ADRENOCORTICAL CARCINOMA CAUSING FEMINIZATION IN AN ADULT MALE: HORMONAL CONSIDERATIONS, AND RESULTS OF HETEROTRANS- PLANTATION OF THE TUMOR IN GUINEA PIGS
E. TROWBRIDGE WOLF, M.D.,* LEWIS C. MILLS, M.D.,*| BERNE L. NEWTON, M.D.,t L. L. D. TUTTLE, M.D., ROBERT A. HETTIG, M.D.,* VINCENT P. COLLINS, M.D.§ AND WILLIAM B. GORDON, M.D.} The Methodist Hospital and Baylor University College of Medicine, Houston, Texas
ABSTRACT
A 46-year-old man with an adrenocortical carcinoma is reported, in whom there was clinical evidence of feminization and increased urinary excretion of estrogens. Urinary 17-ketosteroids, 17-hydroxycorticoids and pregnanediol were also increased. Postoperatively libido returned to normal and gyneco- mastia subsided. The adrenal tumor of this patient was successfully trans- planted into the anterior chamber of the guinea-pig eye. Transplants of the tumor maintained their ability to secrete estrogens, and regressed following x-irradiation.
A DRENOCORTICAL carcinomas associated with excessive estrogen production leading to feminization in the male are quite rare. To our knowledge only 34 patients have been reported in the literature. In many of these cases only a limited number of steroid assays were performed, because suitable methods were lacking at the time the patients were seen. Therefore, it seemed desirable to report the clinical and laboratory findings in an additional patient in whom it was possible to determine the excretion of 17-hydroxycorticoids, 17-ketosteroids, estrogens and pregnanediol be- fore and after surgical removal of the adrenal tumor. The growth and estro- gen secretion of a heterotransplant of the tumor were of further interest.
Received July 8, 1957.
* Department of Medicine.
t Department of Pathology.
# Department of Surgery.
§ Department of Radiology.
|| Currently, Chief of Section, Endocrinology and Metabolism, Hahnemann Medical College and Hospital, Philadelphia, Pennsylvania.
CASE HISTORY
A 46-year-old white, male refinery worker was first seen in October 1953 because of soreness of the nipples of his breasts. A small tender 1-cm. lump could be palpated under the left nipple, the breasts were enlarged and tender, and there was loss of libido (which he estimated to be 50 per cent of normal). A left varicocele had been present for eight months. He had also noted some “weakness” in his legs. The remainder of the history was noncontributory.
A large non-tender mass was felt in the left upper quadrant of the abdomen, extending to 10 cm. below the left costal margin. It moved downward 5-7 cm. with deep inspiration, and was thought by most observers to be an enlarged spleen. However, the mass could be palpated in the left costovertebral angle, and other observers thought that it was a large retroperitoneal tumor, possibly of adrenal or renal origin. The testes were slightly smaller and softer than normal.
Laboratory data. On admission a complete blood count was normal, as were values for blood urea nitrogen, serum bilirubin, and alkaline phosphatase. Results of a bromsul- phalein test were within normal limits. Urinalysis revealed 1+ sugar. An oral glucose tolerance test (50 grams) showed an abnormal curve, with a fasting blood sugar level of 114 mg. per 100 ml., and values of 223 mg., 217 mg., 126 mg. and 93 mg. per 100 ml. at half an hour, one hour, two hours, and three hours respectively. Results of an intra- venous regitine test, performed because of variably high blood pressure, were negative.
X-ray examination of the chest and skeleton showed only moderately severe kypho- scoliosis and mild pulmonary emphysema. An intravenous pyelogram revealed slight rotation of the left kidney and a questionable pressure deformity of the calyces of the upper pole of the left kidney. An extra-intestinal mass was noted in the left upper quadrant during roentgenographic examination of the gastro-intestinal tract. This mass displaced the stomach to the right and anteriorly, and the left portion of the transverse colon downward (Fig. 1).
