• No results found

Value of Random Urinary Homovanillic Acid and Vanillylmandelic Acid Levels in the Diagnosis and Management of Patients with Neuroblastoma: Comparison with 24-Hour Urine Collections

N/A
N/A
Protected

Academic year: 2020

Share "Value of Random Urinary Homovanillic Acid and Vanillylmandelic Acid Levels in the Diagnosis and Management of Patients with Neuroblastoma: Comparison with 24-Hour Urine Collections"

Copied!
7
0
0

Loading.... (view fulltext now)

Full text

(1)

Value

of Random

Urinary

Homovanillic

Acid

and Vanillylmandelic

Acid

Levels

in the

Diagnosis

and Management

of Patients

with

Neuroblastoma:

Comparison

with 24-Hour

Urine

Collections

Mendel

Tuchman,

MD, Christopher

L. Morris,

MD,

Margaret

L. Ramnaraine,

BS, Larry

D. Bowers,

PhD,

and

William

Krivit,

MD, PhD

From the Departments of Pediatrics, and Laboratory Medicine and Pathology, University

of Minnesota, Minneapolis

ABSTRACT. Urinary homovanillic acid (HVA) and van-illylmandelic acid (VMA) levels were determined in ran-dom samples and in 24-hour collections from 13 patients with neuroblastoma and 22 patients without neuroblas-toma. Random sample levels were compared with levels in 24-hour collections and showed a positive correlation of 95% for HVA (N = 59) and 93% for VMA (N = 52).

No false positives or false negatives occurred using

ran-dom samples for diagnosis. Nonneuroblastoma (normal) HVA (N = 126) and VMA (N = 1 19) levels are reported for different age groups. Sequential random HVA and VMA determinations in patients with neuroblastoma during and after therapy are shown. Random urinary

HVA and VMA levels are shown to be adequate for

utilization in the diagnosis of neuroblastoma and sequen-tial determinations of random HVA and VMA are shown to be helpful in the follow-up of those patients. Pediatrics

1985;75:324-328; homovanillic acid, vanillylmandelic acid, neuroblastoma, neural crest tumors, catecholamines.

Catecholamines and their acidic metabolites are

excreted in larger than normal amounts in patients

with tumors originating from the neural crest.’6

The diagnosis is easily established by determination of urinary homovanillic

(4-hydroxy-3-methoxy-phenylacetic) acid and vanillylmandelic

(4-hy-droxy-3-methoxymandelic) acid. During the past 20

years since this test was first used, the

measure-Received for publication Jan 30, 1984; accepted March 15, 1984.

Reprint requests to (MT.) Department of Pediatrics, University

of Minnesota Hospitals, 420 Delaware St, SE, Minneapolis, MN

55455

PEDIATRICS (ISSN 0031 4005). Copyright © 1985 by the

American Academy of Pediatrics.

ments of HVA and VMA have become a routine

test for diagnosis and follow-up of children with

neuroblastoma.7’#{176}

The original methodology assumes that a 24-hour

urine collection is needed, and several authors still

recommend a 24-hour urine collection as the only

way to obtain reliable results.1’’3 The question

whether random urinary HVA and VMA levels are

adequate for diagnosis and follow-up of patients

with neuroblastoma has not been answered.

Pro-longed urine collections especially in young infants

are hard to obtain, time consuming, inconvenient

for patients and staff, and lead to higher cost.’4

We have studied the value of random urinary

HVA

and

VMA

levels

in the

diagnosis

of patients

with neuroblastoma by comparing random urine

samples and 24-hour urine collections. We report

normal values of random urinary HVA and VMA

levels in different age groups, and, finally, we

dem-onstrate the use of sequential random HVA and

VMA

determinations

in follow-up

of patients

with

neuroblastoma.

