesis, 7: of the teratogen and transplacental carcinogen diethyl- 1329–1334. doi:10.1093/carcin/7.8.1329 PMID:3015447 stilbestrol in the fetal Syrian golden hamster. J Environ Fauth E, Scherthan H, Zankl H (2000). Chromosome Pathol Toxicol Oncol, 5: 329–338. PMID:6520735 painting reveals speci%c patterns of chromosome Gray K, Bullock B, Dickson R et al. (1996). Potentiation occurrence in mitomycin C- and diethylstilboestrol- of diethylstilbestrol-induced alterations in the female induced micronuclei. Mutagenesis, 15: 459–467. mouse reproductive tract by transforming growth factor- doi:10.1093/mutage/15.6.459 PMID:11076996 alpha transgene expression. Mol Carcinog, 17: 163–173. Fetherston WC (1975). Squamous neoplasia of vagina doi:10.1002/(SICI)1098-2744(199611)17:3<163::AID- related to DES syndrome. Am J Obstet Gynecol, 122: MC9>3.0.CO;2-G PMID:8944077 176–181. PMID:1155501 Green M, Newell O, Aboyade-Cole A et al. (2007). Diallyl Fischer LJ, Kent TH, Weissinger JL (1973). Absorption of sul%de induces the expression of estrogen metaboliz- diethylstilbestrol and its glucuronide conjugate from ing genes in the presence and/or absence of diethyl- the intestines of %ve- and twenty-%ve-day-old rats. J stilbestrol in the breast of female ACI rats. Toxicol Pharmacol Exp #er, 185: 163–170. PMID:4693182 Lett, 168: 7–12. doi:10.1016/j.toxlet.2006.10.009 Fitzgerald DJ, Piccoli C, Yamasaki H (1989). Detection PMID:17129689 of non-genotoxic carcinogens in the BALB/c 3T3 cell Green M, $omas R, Gued L, Sadrud-Din S (2003). transformation/mutation assay system. Mutagenesis, Inhibition of DES-induced DNA adducts by diallyl 4: 286–291. doi:10.1093/mutage/4.4.286 PMID:2674607 sul%de: implications in liver cancer prevention. Oncol Ford CD, Johnson GH, Smith WG (1983). Natural killer Rep, 10: 767–771. PMID:12684656 cells in in utero diethylstilbesterol-exposed patients. Green M, Wilson C, Newell O et al. (2005). Diallyl sul%de Gynecol Oncol, 16: 400–404. doi:10.1016/0090- inhibits diethylstilbesterol-induced DNA adducts in the 8258(83)90168-3 PMID:6654182 breast of female ACI rats. Food Chem Toxicol, 43: 1323– Forsberg JG (1991). Estrogen e"ects on chromosome 1331. doi:10.1016/j.fct.2005.02.005 PMID:15989972 number and sister chromatid exchanges in uterine
((! IARC MONOGRAPHS – 100A
Greenberg ER, Barnes AB, Resseguie L et al. (1984). (United States). Cancer Causes Control, 12: 837–845. Breast cancer in mothers given diethylstilbestrol in doi:10.1023/A:1012229112696 PMID:11714112 pregnancy. N Engl J Med, 311: 1393–1398. doi:10.1056/ Hatch EE, Palmer JR, Titus-Ernsto" L et al. (1998). Cancer NEJM198411293112201 PMID:6493300 risk in women exposed to diethylstilbestrol in utero. Greenman DL, Highman B, Chen J et al. (1990). JAMA, 280: 630–634. doi:10.1001/jama.280.7.630 Estrogen-induced thyroid follicular cell adenomas in PMID:9718055 C57BL/6 mice. J Toxicol Environ Health, 29: 269–278. Hayashi N, Hasegawa K, Komine A et al. (1996). Estrogen- doi:10.1080/15287399009531390 PMID:2313739 induced cell transformation and DNA adduct for- Greenman DL, Highman B, Chen JJ et al. (1986). In'uence mation in cultured Syrian hamster embryo cells. of age on induction of mammary tumors by diethyl- Mol Carcinog, 16: 149–156. doi:10.1002/(SICI)1098- stilbestrol in C3H/HeN mice with low murine mam- 2744(199607)16:3<149::AID-MC5>3.0.CO;2-C mary tumor virus titer. J Natl Cancer Inst, 77: 891–898. PMID:8688150 PMID:3020299 Heinonen OP (1973). Diethylstilbestrol in pregnancy. Greenman DL, Kodell RL, Highman B et al. (1987). Frequency of exposure and usage patterns. Cancer, 31: Mammary tumorigenesis in C3H/HeN-MTV + mice 573–577. doi:10.1002/1097-0142(197303)31:3<573::AID- treated with diethylstilboestrol for varying periods. CNCR2820310312>3.0.CO;2-# PMID:4693585 Food Chem Toxicol, 25: 229–232. doi:10.1016/0278- Henderson BE, Benton B, Jing J et al. (1979). Risk factors 6915(87)90087-1 PMID:3570111 for cancer of the testis in young men. Int J Cancer, 23: Greenwald P, Barlow JJ, Nasca PC, Burnett WS (1971). 598–602. doi:10.1002/ijc.2910230503 PMID:37169 Vaginal cancer a!er maternal treatment with synthetic Henderson BE, Benton BD, Weaver PT et al. (1973). estrogens. N Engl J Med, 285: 390–392. doi:10.1056/ Stilbestrol and urogenital-tract cancer in adolescents NEJM197108122850707 PMID:5556578 and young adults. N Engl J Med, 288: 354 doi:10.1056/ Gued LR, $omas RD, Green M (2003). Diallyl sul%de NEJM197302152880708 PMID:4682947 inhibits diethylstilbestrol-induced lipid peroxida- Herbst AL (1981). Clear cell adenocarcinoma and the current tion in breast tissue of female ACI rats: implications status of DES-exposed females. Cancer, 48: Suppl484– in breast cancer prevention. Oncol Rep, 10: 739–743. 488. doi:10.1002/1097-0142(19810715)48:1+<484::AID- PMID:12684652 CNCR2820481308>3.0.CO;2-X PMID:7272973 Hadjimichael OC, Meigs JW, Falcier FW et al. (1984). Herbst AL & Anderson D (1990). Clear cell adenocarci- Cancer risk among women exposed to exogenous noma of the vagina and cervix secondary to intrauter- estrogens during pregnancy. J Natl Cancer Inst, 73: ine exposure to diethylstilbestrol. Semin Surg Oncol, 6: 831–834. PMID:6592380 343–346. doi:10.1002/ssu.2980060609 PMID:2263810 Hajek RA, King DW, Hernández-Valero MA et al. (2006). Herbst AL, Anderson S, Hubby MM et al. (1986). Risk Detection of chromosomal aberrations by 'uores- factors for the development of diethylstilbestrol-asso- cence in situ hybridization in cervicovaginal biopsies ciated clear cell adenocarcinoma: a case-control study. from women exposed to diethylstilbestrol in utero. Am J Obstet Gynecol, 154: 814–822. PMID:3963071 Int J Gynecol Cancer, 16: 318–324. doi:10.1111/j.1525- Herbst AL, Kurman RJ, Scully RE, Poskanzer DC (1972). 