Urinary 17-ketosteroids, extracted by the procedure of Drekter et al. (1) with colorim- ctry by the method of Callow et al. (2), averaged 28.9 mg. per twenty-four hours (normal range for males by this method, 7-24 mg.). The excretion of beta 17-ketosteroids was 2.5 mg. per twenty-four hours.1 The 17-hydroxycorticoids, extracted by the method of Reddy (3) with colorimetry by the modified Porter-Silber method of Smith et al. (4), averaged 40.5 mg. per twenty-four hours (normal range for males by this method, 5-16 mg.). Total urinary estrogens were determined in two ways. With extraction by the method of Engle (5), chromatography on activated alumina, and fluorimetry by the method of Bates and Cohen (6), a value of 155 micrograms (ug.) per twenty-four hours was obtained1 (normal range for males by this technique, 4-30 ug.). By another pro- cedure,2 total estrogens were determined to be equivalent to 600 ug. of estrone per twenty-four hours (normal range for males by this method, 0-200 µg.). Urinary preg- nanediol’ excretion was 15.8 mg. per twenty-four hours. During ACTH stimulation (40 units given intravenously over an eight-hour period on each of two days) there was no change in 17-ketosteroid excretion and only a subnormal rise in urinary 17- hydroxycorticoids (Fig. 2).
Course. On December 1, 1954, a large retroperitoneal tumor was removed through a left subcostal incision (Fig. 3, upper portion). Results of examination of frozen sections were compatible with the diagnosis of adrenocortical carcinoma. There were no visible
1 Determined by Bio-Science Laboratories, Los Angeles, California.
2 Determined by Hormone Chemistry Laboratory, Houston, Texas.
metastases. It was technically impossible, however, to remove all of the tumor bed, due to the large area of attachment posteriorly.
Because of the possibility of postoperative hypoadrenalism, the patient was given 50 mg. of hydrocortisone intravenously during the first hour of surgery followed by 150 mg. intravenously during the next twenty-four hours. In addition, he was given 200 mg. of cortisone intramuscularly at the time of surgery and 100 mg. twelve hours later. Subsequently the dose of cortisone was gradually reduced and on the thirteenth
postoperative day it was discontinued (Fig. 2). No evidence of adrenal insufficiency developed.
On the second postoperative day the urinary 17-ketosteroids decreased to 3.4 mg. per twenty-four hours and ranged from 3.6 to 7.7 mg. per twenty-four hours after cortisone was discontinued. Urinary 17-hydroxycorticoids remained at levels above normal during the immediate postoperative period due to administration of cortisone, but gradually returned to normal following cessation of therapy (Fig. 2). Urinary estrogens and pregnanediol were measured on the sixteenth postoperative day; estrogens were within normal limits, but pregnanediol, although considerably below preoperative levels, was still elevated (Table 1).
Postoperatively, the patient voluntarily stated that his libido had returned to normal, and that there was no longer any tenderness in his breasts. The blood pressure returned to normal. Following discharge from the hospital in December 1954, the patient felt well and returned to work. Urinary steroids were determined at monthly intervals thereafter. There was no change in 17-ketosteroid excretion, but on several occasions prior to death the excretion of 17-hydroxycorticoids was above normal limits (Fig. 2). Although clinically there was no indication of recurrence of the tumor, the patient was noted to be somewhat depressed, and on September 5, 1956, he committed suicide. Permission for autopsy was denied.
Pathology. The specimen received in the surgical pathologic laboratory was a smooth,
FEMINIZING ADRENAL CARCINOMA
60
ACTH
17- HYDROXYCORTICOIDS mgm. / 24 hrs.
50
J.C. - 47 w &
40
30
20
10
o
17-KE TOSTEROIDS mgm. / 24 hrs.
Surgery
ACTH
Tumor Removed
30
20
10
CORTISONE R mgm./24 hrs.
