MONOCLONAL ANTIBODIES TO IDENTIFY TUMOUR CELLS IN CSF

739 TECHNICAL DATA ON RADIOTHERAPY FOR CHILDHOOD TUMOURS

_____j_______________-_____<________-____!______________

’Treatments through anterior and posterior portals in all patients. Patient 2 also received 1000 rad to abdomen and 900 additional rad to left groin. Mediastinal field in patient 3 was 6 cm wide and extended down to 12th thoracic vertebra.

that received at least 10% of the midplane dose. This amount of radiation is associated in other studies with induction of breast cancer. 1-3 The t-intervals (24, 30, and 37 years) between radiation exposure and diagnosis of cancer in our patients are also consistent with a radiation effect. The three patients contribute to the evidence for increased risk of breast carcinoma after exposure in childhood to several hundred rad. Our patients had no history of breast cancer in close relatives, but host susceptibility and chemotherapy (in patients 1 and 3) may be additional aetiological factors. Patient 1 is the fifth reported instance of breast cancer developing in women with radiationinduced breast hypoplasia.4,5Radiation-associated breast cancer has now been reported in ten men, including patient 2.6 Men and women who had radiotherapy to the chest in childhood should be taught breast self-examination, and have medical attention to detect early breast cancer. Studies. of Japanese men exposed to atomic bombing may help clarify the breast cancer risk among irradiated

Fig I-Large foamy cells in CSF, with occasional lymphocytes (L) and erythrocytes.

males. Clinical Epidemiology Branch, National Cancer Institute, Bethesda, Maryland; and Division of Biostatistics and Epidemiology, Dana-Farber Cancer Institute, Boston, Massachusetts 02115, USA

FREDERICK P. Li

Joint Center for Radiation Therapy, Harvard Medical School, Boston, Massachusetts

ELIOT ROSEN

MONOCLONAL ANTIBODIES TO IDENTIFY TUMOUR CELLS IN CSF use of monoclonal markers for tumour cells in tissues and serous fluids, although questions have been raised about the specificity of such markers. An alternative approach is to use epithelium-specific and leucocyte-specific monoclonal antibodies to identify cells present in abnormal sites or increased cell numbers. This report describes the use of such cell markers to identify malignant cells found in the CSF. A 53-year-old male builder presented complaining of backache, progressive deafness, and sudden attacks of headache, which were associated with ataxia and nystagmus. A neurologist suggested basal meningitis of neoplastic or inflammatory origin. Cytological examination of CSF, using Papanicolaou and Romanovsky stains, stains, showed the presence of many abnormal cells in the CSF (fig 1) in conjunction with occasional lymphocytes. The abnormal cells included both isolated and aggregated large cells with foamy which were multinucleate. The nature of these cytoplasm, some of which cells was uncertain since they shared morphological features of both adrenocarcinoma and histiocytic cells. Cytocentrifuge smears of CSF cells were prepared and fixed in periodate-lysine-paraformaldehyde (PLP).7 Ten smears, each

SIR,-There is considerable interest in the SIR,—There

antibodies

WW, Zola H, Atkins RC. Antigenic heterogeneity of human mononuclear phagocytes: Immunohistological analysis using monoclonal antibodies. Blood (in press). 9. Hancock WW, Atkins RC. Monoclonal antibodies to human glomerular cells: A marker for glomerular epithelial cells. Nephron 1983; 33: 83-90. 10. Thompson CH, Jones SL, Whitehead RH, McKenzie IFC. A human breast tissueassociated antigen detected by a monoclonal antibody. JNCI 1983; 70: 409-20. 8. Hancock

as

4. Reimer

RR, Fraumeni JF Jr, Reddick R, Moorhead EL. Breast carcinoma following radiotherapy of metastatic Wilms tumor. Cancer 1977; 40: 1450-52.

5. Kleinfeld G. Radiation-induced hypoplasia and carcinoma of the breast. Breast

1978; 4:

25-26. 6. Greene MH, Goedert

JJ, Bech-Hansen NT, et al. Radiogenic male breast cancer with in sensitivity to ionizing radiation and bleomycin. Cancer Invest (in press). Hancock WW, Becker GJ, Atkins RC. A comparison of fixatives and immunohistochemical techniques for use with monoclonal antibodies to cell surface antigens. Am J Clin Pathol 1982; 78: 825-31. vitro

7

Fig 2-Lymphocytes (L) in CSF labelled by leucocyte-common antigen marker (PHMI); large foamy cells unstained. (PAP immunoperoxidase, haematoxylin; reduced to 2/3 of x 1000.)

