The

new england journal

of

medicine

review article

mechanisms of disease

The ChromograninSecretogranin Family

Laurent Taupenot, Ph.D., Kimberly L. Harper, M.D., and Daniel T. OConnor, M.D.
From the Department of Medicine (L.T.,
K.L.H., D.T.O.) and the Center for Molecular
Genetics (D.T.O.), University of California
at San Diego, La Jolla; and the Veterans
Affairs San Diego Healthcare System, San
Diego, Calif. (L.T., K.L.H., D.T.O.). Address
reprint requests to Dr. OConnor at the
Department of Medicine (9111H), University of California at San Diego, 3350 La Jolla
Village Dr., San Diego, CA 92161, or at
doconnor@ucsd.edu.
N Engl J Med 2003;348:1134-49.
Copyright 2003 Massachusetts Medical Society.

eurons and neuroendocrine cells contain membranedelimited pools of peptide hormones, biogenic amines, and neurotransmitters with a characteristic electron-dense appearance on transmission electron
microscopy (Fig. 1). These vesicles, which are present throughout the neuroendocrine
system1,2 and in a variety of neurons, store and release chromogranins and secretogranins
(also known as granins), a unique group of acidic, soluble secretory proteins.3,4 The
three classic granins are chromogranin A, which was first isolated from chromaffin
cells of the adrenal medulla5,6; chromogranin B, initially characterized in a rat pheochromocytoma cell line7; and secretogranin II (sometimes called chromogranin C), which
was originally described in the anterior pituitary.8,9 Four other acidic secretory proteins were later proposed for membership in the granin family10: secretogranin III (or
1B1075),11 secretogranin IV (or HISL-19),12 secretogranin V (or 7B2),13 and secretogranin VI (or NESP55).14
In this article, we review aspects of the structures, biochemical properties, and clinical importance of granins, with particular emphasis on chromogranin A, the granin
that was discovered first and that has been studied most extensively. We discuss how
granins contribute to the formation of secretory granules and how, as prohormones,
they give rise to bioactive peptides through proteolytic processing. Because of their
ubiquitous distribution in neuroendocrine and nervous-system tissues and their cosecretion with resident peptide hormones and biogenic amines, granins are valuable indicators of sympathoadrenal activity and clinically useful markers of secretion from
normal and neoplastic neuroendocrine cells.1,15-17 Indeed, numerous studies have documented the clinical value of detecting granins in tissues and measuring circulating
levels of granins, particularly chromogranin A. In addition to providing information
about the neuroendocrine character of various neoplasms, measurement of chromogranin A has yielded insights into the pathogenesis of essential hypertension.

molecular and genetic aspects of granins

structural and physicochemical properties

Granins consist of single-polypeptide chains of approximately 180 to 700 amino acid

residues, bearing an amino-terminal signal peptide that directs the movement of the
preproteins from ribosomes to the endoplasmic reticular lumen and, hence, the Golgi
complex, where further post-translational modifications occur. Granins tend to bind
calcium with low affinity but high capacity and then aggregate in vitro at low pH in the
presence of calcium.18-24 These aggregation characteristics suggest that granins
have functions within the core of secretory granules.
genomic organization and transcriptional regulation

The chromosomal positions of all granins except secretogranin IV have been determined
in humans, cows, mice, and rats (Table 1); in each case, the loci lie in regions of locally

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mechanisms of disease

sorting mechanisms

Proteins are secreted from cells by exocytosis in either a constitutive or a regulated manner.39,40 The
rate of secretion through the constitutive pathway,
which operates in every type of cell, is a simple func-

n engl j med 348;12

pH
5.8

5.4

5.0

4.6

4.2

CgB
DBH
CgA

97

66

Molecular Mass (kD)

conserved gene order in homologous chromosomes (Fig. 2).25

The distribution of granins throughout the neuroendocrine system has been studied with Northern
blot analysis of messenger RNA. Granin messages
have been found in cells of various neuroendocrine
tissues that have a regulated secretory pathway.9,26,27
Moreover, granin synthesis responds differently
in different cell types to agents that elevate cyclic
AMP (cAMP), steroid hormones, neurotrophins, and
phorbol ester.
Experiments with transfected granin-gene promoters have clarified the mechanism of constitutive
and secretagogue-inducible expression of granins
in specific cells.28 The proximal promoter regions
of chromogranin A, chromogranin B, and secretogranin II contain a functional cAMP-response element (CRE) upstream of a TATA box (a region of
seven nucleotides, mainly thymidine and adenine,
located upstream of the starting point of transcription); otherwise, their promoter sequences differ.29,30 The specificity of expression of chromogranin A, chromogranin B, and secretogranin III in
mouse neuroendocrine cells has been mapped to
the CRE site.30-32 Upstream promoter elements may
also be important in cell-specific expression of human chromogranin A and secretogranin II.33,34
These CRE sites may explain how the expression
of chromogranin A, chromogranin B, and secretogranin II is up-regulated in neuroendocrine cells by
nicotiniccholinergic agonists and the preganglionic neuropeptide pituitary adenylyl cyclaseactivating polypeptide.31,32,35,36 Moreover, neuronal
differentiation of a pheochromocytoma cell line
(PC12) induced by neurotrophin nerve growth factor up-regulates expression of the genes for chromogranin A and chromogranin B through an effect
on the CRE site.31,37
An upstream serum response element also has
an important role in the expression of the mouse
secretogranin II gene,32 and a proximal G- or
C-rich region contributes to the expression of the
mouse chromogranin B gene.31 Glucocorticoid
sensitivity has been mapped to a novel glucocorticoid-response-element variant in the rat chromogranin A.38

