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The Huggins test in pregnancy
THE HUWIEFB T3WT W PRmGWmCY RICHARD Et. FISCHER, B.S., ;M.D., WAS;HINGTOX~
I). C.
N 1949, Huggins’” reported on the relatively consistent alterations in the thermal coagulability of serum proteins in malignancy. Tn his initial report, the iodoacetate index of 6 pregnant women was reported as being above the critical level of 9.0 in 5 of t,he 6 c:~es and very slightly decreased (8.72) in the remaining one. As a portion of thr control series, therefore, it was intimated that in pregnancy t,here were no consistent alterations in the coagulative propert,ies of the serum prot.eins. In view of the rnany other reports in which pregnancy produces changes resembling those seen in persons with malignant neoplastic disease, it was felt, that further investigation of the iodoaceta.te index irr late pregnancy might prove informative. I
Materials md Methods Patients in the last trimest,er of pregnancy were used as a source of serum and the total proteins determined by the method of Greenberg.” The iodoacetate index was t,hen determined by the procedure as out,lineil by Huggins”’ in his original article. None of the patients select,ed for the test exhibit,ed any clinical signs or symptoms of disease at the time the test was run.
Results Of the 50 pregnant patients test,ed. 23. or 46 per cent, had an index of less than t,he proposed rninimal index of 9.0, while 27. or 54 per cent, had an iodoacetate index above t,his figure. ‘fhc number of cases studied were insufficient to determine any correlat,ion with the duration of pregnancy, but it may be pointed out that the percentage of positive results was-greater between the thirty-sixth and thirty-seventh weeks than in the over-all study. Fig. 1 is a scattergraph of the results hut there is no significant distribntion apparent. These findings correspond closely t,o the per cent of “false positives” in nonmalignant pathologic states reported by Gilligan and associat.es.” In a series of 107 patients with rronmalignant pathologic states (not specified), an iodoacetate index of less than 9.0 was found in 42 per cent,. Tn addiCon. 28 per cent of a series of known cancer cases showed an index above this figure.
Comment
Accumulating data t,end to support the hypothesis that the alteration in the serum proteins responsible for the changes in thermal coamgulability is a manifestation of body response IO stress. I%odanskg and McTnttesJ demonstrated that the iodoacetate index falls to ahnormal levels in 7 out of 8 patients operated on for nonmalignant corrditions, regardless of the preoperative value. ‘These values returned to normal at a rate dependent upon the estensiveness of the procedure and the presence or absence of complicating fact.ors in the postoperative period. The same authors brought. to light that-the administration of cortisone and ACTH resulted in a consistent decrease in MiO
HUGGINS
Volume 6 I Number 3
TEST
IN PREGNANCY
661
The values returned to normal upon cessation of the iodoacetate index. therapy. That pregnancy represents a condition of st,ress demanding adequate responsiveness on the part of the entire endocrine system goes without However, pregnancy resembles malignant states in other bioquestion. chemical aspects beside serum protein alterations. In studies of serum proteins in patients with malignant disease,l it has been shown that there exists a lowered concentration of protein and albumin This finding with a low albumin/globulin ratio and an increase in fibrinogen. is consistent with those previously reported for normal pregnancy,4 although more thorough analysis has revealed that the lowered concentration reflects the physiological hemodilution, and that the total amount of circulating protein is actually increased.5 Whether the serum protein alterations in malignancy are relative or absolute remains to be established. . 13.0
-
12.0
-
11.0 10.0
.
. -.
-.
.
.
.
-
.
-
.
.
.
. . . .
. .
. 9.0
-
8.0
-
7.0
-
6.0
-
5.0
-
*
.
.
. .
.
. .
.
.
.
.
1 32
RESULTS
.
1 33
OF
tttKXlNS
, 34
I 35
I 36
WEEK
OF
TEST
IN
OF
37
38
39
I 40
I 41
GESTATION 50
WOMEN
IN
THE
LAST
TRIMESTER
PREGNANCY Fig.
1.