1438.2006.00338.x PMID:16445652 Clear-cell adenocarcinoma of the genital tract in young Haney AF, Newbold RR, McLachlan JA (1984). Prenatal females. Registry report. N Engl J Med, 287: 1259–1264. diethylstilbestrol exposure in the mouse: e"ects on doi:10.1056/NEJM197212212872501 PMID:4636892 ovarian histology and steroidogenesis in vitro. Biol Herbst AL, Poskanzer DC, Robboy SJ et al. (1975). Reprod, 30: 471–478. doi:10.1095/biolreprod30.2.471 Prenatal exposure to stilbestrol. A prospective com- PMID:6704476 parison of exposed female o"spring with unexposed Hanselaar A, van Loosbroek M, Schuurbiers O et al. (1997). controls. N Engl J Med, 292: 334–339. doi:10.1056/ Clear cell adenocarcinoma of the vagina and cervix. An NEJM197502132920704 PMID:1117962 update of the central Netherlands registry showing twin Herbst AL, Robboy SJ, Scully RE, Poskanzer DC (1974). age incidence peaks. Cancer, 79: 2229–2236. doi:10.1002/ Clear-cell adenocarcinoma of the vagina and cervix (SICI)1097-0142(19970601)79:11<2229::AID- in girls: analysis of 170 registry cases. Am J Obstet CNCR22>3.0.CO;2-X PMID:9179071 Gynecol, 119: 713–724. PMID:4857957 Hartley-Asp B, Deinum J, Wallin M (1985). Herbst AL & Scully RE (1970). Adenocarcinoma of the vagina Diethylstilbestrol induces metaphase arrest and inhib- in adolescence. A report of 7 cases including 6 clear-cell its microtubule assembly. Mutat Res, 143: 231–235. carcinomas (so-called mesonephromas). Cancer, 25: 745– doi:10.1016/0165-7992(85)90086-7 PMID:2862579 757. doi:10.1002/1097-0142(197004)25:4<745::AID- Hatch EE, Herbst AL, Hoover RN et al. (2001). Incidence CNCR2820250402>3.0.CO;2-2 PMID:5443099 of squamous neoplasia of the cervix and vagina Herbst AL, Ulfelder H, Poskanzer DC (1971). in women exposed prenatally to diethylstilbestrol Adenocarcinoma of the vagina. Association of mater- nal stilbestrol therapy with tumor appearance in young
((( Diethylstilbestrol
women. N Engl J Med, 284: 878–881. doi:10.1056/ Mlh1-de%cient mice. Int J Cancer, 115: 666–669. NEJM197104222841604 PMID:5549830 doi:10.1002/ijc.20918 PMID:15700306 Hill EC (1973). Clear cell carcinoma of the cervix and Kalyanaraman B, Sealy RC, Liehr JG (1989). vagina in young women. A report of six cases with Characterization of semiquinone free radicals formed association of maternal stilbestrol therapy and adeno- from stilbene catechol estrogens. An ESR spin stabi- sis of the vagina. Am J Obstet Gynecol, 116: 470–484. lization and spin trapping study. J Biol Chem, 264: PMID:4709483 11014–11019. PMID:2544580 Hoover R, Gray LA Sr, Fraumeni JF Jr (1977). Stilboestrol Kaufman RH & Adam E (1978). Genital tract anomalies (diethylstilbestrol) and the risk of ovarian cancer. associated with in utero exposure to diethylstilbestrol. Lancet, 2: 533–534. doi:10.1016/S0140-6736(77)90667-5 Isr J Med Sci, 14: 353–362. PMID:640820 PMID:95735 Kaufman RH & Adam E (2002). Findings in female o"- Hornsby PP, Wilcox AJ, Weinberg CR, Herbst AL (1994). spring of women exposed in utero to diethylstilbestrol. E"ects on the menstrual cycle of in utero exposure to Obstet Gynecol, 99: 197–200. doi:10.1016/S0029- diethylstilbestrol. Am J Obstet Gynecol, 170: 709–715. 7844(01)01682-9 PMID:11814496 PMID:8141188 Kaufman RH, Korhonen MO, Strama T et al. (1982). Huang WW, Yin Y, Bi Q et al. (2005). Developmental Development of clear cell adenocarcinoma in DES- diethylstilbestrol exposure alters genetic pathways of exposed o"spring under observation. Obstet Gynecol, uterine cytodi"erentiation. Mol Endocrinol, 19: 669– 59: Suppl68S–72S. PMID:7088431 682. doi:10.1210/me.2004-0155 PMID:15591538 Kerklaan PR, Bouter S, van Elburg PE, Mohn GR (1986). Hubby MM, Haenszel WM, Herbst AL (1981) E"ects Evaluation of the DNA repair host-mediated assay. II. on mother following exposure to diethylstilbestrol Presence of genotoxic factors in various organs of mice during pregnancy. In: Herbst AL, Bern HA (eds) treated with chemotherapeutic agents. Mutat Res, 164: Developmental e(ects of diethylstilbestrol (DES) in preg- 19–29. PMID:2419750 nancy. New York: $ieme-Stratton. Khurana S, Ranmal S, Ben-Jonathan N (2000). Exposure IARC. (1979b). Diethylstilboestrol and diethylstilboestrol of newborn male and female rats to environmental dipropionate. IARC Monogr Eval Carcinog Risk Chem estrogens: delayed and sustained hyperprolactine- Hum, 21: 173–231. PMID:397181 mia and alterations in estrogen receptor expres- IARC. (1979a). Sex Hormones (II). IARC Monogr Eval sion. Endocrinology, 141: 4512–4517. doi:10.1210/ Carcinog Risk Chem Hum, 21: 1–583. en.141.12.4512 PMID:11108262 IARC. (1987b). Genetic and related e"ects: An updating Kitamura T, Nishimura S, Sasahara K et al. (1999). of selected IARC monographs from Volumes 1 to 42. Transplacental administration of diethylstilbestrol IARC Monogr Eval Carcinog Risks Hum Suppl, 6: 1–729. (DES) causes lesions in female reproductive organs of PMID:3504843 Donryu rats, including endometrial neoplasia. Cancer IARC. (1987a). Overall evaluations of carcinogenicity: an Lett, 141: 219–228. doi:10.1016/S0304-3835(99)00108-1 updating of IARC Monographs volumes 1 to 42. IARC PMID:10454265 Monogr Eval Carcinog Risks Hum Suppl, 7: 1–440. Klip H, Verloop J, van Gool JD et al.OMEGA Project PMID:3482203 Group. (2002). Hypospadias in sons of women exposed Je"erson WN, Couse JF, Banks EP et al. (2000). Expression to diethylstilbestrol in utero: a cohort study. Lancet, of estrogen receptor beta is developmentally regulated 359: 1102–1107. doi:10.1016/S0140-6736(02)08152-7 in reproductive tissues of male and female mice. Biol PMID:11943257 Reprod, 62: 310–317. doi:10.1095/biolreprod62.2.310 Klotz DM, Hewitt SC, Korach KS, Diaugustine RP PMID:10642567 (2000). Activation of a uterine insulin-like growth Jiang YG, Chen JK, Wu ZL (2000). Promotive e"ect of factor I signaling pathway by clinical and environ- diethylstilbestrol on urethan-induced mouse lung