45

24

18

100 nm

5 mm

Figure 1. Localization of Chromogranins with Dense-Core Secretory Granules

of Sympathoadrenal Chromaffin Cells.
Panel A shows soluble-core proteins in bovine chromaffin vesicles after twodimensional sodium dodecyl sulfatepolyacrylamide gel electrophoresis, followed by Coomassie blue staining. DBH denotes dopamine b-hydroxylase, CgA
chromogranin A, and CgB chromogranin B. Panel B shows an electron micrograph of bovine chromaffin cells. The electron-dense spherical and oblong structures are dense-core secretory chromaffin granules. The black particles, which
have a diameter of 8 to 12 nm, represent immunogold labeling of chromogranin
A with rabbit antibovine chromogranin A antibody. Panel C shows the subcellular
distribution of a human chromogranin Aenhanced green fluorescent protein
(EGFP) chimeric photoprotein, in living sympathoadrenal PC12 cells. Chromogranin AEGFP expression was examined by three-dimensional deconvolution
microscopy. Nuclei were visualized with blue dye (Hoechst 33342). Optical sections along the z axis were acquired with increments of 200 nm and the use of
a 100 oil-immersion objective to generate three-dimensional views of the
photoprotein distribution. Chromogranin AEGFP displays a bright, punctate
or vesicular fluorescence signal, especially within the subplasmalemmal region, indicating storage of the chimera in chromaffin secretory granules.

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Table 1. Physicochemical Properties of Granins.*

SgIII
(1B1075)

SgIV
(HISL-19)

SgV
(7B2)

SgVI
(NESP55)

2 (human),
9 (rat),
1 (mouse)

2 (mouse)

ND

15 (human),
2 (mouse)

20 (human)

626657

559586

449507

ND

185

4952
7480

4852
100120

67.5
86

5157
57

ND
35

21
23

27.5
55

25

24

ND

16

21

4.55.0

5.15.2

5.0

810

1518

Disulfide-bonded loop

Yes

Calcium binding

Property

CgA

CgB

SgII

14 (human),
21 (bovine),
6 (rat),
12 (mouse)

20 (human),
3 (rat),
2 (mouse)

Amino acid residues

431445

Molecular mass (kD)

Calculated
Apparent

Chromosome localization

Acidic residues (%)

Isoelectric point (pHi)

20

19
5.1

5.6

610

ND

Yes

No

No

ND

No

No

Yes

Yes

Yes

ND

ND

Yes

ND

Thermostability

Yes

Yes

Yes

ND

ND

Yes

Yes

Phosphorylation

Yes

Yes

Yes

ND

ND

Yes

Yes

Sulfation

Yes

Yes

Yes

Yes

ND

Yes

ND

O-glycosylation

Yes

Yes

Yes

ND

ND

ND

Yes

N-glycosylation

No

Yes

No

No

No

No

No

Phosphorylation

Yes

Yes

Yes

ND

ND

Yes

Yes

Multibasic sites

5.2

241

4.45.2

* CgA denotes chromogranin A, CgB chromogranin B, SgII secretogranin II, SgIII secretogranin III, SgIV secretogranin IV, SgV secretogranin V,
SgVI secretogranin VI, and ND not determined.
Amino acid residues are for mature protein without signal peptide.
The molecular mass was calculated from the primary structure. The apparent molecular mass was determined with the use of sodium dodecyl
sulfatepolyacrylamide-gel electrophoresis.
Multibasic sites refers to sites with two or more consecutive Arg or Lys residues.

tion of the rate of synthesis of the secreted substance. In this pathway, newly synthesized proteins
(e.g., albumin and immunoglobulins) continuously pass through to the trans-Golgi network and are
then transported in constitutive vesicles to the plasma membrane for immediate release. In contrast,
the regulated secretory pathway operates in specialized cells, such as neuroendocrine cells and neurons.
In this pathway, secretory vesicles (frequently called
secretory granules) containing a condensed cargo
of peptide or amine hormones or neurotransmitters may remain in the cell for extended periods of
time. These granules release their contents only in
response to a stimulus that is specific for a particular type of cell (e.g., acetylcholine for the chromaffin cell). There is a third, constitutive-like secretory
pathway for protein sorting within immature secretory granules, leading to constitutive secretion of