The Black test for malignancy, based on the reduction time of methylene blue, is also reported as being positive in pregI1ancy.l Black states that the reduction time was definitely prolonged in two patients in the last trimester of pregnancy. As both the methylene blue reduction time and the inhibition of thermal coagulation of serum proteins by iodoacetate is believed to be related to the sulfhydryl group in the serum proteins,2, I* it would seem plausible that pregnancy results in similar changes to that produced by the presence of malignant disease. In 1947, Ode11 and McDonald’* reported on the beta-glucoronidase activity of serum during pregnancy. This enzyme, catalyzing the conjugation of those steroids containing a phenol group with glucuronic acid, declines slightly during the first trimester, and then rises during the remainder of pregnancy
lo a mean high of 14.0 gamma short 1~’ I~fore parturltitnl. This constitu1t.s a threefold increase over bhe vn.lues found in norma I. norlpregnant irl(lividnals. The rise apparently parallels the rising tit,ers of estrogens and progesterone. Fishman” reported similar findings in obstetrical patient,s, hnt, in addition, found that mamma.ry c~arcinorna, contained JO to 20 times as much enzyme as the surrounding uninvolved I)reast, tissue. In addition. 4 of 6 patients with gastrointestinal malignant~.v showrd a high tumor caontent. More recent,ly, Ode11 and 13urtX4 ha-\-e reported a high Lei.a-glucuroniclase content of cervical carcinoma as cotnl)a,t’ed with nonmalignant lesions of thcl cervix, although the same is apparently trot. true of certain malignant tumors of the corpus uteri. These facts have hren substantiatrtl I)y Fishman. Kostlort. and Hornburger.” Norris and Majnarich’:4 in studies of the sera of I)regnant patients, foun(l that they possessed a preponderance of substance c*apable of’ inhihitir!g. the proliferation of normal cells in tissue culture. The degree CJf this inhibition apparently increased with the period o-1’gestation. 111this respect, the serpit. from patients in late pregnancy resembles the sera from patients with rrraligtlant neoplastic disease, pernicious and :lJjliLStiC! anemias. and leucenlia. Although the accumulated data are meager, it would appear that. the alterations in steroid production and metabolism in pregnancy do bear some similarity to those so far demonstra.ted in malignant neoplasia. It is suggested that, because of the active growth of th(a l)enign tumor 011pregnancy, not seen in most other benign conditions, thera> will bc deruonstrat,ed cousistent similarities between these not so widely diversified conditions. The role of the steroids in normal and abnormal tissue growth is only beginning to emerge and it may well ho t,lrat quantitative differences alone tuay separa.te the benign from the malignant.. 7f this should Provo to be the case9 the pregrlalrt, woman offers
;I storehonsc2
of
itlfOl~~rli~tiOJl
mnc~c~l~rlinp
tbr
1w1t'
I)f
the
Stcl'(licis
in
tnrllor
growth.
Summary 1. The iodoacetate index was found to be positive irr 46 per cent of t,he 50 women studied in the last trimester oi pregnancy. 2. Evidence is presented suggesting the probability that the iodoacetate index measures another manifestation of the reaction to stress. 3. Similarities between the host response to the presence of malignancy and the benign tumor of pregnancy ittee pointed out. 4. It. is suggested for thought and investigation that the diff’erences bet,ween normal and abnormal tissue growth may be a, quantitative difference in the st,eroid hormones. The study of the physiology of pregnancy may PI*Oduce information applicable to the cancer problem. I wish to acknowledge my indebtedness McColgan, M.S., through whose generosity this
to study
Oscar B. was made
Hunter, possible.
M.D.,
and
Stanley
MM.
References 1. 2. 3. 4.
Cancer Eesearch 7: 321, 194;. Black, M. M.: Black, M. M., and Speer, F. D.: Am. J. Clin. Path. 20: 416, 1950. Bodansky, O., and McInnes, Q. F.: Clenccr 3: 1, 1950. Dieckman, W. J.: The Toxemias uf Pri:gnancy, St. IlouisT 1041,
The
C.
IT.
Monby
Company. 5. Fishman, 6. Fishman,
W. H.: W. H.,
Science Kodson,
105: 646, 1947. 8. C., and Honhwrger,
‘I’.:
(‘ancer
Research
10:
216,
1950.
Volume 61 Number 3
HUGGINS
TEST
IN
PR,EGNANCY
663
7. Freis, E. E., and Kenny, J. F.: J. Clin. Investigation 27: 283, 1948. 8. Gilligan, D. R., Rothwell, J. T., and Warren, Shields: New England J. Med. 242: 807, 1950. 9. Greenberg, D. M.: J. Biol. Chem. 82: 545, 1929. 10. Huggins, Charles, Miller, Gerald M., and Jensen, Elwood V.: Cancer Research 9: 177, 1949. 11. Huggins, Charles: Cancer Research 9: 321, 1949. 12. McDonald, D. F., and Odel!, L. D.: J. Clin. Endocrinol. 7: 535, 1947. 13. Norris, E. R., and Majnamh, J. J.: Proc. Sot. Exper. Biol. & Med. 70: 663, 1949. 14. Odell, L. D., and Burt, J. C.: Cancer Research 9: 362, 1949.