MATERIALS

AND

METHODS

Comparison

Between

Random

Samples

and

24-Hour Collections

The study included 35 patients ranging in age

from newborn to 18 years; there were 13 patients

with neuroblastoma (as diagnosed by histology) in

various stages of disease, and 22 patients who were

sick at the time of sampling but in whom the

(2)

Some patients with neuroblastoma had more than

one urine collection performed. No dietary or drug

restrictions were imposed except in the case of

drugs known to increase HVA or VMA excretion

(eg, adrenalin, L-dopa, dopamine, ACTH, insulin,

caffeine). Twenty-four hour urine collections were

performed on ice, and a paired random sample,

consisting of a single void, was collected arbitrarily

within 24 hours before or after the 24-hour urine

collection. Urine that was not run immediately was

kept at less than 5#{176}C.

HVA

and

VMA

determinations

were

performed

in our laboratory by capillary gas chromatography

as described previously.9 Briefly, the method

in-cludes solvent extraction of urinary acids with

eth-ylacetate and ether, drying the organic phases, and

derivatization for capillary gas chromatographic

analysis. Quantities were then calculated relative

to an internal standard, and concentrations were

expressed relative to urinary creatinine, which

avoids factitious high or low levels due to

differ-ences in urinary levels of concentration.

Determi-nations on 24-hour collections were done in another

laboratory using a packed column gas

chromato-graphic method as described previously.’0 That

method is the standard procedure for urinary HVA

and VMA determination in several laboratories.

Seven samples could not be included in the study

because the other laboratory could not obtain exact

determinations. This problem is relatively common

to packed column chromatography and is due to

interfering urinary substances.’5’7

HVA

and

VMA

determinations

(N

= 59 and 52,

respectively) from random samples and 24-hour

collections were statistically analyzed by Student’s t test using a null hypothesis and by linear regres-sion (forced through the origin) for correlation.

Normal

Values

Normal values of HVA and VMA in random

urine samples were obtained from 93 pediatric

pa-tients in whom neural crest tumors have been

ex-cluded and eight healthy, adult laboratory

person-nel. Dietary and drug restrictions were the same as

described above. The ages of patients ranged from

newborn to 32 years. Random urine samples were

collected and run as stated above. HVA and VMA

determinations were arranged into six pediatric age

groups and an adult age group. Mean and standard

deviations were determined for HVA and VMA for

each age group, a total of 126 and 119

determina-tions, respectively, with between eight and 30

de-terminations per group.

Sequential

Determinations

Two patients with stage IV neuroblastoma were

followed after diagnosis for 150 and 200 days,

re-spectively. Sequential random HVA and VMA

levels were done (22 and 19 determinations,

respec-tively) before, during, and after several courses of

chemotherapy. Some sequential determinations

were done within the same day. The results of

sequential determinations were plotted graphically.

RESULTS

Using capillary gas chromatography, we found no

interference in either separating or quantitating

HVA

and

VMA.

The

result

of

t test showed no

significant differences between paired random

sam-ples and 24-hour urine samples. Mean values are

compared in Table 1 and show small variations.

Because the sample population is not normally

distributed, linear regression was done plotting

ran-dom v 24-hour values for HVA (Fig 1) and VMA

(Fig 2) and showed correlation coefficients (R) of

.951 and .929, respectively. (P < .001). The observed

variabilities (R2) show that 10% of HVA and 14%

of VMA variabilities cannot be accounted for by

the 24-hour urine collections (R2 = .904 for HVA

and .863 for VMA, P < .001). In the time since we

started using random samples, ten cases of

neuro-blastoma have been newly diagnosed; there have

been no false-positive or false-negative results.

Normal values of HVA and VMA are shown in

Table 2, with mean values and standard deviations

for seven age groups. These values closely match

those established for 24-hour urine collections by

the second laboratory. The graph of the mean

val-ues by age group (Fig 3) shows the expected sharp

decline with age and leveling off to adult values. In

patients who do not have neuroblastoma, the ratio

between HVA and VMA levels remains relatively

TABLE 1. Mean Values of Homovanillic Acid (HVA) an

in Random Samples Versus 24-Hour Collections

d Vanillylmandelic Acid (VMA)

Test HVA (zg/mg of

Urinary Creatinine)

VMA (pg/mg of Urinary Creatinine)

Mean ± SE No. of Determinations

Mean ± SE No. of

Determinations

Random samples 95.61 ± 15.45 59 24-h urine collections 90.93 ± 16.23 59

(3)

constant. The mean HVA/VMA molar ratio was 1.642 ± 0.242.