0
&Estrogen 0.6 mgm./24 hrs.
+
Hydrocortisone
cortisone
Estrogen 0.07 mgm./24 hrs.
400
200 mgm. I.V.
7
300 mgm. I.M.
+
+
200
ACTH TEST
I.M.
I.M.
40 U. I.V in 8 hours
I.M.
P.O.
P. O.
0
P. O.
20 21 22 26 27 28
1
2
3
4
5
6
7
8
9
10
It
12
13
14
15
16
17
18
19
9 22 12 6. 22 1 5 11 2
November
Days
December
Jan
Feb
Mar
May
Jun
Jul.
Aug
lobulated, moderately firm to soft tumor mass measuring 17×16×11 cm. and weighing 1,750 grams. Compressed tissue resembling the normal adrenal was attached to the external surface in one area. The cut surfaces of the tumor were solid, grey-pink to mottled dark red, with areas of yellowish discoloration where infarction was present.
Microscopic examination of sections of the tumor revealed neoplastic cells with a moderate amount of eosinophilic, slightly granular or ridged cytoplasm (Fig. 3, lower portion). The cell nuclei varied from small oval, hyperchromatic forms to bizarre and enlarged ones. Occasional cells exhibited mitotic division. The arrangement of the tumor cells was predominantly in the form of cords and columns with some areas of more solid pattern. Scattered areas of necrosis were present; sparse fibrous stroma ac- companied the epithelial component, with slight associated inflammatory response. Loss of structural detail due to necrosis and infarction was obvious in some parts of the section. In one area, invasion of the surrounding limiting fibrous membrane had occurred, as well as involvement of the walls of a few small, thin-walled blood vessels
| Date (1954) | 17-OHCS (mg./ 24 hrs.) | 17-KS (mg./ 24 hrs.) | Beta 17-KS (mg./ 24 hrs.) | Estrogens* (ug./ 24 hrs.) | Estrogenst (ug./ 24 hrs.) | Preg- nanediol (mg./ 24 hrs.) |
|---|---|---|---|---|---|---|
| Preop., Nov. 20 | 40.4 | 26.4 | 2.5 | 155 | 600 | 15.8 |
| Postop., 16th day, Dec. 17 | 9.8 | 6.4 | - | 27 | 70 | 3.8 |
| Normal values* | 5-16 | 7-24 | 10% of total 17-KS | 4-30 | 0-200 | 0-0.5 |
* Determination by Bio-Science Laboratories (sce text).
t Determination by Hormone Chemistry Laboratory (see text).
within the tumor. Sections stained by Masson trichrome and periodic acid-Schiff tech- niques in order to demonstrate the presence of fuchsinophilic granules showed a very few scattered lilac-stained granules within the cytoplasm.
Transplantation. Heterologous transplantation of a small portion of the fresh tumor was performed by the method of Greene (7), utilizing the anterior chambers of the eyes in 4 guinea pigs. Successful transfer occurred in 1 animal, and growth was also obtained when serial transfer was carried out subsequently in 2 groups of guinea pigs. Hormone bioassay2 of a five-day pooled urine of 2 male guinea pigs bearing the heterotransplants indicated an estrogen content of 25 µg. in 80 ml. of urine. Urine from normal male guinea pigs was similarly assayed, but estrogens could not be detected. In 2 guinea pigs a single dose of x-irradiation (700 r, air) to the tumor-bearing eye led to marked regres- sion of the tumor ten days after therapy.
DISCUSSION
The diagnosis of feminizing adrenal carcinoma seemed justified in this patient on the basis of gynecomastia, similarity of other physical findings and symptoms to those of previously reported cases, and increased urinary excretion of estrogen. Urinary 17-ketosteroids and 17-hydroxycorticoids were also increased. However, with the exception of impaired glucose toler- ance and minimal hypertension, none of the other manifestations usually associated with excessive hydrocortisone or androgen production was observed.