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nonretained proteins.41 The mechanism by which

granins are sorted at the trans-Golgi network to enter the regulated pathway of secretion is unclear.41-48
Selective aggregation of regulated secretory
proteins at the level of the trans-Golgi network
(sorting by retention) may occur under conditions
of high Ca2+ and acidic pH. This mechanism segregates the regulated cargo from constitutively secreted proteins and prevents the escape of regulated secretory proteins from immature granules into
the constitutive-like secretory pathway.41 For chromogranin A, chromogranin B, and secretogranin II,
this aggregation depends on millimolar calcium
concentrations and a mildly acidic pH, conditions
that are fulfilled in the lumen of the trans-Golgi
network.21,22,43
A specific sorting signal in the secretory protein
that binds to a sorting receptor may facilitate the

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mechanisms of disease

Chromogranin A
I

II

III

IV

VI

VII

VIII

Chromogranin B
I

II

III

IV

Secretogranin II
I

II

Untranslated domain
Signal-peptide domain
Translated domain
Disulfide-bonded loop domain
Homologous C-terminal domain

Figure 2. Comparison of the Organization of the Genes Encoding Chromogranin A, Chromogranin B, and Secretogranin II and Homologous
Domains within Each Protein.
Roman numerals designate exon numbers. The genes are not drawn to scale.

movement of the protein to the regulated pathway

of secretion (sorting for entry).41,44,45 Indeed,
chromogranin B contains a hydrophobic loop structure, which may guide the sorting of chromogranin
B from the trans-Golgi network to secretory granules of neuroendocrine PC12 pheochromocytoma
cells.49-52 Chromogranin A also contains such a loop
structure.

in tracellular function s
of granins

A appears to be crucial for the formation of secretory granules and sequestration of hormones in neuroendocrine cells.58 Impairment of chromogranin
A expression by antisense RNA depletes secretory
granules, inhibits regulated secretion of a prohormone, and reduces secretory granule protein in
cells. Reestablishment of the regulated secretory
phenotype in chromogranin Adeficient cells has
been achieved with the reintroduction of chromogranin A by transfection.58

formation of secretory granules

modulation of peptide hormone

and neuropeptide processing

Several granins undergo aggregation induced by

low pH and high calcium levels and interact with
other components of the matrix of the secretory
granule, such as catecholamines, serotonin, and histamine, suggesting that granins contribute to the
formation of secretory granules.21-24,53-55 The prevailing view is that granins contribute to the formation of the secretory vesicle when the immature vesicle buds from the trans-Golgi network. Granins
facilitate the formation of storage complexes and
function as chaperones in the sorting of other regulated secretory proteins.21,22,55-57 Chromogranin

Granins are proproteins, with multiple recognition

sites for endopeptidases, such as prohormone convertase 1 and 2 (PC1 and PC2), which are serine endoproteases, and plasmin.59-62 A neuroendocrine
peptide from the carboxy-terminal of secretogranin
V (7B2) selectively inhibits the prohormone convertase PC2, whereas the amino-terminal domain of
7B2 acts as a PC2 chaperone in the endoplasmic
reticulum, where it may be required for pro-PC2 activation.13 In 7B2-knockout mice, which have no
demonstrable PC2 activity, the processing of pancreatic-islet hormones is deficient, and such mice

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have hypoglycemia, hyperproinsulinemia, and hy- cells.65,66 In humans, exogenous pancreastatin dipoglucagonemia.63
minishes glucose uptake by skeletal muscle.67 Pancreastatin also activates hepatic glycogenolysis and
inhibits insulin signaling in adipocytes effects
extracellular functions
that seem to depend on activation of a phospholipase by particular subunit isoforms of heterotriautocrine and paracrine inhibition
of secretion
meric G proteins65,66; however, a unique G protein
The presence of numerous paired basic amino ac- coupled receptor for pancreastatin has not been
ids in granins suggests that they function as prohor- identified. In addition, pancreastatin inhibits the
mones, giving rise to bioactive peptides as a result release of amylase from exocrine pancreas, the reof post-translational proteolytic processing. Indeed, lease of gastric acid from parietal cells, and the repeptides derived from chromogranin A, chromo- lease of parathyroid hormone from parathyroid
granin B, and secretogranin II have autocrine, para- chief cells.65,66
Chromogranin A is also the precursor of aminocrine, and endocrine activities (Fig. 3 and Table 2).
One such peptide is chromogranin Aderived pan- terminal fragments (vasostatins I and II), which
creastatin from porcine pancreas.64 Pancreastatin inhibit vasoconstriction in isolated human blood
elevates blood glucose by inhibiting glucose-stim- vessels68 and modulate the adhesion of fibroblasts
ulated insulin release from pancreatic islet beta and coronary-artery smooth muscle cells.69 Sup-

Primary transcript

II

III

IV

VI

VII

VIII

Exon

II

III

IV

VI

VIII

VII

Mature mRNA
18 4 13

44

67

100

251

412 439

Chromogranin A
s

Functional peptides

100

CgA 140
s

200

Chromacin 176197

Catestatin 352372

Prochromacin 79439

Pancreastatin
250301

Vasostatin II (1115)
s

400

Vasostatin I
(176)
s

300

Parastatin
357428

Untranslated region

Paired basic residues

Signal-peptide domain

Oligoglutamate region

Disulfide-bonded loop domain

Intron

Figure 3. Peptide-Encoding Regions and Putative Functional Domains of Human Chromogranin A (CgA).
Arabic numbers designate amino acids in the mature protein (minus signal peptide). Roman numerals designate exon numbers. The intron
exon structure is not drawn to scale.