Sequential HVA and VMA levels in random urine

samples from two patients with stage IV

neuroblas-toma following the diagnosis are shown in Fig 4.

The levels are slowly declining following multiple

courses of chemotherapy. The sequential

determi-nations done within the same day are all

signifi-cantly above normal values.

DISCUSSION

Increased urinary excretion of catecholamines

and their metabolites in patients with

neuroblas-toma was first reported by Voorhess and

Gard-ner.’8’19 The diagnostic value of VMA in

neuroblas-toma has been emphasized because this acid is the

metabolite of epinephrine and norepinephrine.2#{176}

The

diagnostic

value

of HVA,

the dopamine

me-0 C 0 - -00 #{176}D) 40( 0

tabolite, became apparent when several authors’4’2’

reported that HVA is more consistently elevated in

neuroblastoma

and

that

20%

to 30%

of patients

with neuroblastoma excrete normal amounts of

VMA.2’24

Several authors”3 still feel that HVA and VMA

levels in 24-hour urine collections only, are reliable

enough

in establishing

the

diagnosis

of

neuroblas-toma.

This

concept

persisted

as more

data

became

available regarding the effects of diet on quantities

of catecholamine metabolite excretion as well as

information on the circadian rhythm and seasonal

variations of catecholamine excretion.253#{176} The effects of different diets containing increased

ci%o:#{176} I

0 100 200 300

pg/mg UCr Random Sample

Fig 2.

Vanillylmandelic acid levels in random urinary

samples u 24-hour urine collections. A total of 52

deter-minations were compared. Correlation coefficient was .929 (P < .001). Abbreviation used is: UCr, urinary cre-atinine.

(HVA) and Vanillylmandelic Acid 1

0

100

200

300 400

,ug/mg UCr Random Sample

Fig 1. Homovanillic acid levels in random urinary

sam-ples v 24-hour urine collections. A total of 59

determi-nations were compared. Correlation coefficient was 0.951

(P < .001). Abbreviation used is: UCr, urinary creatinine.

TABLE 2. Nonneuroblastoma Levels of Random Urinary Homovanillic Acid

(VMA) in Different Age Groups*

Age HVA (zg/mg of

Urinary Creatinine)

VMA (zg/mg of Urinary Creatinine)

Range Mean ± SD No. of Range Mean ± SD No. of

Determinations Determinations

(N = 126) (N = 119)

0-3 mo 11.3-35.0

(0-46)

22.33 ± 7.46 12 5.9-37.0

(0-56.8)

19.49 ± 10.32 12

3-12 mo 8.4-44.9

(0-46)

27.79 ± 9.57 30 8.4-43.8 (0-22.2)

22.81 ± 10.59 28

1-2 yr 12.2-31.8 (4.7-41.5)

19.65 ± 6.00 16 7.9-23.0

(0-13.6)

14.88 ± 3.85 15

2-5 yr 5-10 yr 3.4-32.0 (3.1-28.7) 6.8-23.7 (0.6-19.4)

15.33 ± 7.69 21

12.80 ± 5.10 25

2.9-23.0 (2.2-11.6) 5.8-18.7 (2-8.3)

11.25 ± 7.61

9.34 ± 3.68

22

21

10-15 yr 3.2-13.6 (0-18.1)

8.12 ± 3.88 13 1.6-10.6

(0-7.6)

5.17 ± 2.51 13

>15 yr 3.2-9.6

(0-5.7)

5.66 ± 1.86 9 2.8-8.3

(0-6.2)

4.52 ± 1.77 8

(4)

300

ii

0

a,

E

a,

Fig 3. Mean normal homovanillic acid (HVA) and

va-nillylmandelic acid (VMA) levels in random urinary sam-ples from various age groups. Abbreviation used is: UCr,

urinary creatinine.