mental estrogens: requirement of estrogen receptor- tumorigenesis. Chemosphere, 41: 187–190. doi:10.1016/ alpha. Endocrinology, 141: 3430–3439. doi:10.1210/ S0045-6535(99)00410-5 PMID:10819200 en.141.9.3430 PMID:10965916 Johnstone SR, Stanley MA, Quigley JP (1984). $e Konac E, Ekmekci A, Barkar V et al. (2005). E"ects of e"ect of diethylstilboestrol on the in vitro growth of diethylstilbestrol in human lymphocytes in vitro: a human ectocervical cells. Carcinogenesis, 5: 741–745. dose and time-dependent study on genotoxic, cyto- doi:10.1093/carcin/5.6.741 PMID:6609784 toxic and apoptotic e"ects. Mol Cell Biochem, 276: Kabbarah O, Mallon MA, Pfeifer JD et al. (2003). A panel 45–53. doi:10.1007/s11010-005-2815-8 PMID:16132684 of repeat markers for detection of microsatellite insta- Korah RM & Humayun MZ (1993). Mutagenic and recom- bility in murine tumors. Mol Carcinog, 38: 155–159. binagenic e"ects of diethylstilbestrol quinone. Mutat doi:10.1002/mc.10157 PMID:14639654 Res, 289: 205–214. PMID:7690889 Kabbarah O, Sotelo AK, Mallon MA et al. (2005). Labarthe D, Adam E, Noller KL et al. (1978). Design and Diethylstilbestrol e"ects and lymphomagenesis in preliminary observations of National Cooperative
(() IARC MONOGRAPHS – 100A
Diethylstilbestrol Adenosis (DESAD) Project. preceding diethylstilbestrol-induced carcinogen- Obstet Gynecol, 51: 453–458. doi:10.1097/00006250- esis. Carcinogenesis, 6: 1067–1069. doi:10.1093/ 197804000-00014 PMID:662228 carcin/6.7.1067 PMID:4017174 Lanier AP, Noller KL, Decker DG et al. (1973). Cancer Liehr JG, Roy D, Gladek A (1989). Mechanism of inhibi- and stilbestrol. A follow-up of 1,719 persons exposed tion of estrogen-induced renal carcinogenesis in male to estrogens in utero and born 1943–1959. Mayo Clin Syrian hamsters by vitamin C. Carcinogenesis, 10: 1983– Proc, 48: 793–799. PMID:4758151 1988. doi:10.1093/carcin/10.11.1983 PMID:2572356 Larson PS, Ungarelli RA, de Las Morenas A et al. (2006). Liehr JG & Wheeler WJ (1983). Inhibition of estrogen- In utero exposure to diethylstilbestrol (DES) does not induced renal carcinoma in Syrian hamsters by vita- increase genomic instability in normal or neoplastic min C. Cancer Res, 43: 4638–4642. PMID:6883321 breast epithelium. Cancer, 107: 2122–2126. doi:10.1002/ Linden G & Henderson BE (1972). Genital-tract can- cncr.22223 PMID:16998936 cers in adolescents and young adults. N Engl J Med, Li JJ, Gonzalez A, Banerjee S et al. (1993). Estrogen car- 286: 760–761. doi:10.1056/NEJM197204062861406 cinogenesis in the hamster kidney: role of cytotoxic- PMID:5025778 ity and cell proliferation. Environ Health Perspect, 101: Lopez J, Ogren L, Verjan R, Talamantes F (1988). E"ects of Suppl 5259–264. doi:10.2307/3431878 PMID:8013417 perinatal exposure to a synthetic estrogen and proges- Li JJ, Hou X, Banerjee SK et al. (1999). Overexpression tin on mammary tumorigenesis in mice. Teratology, 38: and ampli%cation of c-myc in the Syrian hamster kid- 129–134. doi:10.1002/tera.1420380205 PMID:3175946 ney during estrogen carcinogenesis: a probable criti- Lundgren K, Randerath K, Everson RB (1988). Role of cal role in neoplastic transformation. Cancer Res, 59: metabolism and DNA adduct formation in the induc- 2340–2346. PMID:10344741 tion of sister chromatid exchanges in human lym- Li JJ, Li SA, Oberley TD, Parsons JA (1995). Carcinogenic phocytes by diethylstilbestrol. Cancer Res, 48: 335–338. activities of various steroidal and nonsteroidal estro- PMID:3335009 gens in the hamster kidney: relation to hormonal activ- Ma L, Benson GV, Lim H et al. (1998). Abdominal B ity and cell proliferation. Cancer Res, 55: 4347–4351. (AbdB) Hoxa genes: regulation in adult uterus by PMID:7671246 estrogen and progesterone and repression in müllerian Li S, Hansman R, Newbold R et al. (2003a). Neonatal duct by the synthetic estrogen diethylstilbestrol (DES). diethylstilbestrol exposure induces persistent elevation Dev Biol, 197: 141–154. doi:10.1006/dbio.1998.8907 of c-fos expression and hypomethylation in its exon-4 PMID:9630742 in mouse uterus. Mol Carcinog, 38: 78–84. doi:10.1002/ Maier DB, Newbold RR, McLachlan JA (1985). Prenatal mc.10147 PMID:14502647 diethylstilbestrol exposure alters murine uter- Li S, Ma L, Chiang T et al. (2001). Promoter CpG meth- ine responses to prepubertal estrogen stimulation. ylation of Hox-a10 and Hox-a11 in mouse uterus not Endocrinology, 116: 1878–1886. doi:10.1210/endo-116- altered upon neonatal diethylstilbestrol exposure. 5-1878 PMID:3987622 Mol Carcinog, 32: 213–219. doi:10.1002/mc.10015 Marselos M & Tomatis L (1992). Diethylstilboestrol: PMID:11746833 II, pharmacology, toxicology and carcinogenicity in Li S, Washburn KA, Moore R et al. (1997). Developmental experimental animals. Eur J Cancer, 29A: 149–155. exposure to diethylstilbestrol elicits demethylation of PMID:1445734 estrogen-responsive lactoferrin gene in mouse uterus. Martin OV, Shialis T, Lester JN et al. (2008). Testicular Cancer Res, 57: 4356–4359. PMID:9331098 dysgenesis syndrome and the estrogen hypothesis: a Liehr JG, Avitts TA, Randerath E, Randerath K (1986). quantitative meta-analysis. Environ Health Perspect, Estrogen-induced endogenous DNA adduction: pos- 116: 149–157. doi:10.1289/ehp.10545 PMID:18288311 sible mechanism of hormonal cancer. Proc Natl Acad Mattingly RF & Sta' A (1976). Cancer risk in diethyl- Sci USA, 83: 5301–5305. doi:10.1073/pnas.83.14.5301 stilbestrol-exposed o"spring. Am J Obstet Gynecol, PMID:3460092 126: 543–548. PMID:984124 Liehr JG, DaGue BB, Ballatore AM (1985a). Reactivity of Maydl R, McLachlan JA, Newbold RR, Metzler M (1985). 4',4''-diethylstilbestrol quinone, a metabolic interme- Localization of diethylstilbestrol metabolites in the diate of diethylstilbestrol. Carcinogenesis, 6: 829–836. mouse genital tract. Biochem Pharmacol, 34: 710–712. doi:10.1093/carcin/6.6.829 PMID:4006069 doi:10.1016/0006-2952(85)90270-9 PMID:3977948 Liehr JG, DaGue BB, Ballatore AM, Henkin J (1983). McAnulty PA & Skydsgaard M (2005). Diethylstilbestrol Diethylstilbestrol (DES) quinone: a reactive inter- (DES): carcinogenic potential in Xpa-/-, Xpa- mediate in DES metabolism. Biochem Pharmacol, /- / p53+/-, and wild-type mice during 9 months’ 32: 3711–3718. doi:10.1016/0006-2952(83)90139-9 dietary exposure. Toxicol Pathol, 33: 609–620. PMID:6661246 doi:10.1080/01926230500261377 PMID:16178126 Liehr JG, Randerath K, Randerath E (1985b). Target organ-speci%c covalent DNA damage