I). C.
N 1949, Huggins’” reported on the relatively consistent alterations in the thermal coagulability of serum proteins in malignancy. Tn his initial report, the iodoacetate index of 6 pregnant women was reported as being above the critical level of 9.0 in 5 of t,he 6 c:~es and very slightly decreased (8.72) in the remaining one. As a portion of thr control series, therefore, it was intimated that in pregnancy t,here were no consistent alterations in the coagulative propert,ies of the serum prot.eins. In view of the rnany other reports in which pregnancy produces changes resembling those seen in persons with malignant neoplastic disease, it was felt, that further investigation of the iodoaceta.te index irr late pregnancy might prove informative. I
Materials md Methods Patients in the last trimest,er of pregnancy were used as a source of serum and the total proteins determined by the method of Greenberg.” The iodoacetate index was t,hen determined by the procedure as out,lineil by Huggins”’ in his original article. None of the patients select,ed for the test exhibit,ed any clinical signs or symptoms of disease at the time the test was run.
Results Of the 50 pregnant patients test,ed. 23. or 46 per cent, had an index of less than t,he proposed rninimal index of 9.0, while 27. or 54 per cent, had an iodoacetate index above t,his figure. ‘fhc number of cases studied were insufficient to determine any correlat,ion with the duration of pregnancy, but it may be pointed out that the percentage of positive results was-greater between the thirty-sixth and thirty-seventh weeks than in the over-all study. Fig. 1 is a scattergraph of the results hut there is no significant distribntion apparent. These findings correspond closely t,o the per cent of “false positives” in nonmalignant pathologic states reported by Gilligan and associat.es.” In a series of 107 patients with rronmalignant pathologic states (not specified), an iodoacetate index of less than 9.0 was found in 42 per cent,. Tn addiCon. 28 per cent of a series of known cancer cases showed an index above this figure.
Comment
Accumulating data t,end to support the hypothesis that the alteration in the serum proteins responsible for the changes in thermal coamgulability is a manifestation of body response IO stress. I%odanskg and McTnttesJ demonstrated that the iodoacetate index falls to ahnormal levels in 7 out of 8 patients operated on for nonmalignant corrditions, regardless of the preoperative value. ‘These values returned to normal at a rate dependent upon the estensiveness of the procedure and the presence or absence of complicating fact.ors in the postoperative period. The same authors brought. to light that-the administration of cortisone and ACTH resulted in a consistent decrease in MiO
HUGGINS
Volume 6 I Number 3
TEST
IN PREGNANCY
661
The values returned to normal upon cessation of the iodoacetate index. therapy. That pregnancy represents a condition of st,ress demanding adequate responsiveness on the part of the entire endocrine system goes without However, pregnancy resembles malignant states in other bioquestion. chemical aspects beside serum protein alterations. In studies of serum proteins in patients with malignant disease,l it has been shown that there exists a lowered concentration of protein and albumin This finding with a low albumin/globulin ratio and an increase in fibrinogen. is consistent with those previously reported for normal pregnancy,4 although more thorough analysis has revealed that the lowered concentration reflects the physiological hemodilution, and that the total amount of circulating protein is actually increased.5 Whether the serum protein alterations in malignancy are relative or absolute remains to be established. . 13.0
-
12.0
-
11.0 10.0
.
. -.
-.
.
.
.
-
.
-
.
.
.
. . . .
. .
. 9.0
-
8.0
-
7.0
-
6.0
-
5.0
-
*
.
.
. .
.
. .
.
.
.
.
1 32
RESULTS
.
1 33
OF
tttKXlNS
, 34
I 35
I 36
WEEK
OF
TEST
IN
OF
37
38
39
I 40
I 41
GESTATION 50
WOMEN
IN
THE
LAST
TRIMESTER
PREGNANCY Fig.
1.