740 The combination of monoclonal markers for normal cell types and

immunocytological techniques may be of considerable diagnostic value in cytological examinations of CSF and other body fluids. Departments of Nephrology and Pathology, Prince Henry’s Hospital,

W. W. HANCOCK G. MEDLEY

South Melbourne, Victoria 3004, Australia

URINARY EXCRETION OF NORADRENALINE METABOLITE DECREASED IN PANIC DISORDER

SIR,-Relationships between anxiety and increased adrenergic activity are being inferred in several anxiety syndromes, including spontaneous anxiety attacks.1-4 We have compared the urinary excretion of the main catabolite of brain noradrenaline (methoxyhydroxy-phenylethyleneglycol, MHPG) in outpatients with panic disorder or agoraphobia with panic attack (DSM III criteria) and in age-matched controls who denied anxiety attacks, significant depression, drug abuse, or the use of psychotropic drugs. We excluded patients with major depressive disorders or complex partial epilepsy and those with abnormal dexamethasone suppression, TRH infusion, or glucose tolerance tests, serum calcium

Fig 3-Large cells and processes labelled by both epithelial cell markers (PHM5 shown); adjacent lymphocytes (L) and infrequent macrophages (M) unstained. (PAP immunoperoxidase, haematoxylin;

reduced

to

2/3 of

x

1000.)

were labelled. These cells were also unstained by Ia and any of the three other monocyte markers tested. By contrast, the large cells alone were labelled by both of the epithelial markers (fig 3), displaying diffuse staining of the cells and associated villous processes. Control smears were unstained. After further investigations into the site of the primary carcinoma, a mucin-secreting adenocarcinoma of the ethmoid sinus was subsequently detected (fig 4), a so-called "woodworker’s" carcinoma. This case illustrates the use of monoclonal markers for normal cell types to aid in the differential diagnosis of an otherwise difficult clinical problem. The abnormal cells within the CSF did not express markers usually found on normal or malignant haemopoietic cells. However, these cells did express two normal epithelial antigens which, in the context of CSF where such epithelial cells are not normally found, indicated they were of carcinomatous origin. Subsequent experience has shown this approach may also be used to diagnose and monitor patients with lymphoid malignancies involving the CSF. Such techniques applied to cytocentrifuge smears are ideal because of the low cell yields often recovered from CSF specimens.

lymphocytes

levels,

or

EEGs. Patients

were

two

weeks free of

antidepressants and one week free of benzodiazepines. MHPG was measured by gas chromatography coupled to an electron capture detector.Subjects maintained a low monoamine diet for two days before and the one day of the urine collection. Urines were collected at ambient temperature and assayed within 48 h of collection for MHPG and creatinine. Urine voumes less than 1 litre or with creatinine excretion less than 800 mg were excluded. The prediction of a simple hyperadrenergic turnover hypothesis is that 24 h MHPG excretion in panic disordered patients would be significantly higher than that of controls. We found 24 h MHPG excretion in these anxiety patients to be significantly lower than that of controls (see table). This paradoxical finding suggests a decrease in the average daily turnover of brain noradrenaline in panic disorder. The observation does not contradict the possibility of bursts of adrenergic hypersecretion during the panic attacks. Pilot data suggest that chronic desipramine treatment normalises this low turnover. Thus, rather than absolute synthetic deficiency, a problem in the regulation of neuronal turnover is suggested. However paradoxical a hypoadrenergic model of anxiety attacks may seem from the perspective of Redmond’s theory, it is not unheralded.6 Parkinsonian patients who have locus coeruleus lesions and 7 presumably low MHPG also have spontaneous attacks. The implications of this finding are: 24 h MHPG excretion may be useful diagnostically to differentiate panic disorder conditions 1. Liebowitz

2.

M, Fyer A, McGrath P, et al. Clonidine treatment of panic disorder. Psychopharmacol Bull 1981; 17: 122. Gold MS, Redmond D, Kleber H. Clonidine blocks acute opiate withdrawal symptoms. Lancet 1978; ii: 599-602.

Sweeney D, Maas J, Heninger G. State anxiety, physical activity, and urinary MHPG excretion. Arch Gen Psychiatry 1978; 35: 1418. 4. Ko G, Elsworth J, Roth R, et al. Panic-induced elevations of plasma MHPG levels in phobic-anxious patients. Arch Gen Psychiatry 1983; 40: 425. 5. Lombrozo L, Anderson K, Hollister L. Modification of assays for the routine analysis of 3-methoxy-4-hydroxy phenylethylene glycol in urine by electron capture gas chromatography. J Chromatography 1980; 181: 1. 6. Redmond E. Alterations in the function of the nucleus locus coeruleus: a possible model for studies of anxiety. In: Hanin I, Usdin F, eds. Animal models in psychiatry and neurology. Oxford: Pergamon Press, 1977: 295. 7. Schwab R, Fabing H, Pritchard A. Psychiatric symptoms in Parkinson’s disease. Am J Psychiatry 1951; 107: 901-07. 3.

MHPG EXCRETION IN PANIC DISORDERED AND CONTROLS I

I

Fig 4-Photomicrograph

of

primary

tumour, adenocarcinoma of

ethmoid sinus.

(Haematoxylin and eosin;

reduced

to

2/3 of

x 250.)

*Mean±SD

(and range). p<0’0t

(unpatredt test).