((* Diethylstilbestrol
McEvoy GK, editor (2007) 2007 AHFS Drug Information, Newbold RR, Hanson RB, Je"erson WN et al. (1998). Bethesda, MD, American Society of Health-System Increased tumors but uncompromised fertility in the Pharmacists, American Hospital Formulary Service. female descendants of mice exposed developmentally McMartin KE, Kennedy KA, Greenspan P et al. (1978). to diethylstilbestrol. Carcinogenesis, 19: 1655–1663. Diethylstilbestrol: a review of its toxicity and use as doi:10.1093/carcin/19.9.1655 PMID:9771938 a growth promotant in food-producing animals. J Newbold RR, Hanson RB, Je"erson WN et al. (2000). Environ Pathol Toxicol, 1: 279–313. PMID:363962 Proliferative lesions and reproductive tract tumors in Medlock KL, Branham WS, Sheehan DM (1992). Long- male descendants of mice exposed developmentally term e"ects of postnatal exposure to diethylstilbestrol to diethylstilbestrol. Carcinogenesis, 21: 1355–1363. on uterine estrogen receptor and growth. J Steroid doi:10.1093/carcin/21.7.1355 PMID:10874014 Biochem Mol Biol, 42: 23–28. doi:10.1016/0960- Newbold RR, Je"erson WN, Grissom SF et al. (2007). 0760(92)90007-6 PMID:1558818 Developmental exposure to diethylstilbestrol alters Melnick S, Cole P, Anderson D, Herbst A (1987). Rates and uterine gene expression that may be associated with risks of diethylstilbestrol-related clear-cell adenocarci- uterine neoplasia later in life. Mol Carcinog, 46: 783– noma of the vagina and cervix. An update. N Engl J 796. doi:10.1002/mc.20308 PMID:17394237 Med, 316: 514–516. doi:10.1056/NEJM198702263160905 Ninomiya K, Kawaguchi H, Souda M et al. (2007). PMID:3807995 E"ects of neonatally administered diethylstilbestrol Metzler M (1984). Metabolism of stilbene estrogens and on induction of mammary carcinomas induced by 7, steroidal estrogens in relation to carcinogenicity. 12-dimethylbenz(a)anthracene in female rats. Toxicol Arch Toxicol, 55: 104–109. doi:10.1007/BF00346047 Pathol, 35: 811–818. doi:10.1080/01926230701584205 PMID:6383273 PMID:17943655 Metzler M & Fischer LJ (1981). $e metabolism of Noller KL, Blair PB, O’Brien PC et al. (1988). Increased diethylstilbestrol. CRC Crit Rev Biochem, 10: 171–212. occurrence of autoimmune disease among women doi:10.3109/10409238109113599 PMID:6163591 exposed in utero to diethylstilbestrol. Fertil Steril, 49: Metzler M & Pfei"er E (1995). E"ects of estrogens on 1080–1082. PMID:3371486 microtubule polymerization in vitro: correlation with Noller KL, Decker DG, Lanier AP, Kurland LT (1972). estrogenicity. Environ Health Perspect, 103: Suppl 721– Clear-cell adenocarcinoma of the cervix a!er maternal 22. doi:10.2307/3432502 PMID:8593868 treatment with synthetic estrogens. Mayo Clin Proc, 47: Miller C, Degenhardt K, Sassoon DA (1998). Fetal expo- 629–630. PMID:5073941 sure to DES results in de-regulation of Wnt7a dur- Noller KL, Townsend DE, Kaufman RH et al. (1983). ing uterine morphogenesis. Nat Genet, 20: 228–230. Maturation of vaginal and cervical epithelium in women doi:10.1038/3027 PMID:9806537 exposed in utero to diethylstilbestrol (DESAD Project). Miyagawa S, Katsu Y, Watanabe H, Iguchi T (2004a). Am J Obstet Gynecol, 146: 279–285. PMID:6859137 Estrogen-independent activation of erbBs signal- O’Brien PC, Noller KL, Robboy SJ et al. (1979). Vaginal ing and estrogen receptor alpha in the mouse vagina epithelial changes in young women enrolled in the exposed neonatally to diethylstilbestrol. Oncogene, 23: National Cooperative Diethylstilbestrol Adenosis 340–349. doi:10.1038/sj.onc.1207207 PMID:14647453 (DESAD) project. Obstet Gynecol, 53: 300–308. Miyagawa S, Suzuki A, Katsu Y et al. (2004b). Persistent PMID:424101 gene expression in mouse vagina exposed neonatally Oberley TD, Gonzalez A, Lauchner LJ et al. (1991). to diethylstilbestrol. J Mol Endocrinol, 32: 663–677. Characterization of early kidney lesions in estrogen- doi:10.1677/jme.0.0320663 PMID:15171707 induced tumors in the Syrian hamster. Cancer Res, 51: Moss AR, Osmond D, Bacchetti P et al. (1986). Hormonal 1922–1929. PMID:2004377 risk factors in testicular cancer. A case-control study. Ochi T (1999). Induction of multiple microtubule-organ- Am J Epidemiol, 124: 39–52. PMID:2872797 izing centers, multipolar spindles and multipolar divi- Nash S, Tilley BC, Kurland LT et al. (1983). Identifying and sion in cultured V79 cells exposed to diethylstilbestrol, tracing a population at risk: the DESAD Project expe- estradiol-17beta and bisphenol A. Mutat Res, 431: 105– rience. Am J Public Health, 73: 253–259. doi:10.2105/ 121. PMID:10656490 AJPH.73.3.253 PMID:6824111 Okada A, Sato T, Ohta Y et al. (2001). E"ect of diethyl- Newbold RR, Bullock BC, McLachlan JA (1990). Uterine stilbestrol on cell proliferation and expression of adenocarcinoma in mice following developmental epidermal growth factor in the developing female treatment with estrogens: a model for hormonal car- rat reproductive tract. J Endocrinol, 170: 539–554. cinogenesis. Cancer Res, 50: 7677–7681. PMID:2174729 doi:10.1677/joe.0.1700539 PMID:11524234 Newbold RR, Hanson RB, Je"erson WN (1997). Ontogeny Palmer JR, Anderson D, Helmrich SP, Herbst AL (2000). of lactoferrin in the developing mouse uterus: a marker Risk factors for diethylstilbestrol-associated clear of early hormone response. Biol Reprod, 56: 1147–1157. cell adenocarcinoma. Obstet Gynecol, 95: 814–820. doi:10.1095/biolreprod56.5.1147 PMID:9160713 doi:10.1016/S0029-7844(00)00827-9 PMID:10831973
