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(WDHA) Syndrome Due to Vasoactive Intestinal Poly

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(WDHA) Syndrome Due to Vasoactive Intestinal Poly Endocrinol. Japon. 1980, S. R. No. 1, 79-86 Clinical and Hormonal Aspects of the Watery Diarrhea- Hypokalemia-Achlorhydria (WDHA) Syndrome due to Vasoactive Intestinal Polypeptide (VIP)-producing Tumor KEN YAMAGUCHI1, KAORU ABE1, ISAMU ADACHI1, MASAHIRO TANAKA1, MASAKAZU UEDA1, YUJI OKA1 SUMIKO MIYAKAWAl, TORU KAMEYA2 AND NOBORU YANAIHARA3 1Endocrinology and 2Pathology Division, National Cancer Center Research Institute, Chuo-ku, Tokyo 104 and 3Laboratory of Bioorganic Chemistry, Shizuoka College of Pharmacy, Shizuoka City, Shizuoka 422 Synopsis Three patients with the watery diarrhea-hypokalemia-achlorhydria (WDHA) syn- drome were studied. All had watery diarrhea, hypokalemia and hypercalcemia. Plasma vasoactive intestinal polypeptide (VIP) levels determined by radioimmunoassay were markedly elevated in these patients, indicating that they had VIP-producing tumors. Plasma VIP levels determined serially after the operation indicate that its determination is useful in estimating the effect of a treatment. As for multiple endocrine neoplasia type 1 (MEN1), two out of the three cases belonged to this category. Patient 1 had a brother with insulinoma, and in case 2, even though there was no family history, the autopsy revealed not only multiple tumors of the pancreas but also pituitary adenomas, chief cell hyperplasia of the parathyroid glands, thyroid adenomas and adrenocortical adenomas. VIP and other hormones in the tumors as well as in the plasma were examined extensively in these cases. In case 1, VIP, gastrin and calcitonin were produced in the tumor and only plasma VIP levels were elevated. In case 2, with multiple tumors, tumor 1 produced VIP, glucagon, pancreatic polypeptide, gastrin and cal- citonin, and tumor 2, VIP, pancreatic polypeptide, gastrin and ƒÀ-melanocyte stimu- lating hormone. In this case, plasma VIP, pancreatic polypeptide and glucagon levels were elevated. In case 3, VIP and calcitonin were produced in the tumor, and plasma VIP and calcitonin levels were elevated. These results indicate that (1) VIP is a good tumor marker for the WDHA syndrome due to VIP-producing tumors ; (2) patients with the WDHA syndrome are sometimes associated with MEN1 ; and (3) VIP-producing tumors are multiple hor- mone-producing tumors, and VIP predominantly elevated in the plasma results in the WDHA syndrome, although other hormones such as pancreatic polypeptide, glucagon and calcitonin are sometimes found to be elevated in plasma without contributing to the clinical features. Vasoactive intestinal polypeptide (VIP) (Bloom et al., 1973), the so-called watery is a straight-chain polypeptide composed of diarrhea-hypokalemia-achlorhydria (WDHA) 28 amino acids with a wide variety of syndrome (Marks et al., 1967). In this paper, biological activities (Said, 1975), and its we report clinical and hormonal data overproduction by the endocrine tumors of obtained from three cases of the WDHA the pancreas or ganglioneuroblastoma is syndrome due to VIP-producing tumors of known to result in profuse watery diarrhea the pancreas. Endocrinol. Japan. 80 YAMNGUCHI et al. December 1980 ACTH and ƒÀ-MSH, the hormone detected was thought to be derived from tumor cells. Materials and Methods The tumor tissues were examined by conventional morphological techniques such as tinctorial and silver Three patients with the WDHA syndrome who staining for identifying the type of endocrine cells. were shown to have endocrine tumors of the pancreas Furthermore, the indirect immunofluorescence tech- (Kawanaka et al. , 1978 ; Yamada et al. , 1978 ; Isono nique (Kameya et al., 1977) was used to detect et al., 1979) were studied. Clinical information con- tumor cells which contained Ins, Glu, PP, VIP, Gas cerning the following items was obtained from these and CT. patients : age, sex, family history, past history, the daily volume of watery diarrhea, serum potassium and calcium levels, basal acid output of the stomach, Results 50-g oral glucose tolerance tests (50-g O-GTT), angio- graphic studies and surgical or autopsy data. Peripheral venous blood was obtained from these Clinical and laboratory data on the three patients and treated as reported previously (Abe et patients are summarized in Table 1. They al., 1979) and plasma hormone levels were assayed were all female. The volume of watery by the radioimmunoassays for insulin (Ins), glucagon (Glu), pancreatic polypeptide (PP), VIP, gastrin diarrhea reached 5 1/day in case 2. All had (Gas), calcitonin (CT) and parathyroid hor- mone marked hypokalemia and hypercalcemia. (PTH). The basal acid output was low in cases 1 Plasma VIP levels were also studied in 13 normal and 3. Glucose tolerance was abnormal in subjects, 52 patients with uremia, 14 with liver cir- rhosis, 10 with other types of endocrine tumors of case 1. Celiac