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mechanisms of disease

Table 2. Proposed Actions of Granin-Derived Peptides.

Fragment and Position*

Biologic Activity of the Fragment or Its Orthologue

Chromogranin A
Bovine CgA 140

Increases release of calcitonin and calcitonin generelated peptide

from lung tumor cells, inhibits vasoconstriction, inhibits parathyroid hormone secretion from parathyroid chief cells

Chromofungin (bovine CgA 4766)

Exerts antifungal activity

Vasostatin I (bovine CgA 176)

Inhibits vasoconstriction, promotes fibroblast adhesion, inhibits

parathyroid hormone secretion from parathyroid chief cells,
triggers microglial-cellmediated neuronal apoptosis and exerts bacteriolytic and antifungal effects

Vasostatin II (bovine CgA 1113)

Inhibits vasoconstriction and parathyroid hormone secretion

Prochromacin (bovine CgA 79431)

Exerts bacteriolytic and antifungal effects

Chromacin I and II (bovine CgA 173194

and bovine CgA 195221)

Exerts bacteriolytic and antifungal effects

Pancreastatin (porcine CgA 240288)

Inhibits insulin release from pancreatic-islet beta cells; promotes

hepatic glycogenolysis; decreases insulin-induced glycogen
synthesis in skeletal myocytes, hepatocytes, and adipocytes;
stimulates amylase release from pancreatic acini; decreases
gastric acid release from parietal cells; diminishes glucose uptake by skeletal muscles in humans

Catestatin (bovine CgA 344364)

Inhibits catecholamine release from the adrenal medulla

Parastatin (porcine CgA 347419)

Inhibits parathyroid hormone secretion from parathyroid chief

cells

Chromogranin B
Bovine CgB 141

Inhibits parathyroid hormone secretion from parathyroid chief

cells

Chrombacin (bovine CgB 564626)

Exerts bacteriolytic effects

Secretolytin (bovine CgB 614626)

Exerts bacteriolytic effects

Mouse CgB 1657

Inhibits biosynthesis and release of insulin

Secretogranin II
Secretoneurin (rat SgII 154186)

Stimulates dopamine release from central striatal neurons and basal ganglia; stimulates gonadotropin II secretion from pituitary; inhibits serotonin and melatonin release from pinealocytes; promotes chemotactic attraction of monocytes,
eosinophils, and fibroblasts; stimulates proliferation and migration of vascular smooth-muscle cells; stimulates migration
and inhibits proliferation of endothelial cells; stimulates
transendothelial migration of monocytes; activates endothelial
cells for neutrophil adherence

Secretogranin V
Amino-terminal (NT) peptide (human 7B2 1135)

Acts as activator and chaperone of pre-prohormone convertase 2

Carboxy-terminal (CT) peptide (human 7B2

155185)

Inhibits prohormone convertase 2

Secretogranin VI
Bovine SgVI 159162

Acts as antagonist of 5-HT1B serotonergic receptor

* The actions of secretogranin III and IV have not been described. CgA denotes chromogranin A, CgB chromogranin B,
SgII secretogranin II, and SgVI secretogranin VI.

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pression of the release of parathyroid hormone

has been reported in association with the chromogranin A fragments vasostatin70 and parastatin.71
Chromogranin A has also been reported to inhibit
secretion of proopiomelanocortin hormone,72 but
such activity has yet to be ascribed to a discrete region of the protein.
Catestatin, another fragment of chromogranin
A, inhibits the release of catecholamines from sympathoadrenal chromaffin cells by blocking the neuronal nicotinic cholinergic receptor, which is the
physiologic trigger for secretion (Fig. 4).73-76 Catestatin also prevents the desensitization of catecholamine release from chromaffin cells that is induced by repeated nicotinic-agonist stimulation.76
Thus, catestatin may contribute to an autocrine
negative-feedback mechanism that modulates catecholamine release within the sympathoadrenal
system. Since excess sympathetic activity has been
implicated in the development of hypertension, a
disturbance of the catestatin mechanism may be a
contributing factor. Indeed, recent studies show
that the plasma catestatin level is diminished in patients with hypertension and even in normotensive
persons at genetic risk for hypertension. The observation that a low catestatin level is correlated with
increased adrenal epinephrine secretion and augmented pressor responses to sympathoadrenal
stressors provides further evidence of a link between
diminished catestatin and hypertension.77
Some of the responses of secretoneurin and pancreastatin are impaired by pertussis toxin, suggesting a role of G proteincoupled receptors.9,65,66,78
However, unique receptors have not been identified
for most granin fragments.66,78,79 Catestatin seems
to act by binding directly to the nicotinic cholinergic
receptor,74-76 whereas vasostatin may relax vascular
smooth-muscle myocytes by opening hyperpolarizing cell-surface potassium channels.79
antimicrobial properties of granins