((# IARC MONOGRAPHS – 100A
Palmer JR, Hatch EE, Rao RS et al. (2001). Infertility Cooperative Diethylstilbestrol Adenosis (DESAD) among women exposed prenatally to diethylstilbestrol. project. Obstet Gynecol, 53: 309–317. PMID:424102 Am J Epidemiol, 154: 316–321. doi:10.1093/aje/154.4.316 Robboy SJ, Noller KL, O’Brien P et al.Experience of the PMID:11495854 National Collaborative Diethylstilbestrol Adenosis Palmer JR, Wise LA, Hatch EE et al. (2006). Prenatal Project. (1984b). Increased incidence of cervical and diethylstilbestrol exposure and risk of breast cancer. vaginal dysplasia in 3,980 diethylstilbestrol-exposed Cancer Epidemiol Biomarkers Prev, 15: 1509–1514. young women. JAMA, 252: 2979–2983. doi:10.1001/ doi:10.1158/1055-9965.EPI-06-0109 PMID:16896041 jama.252.21.2979 PMID:6502858 Palmer JR, Wise LA, Robboy SJ et al. (2005). Hypospadias Robboy SJ, Szyfelbein WM, Goellner JR et al. (1981). in sons of women exposed to diethylstilbestrol in Dysplasia and cytologic %ndings in 4,589 young utero. Epidemiology, 16: 583–586. doi:10.1097/01. women enrolled in diethylstilbestrol-adenosis ede.0000164789.59728.6d PMID:15951681 (DESAD) project. Am J Obstet Gynecol, 140: 579–586. Parry EM, Danford N, Parry JM (1982). Di"erential stain- PMID:7195652 ing of chromosomes and spindle and its use as an assay Robboy SJ, Young RH, Welch WR et al. (1984a). for determining the e"ect of diethylstilboestrol on Atypical vaginal adenosis and cervical ectropion. cultured mammalian cells. Mutat Res, 105: 243–252. Association with clear cell adenocarcinoma in diethyl- doi:10.1016/0165-7992(82)90037-9 PMID:6182462 stilbestrol-exposed o"spring. Cancer, 54: 869–875. Perez KM, Titus-Ernsto" L, Hatch EE et al.National doi:10.1002/1097-0142(19840901)54:5<869::AID- Cancer Institute’s DES Follow-up Study Group. (2005). CNCR2820540519>3.0.CO;2-I PMID:6537153 Reproductive outcomes in men with prenatal expo- Rogers JM, Kavlock RJ (2008) Chapter 10. Developmental sure to diethylstilbestrol. Fertil Steril, 84: 1649–1656. Toxicology. In: Klaassen, C.D., ed., Casarett and doi:10.1016/j.fertnstert.2005.05.062 PMID:16359959 Doull’s Toxicology, #e Basic Science of Poisons, 7th Ed., Pons JC, Papiernik E, Billon A et al. (2005). Hypospadias New York, McGraw-Hill Medical Publishing Division, in sons of women exposed to diethylstilbestrol in p.418. utero. Prenat Diagn, 25: 418–419. doi:10.1002/pd.1136 Ross D, Mehlhorn RJ, Moldeus P, Smith MT (1985). PMID:15906411 Metabolism of diethylstilbestrol by horseradish per- Prins GS, Birch L, Couse JF et al. (2001). Estrogen oxidase and prostaglandin-H synthase. Generation of imprinting of the developing prostate gland is medi- a free radical intermediate and its interaction with glu- ated through stromal estrogen receptor alpha: studies tathione. J Biol Chem, 260: 16210–16214. PMID:2999150 with alphaERKO and betaERKO mice. Cancer Res, 61: Rothschild TC, Boylan ES, Calhoon RE, Vonderhaar BK 6089–6097. PMID:11507058 (1987). Transplacental e"ects of diethylstilbestrol on Pylkkänen L, Jahnukainen K, Parvinen M, Santti R (1991a). mammary development and tumorigenesis in female Testicular toxicity and mutagenicity of steroidal and ACI rats. Cancer Res, 47: 4508–4516. PMID:3607779 non-steroidal estrogens in the male mouse. Mutat Roy D, Bernhardt A, Strobel HW, Liehr JG (1992). Res, 261: 181–191. doi:10.1016/0165-1218(91)90066-U Catalysis of the oxidation of steroid and stilbene estro- PMID:1719410 gens to estrogen quinone metabolites by the beta- Pylkkänen L, Mäkelä S, Valve E et al. (1993). Prostatic dys- naphtho'avone-inducible cytochrome P450 IA family. plasia associated with increased expression of c-myc in Arch Biochem Biophys, 296: 450–456. doi:10.1016/0003- neonatally estrogenized mice. J Urol, 149: 1593–1601. 9861(92)90596-O PMID:1632637 PMID:8501817 Roy D, Floyd RA, Liehr JG (1991c). Elevated 8-hydrox- Pylkkänen L, Santti R, Newbold R, McLachlan JA (1991b). ydeoxyguanosine levels in DNA of diethylstilbestrol- Regional di"erences in the prostate of the neonatally treated Syrian hamsters: covalent DNA damage by estrogenized mouse. Prostate, 18: 117–129. doi:10.1002/ free radicals generated by redox cycling of diethyl- pros.2990180204 PMID:2006118 stilbestrol. Cancer Res, 51: 3882–3885. PMID:1855206 Quick EL, Parry EM, Parry JM (2008). Do oestrogens Roy D, Kalyanaraman B, Liehr JG (1991b). Xanthine oxi- induce chromosome speci%c aneuploidy in vitro, simi- dase-catalyzed reduction of estrogen quinones to sem- lar to the pattern of aneuploidy seen in breast cancer? iquinones and hydroquinones. Biochem Pharmacol, Mutat Res, 651: 46–55. PMID:18162433 42: 1627–1631. doi:10.1016/0006-2952(91)90433-6 Rinehart CA, Xu LH, Van Le L, Kaufman DG (1996). PMID:1656992 Diethylstilbestrol-induced immortalization of human Roy D & Liehr JG (1988). Characterization of drug metab- endometrial cells: alterations in p53 and estrogen recep- olism enzymes in estrogen-induced kidney tumors tor. Mol Carcinog, 15: 115–123. doi:10.1002/(SICI)1098- in male Syrian hamsters. Cancer Res, 48: 5726–5729. 2744(199602)15:2<115::AID-MC4>3.0.CO;2-I PMID:3048647 PMID:8599578 Roy D & Liehr JG (1989). Metabolic oxidation of diethyl- Robboy SJ, Kaufman RH, Prat J et al. (1979). Pathologic stilbestrol to diethylstilbestrol-4',4''-quinone in Syrian %ndings in young women enrolled in the National
(($ Diethylstilbestrol