angiography revealed hyper- the pancreas including insulinoma and the Zollinger- vascular tumor stains in cases 1 and 3. Ellison syndrome, and 34 with watery diarrhea. The presence of multiple endocrine In two patients with the WDHA syndrome, plasma neoplasia type 1 (MEN1) in these patients VIP levels before and after operation were deter- mined serially. is summarized in Table 2. The family history The tumor tissues and macroscopically normal of case 1 revealed an elder brother with pancreatic tissues removed with the tumor were ob- insulinoma. No patient had a past history tained at operation (cases 1 and 2) or at autopsy suggesting the presence of MEN1. In the (cases 2 and 3). They were extracted by the method reported previously (Tanaka et al., 1979). In one laboratory data, all showed hypercalcemia. case (case 2), the tumors were multiple and the two These observations, however, did not neces- tumor tissues were examined separately. One tumor sarily mean a parathyroid lesion, as will (tumor 1) was obtained at the time of operation and the other (tumor 2) at autopsy. be mentioned later. In case 2, the autopsy The content of various hormones in the tumor revealed not only multiple tumors of the was assayed by the radioimmunoassays for C-peptide pancreas but also multiple pituitary ade- (C-P), Glu, PP, somatostatin (GIF), VIP, Gas, CT, nomas, thyroid colloid adenomas, chief cell secretin (Sec), motilin (Mot), adrenocorti- cotropic hormone (ACTH) and p-melanocyte stimu- lating hyperplasia of the parathyroid glands and hormone (p-MSH). The extracts were assayed at bilateral adrenocortical adenomas, indicat- three or more dilutions to obtain a dose response ing that this case belonged to the MEN1 curve. When a significant displacement was observed with only one dilution, the sample was considered to be undetectable. In order to decide whether or not Table 1. Clinical and laboratory data on three the hormone detected in the tumor was derived from cases of the WDHA syndrome it, the amount detected was compared with that found in the normal pancreas. In the case of a hormone that is normally present in the pancreas, such as C-P, Glu, PP, GIF and VIP, the hormone detected in the tumor was considered to be produced in the tumor cells when the values exceeded those of the normal pancreas. In the case of hormones that were not detected in the normal pancreas or, if detected, were not always present or were found only in small amounts, such as Gas, CT, Sec, Mot, S. R. No.1 VIP-PRODUCING TUMORS 81 Table 2. The presence of MEN1 Fig. 1. Plasma VIP levels plotted on a log scale in normal subjects and in patients with various dis- eases. In three patients with the WDHA syn- drome, plasma VIP levels on different occasions are plotted, and in case 1 open circles are the levels at times when watery di- arrhea was not severe. category, although there was no family of watery diarrhea in about two-thirds of history of the disease. In case 3, the these cases. There were three cases with autopsy did not reveal other endocrine elevated plasma VIP level. One patient who lesions. To sum up, two of the three cases had a level of 360 pg/ml received a laparo- had some findings compatible with MEN1. tomy, but no tumor was found in the pan- Plasma VIP levels in various types of creas and the pancreatic tail was removed. In this patient plasma VIP levels were still patients including the three with the WDHA syndrome are shown in Fig. 1. The norml high even after the operation, and she is values are less than 100 pg/ml. In some still under careful observation. In the other patients with uremia or liver cirrhosis, slight two with a slightly elevated level, one was elevation of plasma VIP levels were obser- a uremic patient, and in the other the ved. In the cases with insulinoma or the etiology was unknown. The plasma VIP Zollinger-Ellison syndrome, plasma VIP levels obtained from the three patients with levels were normal. In 34 cases with watery the WDHA syndrome on different occasions diarrhea, 31 showed normal plasma VIP are plotted in Fig. 1. These values were values. They were patients with pancreatic much higher than those observed in the carcinoma, lung carcinoma, medullary other diseases. An shown in the WDHA thyroid carcinoma, malignant lymphoma, case 1, the values obtained at times when parasitosis, sprue or chronic pancreatitis, but watery diarrhea was not severe were lower a general survey failed to reveal the etiology than the others. Endocrinol. Japon. 82 YAMAGUCHI et al. December 1980 even after the operation and the patient ex- Case 1 pired after several days. The parts of the pancreas removed at operation and autopsy were found to contain multiple tumors. The histochemical studies showed that a large tumor (0.7•~0.7 cm, tumor 1 in Fig. 2) removed at operation was an A-cell tumor and that even larger one (2•~2 cm, tumor 2 in Fig. 2) located at the head and found at Case 2 autopsy, was a non-A, non-B cell tumor.
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