During stress, granins are released through exocytosis into the blood from both the sympathoadrenal system and the anterior pituitary gland.80,81
These granins and their fragments may have a role
in systemic infection. The antibacterial and antifungal activities of fragments of chromogranin A
(prochromacin, chromacin I, and chromacin II) result from the ability of these fragments to form ion
channels through membranes.82,83 The chromogranin B fragment secretolytin also has bacteriolytic
properties.84 Chromogranin A or its vasostatin frag-

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ments induce a neurotoxic phenotype in brain macrophages (microglia), which triggers apoptotic degeneration of cortical neurons.85-87 A secretogranin
IIderived peptide, secretoneurin, stimulates the release of dopamine from nigrostriatal neurons and
has chemoattractant effects on monocytes, eosinophils, fibroblasts, vascular smooth-muscle cells,
and endothelial cells.9,88

distribution in normal
neuroendocrine tissues
The widespread distribution of granins within the
endocrine, neuroendocrine, and central and peripheral nervous systems is now firmly established. In
the central nervous system, chromogranin A is detectable in neurons in the cerebellum, cerebral cortex, septum, and amygdala and perhaps in astroglial
cells.3,89-91 Chromogranin B and secretogranin II
are similarly distributed, though their quantity varies according to the type of neuroendocrine cell.9,27
There is also widespread distribution of secretogranin V in the central nervous system and various
neuroendocrine tissues13; secretogranin VI is present
in the central nervous system, adrenal medulla, anterior and posterior pituitary, and intestine.14

clinical uses
Numerous studies have established that granins
can be detected in an array of endocrine, neuroendocrine, and neuronal tumors (Table 3), from which
they are secreted into the bloodstream.92 The distribution of granins in neoplasms is generally correlated with their expression in the corresponding
normal tissue.
assays for chromogranin a

A competitive radioimmunoassay can detect circulating chromogranin A, with the use of purified fulllength human chromogranin A.92,93 Plasma chromogranin A immunoreactivity is remarkably stable
in vitro, readily surviving prolonged heating at
37C, as well as repeated freezing and thawing.93
Several other radioimmunoassays94,95 and enzyme
immunoassays96,97 have been developed for the
measurement of granins or granin-derived peptides
in plasma or serum.16,77,94,98 In general, the measurement of intact chromogranin A in plasma has
greater sensitivity for the diagnosis of neuroendocrine tumors than the measurement of fragments.16
The results of enzyme immunoassays and radioim-

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mechanisms of disease

Nicotinic cholinergic
agonist binding site

Extracellular
Na+

Ca2+

Voltagegated
calcium
channel

Catestatin
Nicotinic
cholinergic
receptor

Catecholamines
Chromogranins, secretogranins
Neuropeptides
Cell
membrane

Exocytosis

Membrane
depolarization

Cytoplasm

Ca2+

Na+

Fusion

+
Docking

Golgi
complex

Chromogranin A
processing
Chromaffin
granule

Transcription
Translation
Sorting

Nucleus
Chromaffin
cell
Chromogranin A
gene

Figure 4. AutocrineParacrine Regulation of Catecholamine Release from Sympathoadrenal Chromaffin Cells by Catestatin.
The physiologic secretagogue acetylcholine binds to the agonist pocket on the nicotinic cholinergic receptor, triggering
sodium influx and consequent membrane depolarization, which activates calcium influx through voltage-gated channels
and leads to exocytotic release of the chromaffin-granule cargo. After the cargo has been released, catestatin exerts potent antagonistic effects on nicotinic cholinergic signaling, resulting in negative-feedback modulation of catecholamine
release. Arrows with plus signs indicate stimulation, and the arrow with a minus sign inhibition.

munoassays are closely correlated.94 The limit of

detection may be lower with enzyme immunoassays than with radioimmunoassays, but radioimmunoassays cover a wider range of concentrations.94
In addition to the availability of granin assays from
reference laboratories for clinical samples,93,99

n engl j med 348;12

three radioimmunoassay kits for the detection of

chromogranin A are available commercially.16,94,95
Internet-based protocols for human chromogranin
A radioimmunoassay are available free of cost
for research purposes (http://medicine.ucsd.edu/
hypertension).