hamsters. Carcinogenesis, 10: 1241–1245. doi:10.1093/ of vaginal epithelium of mice exposed neonatally carcin/10.7.1241 PMID:2736717 to diethylstilbestrol. Reprod Toxicol, 19: 43–51. Roy D, Strobel HW, Liehr JG (1991a). Cytochrome doi:10.1016/j.reprotox.2004.05.004 PMID:15336711 b5-mediated redox cycling of estrogen. Arch Biochem Sato Y, Murai T, Oda T et al. (1987). Inhibition of micro- Biophys, 285: 331–338. doi:10.1016/0003-9861(91)90368- tubule polymerization by synthetic estrogens: forma- S PMID:1897935 tion of a ribbon structure. J Biochem, 101: 1247–1252. Royal Pharmaceutical Society of Great Britain (2007) PMID:3654591 British National Formulary, No. 54, BMJ Publishing Schottenfeld D, Warshauer ME, Sherlock S et al. (1980). Group Ltd./RPS Publishing, London. $e epidemiology of testicular cancer in young adults. Rumsey TS, Oltjen RR, Daniels FL, Kozak AS (1975a). Am J Epidemiol, 112: 232–246. PMID:6106385 Depletion patterns of radioactivity and tissue resi- Schuler M, Hasegawa L, Parks R et al. (1998). Dose-response dues in beef cattle a!er the withdrawal of oral studies of the induction of hyperdiploidy and polyploidy C-diethylstilbestrol. J Anim Sci, 40: 539–549. by diethylstilbestrol and 17beta-estradiol in cultured PMID:1116975 human lymphocytes using multicolor 'uorescence in Rumsey TS, Oltjen RR, Kozak AS et al. (1975b). situ hybridization. Environ Mol Mutagen, 31: 263–273. Fate of radiocarbon in beef steers implanted with doi:10.1002/(SICI)1098-2280(1998)31:3<263::AID- 14C-diethylstilbestrol. J Anim Sci, 40: 550–560. EM8>3.0.CO;2-L PMID:9585265 PMID:1116976 Segura-Aguilar J, Cortés-Vizcaino V, Llombart-Bosch A Rupa DS, Schuler M, Eastmond DA (1997). Detection of et al. (1990). $e levels of quinone reductases, superox- hyperdiploidy and breakage a"ecting the 1cen-1q12 ide dismutase and glutathione-related enzymatic activ- region of cultured interphase human lymphocytes ities in diethylstilbestrol-induced carcinogenesis in the treated with various genotoxic agents. Environ kidney of male Syrian golden hamsters. Carcinogenesis, Mol Mutagen, 29: 161–167. doi:10.1002/(SICI)1098- 11: 1727–1732. doi:10.1093/carcin/11.10.1727 2280(1997)29:2<161::AID-EM7>3.0.CO;2-H PMID:2119905 PMID:9118968 Shah HC & McLachlan JA (1976). $e fate of diethyl- Russo J, Hasan Lareef M, Balogh G et al. (2003). Estrogen stilbestrol in the pregnant mouse. J Pharmacol Exp and its metabolites are carcinogenic agents in #er, 197: 687–696. PMID:819646 human breast epithelial cells. J Steroid Biochem Mol Sharp DC & Parry JM (1985). Diethylstilboestrol: the Biol, 87: 1–25. doi:10.1016/S0960-0760(03)00390-X binding and e"ects of diethylstilboestrol upon the PMID:14630087 polymerisation and depolymerisation of puri%ed Russo J, Hu YF, Tahin Q et al. (2001). Carcinogenicity microtubule protein in vitro. Carcinogenesis, 6: 865– of estrogens in human breast epithelial cells. APMIS, 871. doi:10.1093/carcin/6.6.865 PMID:4006072 109: 39–52. doi:10.1111/j.1600-0463.2001.tb00013.x Sharp GB & Cole P (1990). Vaginal bleeding and diethyl- PMID:11297193 stilbestrol exposure during pregnancy: relationship Sakakibara Y, Saito I, Ichinoseki K et al. (1991). E"ects to genital tract clear cell adenocarcinoma and vaginal of diethylstilbestrol and its methyl ethers on aneu- adenosis in daughters. Am J Obstet Gynecol, 162: 994– ploidy induction and microtubule distribution in 1001. PMID:2327468 Chinese hamster V79 cells. Mutat Res, 263: 269–276. Sharp GB & Cole P (1991). Identi%cation of risk factors for doi:10.1016/0165-7992(91)90012-S PMID:1861692 diethylstilbestrol-associated clear cell adenocarcinoma Salo LK, Mäkelä SI, Stancel GM, Santti RS (1997). Neonatal of the vagina: similarities to endometrial cancer. Am J exposure to diethylstilbestrol permanently alters the Epidemiol, 134: 1316–1324. PMID:1755445 basal and 17 beta-estradiol induced expression of c-fos Siegfried JM, Nelson KG, Martin JL, Kaufman DG proto-oncogene in mouse urethroprostatic complex. (1984). Promotional e"ect of diethylstilbestrol on Mol Cell Endocrinol, 126: 133–141. doi:10.1016/S0303- human endometrial stromal cells pretreated with a 7207(96)03978-0 PMID:9089651 direct-acting carcinogen. Carcinogenesis, 5: 641–646. Sarma AV, McLaughlin JC, Schottenfeld D In: Schottenfeld doi:10.1093/carcin/5.5.641 PMID:6144401 D, Fraumeni JF Jr (eds) (2006) Testicular Cancer in Singh KP & Roy D (2004). Somatic mutations in stil- Cancer Epidemiology (3rd edition). Oxford Univ Press; bene estrogen-induced Syrian hamster kidney tumors ch 60; pp 1151–1165. identi%ed by DNA %ngerprinting. J Carcinog, 3: 4 Sato K, Fukata H, Kogo Y et al. (2006). Neonatal exposure doi:10.1186/1477-3163-3-4 PMID:15003126 to diethylstilbestrol alters the expression of DNA meth- Singh KP & Roy D (2008). Allelic loss and mutations in a yltransferases and methylation of genomic DNA in the new ETRG-1 gene are early events in diethylstilbestrol- epididymis of mice. Endocr J, 53: 331–337. doi:10.1507/ induced renal carcinogenesis in Syrian hamsters. endocrj.K06-009 PMID:16714842 Gene, 408: 18–26. doi:10.1016/j.gene.2007.10.022 Sato T, Fukazawa Y, Ohta Y, Iguchi T (2004). Involvement PMID:18068315 of growth factors in induction of persistent proliferation
((% IARC MONOGRAPHS – 100A