In most of the 34 previously reported cases (8), the manifestations were gynecomastia, testicular atrophy, and loss of libido. In the majority of
patients a palpable tumor was found at the time medical advice was first obtained. With few exceptions, these tumors were subsequently demon- strated to be carcinomas.
In spite of the fairly consistent clinical syndrome, the results of hormonal studies have been variable, with the exception of urinary estrogens. Estro- gen excretion was elevated in all but 1 of the patients in whom such assays were performed. Urinary 17-ketosteroids were measured in 17 patients. In 8 the daily excretion was above normal, ranging from 26 mg. to 600 mg. per twenty-four hours. In 2 other patients, urinary androgens were above normal limits as measured by bioassay. These findings indicate that about half of the patients with this syndrome could be expected to have increased urinary 17-ketosteroids. Although the individual steroids accounting for this increase have apparently not been isolated, the beta 17-ketosteroids, presumed to be chiefly dehydroepiandrosterone, have been elevated in sev- eral instances.
Due to the scarcity of reports concerning excretion of adrenal corticoids, no definite conclusions can be drawn about the secretion of hydrocortisone or related C21 steroids by the tumor in these patients. In the patient re- ported here, excretion of 17-hydroxycorticoids was increased; however, in 4 of 5 previously reported cases, urinary corticoids determined by other methods were within normal limits.
Other hormonal abnormalities have also been reported. In the case of McFadzean (9), results of the Aschheim-Zondek test were positive; and in the patients of Landau et al. (10), Higgins et al. (11), and Diczfalusy and Luft (12), urinary pregnanediol was increased. Urinary pregnanediol was also increased in our patient.
Although the gynecomastia in these patients is undoubtedly related to increased estrogen secretion, there seems to be little direct correlation with the amount of estrogens being secreted. It seems likely that other factors may exert a major effect in the amount of breast development which takes place during stimulation with estrogen. This concept is borne out, at least in part, by the fact that, from a review of the laboratory data concerning hormone excretion, one cannot predict with any degree of certainty whether a given patient with adrenal hyperfunction will have gynecomas- tia. Before this problem can be elucidated, further studies appear necessary to determine the amounts and types of various steroids both in the tumor and in the blood of these patients.
The heterologous growth of the adrenocortical neoplasm suggests the development of complete autonomy (7, 13). Such behavior usually paral- lels ability of a tumor to metastasize. It is of interest that Wallach et al. (8) reported “gross proliferation of tumor cells” after heterotransplanta- tion to the eyes of 4 guinea pigs, although no further details were pre- sented.
March, 1958 FEMINIZATION OF ADULT MALE FROM ADRENAL CA. 317
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2. CALLOW, N. H .; CALLOW, R. K., and EMMENS, C. W .: Colorimetric determination of substances containing the grouping -CH2 . CO- in urine extracts as an indication of androgen content, Biochem. J. 32: 1312, 1938.
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9. McFADZEAN, A. J. S .: Feminization associated with carcinoma of the adrenal cortex, Lancet 2: 940, 1946.
10. LANDAU, R. L .; STIMMEL, B. F .; HUMPHREYS, E., and CLARK, D. E .: Gynecomastia and retarded sexual development resulting from a long-standing estrogen-secreting adrenal tumor, J. Clin. Endocrinol. & Metab. 14: 1097, 1954.
11. HIGGINS, G. A .; BROWNLEE, W. D., and MANTZ, F. A .: Feminizing tumors of the adrenal cortex, Am. Surgeon 22: 56, 1956.
12. DICZFALUSY, E., and LUFT, R .: A qualitative study of the estrogens excreted by a male patient with an adrenal cortical tumor, Acta endocrinol. 9: 327, 1952.
13. GREENE, H. S. N., and NEWTON, B. L .: Evolution of cancer of the uterine fundus in the rabbit, Cancer 1: 82, 1948.
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