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Table 3. Detection of Granins in Human Neuroendocrine Tumors.*

CgA

CgB

SgII

SgIII
(1B1075)

SgIV
(HISL-19)

SgV
(7B2)

ND

ND

Corticotropinoma

ND

ND

Gonadotropinoma

ND

ND

ND

Somatotropinoma

ND

ND

Thyrotropinoma

ND

ND

ND

Prolactinoma

ND

ND

Nonfunctioning adenoma

ND

ND

Liver

ND

ND

ND

ND

Lung

ND

Middle ear

ND

ND

ND

ND

ND

Ovary

ND

ND

ND

ND

ND

Prostate

ND

ND

ND

Thymus

ND

ND

ND

ND

ND

Uterus

ND

ND

ND

ND

ND

Carcinoid

ND

ND

ND

Gastrinoma

ND

ND

ND

ND

Glucagonoma

ND

Insulinoma

ND

PPoma

ND

ND

ND

Somatostatinoma

ND

ND

ND

ND

ND

VIPoma

ND

ND

ND

ND

ND

Nonfunctioning islet-cell carcinoma

ND

ND

ND

ND

Aortic body

ND

ND

ND

ND

ND

Carotid body

ND

ND

ND

ND

Site and Type of Tumor

Adrenal medulla
Pheochromocytoma
Anterior pituitary

Carcinoid

Gastroenteropancreatic

Cardiovascular

Parathyroid
Adenoma

ND

ND

ND

Carcinoma

ND

ND

ND

ND

ND

Hyperplasia

ND

ND

ND

ND

agnostic of these neoplasms.3,15 Measurement of

chromogranin A levels in blood can also be used to
Chromogranin A is a standard probe for immuno- monitor the progression or regression of neuroenhistochemical analyses of neuroendocrine tumors, docrine tumors during treatment.99-101
and elevated serum chromogranin A levels are diMeasurement of plasma chromogranin A in
use of granins as diagnostic markers
or biologic markers

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mechanisms of disease

Table 3. (Continued.)
CgA

CgB

SgII

SgIII
(1B1075)

SgIV
(HISL-19)

SgV
(7B2)

Ganglioneuroblastoma

ND

ND

ND

ND

ND

Ganglioneuroma

ND

ND

ND

ND

Neuroblastoma

ND

ND

ND

Medulloblastoma

ND

ND

ND

ND

ND

Paraganglioma

ND

ND

ND

ND

ND

Carcinoma

ND

Hyperplasia

ND

ND

Prostate

ND

ND

Breast

ND

ND

ND

Site and Type of Tumor

Neural

Skin
Merkel-cell tumor
Medullary thyroid

Tumors with variable neuroendocrine

differentiation

* A plus sign denotes detectable immunoreactivity, the presence of messenger RNA for the granin, or both; a minus sign
denotes the absence of either detectable immunoreactivity or messenger RNA. ND denotes not determined. No data are
available for secretogranin VI (NESP55) immunoreactivity in human tumors. CgA denotes chromogranin A, CgB chromogranin B, SgII secretogranin II, SgIII secretogranin III, SgIV secretogranin IV, SgV secretogranin V, PP pancreatic polypeptide, and VIP vasoactive intestinal polypeptide.

children with suspected neuroblastoma has a sensitivity of 91 percent and a specificity of 100 percent
for the diagnosis,102 and since chromogranin A
levels are correlated with the tumor burden (or
stage of disease), the test can be used to monitor
the response to treatment and to predict survival.
Chromogranin A levels may also be elevated in patients with primary parathyroid hyperplasia,15 thyroid C-cell hyperplasia,15 or gastric enterochromaffin-like cell hyperplasia.103,104 For this reason, an
increased chromogranin A level may not reliably
distinguish neuroendocrine hyperplasia from adenoma or carcinoma.
Immunohistochemical detection and plasma
quantification of other granins and granin-derived
peptides may be of diagnostic importance. Immunoreactivity for chromogranin B and, to some extent,
secretogranin II, III, IV, and V has been documented
in various neuroendocrine tumors (Table 3), and circulating levels of these granins may reflect the secretory activity of the tumor. Prolactin-producing tumor
cells of the anterior pituitary are negative for chromogranin A but are positive for both chromogranin B and secretogranin II (Table 3), and plasma levels

n engl j med 348;12

of the chromogranin Bderived peptides GAWK

and CCB are elevated in patients with pancreatic
islet-cell tumors105,106 and those with bronchial
tumors.107 Plasma secretoneurin (a secretogranin II
fragment) may be elevated in patients with gastroenteropancreatic neuroendocrine tumors or pheochromocytomas.98 Elevated plasma secretogranin
V levels are associated with several types of neuroendocrine tumors13,108-111 and small-cell lung
carcinoma.109,112
pheochromocytoma

Several circulating granins are sensitive biologic

markers for pheochromocytoma. An elevated plasma chromogranin A level may be diagnostic of pheochromocytoma, von HippelLindau disease,113,114
multiple endocrine neoplasia type II, or neurofibromatosis. In sporadic cases of pheochromocytoma,
elevation of the plasma chromogranin A level has a
sensitivity of 83 percent and a specificity of 96 percent for the diagnosis, and the chromogranin A
level is correlated with the tumor mass.115 Drugs
commonly used to diagnose or treat pheochromocytoma, such as phentolamine, tyramine, clonidine,

