Sera from 391 southern African Blacks with hepatocellular carcinoma, matched controls, patients with other malignant tumours, and with various forms of hepatobiliary disease were fractionated by polyacrylamide gradient gel electrophoresis to determine the prevalence of tumour-associated gamma-glutamyl transferase isoenzymes in Black patients with hepatocellular carcinoma. One or more tumour-associated isoenzymes (I', I'' or II') were present in 58.6% of the patients with hepatocellular carcinoma: I' in 54.5%, I'' in 27.1%, and II' in 34%. These isoenzymes were detected in one patient with prostatic cancer, occasionally in patients with acute viral hepatitis, but in no normal individuals. The presence of tumour-associated isoenzymes was not related to patient age, sex or hepatitis-B virus status or to the tumour burden. Isoenzymes were present in 42 percent of hepatocellular carcinoma patients with a normal serum alpha-foetoprotein concentration and in 50% of those with a non-diagnostic value. gamma-glutamyl transferase isoenzymes may be supplementary to alpha-foetoprotein in the diagnosis of hepatocellular carcinoma. Images Figure 1

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EDITORIAL SYNOPSIS This is a detailed study on the protein, electrolyte, and enzymatic output of a mucus-secreting villous adenoma of the rectum in a patient who was admitted desperately ill as a result of the loss of electrolytes.There have been sufficient case reports in the literature (McKittrick and Wheelock, 1954;Fitzgerald, 1955;Starr, Mueller and McKittrick, 1956;Cooling and Marrack, 1957;Gutierrez Blanco, 1957;Goldgraber and Kirsner, 1958;Jordan and Erickson, 1958;Frye, 1959;Hoffman, 1959;Mayfield and Milnor, 1959;Roy and Ellis, 1959;Walters, Monks, and Chitty, 1959;Rudman, Otto, and Novota, 1960;Findlay and O'Connor, 1961;Shnitka, Friedman, Kidd, and MacKenzie, 1961;Davis, Seavey, and Sessions, 1962;Magness, Spier, and Murray, 1962;Rabinowitz, Farber, and Friedman, 1962;Wells, Morgan and Cooper, 1962) In September 1945 he had undergone resection of the caecum, ascending colon, and terminal ileum for a mucoid adenocarcinoma of the caecum. Three weeks postoperatively he had begun to pass small quantities of mucus per rectum but, assuming this to be a normal sequel to his operation, failed to report it to his doctor. Over the next 17 years he remained perfectly well, except that he continued to pass ever-increasing quantities of rectal mucus.His admission to hospital was finally precipitated by an acute influenzal illness in which he was anorexic to the extent that he did not take any food or fluid for three days at the same time continuing to pass large quantities of rectal mucus.At the time of admission to hospital no history of abnormal fluid loss was obtained or volunteered and the patient was treated with 2 litres of intravenous normal saline which resulted in a dramatic clinical improvement.The haematocrit was 58%, haemoglobin 13-5%, white cell count 13,000/c.mm. (67 % neutrophils, 18 % lymphocytes, 7 % monocytes, and 8 % band forms); serum electrolytes, (sodium 120 mEq./l., potassium 2-8 mEq./l., calcium 4-7 mEq./l ., phosphorus 1-4 mEq./I., bicarbonate 16 mEq./1); blood sugar 100 mg. %, blood urea 180 mg. % serum bilirubin 0 3 mg. %; serum proteins 7-4 g. % (albumin 3-8 g. %, globulin 3-6 g. %); alkaline phosphatase 8.5 King-Armstrong units.The patient was therefore dehydrated, hyponatraemic, hypohalaemic, hypochloraemic, hypocalcaemic, acidotic, and uraemic. At this stage the history was obtained of the loss of mucus per rectum. Sigmoidoscopy revealed, and biopsy confirmed, the presence of a large mucussecreting villous adenoma of the rectum. Accordingly a number of studies on the mucus, urine, and blood of this patient were performed, and the results of two of these studies are shown in Table I

The prevalence of variant alkaline phosphatase in the serum of 335 southern African blacks with hepatocellular carcinoma was determined using polyacrylamide gel electrophoresis. The isoenzyme was detected in 2% (seven of 335) of the patients: it could not be found in the serum of 300 matched, healthy individuals or in 56 patients with various benign hepatic diseases. Variant alkaline phosphatase is thus of little use as a diagnostic marker of hepatocellular carcinoma in southern African blacks. The reported prevalence of this isoenzyme in hepatocellular carcinoma ranges between 3% and 31%. Higher frequencies usually are recorded in populations with a low incidence of the tumor, and the lowest frequencies have been found in Chinese patients. Our finding of variant alkaline phosphatase in only 2% of another high incidence population fits this trend. Patients with tumors that secreted the variant isoenzyme had a significantly higher serum total alkaline phosphatase activity than those with tumors lacking this property.