Sofuni T, Honma M, Hayashi M et al. (1996). Detection Tam NN, Ghatak S, Ho SM (2003). Sex hormone- of in vitro clastogens and spindle poisons by the induced alterations in the activities of antioxidant mouse lymphoma assay using the microwell method: enzymes and lipid peroxidation status in the prostate interim report of an international collaborative study. of Noble rats. Prostate, 55: 1–8. doi:10.1002/pros.10169 Mutagenesis, 11: 349–355. doi:10.1093/mutage/11.4.349 PMID:12640655 PMID:8671759 Tang WY, Newbold R, Mardilovich K et al. (2008). Sta' A & Mattingly RF (1974). Vaginal adenosis: a pre- Persistent hypomethylation in the promoter of nucleo- cancerous lesion? Am J Obstet Gynecol, 120: 666–677. somal binding protein 1 (Nsbp1) correlates with over- PMID:4422247 expression of Nsbp1 in mouse uteri neonatally exposed Stanley MA, Crowcro! NS, Quigley JP, Parkinson EK to diethylstilbestrol or genistein. Endocrinology, 149: (1985). Responses of human cervical keratinoc- 5922–5931. doi:10.1210/en.2008-0682 PMID:18669593 ytes in vitro to tumour promoters and diethylstil- Tayama S, Nakagawa Y, Tayama K (2008). Genotoxic e"ects boestrol. Carcinogenesis, 6: 1011–1015. doi:10.1093/ of environmental estrogen-like compounds in CHO- carcin/6.7.1011 PMID:2410159 K1 cells. Mutat Res, 649: 114–125. PMID:17913570 Stopper H, Kirchner S, Schi"mann D, Poot M (1994). Cell Teras LR, Patel AV, Rodriguez C et al. (2005). Parity, other cycle disturbance in relation to micronucleus formation reproductive factors, and risk of pancreatic cancer mor- induced by the carcinogenic estrogen diethylstilbestrol. tality in a large cohort of U.S. women (United States). Pathobiology, 62: 180–185. doi:10.1159/000163908 Cancer Causes Control, 16: 1035–1040. doi:10.1007/ PMID:7734061 s10552-005-0332-4 PMID:16184468 Storer RD, French JE, Haseman J et al. (2001). $omas RD, Green MR, Wilson C, Sadrud-Din S (2004). P53+/- hemizygous knockout mouse: overview Diallyl sul%de inhibits the oxidation and reduction of available data. Toxicol Pathol, 29: Suppl30–50. reactions of stilbene estrogens catalyzed by micro- doi:10.1080/019262301753178465 PMID:11695560 somes, mitochondria and nuclei isolated from breast Strecker TE, Spady TJ, Scha"er BS et al. (2005). Genetic tissue of female ACI rats. Carcinogenesis, 25: 787–791. bases of estrogen-induced pituitary tumorigenesis: iden- doi:10.1093/carcin/bgg161 PMID:12949044 ti%cation of genetic loci determining estrogen-induced $omas RD & Roy D (1995). Mitochondrial enzyme-cat- pituitary growth in reciprocal crosses between the ACI alyzed oxidation and reduction reactions of stilbene and Copenhagen rat strains. Genetics, 169: 2189–2197. estrogen. Carcinogenesis, 16: 891–895. doi:10.1093/ doi:10.1534/genetics.104.039370 PMID:15687265 carcin/16.4.891 PMID:7728971 Strohsnitter WC, Noller KL, Hoover RN et al. (2001). $omas RD & Roy D (2001a). Base sequence-speci%c attack Cancer risk in men exposed in utero to diethyl- of stilbene estrogen metabolite(s) on the mitochondrial stilbestrol. J Natl Cancer Inst, 93: 545–551. doi:10.1093/ DNA: implications in the induction of instability in the jnci/93.7.545 PMID:11287449 mitochondrial genome in the kidney of Syrian ham- Suzuki A, Enari M, Iguchi T (1996). E"ect of neonatal sters. Int J Mol Med, 7: 389–395. PMID:11254879 exposure to DES in Fas and Bcl-2 expression in the $omas RD & Roy D (2001b). Stilbene estrogen pro- adult mouse vagina and approach to the DES syn- duces higher levels of mitochondrial DNA adducts drome. Reprod Toxicol, 10: 465–470. doi:10.1016/ than nuclear DNA adducts in the target organ of can- S0890-6238(96)00133-5 PMID:8946560 cer (liver) of male Sprague Dawley rats. Oncol Rep, 8: Suzuki A, Watanabe H, Mizutani T et al. (2006). Global 1035–1038. PMID:11496312 gene expression in mouse vaginae exposed to diethyl- Titus-Ernsto" L, Hatch EE, Hoover RN et al. (2001). Long- stilbestrol at di"erent ages. Exp Biol Med (Maywood), term cancer risk in women given diethylstilbestrol 231: 632–640. PMID:16636312 (DES) during pregnancy. Br J Cancer, 84: 126–133. Suzuki K, Ishii-Ohba H, Yamanouchi H et al. (1994). doi:10.1054/bjoc.2000.1521 PMID:11139327 Susceptibility of lactating rat mammary glands to Titus-Ernsto" L, Troisi R, Hatch EE et al. (2006b). gamma-ray-irradiation-induced tumorigenesis. Int Menstrual and reproductive characteristics of women J Cancer, 56: 413–417. doi:10.1002/ijc.2910560321 whose mothers were exposed in utero to diethyl- PMID:8314329 stilbestrol (DES). Int J Epidemiol, 35: 862–868. Sweetman SC, editor (2008) Martindale: #e Complete doi:10.1093/ije/dyl106 PMID:16723367 Drug Reference, London, Pharmaceutical Press, Titus-Ernsto" L, Troisi R, Hatch EE et al. (2006a). Electronic version, (Edition 2008) Mortality in women given diethylstilbestrol dur- Takahashi T, Eitzman B, Bossert NL et al. (1994). ing pregnancy. Br J Cancer, 95: 107–111. doi:10.1038/ Transforming growth factors beta 1, beta 2, and beta sj.bjc.6603221 PMID:16786044 3 messenger RNA and protein expression in mouse Titus-Ernsto" L, Troisi R, Hatch EE et al. (2008). O"spring uterus and vagina during estrogen-induced growth: of women exposed in utero to diethylstilbestrol (DES): a comparison to other estrogen-regulated genes. Cell a preliminary report of benign and malignant pathol- Growth Di(er, 5: 919–935. PMID:7819129
((" Diethylstilbestrol
ogy in the third generation. Epidemiology, 19: 251–257. Vessey MP, Fairweather DV, Norman-Smith B, Buckley J doi:10.1097/EDE.0b013e318163152a PMID:18223485 (1983). A randomized double-blind controlled trial of Troisi R, Hatch EE, Titus-Ernsto" L et al. (2007). Cancer the value of stilboestrol therapy in pregnancy: long-term risk in women prenatally exposed to diethylstilbestrol. follow-up of mothers and their o"spring. Br J Obstet Int J Cancer, 121: 356–360. doi:10.1002/ijc.22631 Gynaecol, 90: 1007–1017. doi:10.1111/j.1471-0528.1983. PMID:17390375 tb06438.x PMID:6357269 Tsutsui T & Barrett JC (1997). Neoplastic transformation Waalkes MP, Liu J, Ward JM et al. (2006a). Urogenital car- of cultured mammalian cells by estrogens and estro- cinogenesis in female CD1 mice induced by in utero genlike chemicals. Environ Health Perspect, 105: Suppl arsenic exposure is exacerbated by postnatal diethyl- 3619–624. doi:10.2307/3433380 PMID:9168005 stilbestrol treatment. Cancer Res, 66: 1337–1345. Tsutsui T, Degen GH, Schi"mann D et al. (1984). doi:10.1158/0008-5472.CAN-05-3530 PMID:16452187 Dependence on exogenous metabolic activation for Waalkes MP, Liu J, Ward JM, Diwan BA (2006b). induction of unscheduled DNA synthesis in Syrian Enhanced urinary bladder and liver carcinogenesis in hamster embryo cells by diethylstilbestrol and related male CD1 mice exposed to transplacental inorganic compounds. Cancer Res, 44: 184–189. PMID:6317168 arsenic and postnatal diethylstilbestrol or tamoxifen. Tsutsui T, Suzuki N, Maizumi H, Barrett JC (1990). Toxicol Appl Pharmacol, 215: 295–305. doi:10.1016/j. Aneuploidy induction in human %broblasts: compari- taap.2006.03.010 PMID:16712894 son with results in Syrian hamster %broblasts. Mutat Waggoner SE, Anderson SM, Luce MC et al. (1996). p53 Res, 240: 241–249. doi:10.1016/0165-1218(90)90074-C protein expression and gene analysis in clear cell adeno- PMID:2330010 carcinoma of the vagina and cervix. Gynecol Oncol, 60: Tsutsui T, Taguchi S, Tanaka Y, Barrett JC (1997). 