0

C)

E

0)

0

:D

0)

E

C) 3mo l2mo y 5y lOy 15y

Age

0-0 HVA

o----0 VMA

A Chemotherapy

ii

50 100 150 200

400

amounts of vanillin, vanilla, and phenolic acids on

HVA and VMA excretion were studied by Weetman

et al.’3 They concluded that restricted diet is not

necessary prior to screening children for neuroblas-toma.

Despite the fact that a diurnal variation is pres-ent in the excretion of catecholamines, being higher

in the evening than in the morning,27 Oishi3’ found

that in pheochromocytoma, VMA excretion is

in-variably higher than normal values at any time

during the day. He concluded that random

one-hour urine samples were useful for diagnosis of

pheochromocytoma. Hinterberger and

Barthol-omew’4

have

shown

that

random

specimens

may be

useful in screening for neural crest tumors.

Our

data

show

that

the correlation

of HVA

and

VMA levels between random samples and 24-hour

urine collections is high enough to be reliable for

the diagnosis of neuroblastoma. The fact that the

tests were done in two different laboratories

in-creases the reliability of this information. The

ac-curacy of the capillary gas chromatographic method

helps to avoid false positives and false negatives.

The

nonneuroblastoma

“normals”

are suitable

as

control subjects. McKendrick and Edwards” have

found that residence of children in hospitals rather

than at home, sex and presence of tumor other than

neural crest in origin, or postoperative stress have

no effect on VMA excretion. Our study agrees with

their findings. The nonneuroblastoma HVA and

VMA

levels

that

were

obtained

from

sick patients

did not show elevation of excretion in diseases other

than neuroblastoma. The relative constant molar

Days Post Diagnosis

Fig 4. Sequential homovanillic acid (HVA) and

vanil-lylmandelic acid (VMA) determinations in random

un-nary samples of two patients with neuroblastoma: patient

1, a 2#{189}-year-old-girl with stage IV neuroblastoma, and patient 2, a 4-year-old boy with stage IV neuroblastoma. Abbreviation used is: UCr, urinary creatinine.

ratio between

HVA

and

VMA

levels

in our control

subjects probably reflects the activity of the enzyme

dopamine j3-hydroxylase which catalyzes the

hy-droxylation of dopamine to norepinephnine which

is then metabolized to VMA.32 Preliminary results

of a study that we are currently conducting show

that sequential determinations of HVA and VMA

in random urinary specimens are useful in

follow-up of patients with neuroblastoma after surgical

resection or during and after chemotherapy. In view

of the data presented here, we feel that random

urinary specimens are adequate for diagnosis and

follow-up of patients with neuroblastoma.

ACKNOWLEDGMENTS

This work was supported by the following grants:

Hematology training grant NIH-NHLBI-5T32-AM07145,

Oncology training grant NIH-NCI 5T32-CA09445,

(5)

and Pediatric Oncology/Marrow Transplantation

Pro-gram Project NIH-NIC 2P01-CA21737.

We thank Dr Les Robison, Sheryl Frankel, and the

personnel of the Steroid Lipid Laboratory of the Univer-sity of Minnesota Hospitals for their help in the

prepa-ration of this work.

REFERENCES

1. Bell M, Steward JK: Neuroblastoma and catecholamine excretion. Lancet 1961;1:1288

2. Voorhess ML, Gardner LI: Studies of catecholamine

excre-tion by children with neural tumors. J Clin Endocrinol

Metab 1962;22:126-133

3. Von Studnitz W: Chemistry and pharmacology of

catechol-amine secreting tumors. Pharrnacol Rev 1966;18:645

4. Bohuon C: Catecholamine metabolism in neuroblastoma. J Pediatr Surg 1968;3:114-118

5. Schweisguth 0: Excretion of catecholamine metabolites in

urine of neuroblastoma patients. J Pediatr Surg

1968;3:118-120

6. Hinterberger H, Bartholomew RI: Catecholamines and their

acidic metabolites in urine and in tumor tissue in neuro-blastoma ganglioneuroma and pheochromocytoma. Clin