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new england journal

and metoprolol, do not substantially alter the serum

chromogranin A level. Furthermore, unlike plasma
epinephrine and norepinephrine levels, the plasma
chromogranin A level can be used to distinguish
between malignant and benign pheochromocytomas. In one study, patients with benign disease had
a mean (SE) chromogranin A level of 18840.6 ng
per milliliter, whereas those with malignant disease
had a mean chromogranin A level of 2932900 ng
per milliliter.100 Elevated levels of serum chromogranin A may not be specific for the diagnosis of
pheochromocytoma in patients with impaired renal function.93,116 However, this limitation can be
overcome by evaluating renal function93,116,117 and
combining the measurement of chromogranin A
with that of plasma catecholamines, which may
have a lower diagnostic sensitivity but have a higher specificity and positive predictive value.117 A normal plasma chromogranin A level may be a valuable
clue to the diagnosis of factitious pheochromocytoma.118 Measurements of chromogranin B and
secretogranin II may also be of diagnostic value in
patients with suspected pheochromocytoma. In one
study, plasma chromogranin B levels were elevated
in 81 percent of such patients,119 and another study
showed that the plasma secretoneurin level was increased by a factor of 4 to 5.98
carcinoid tumors

The highest levels of serum chromogranin A (up to

1000 times the upper limit of the normal range)
have been found in patients with metastatic carcinoid tumors.15 The stability of serum chromogranin A speaks favorably for its use in detecting carcinoid tumors and monitoring their progression;
alternative diagnostic tests for carcinoid tumors
include tests of urinary 5-hydroxyindoleacetic acid,
serum serotonin (5-hydroxytryptamine), and serum
neuron-specific enolase. In multiple endocrine neoplasia type I, there is a clear correlation between the
tumor mass and the circulating level of chromogranin A.120 In patients with midgut carcinoid tumors, an elevated chromogranin A level is an independent predictor of death.101,121

of

medicine

for monitoring such patients.122 In patients with

gastrinoma (the ZollingerEllison syndrome), the
role of chromogranin A is not well defined. Elevated
levels of chromogranin A appear to reflect the associated gastrin-mediated enterochromaffin-like cell
hyperplasia,123 rather than the actual size of the
gastrinoma, and excision of the stomach alone substantially reduces the plasma chromogranin A level, even without excision of the gastrinoma.103 Although the chromogranin A level may be elevated
in patients with primary hyperparathyroidism, it
is most likely to be elevated in those who also have
the ZollingerEllison syndrome, and in such patients, parathyroidectomy is especially likely to lower the plasma chromogranin A level.124
lung, prostate, colon, and breast tumors

In patients who have small-cell lung cancers with

neuroendocrine differentiation, the plasma chromogranin A level may serve as a marker of the response to treatment and may be useful in monitoring patients for recurrent disease. Although the
chromogranin A level indicates the likely degree
of neuroendocrine differentiation within lung tumors, its low sensitivity makes it unreliable as a diagnostic marker of such neoplasms.15,122,125
In men with prostate cancer, measurement of
the chromogranin A level may be useful in establishing the diagnosis and determining the prognosis.126,127 Circulating chromogranin A levels may
be increased even if the prostate-specific antigen
level is normal.128 An elevated chromogranin A level, possibly because it is a marker of neuroendocrine
differentiation, may also predict a lack of response
of the tumor to hormone therapy; indeed, elevated
levels may portend a poor prognosis.129
Chromogranin A immunoreactivity has been
reported in some cells in colorectal tumors130 and
breast tumors,131 but its diagnostic or prognostic
value has not been established. Several other tumors
with suspected or partial neuroendocrine differentiation or lineage (choriocarcinoma, thymoma, malignant melanoma, and renal-cell carcinoma) are
not associated with an elevated plasma chromogranin A level.93,121

endocrine pancreatic tumors

Two thirds of patients with endocrine pancreatic

tumors have clinically functional tumors that secrete hormonal markers. In patients with tumors
that secrete glucagon, somatostatin, or vasoactive
intestinal polypeptide, serum chromogranin A levels are usually elevated and serve as tumor markers

1144

n engl j med 348;12

nonfunctioning neuroendocrine tumors

Chromogranin A can also aid in the diagnosis of

clinically silent, or nonfunctioning, neuroendocrine tumors.17,132-134 Indeed, cases of medullary
thyroid carcinoma, anterior pituitary adenoma,
small-cell lung cancer, and islet-cell carcinoma that

