[CANCER RESEARCH 38, 4345-4348, November 1978] 0008-5472/78/0038-0000$02.00 Correlation between Clinical Response to Hormone Therapy and Steroid Receptor Content in Prostatic Cancer1
Jan-Àke Gustafsson, Peter Ekman, Marek Snochowski, Anders Zetterberg, Ake Pousette, and Bertil Hogberg Department of Chemistry, Karolinska Institute [J.-A. G., M. S., A. P.], and Department of Urology [P. E.¡and Clinical Pathology Laboratory ¡A.2.], Karolinska Hospital, 104 01 Stockholm 60, Sweden, and Department of Pharmacology, Karolinska Institute and AB LEO Research Laboratories, Helsingborg, Sweden [B. H.]
Abstract radical prostatectomy (3); in most other countries the figures are much lower. Hormonal therapy is the dominating form of treatment Thus, hormonal treatment (orchidectomy, estrogen or for prostatic carcinoma. The majority of cases (80%) are progestin administration) is the major tool to control the well controlled for varying times with this regimen. How growth of prostatic cancer. Estrogen therapy is the most ever, thus far there have been no adequate methods to common form of therapy in many countries. However, this predict in which cases hormonal therapy is of less benefit. treatment has many side effects, and the cardiovascular Measurement of cancer tissue content of intracellular complications have gained increasing attention. The mech hormone receptors constitutes progress toward a more anism behind the estrogen activity is still obscure; the individualized therapy in prostatic carcinoma. In this study secretion of luteinizing hormone from the pituitary is de biopsies from 16 cancer patients were taken before ther creased, and, consequently, androgen secretion from the apy was given, and the specimens were analyzed with testes is decreased. A direct estrogenic effect on the regard to content of specific methyltrienolone-binding prostatic cancer still has not been proved. sites. A correlation has been made between receptor As we know that all steroid hormonal activity is mediated content and clinical response to hormonal therapy in each via highly specific intracellular receptor proteins, it should case. Twelve specimens contained measurable amounts be of great importance to measure the amount of intracel of steroid receptors. Of these, one patient died during lular receptors to determine the sensitivity of the cancer irradiation therapy before onset of hormonal treatment. cells to the hormones in question and thus predict the value However, of the remaining 11 patients, 9 responded well of hormone therapy in each individual case. Cases with no to hormones (9/11 ~ 82%). The two receptor-positive measurable receptors might be offered alternative forms of nonresponders had the lowest measurable receptor therapy, i.e., irradiation or cytotoxic drugs, or they might levels in the series. Four specimens contained no detect be considered for radical prostatectomy. It might also be able amounts of receptors. Three of these patients possible to select among different forms of hormonal ther showed no response to therapy (3/4 = 75%) but one was apy, i.e., with estrogens, progestins, other antiandrogens, "false negative." Our data indicate that steroid receptor or glucocorticoids. analysis may become a valuable diagnostic tool in indi In our ongoing research on steroid receptors in prostatic vidualizing the therapy for prostatic cancer. tissue, several cancer specimens have been examined (5, 12). Most of the patients received estrogen treatment fol Introduction lowing removal of the specimen. The aim of this study was to evaluate the existence of any correlation between the The androgen dependence of the prostate gland is well tissue content of hormone receptors and the response of established (6). It has also been observed that neither the tumor to hormonal therapy. cancer nor hyperplasia of the prostate develops in castrates (10). Estrogen treatment is effective in a majority of the cases with prostatic cancer (8), while it has no effect on Materials and Methods benign prostatic hyperplasia. Benign prostatic hyperplasia always develops in the middle or lateral lobes of the pros Patients. Sixteen patients were investigated. The choice tate, whereas cancer almost exclusively starts in the dorsal of therapy was in no case influenced by the results of the lobe (9). The rare cases with periurethral cancers are hormone receptor analysis. All patients were randomized claimed to be nonresponsive to hormonal treatment (4). and received either polyestradiol phosphate (Estradurin), Radical operations for prostatic cancer are seldom per 80 to 160 mg/month, in combination with ethynyl estradiol formed, partly because many patients suffering from the (Etivex), 100 to 150 ¿¿g/day,orestramustine phosphate disease are poor risks, but also because the tumor has (Estracyt),420 to 840 mg/day. Two of the patients with often spread outside the capsule when first diagnosed. In poorly differentiated tumors had no demonstrable métas the U.S., only 7% of all prostatic cancers are submitted for tases and were therefore started on irradiation therapy according to our general principles for treatment of these cases. One to 2 months after the cessation of irradiation 1 A preliminary report. Presented at the John E. Fogarty International therapy, hormonal therapy was initiated. Patient 10 was Center Conference on Hormones and Cancer, March 29 to 31, 1978, Bethesda, Md. Supported by grants from Riksföreningen mot Cancer, LEO orchidectomized bilaterally at the time of the biopsy and Research Foundation, Svenska Läkaresällskapet, and Karolinska Institute. was also given Estracyt therapy.