Chim Acta 1969;23:169-175

7. Yoshiue M, Yoshioka M, Samirra Z: Determination of

va-nillylmandelic acid and homovanillic acid in urine by gas

chromatography. Chem Pharm Bull 1975;23:3040-3041

8. Soldin SJ, Hill JG: Simultaneous liquid-chromatographic

analysis for 4-hydroxy-3-methoxymandelic acid and 4-hy-droxy-3-methoxyphenylacetic acid in urine. Clin Chem

1980;26:291-294

9. Tuchman M, Crippin PJ, Krivit W: Capillary gas chromato-graphic determination of urinary homovanillic acid and vanillylmandelic acid. Clin Chem 1983;29:828-831

10. Foster-Leiendecker C, Freier .EF: Improved simultaneous

gas-chromatographic analysis for homovanillic acid and

vanillylmandelic acid in urine. Clin Chem 1981;27:2029-2032 1 1. McKendrick T, Edwards WH: The excretion of

4-hydroxy-3-methoxymandelic acid by children. Arch Dis Child

1965;40:418-425

12. Johnsonbaugh RE, Cahill R: Screening procedures for neu-roblastoma: False-negative results. Pediatrics 1975;56:267-270

13. Weetman RM, Rider PS, Oei TO, et al: Effect of diet on

urinary excretion of VMA, HVA, metanephrine and total

free catecholamine in normal preschool children. J Pediatr 1976;88:46-50

14. Hinterberger H, Bartholomew RJ: The chemical diagnosis of ganglioneuroma using random specimens of urine. Aust

Paediatr J 1970;6:222-227

15. Coward RF, Smith P: The gas chromatography of aromatic

acids as their trimethylsilyl derivatives including

applica-tions to urine analysis. J Chromatogr 1969;45:230-243

16. Bjorkman L, McLean C, Steen G: Organic acids in urine

from human newborns. Clin Chem 1976;22:49-52

17. Melchert HV, Hoffmeister H: More on gas liquid chromato-graphic analysis for homovanillic and vanillylmandelic acids

in urine from cases of neuroblastoma. Clin Chem 1978;

24:842-843

18. Voorhess ML, Gardner LI: Catecholamine metabolism in neuroblastoma. Lancet 1960;2:651-652

19. Voorhess ML, Gardner LI: Urinary excretion of

norepineph-rine epinephrine and 3 methoxy-4-hydroxymandelic acid by children with neuroblastoma. J Clin Endocrinol Metab

1961;21:321-335

20. Moyano MB, Bergada C, Becu L: Significance of catechol-amine excretion in the follow-up of sympathoblastomas.

Cancer 1971;27:228-232

21. Brewster MA, Berry DH, Moriarty B, et al: Urinary 3-methoxy-4-hydroxyphenylacetic (homovanillic) and

3-methoxy-4-hydroxymandelic (vanillylmandelic) acids:

Gas-liquid chromatographic methods and experience with 13 cases of neuroblastoma. Clin Chem 1977;23:2247-2249 22. Voorhess ML: Neuroblastoma with normal urinary

cate-cholamine excretion. J Pediatr 1971;78:680-683

23. Helson L, Bethune V, Schwartz MK: Clinical evaluation of the VMA test strip. Pediatrics 1973;51:153

24. Liebner HJ, Rosenthal IM: Serial catecholamines in the radiation management of children with neuroblastoma. Can-cer 1973;32:623-633