17beta- 339–344. doi:10.1006/gyno.1996.0052 PMID:8774636 estradiol, diethylstilbestrol, tamoxifen, toremifene and Wakata A, Matsuoka A, Yamakage K et al. (2006). SFTG ICI 164,384 induce morphological transformation and international collaborative study on in vitro micronu- aneuploidy in cultured Syrian hamster embryo cells. cleus test IV. Using CHL cells. Mutat Res, 607: 88–124. Int J Cancer, 70: 188–193. doi:10.1002/(SICI)1097- PMID:16782396 0215(19970117)70:2<188::AID-IJC9>3.0.CO;2-T Walker BE (1988). Vaginal tumors in mice from methylcho- PMID:9009159 lanthrene and prenatal exposure to diethylstilbestrol. Tucker RW & Barrett JC (1986). Deceased numbers of spin- Cancer Lett, 39: 227–231. doi:10.1016/0304- dle and cytoplasmic microtubules in hamster embryo 3835(88)90064-X PMID:3359417 cells treated with a carcinogen, diethylstilbestrol. Walker BE (1990). Tumors in female o"spring of control Cancer Res, 46: 2088–2095. PMID:3948182 and diethylstilbestrol-exposed mice fed high-fat diets. Turusov VS, Trukhanova LS, Lanko NS et al. (1997). J Natl Cancer Inst, 82: 50–54. doi:10.1093/jnci/82.1.50 1,2-Dimethylhydrazine carcinogenesis in C3HA and PMID:2293656 CBA female mice prenatally treated with diethyl- Walker BE & Haven MI (1997). Intensity of multigenera- stilbestrol. Teratog Carcinog Mutagen, 17: 19–28. tional carcinogenesis from diethylstilbestrol in mice. doi:10.1002/(SICI)1520-6866(1997)17:1<19::AID- Carcinogenesis, 18: 791–793. doi:10.1093/carcin/18.4.791 TCM4>3.0.CO;2-I PMID:9249927 PMID:9111216 Turusov VS, Trukhanova LS, Parfenov YuD , Tomatis Walker BE & Kurth LA (1993). Pituitary tumors in mice L (1992). Occurrence of tumours in the descendants exposed prenatally to diethylstilbestrol. Cancer Res, 53: of CBA male mice prenatally treated with diethyl- 1546–1549. PMID:8453621 stilbestrol. Int J Cancer, 50: 131–135. doi:10.1002/ Wang MY & Liehr JG (1994). Identi%cation of fatty acid ijc.2910500126 PMID:1728603 hydroperoxide cofactors in the cytochrome P450- Usui T, Mutai M, Hisada S et al. (2001). CB6F1-rasH2 mediated oxidation of estrogens to quinone metab- mouse: overview of available data. Toxicol Pathol, olites. Role and balance of lipid peroxides during 29: Suppl90–108. doi:10.1080/019262301753178500 estrogen-induced carcinogenesis. J Biol Chem, 269: PMID:11695565 284–291. PMID:8276808 Utsuyama M, Kanno J, Inoue T, Hirokawa K (2002). Age/ Wang MY & Liehr JG (1995a). Induction by estrogens of sex dependent and non-monotonous dose-response lipid peroxidation and lipid peroxide-derived malonal- e"ect of diethylstilbestrol on the immune functions dehyde-DNA adducts in male Syrian hamsters: role of in mice. Toxicol Lett, 135: 145–153. doi:10.1016/S0378- lipid peroxidation in estrogen-induced kidney carcino- 4274(02)00256-4 PMID:12243873 genesis. Carcinogenesis, 16: 1941–1945. doi:10.1093/ Verloop J, Rookus MA, van Leeuwen FE (2000). Prevalence carcin/16.8.1941 PMID:7634425 of gynecologic cancer in women exposed to diethyl- Wang MY & Liehr JG (1995b). Lipid hydroperoxide- stilbestrol in utero. N Engl J Med, 342: 1838–1839. induced endogenous DNA adducts in hamsters: pos- doi:10.1056/NEJM200006153422415 PMID:10866558 sible mechanism of lipid hydroperoxide-mediated
((& IARC MONOGRAPHS – 100A
carcinogenesis. Arch Biochem Biophys, 316: 38–46. doi:10.1006/abbi.1995.1007 PMID:7840640 Ways SC, Mortola JF, Zvai'er NJ et al. (1987). Alterations in immune responsiveness in women exposed to diethylstilbestrol in utero. Fertil Steril, 48: 193–197. PMID:3609331 Welch WR, Fu YS, Robboy SJ, Herbst AL (1983). Nuclear DNA content of clear cell adenocarcinoma of the vagina and cervix and its relationship to prognosis. Gynecol Oncol, 15: 230–238. doi:10.1016/0090-8258(83)90079-3 PMID:6832636 Wendell DL, Herman A, Gorski J (1996). Genetic separa- tion of tumor growth and hemorrhagic phenotypes in an estrogen-induced tumor. Proc Natl Acad Sci USA, 93: 8112–8116. doi:10.1073/pnas.93.15.8112 PMID:8755612 Wingard DL & Turiel J (1988). Long-term e"ects of expo- sure to diethylstilbestrol. West J Med, 149: 551–554. PMID:3250102 Xu LH, Rinehart CA, Kaufman DG (1995). Estrogen- induced anchorage-independence in human endome- trial stromal cells. Int J Cancer, 62: 772–776. doi:10.1002/ ijc.2910620621 PMID:7558429 Yager JD & Chen JQ (2007). Mitochondrial estro- gen receptors–new insights into speci%c functions. Trends Endocrinol Metab, 18: 89–91. doi:10.1016/j. tem.2007.02.006 PMID:17324583 Yan ZJ & Roy D (1995). Mutations in DNA polymer- ase beta mRNA of stilbene estrogen-induced kidney tumors in Syrian hamster. Biochem Mol Biol Int, 37: 175–183. PMID:8653081 Yuen MT, Leung LK, Wang J et al. (2005). Enhanced induc- tion of prostatic dysplasia and carcinoma in Noble rat model by combination of neonatal estrogen exposure and hormonal treatments at adulthood. Int J Oncol, 27: 1685–1695. PMID:16273225 Zijno A, Quaggia S, Pacchierotti F (1989). A cytoge- netic approach to evaluate in vivo somatic aneuploidy. E"ects of diethylstilboestrol on mouse bone marrow cells. Mutagenesis, 4: 62–66. doi:10.1093/mutage/4.1.62 PMID:2654554
()'