NOVEMBER 1978 4345
Downloaded from cancerres.aacrjournals.org on September 24, 2021. © 1978 American Association for Cancer Research. J.-Â. Gustafsson et al
Clinical response was evaluated by the following param tion therapy before initiation of hormonal treatment. Nine of eters: (a) decreased palpable size of the gland, withdrawal the remaining 11 patients showed a good response to of an indwelling catheter, and improved micturition, (b) estrogen treatment. The 2 receptor-positive nonresponders relief of pain and/or measurable decrease of known métas had the lowest measured amounts of receptor in the series tases; (c) normalization or marked decrease of elevated (Table 1). It is possible that this indicates that a minimum acid phosphatase levels; and (d) squamous cell metaplasia amount of receptor protein is required if a response to as demonstrated by fine-needle aspiration biopsies. hormonal therapy is to be expected. The patients were regularly and carefully checked; the Four specimens lacked measurable amounts of receptor examining physician was unaware of the results of the protein. Three of them did not respond to hormonal treat receptor analyses when judging whether or not improve ment, but one had a good remission from estrogen therapy ment had occurred. Improvement was usually visible within and should be regarded as "false receptor-negative." 3 months after the start of therapy. The relative correlation between steroid receptor content Tumor Specimens. All of the cancer specimens were and response to hormonal treatment in our series was removed via perineal biopsy. The biopsy was performed approximately 80% (9/11 * 82%; 3/4 = 75%). before initiation of any therapy. We used the needle de signed by Veenema in 1953 (13). From each patient 3 or 4 Discussion biopsies were taken, yielding a total specimen weight of 0.05 to 0.20 g. From each biopsy parts were taken for Practical application of the concept of steroid hormone histological examination. A careful histological analysis of receptors has already been achieved in the treatment of each specimen was undertaken since it is almost impossible breast cancer. A good correlation exists between the con to obtain pure adenocarcinomatous tissue with needle tent of estrogen receptors in the cancer tissue and the biopsy. There is usually some contamination, mainly with response to endocrine treatment (7). The conditions are muscle cells but also with fibroblasts. However, this con thought to be similar for prostatic cancer; in fact, the tamination does not seem to disturb the analyses. The clinical importance of steroid receptor measurements may content of steroid receptors in muscle cells is negligible be even greater in this disease, inasmuch as hormonal (unpublished observations). All biopsies containing ele treatment is the dominating form of therapy in prostatic ments of normal and hyperplastic tissue were excluded carcinoma. from the study. Histologically, cancer of the prostate is often quite heter The biopsies were frozen to -70° within 1 hr. At this ogeneous with parts of high degree of differentiation mixed temperature the receptors seemed to be unaffected for at with areas of moderate to low differentiation. It is quite least 6 months. conceivable that different parts of the same tumor may have Receptor Quantitäten.The methodology used for recep different degrees of hormone dependence, possibly as a tor quantitation has been described in detail in a previous result of a multiclonal cancer debut. paper (12). Because of the minor amount of available tissue The receptor assay used in the present investigation is in each case, we were forced to limit our analysis to the use relatively tissue-consuming. The majority of the specimens of one steroid ligand. We have focused our interest on the have been taken from advanced cancers since biopsies tissue content of specific high-affinity, low-capacity binding from small cancers usually are contaminated with noncar- sites for methyltrienolone (R 1881). The analyses were cinomatous elements. The minimum amount of tissue re carried out using a dextran-coated charcoal technique quired for the receptor assay used in this investigation is 75 (12). The B,,,.1XandK,,values were evaluated from Scatchard to 100 mg. It is possible that the sensitive technique based plots (11). The synthetic androgen methyltrienolone (Ref. 2; on isoelectric focusing in polyacrylamide gel, which is Roussel-UCLAF, Romainville, France) has the advantage of already in clinical use for breast cancer estrogen receptor binding to intracellular receptors but not to serum proteins. analysis, may also be useful for analysis of androgen Furthermore, it is not metabolized and exchanges with receptors in the prostate. This might decrease the required endogenous receptor-bound steroid to about 70% during amount of tissue to 10 mg, which is the tissue yield usually 24 hr incubation at 0°(12).However, methyltrienolone binds obtained with fine-needle aspiration biopsy. to the progesterone receptor in human prostate with about Our data suggest that there is a good correlation between the same affinity as to the androgen receptor (1,12). the tissue content of steroid receptors and short-term The Bmaxestimations were expressed as fmol of specific response to hormonal therapy. The results are encouraging binding sites per mg of DNA. The figures were not corrected and support the view that hormone receptor analysis may for the percentage of contamination with fibrous tissue in be a useful tool to optimize and individualize the treatment the specimen. of prostatic cancer.