25. Waalkes TP, Sjoerdsma A, Creveling CR, et al: Serotonin, norepinephrine and related compounds in bananas. Science

1958;127:648-650

26. Zicha L, Au BS: Uber den einfluss von koffien auf den

tagesrhytmus den vanillinmandelsaure und

homovanillin-saure.Med Welt 1969;20:1674-1678

27. Winkel P, Slob 5: Catecholamine excretion of normal male

adolescents during various periods of the day cycle. Clin

Chim Acta 1973;45:113-119

28. Wisser H, Knoll E: Ergebmisse einer kurzzeitstudie uber die

circadiane rhythmik bei normaler und erhohter

katecholam-inausscheidung in urin. Clin Chim Acta 1975;59:1-7

29. Markianos E, Beckmann H: Diurnal changes in dopamine

3hydroxylase. Homovanillic acid and

3-methoxy-4-hydrox-yphenylglycol in serum of man. J Neural Transm 1976;

39:79-93

30. Yamamoto T, Doi K, Takeuchi Y, et al: Seasonal variation of urinary excretion of total metanephrines. Clin Chim Acta

1976;68:241-246

31. Oishi 5: Random one hour urine catecholamine and 4-hydroxy-3-methoxymandelic acid assays for diagnosis of

pheochromocytoma. Clin Chim Acta 1980;103:335-342

32. Laug WE, Siegel SE, Shaw KMF, et al: Initial urinary

(6)

1985;75;324

Pediatrics

William Krivit

Mendel Tuchman, Christopher L. Morris, Margaret L. Ramnaraine, Larry D. Bowers and

24-Hour Urine Collections

Diagnosis and Management of Patients with Neuroblastoma: Comparison with

Value of Random Urinary Homovanillic Acid and Vanillylmandelic Acid Levels in the

Services

Updated Information &

http://pediatrics.aappublications.org/content/75/2/324

including high resolution figures, can be found at:

Permissions & Licensing

http://www.aappublications.org/site/misc/Permissions.xhtml

entirety can be found online at:

Information about reproducing this article in parts (figures, tables) or in its

Reprints

http://www.aappublications.org/site/misc/reprints.xhtml

(7)

1985;75;324

Pediatrics

William Krivit

Mendel Tuchman, Christopher L. Morris, Margaret L. Ramnaraine, Larry D. Bowers and

24-Hour Urine Collections

Diagnosis and Management of Patients with Neuroblastoma: Comparison with

Value of Random Urinary Homovanillic Acid and Vanillylmandelic Acid Levels in the

http://pediatrics.aappublications.org/content/75/2/324

the World Wide Web at:

The online version of this article, along with updated information and services, is located on

American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

Figure

Fig 2.Vanillylmandelicacidlevelsinrandomurinarysamplesu 24-hoururinecollections.A totalof 52 deter-minationswerecompared.Correlationcoefficientwas.929(P<.001).Abbreviationusedis: UCr,urinarycre-atinine.
Fig 4.Sequentialpatienthomovanillicacid(HVA)andvanil-lylmandelicacid(VMA)determinationsinrandomun-narysamplesof twopatientswithneuroblastoma:patient1,a2#{189}-year-old-girlwithstageIVneuroblastoma,and2, a 4-year-oldboywithstageIVneuroblastoma.Abbreviationusedis: UCr,urinarycreatinine.

References

Related documents

Electric output summary and parameters of solar windows used in prototype bus-stop

The analysis of variance revealed significant differences in terms of knowledge building between the two main sub- groups: the subgroups that reported considerable

Subjects applied the product once daily in the morning to the face for 21 days, and after approximately 3–5 minutes they assessed tolerability and short-term cosmetic acceptability

infections with Borrelia burgdorferi sensu lato in Ixodes ricinus ticks (Acari:. Ixodidae) from Republic

Durch vorexistente Daten zu Polymorphismen im MBL-2 Gen, konnte nach Messung der Plasmakonzentration gezeigt werden, dass Patienten mit chronischer Parodontitis und

72 Aside from correlating catalytic efficiencies with the MCA values of the corresponding catalysts and thus establishing a Brønsted-type correlation between reaction rates

For neutron capture reactions involving nuclei near the valley of stability, the formation of the compound nucleus is reasonably well described, while a reliable description of

As for Th2 cytokine secretion (Figure 8C and D), the results revealed that the levels of IL-4 and IL-6 in mice immunized with LBPL-OVA vaccine formulation were significantly