Sir.—The observations by Levine (Am J Dis Child 132:238-240, 1978) and comments by Miller (Am J Dis Child 132:235, 1978) on the curious relationship of adrenal cortical carcinoma in childhood with second primary tumors or dissimilar neoplasms in families emphasizes important considerations for the potential of early detection. Inherent in their concerns were the genetic roots of the patients and families. Environmental influences however, may be virtually impossible to separate from the purely genetic.
The idea that the cancer proneness might be a symbiosis of environment and heredity is not new. This was a consideration when, within six months of diagnosis of adrenal carcinoma in a 7-year-old girl, a medulloblastoma developed in her 4-year-old brother. Despite aggressive surgical and chemotherapeutic treatment, these highly malignant neoplasms resulted in the death of both siblings within a year. The history was unremarkable except that a grandfather and great grandmother had had cancer