The Black test for malignancy, based on the reduction time of methylene blue, is also reported as being positive in pregI1ancy.l Black states that the reduction time was definitely prolonged in two patients in the last trimester of pregnancy. As both the methylene blue reduction time and the inhibition of thermal coagulation of serum proteins by iodoacetate is believed to be related to the sulfhydryl group in the serum proteins,2, I* it would seem plausible that pregnancy results in similar changes to that produced by the presence of malignant disease. In 1947, Ode11 and McDonald’* reported on the beta-glucoronidase activity of serum during pregnancy. This enzyme, catalyzing the conjugation of those steroids containing a phenol group with glucuronic acid, declines slightly during the first trimester, and then rises during the remainder of pregnancy
lo a mean high of 14.0 gamma short 1~’ I~fore parturltitnl. This constitu1t.s a threefold increase over bhe vn.lues found in norma I. norlpregnant irl(lividnals. The rise apparently parallels the rising tit,ers of estrogens and progesterone. Fishman” reported similar findings in obstetrical patient,s, hnt, in addition, found that mamma.ry c~arcinorna, contained JO to 20 times as much enzyme as the surrounding uninvolved I)reast, tissue. In addition. 4 of 6 patients with gastrointestinal malignant~.v showrd a high tumor caontent. More recent,ly, Ode11 and 13urtX4 ha-\-e reported a high Lei.a-glucuroniclase content of cervical carcinoma as cotnl)a,t’ed with nonmalignant lesions of thcl cervix, although the same is apparently trot. true of certain malignant tumors of the corpus uteri. These facts have hren substantiatrtl I)y Fishman. Kostlort. and Hornburger.” Norris and Majnarich’:4 in studies of the sera of I)regnant patients, foun(l that they possessed a preponderance of substance c*apable of’ inhihitir!g. the proliferation of normal cells in tissue culture. The degree CJf this inhibition apparently increased with the period o-1’gestation. 111this respect, the serpit. from patients in late pregnancy resembles the sera from patients with rrraligtlant neoplastic disease, pernicious and :lJjliLStiC! anemias. and leucenlia. Although the accumulated data are meager, it would appear that. the alterations in steroid production and metabolism in pregnancy do bear some similarity to those so far demonstra.ted in malignant neoplasia. It is suggested that, because of the active growth of th(a l)enign tumor 011pregnancy, not seen in most other benign conditions, thera> will bc deruonstrat,ed cousistent similarities between these not so widely diversified conditions. The role of the steroids in normal and abnormal tissue growth is only beginning to emerge and it may well ho t,lrat quantitative differences alone tuay separa.te the benign from the malignant.. 7f this should Provo to be the case9 the pregrlalrt, woman offers
;I storehonsc2
of
itlfOl~~rli~tiOJl
mnc~c~l~rlinp
tbr
1w1t'
I)f
the
Stcl'(licis
in
tnrllor
growth.
Summary 1. The iodoacetate index was found to be positive irr 46 per cent of t,he 50 women studied in the last trimester oi pregnancy. 2. Evidence is presented suggesting the probability that the iodoacetate index measures another manifestation of the reaction to stress. 3. Similarities between the host response to the presence of malignancy and the benign tumor of pregnancy ittee pointed out. 4. It. is suggested for thought and investigation that the diff’erences bet,ween normal and abnormal tissue growth may be a, quantitative difference in the st,eroid hormones. The study of the physiology of pregnancy may PI*Oduce information applicable to the cancer problem. I wish to acknowledge my indebtedness McColgan, M.S., through whose generosity this
to study
Oscar B. was made
Hunter, possible.
M.D.,
and
Stanley
MM.
References 1. 2. 3. 4.
Cancer Eesearch 7: 321, 194;. Black, M. M.: Black, M. M., and Speer, F. D.: Am. J. Clin. Path. 20: 416, 1950. Bodansky, O., and McInnes, Q. F.: Clenccr 3: 1, 1950. Dieckman, W. J.: The Toxemias uf Pri:gnancy, St. IlouisT 1041,
The
C.
IT.
Monby
Company. 5. Fishman, 6. Fishman,
W. H.: W. H.,
Science Kodson,
105: 646, 1947. 8. C., and Honhwrger,
‘I’.:
(‘ancer
Research
10:
216,
1950.
Volume 61 Number 3
HUGGINS
TEST
IN
PR,EGNANCY
663
7. Freis, E. E., and Kenny, J. F.: J. Clin. Investigation 27: 283, 1948. 8. Gilligan, D. R., Rothwell, J. T., and Warren, Shields: New England J. Med. 242: 807, 1950. 9. Greenberg, D. M.: J. Biol. Chem. 82: 545, 1929. 10. Huggins, Charles, Miller, Gerald M., and Jensen, Elwood V.: Cancer Research 9: 177, 1949. 11. Huggins, Charles: Cancer Research 9: 321, 1949. 12. McDonald, D. F., and Odel!, L. D.: J. Clin. Endocrinol. 7: 535, 1947. 13. Norris, E. R., and Majnamh, J. J.: Proc. Sot. Exper. Biol. & Med. 70: 663, 1949. 14. Odell, L. D., and Burt, J. C.: Cancer Research 9: 362, 1949.