Results Acknowledgments Sixteen cancer specimens were analyzed, and the recep The authors are grateful to Barbro Näsman for skillful technical assist ance. tor levels were correlated to clinical response to hormonal therapy (Table 1). Twelve of the specimens contained measurable amounts References of methyltrienolone receptors. Bm;ivvaried between 52 and 1. Asselin. Y.. Labrie. F.. Gourdeau, Y.. Bonne. C., and Raynaud, J.-P. 354 fmol/mg DNA. One of these patients died during irradia- Binding of [3H]Methyltrienolone (R 1881) in Rat Prostate and Human
4346 CANCER RESEARCH VOL. 38
Downloaded from cancerres.aacrjournals.org on September 24, 2021. © 1978 American Association for Cancer Research. Steroid Receptors in Prostatic Carcinoma
QOJ (0 1 >-^5oj^ +k_CD 11"5 0+-^ •¿ «-OJ OJ +ra
—¿ 1 >- ro'io io *•ao OC¡iZ"DCD o o I 1 8 i 1 1+ro ro ro •¿ S£caj a"r." «".„S"i « 2a 2 a(0t»S£*- "aj o^ oj•—à >o. a.<°Si 2 oj aJ oZ£corowtú£ra oÃœ o o o—¿ z 2LL Å’ •¿ —^ *- O* CI ! ^ zzTJ .Q o —¿ roO)
,_i 0)*- OJOJti ,e 3OJ 3OJ ei 'S ^jOJra ai~3^3o OOJo| —¿ ^ OJIS *-I C O OJ si«2^ ° ra ro o f o 'S OOOj 0AtúCOOg
*- «-"e.2 OJo tSTJ OJt5 coC. tu'S OJtú" jjjojm C.ra
0) ,^'C '1 t O ^ SS .9"o•¿ *•* 0.1 .5o.i o "SIC01cu 0Z.OJz—TK8^ruic II"0) ZIro« Z (Olo.2-sSco§00) u1z Xg.2
£ i «- ¿ cu.S¿O. ¿2>CM^•OcotoLUOinCMo_linO*-«IU>Z '¿ 2OliO) 323 O. 3 1.QJCoEo•C01OJ^^ % OJ 0z "^5•aCO0)O^ co-^O) z- 5= Z2^
«_*ï , =I —¿ > >0) ^~_
LJnjIII(Dr: (P O) Q ( Tin ° >co —¿ Q. I^ .Q MC Ãœi111!i
i-co CMCM O h^-*ïCM 01 i-COen 03 CO?sr>-CMra ViC fil•oraQj¿ 0)CoO^£o.OJo6OCCo.o cì~o- |È i-c•^T3coco eninCM co o co_c1 i-co •¿ *00IOco co CMtoC ¿}£E £.=ra
»-»-•'-^C° ciai "O >•ok C, OJH xCJo) *ro ra o g ra oju! S ^S10 ^O£o raroœ gji ro ra ro E| u*"">O OÕ:i '.sLU z:coLU 5»ni ««LU LULUCM LUin8sraIosoLUCO+TJaioi_0.E-c¡mooz—coS!ILU8inoCOÕ»O~>•*+ro'coroa.co'S^•o0>g0.•o(0cooo—?oLUgOco1r~a!LL•n+—a>*- 111™ LULU°SO LUQLU LU LU
¿£"5o>5- OCO oin•* O ininCM T-OJ TtCM! »-t-OJ '»*— 00o03SZCO+ coor^-;u.o0COCM(UtaÃ’J ^C 0)ra ¿? e$ raCU rooj SoQ * 0) a>2 T3 o TJ TJ>1 0^0o 5 88O0 ofeSX ££AA*- ^ -—¿ .<«C J800)3!00 CM s.r--co co r-t-~c/D a.'cn z<5 ^* -i LL BÕ~~».*i0 ^-°^îiiOJfl)•OQZ5 CM+raio cocn+•OJ ^52 s NOVEMBER 1978 4347 Downloaded from cancerres.aacrjournals.org on September 24, 2021. © 1978 American Association for Cancer Research. J.-A. Gustafsson étal. Benign Prostatic Hypertrophy (BPH) Steroids, 28. 449-459. 1976. Estrogen Receptors and Breast Cancer Response to Adrenalectomy. 2. Bonne, C., and Raynaud, J.-P. Assay of Androgen Binding Sites by Nati. Cancer Inst. Monograph,34: 55-59, 1971. Exchange with Methyltrienolone (R 1881). Steroids, 27. 497-503, 1976. 