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mechanisms of disease

are hormone-negative but chromogranin Aposi- and in the swollen neurons of Picks disease.140,141
tive have been reported.133,134
Studies suggest that chromogranin A activates brain
microglial cells, perhaps contributing to neuronal
essential hypertension
degeneration.85-87
Increased sympathoadrenal activity may have a
Cerebrospinal fluid chromogranin A and chrocausative role in essential (idiopathic, familial, or mogranin B levels are reduced in patients with
genetic) hypertension. The release of chromogranin schizophrenia.142 Genetic linkage studies of schizoA with catecholamines indicates that exocytosis is phrenia in Japan implicate a genomic region near
the mechanism of physiologic catecholamine re- the chromogranin B locus on chromosome 20
lease in humans.80 The basal plasma chromogranin (CHGB),143 and allelic-association studies in ChiA level is correlated with sympathetic tone,135,136 na have associated single-nucleotide polymorphisms
and studies in twins indicate that the basal level is at the CHGB locus with schizophrenia.144
highly heritable.137 As compared with age-matched
normotensive controls, patients with essential hy- organ failure
pertension have an increased plasma chromogranin Chromogranin A levels are elevated in patients
A level and an increased release of stored chromo- with kidney, liver, or heart failure. As a result of the
granin A in response to insulin-evoked hypoglyce- retention of midmolecule fragments, chromogranmia.137 The dysglycemic chromogranin A fragment in A levels in patients with end-stage renal disease
pancreastatin is also elevated in patients with es- can be as high as those in patients with neuroendosential hypertension138; its actions may therefore crine neoplasia, suggesting that the kidneys have
contribute to the insulin resistance that often ac- an important role in eliminating chromogranin
companies the condition. Catestatin, the chromo- A.116 The moderate elevation of chromogranin A
granin Aderived peptide that inhibits catechola- levels in patients with hepatic failure suggests that
mine release, is decreased in patients with essential either the liver metabolizes chromogranin A93 or
hypertension and even in normotensive subjects the neuroendocrine system is activated in such pawith a family history of hypertension.77 Moreover, tients. Neuroendocrine activation also occurs in
people with such a family history have increased patients with congestive heart failure, and the plasepinephrine secretion in addition to diminished ma chromogranin A level rises as a result of this
catestatin, suggesting an inhibitory effect of cate- activation. Moreover, the chromogranin A level is
statin on chromaffin cells in vivo.77 Low catestatin directly correlated with the severity of the disease.
levels also predict augmented adrenergic responses In patients with New York Heart Association class
to stressors, suggesting that a reduction in cate- IV heart failure, the chromogranin A level is approxstatin increases the risk of hypertension.
imately 7.6 times the normal level.145
cerebrospinal fluid levels
and neuropsychiatric diseases

conclusions

Chromogranin A is present in the cerebrospinal

fluid and appears to derive from the central nervous system rather than a peripheral source. Whereas plasma chromogranin A responds to alterations
of peripheral sympathoadrenal activity, cerebrospinal fluid chromogranin A is not correlated with
central noradrenergic neuronal activity.139 In patients with Parkinsons disease, the cerebrospinal
fluid chromogranin A level is diminished, which
may be a useful diagnostic finding; however, the
chromogranin A level does not increase after adrenal-to-caudate autografting of chromaffin cells in
such patients.139
Chromogranin A accumulates in the senile and
preamyloid plaques of Alzheimers disease, in Lewy
bodies in the substantia nigra in Parkinsons disease,

n engl j med 348;12

The study of granins was initiated over 30 years ago,

after the discovery of the prototype, chromogranin
A,5,6 and in the past 15 years, our knowledge of the
structure and function of granins has increased dramatically. There is compelling new evidence of the
intracellular and extracellular functions of these
proteins. Within the cells of origin, a granulogenic
or sorting role in the regulated pathway of hormone
or neurotransmitter secretion has been documented, especially in the case of chromogranin A. Granins
also function as prohormones, giving rise by proteolytic processing to a large array of peptide fragments for which diverse autocrine, paracrine, and
endocrine activities have been demonstrated. However, more definitive insights into granin functions
are required, and they may be achieved in the near

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1145

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new england journal

of

medicine

future with the use of strategies such as single or renal overactivity, which in turn leads to the develmultiple granin-gene deletions or knockouts by tar- opment of the syndrome.
Supported by grants from the National Institutes of Health
geted homologous recombination.
to Dr. Taupenot, and HL58120 and HL69758, to Dr.
The emerging technique of RNA-mediated in- (DK59628,
OConnor) and the Department of Veterans Affairs (to Dr. OConnor).
terference with gene expression in mammalian cells
We are indebted to Drs. Peter E. Cadman, Bruce M. Gill, Vivian Y.
and living animals may be of value for determining Hook, Qijiao Jiang, Mala T. Kailasam, Brian P. Kennedy, Nitish R.
Manjula Mahata, Sushil K. Mahata, Robert J. Parmer,
the loss-of-function phenotypes for the granins. Mahapatra,
Fangwen Rao, David J. Rozansky, Mats Stridsberg, Marwan A. TakMeasurements of chromogranin A fragments in pa- iyyuddin, Kechun Tang, Carolyn V. Livsey-Taylor, Hongjiang Wu, Suktients with essential hypertension suggest that a de- kid Yasothornsrikul, Noboru Yanaihara, and Michael G. Ziegler for
collaboration, and to Dr. sa Thureson-Klein for the electron
ficiency of catestatin, a fragment that inhibits the their
micrograph of chromogranin A in chromaffin granules of the adrerelease of catecholamines, triggers sympathoad- nal medulla.
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