8. Jönsson,G., and Högberg,B. Treatment of Advanced Prostatic Carci noma with Estracyt. Scand. J. Urol. Nephrol.,5. 103-108. 1971. 3.Total Correa, Prostatectomy* R. J., Jr., Gibbons, for Stage R. P.,B Carcinoma Cummings, of K. the B., Prostate. and Mason, J. Urol., J. T. 9. McNeal, J. E. Origin and Development of Carcinoma of the Prostate. 117: 328-329, 1977. Cancer, 23. 24-32, 1969. 4. Dube, V. E., Farrow, G. M., and Greene, L. F. Prostatic Adenocarcinoma 10. Moore, R. A. Benign Hypertrophy and Carcinoma of the Prostate. of Ductal Origin. Cancer, 32: 402-411, 1973. Occurrence and Experimental Production in Animals. Surgery. 16: 152- 5. Gustafsson, J.-Â., Ekman, P., Pousette, À.,Snochowski, M., and Hög- 163,1944. berg, B. Demonstration of a Progestin Receptor in Human Benign 11. Scatchard, G. The Attraction of Proteins for Small Molecules and Ions. Prostatic Hyperplasia and Prostatic Carcinoma. Invest. Urol., J5: 361- Ann. N. Y. Acad. Sci., 57: 660-672, 1949. 366, 1978. 12. Snochowski, M., Pousette, A., Ekman, P., Bression, D., Andersson, L., 6. Muggins, C., and Hodges, C. V. Studies on Prostatic Cancer. I. The Högberg,B., and Gustafsson. J.-A. Characterization and Measurement Effect of Castration, of Estrogen and Androgen Injection on Serum of the Androgen Receptor in Human Benign Prostatic Hyperplasia and Phosphatases in Metastatic Carcinoma of the Prostate. Cancer Res., 1: Prostatic Carcinoma. J. Clin. Endocrinol. Metab., 45: 920-930, 1977. 293-297, 1941. 13. Veenema, R. K. A Simplified Prostatic Perineal Biopsy Punch. J. Urol., 7. Jensen, E. V., Block, B. E., Smith, S., Kyser, K., and De Sombre, E. R. 69: 320-322, 1953. 4348 CANCER RESEARCH VOL. 38 Downloaded from cancerres.aacrjournals.org on September 24, 2021. © 1978 American Association for Cancer Research. Correlation between Clinical Response to Hormone Therapy and Steroid Receptor Content in Prostatic Cancer Jan-Åke Gustafsson, Peter Ekman, Marek Snochowski, et al. Cancer Res 1978;38:4345-4348. Updated version Access the most recent version of this article at: http://cancerres.aacrjournals.org/content/38/11_Part_2/4345 E-mail alerts Sign up to receive free email-alerts related to this article or journal. Reprints and To order reprints of this article or to subscribe to the journal, contact the AACR Publications Subscriptions Department at [email protected]. Permissions To request permission to re-use all or part of this article, use this link http://cancerres.aacrjournals.org/content/38/11_Part_2/4345. Click on "Request Permissions" which will take you to the Copyright Clearance Center's (CCC) Rightslink site. Downloaded from cancerres.aacrjournals.org on September 24, 2021. © 1978 American Association for Cancer Research.