Case Reports
FLOW CYTOMETRY IN FEMINIZING ADRENOCORTICAL CARCINOMA
FREDERICK A. KLEIN, NORMAN L. MILLER AND ROBERT H. HACKLER From the Urology Service, McGuire Veterans Administration Hospital, Richmond, Virginia
ABSTRACT
A case of feminizing adrenal cortical neoplasm is presented in which automated flow cytometry determination of deoxyribonucleic acid content was used to confirm malignancy.
Reports of the feminizing syndrome in male subjects with adrenal neoplasms are rarely encountered in the literature. Since Gabrilove and associates reviewed 61 cases through 19701,2 only sporadic reports are available.3-6 The clinical syn- drome is characterized by gynecomastia, diminished libido, attenuated potency, gonadal atrophy, obesity and feminizing hair changes, with the severity of these features determined by the amount of hyperestrogenism. Although the majority of these tumors have been classified as malignant, 22 per cent of the cases in the original report of Gabrilove and associates were classified as adenomas.1 Subsequently, several of these patients had recurrences and died with metastatic disease, illustrating the difficulty in determining malignancy by light microscopic criteria alone. We describe the course of an addi- tional patient, review the clinical and laboratory features of this syndrome, and propose that flow cytometry of the tumor is useful in determining malignancy.
CASE REPORT
T. W., a 65-year-old black man, was evaluated for an 8- month history of progressive bilateral gynecomastia, dimin- ished libido, impotence and mild vesical outlet obstructive symptoms. There was no weight loss, exposure to exogenous estrogens, chest wall trauma or excessive alcohol consumption. Although the patient had a history of myocardial infarction and continued to have occasional angina pectoris relieved by nitroglycerin he did not require digoxin. Mild hypertension was controlled by hydrochlorothiazide. Physical examination re- vealed a blood pressure of 140/90, symmetrical gynecomastia measuring 4 × 4 cm., a feminized body contour, diminished testicular size (3.2 × 3.0 cm. in long axis), a normal phallus and no palpable abdominal masses or organomegaly.
Laboratory evaluation included a normal complete blood count, urinalysis, and serum chemistry and coagulation profiles. Biochemical tests included serum immunoreactive luteinizing and follicle-stimulating hormone concentrations of 5.5 and 1.6 mIU/ml. (normal 2 to 20 mIU/ml.), respectively, serum estra- diol 120 pg./ml. (normal 10 to 60 pg./ml.) and total serum testosterone 20 ng./dl. (normal 160 to 1,200 ng./dl.). The 24- hour urinary studies included a 17-hydroxycorticosteroid level of 11.7 mg. (normal 2 to 10 mg.), neutral 17-ketosteroid level 15 mg. (normal 9 to 23 mg.) and estrogen level 348 ug. (normal 5 to 18 ug.). Serum prolactin, thyroxin, T3 resin uptake, thy- roid-stimulating hormone and cortisol concentrations were nor- mal. Other serum steroid hormone concentrations that occurred in relation to the tumor are shown in the table. Radiographic
studies included a normal chest x-ray and whole lung tomo- grams, an excretory urogram (IVP) that suggested a right adrenal mass and a computerized axial tomographic (CT) scan of the abdomen that revealed a 4 x 5 cm. right solid adrenal mass (fig. 1).
Right adrenalectomy through an extraplural eleventh rib thoracoabdominal incision revealed an 8 × 4 × 4 cm. tumor weighing 80 gm. The tumor was removed and the patient was discharged from the hospital 10 days postoperatively. Followup evaluations, including endocrine studies, performed at 2 weeks and every 3 months thereafter have remained normal.
Histologically, the tumor was encapsulated without evidence of invasion with a homogeneous array of cells and eosinophilic granular cytoplasm, round oval nucleoli and 2 mitoses per 20 high power fields (fig. 2). Although originally the neoplasm was classified as a benign adenoma, a review by the Armed Forces Institute of Pathology classified it as a well differentiated carcinoma. Flow cytometry determination of the deoxyribonu- cleic acid (DNA) content of the lesion by Vindelov’s technique7 revealed an aneuploid stemline of 3.3c, with 58 per cent of the cells in the S + G2 + M phase of the cell cycle, confirming the diagnosis of carcinoma (fig. 3).
DISCUSSION
Carcinoma of the adrenal cortex is a rare malignancy, ac- counting for less than 0.2 per cent of all cancer deaths. Fem- inizing adrenal neoplasms in the male subject are even more rare with approximately 82 cases reported previously.1-6 The majority of the neoplasms have occurred in patients between 25 and 60 years old. Gabrilove and associates reported gyne- comastia as the most frequent change and presenting complaint in 98 per cent of the cases.1,2 Other signs and symptoms in decreasing order of frequency include a palpable tumor (58 per cent), testicular atrophy (52 per cent), diminished libido and/ or potency (48 per cent), pain at the site of tumor (44 per cent),
| Hormone (normal range) | Preop. | Postop. (2 wks.) |
|---|---|---|
| Total testosterone (160-1,200 ng./dl.) | 20 | 691 |
| % Free (1.0-2.7) | 1.4 | 1.6 |
| Free testosterone (50-210 pg./dl.) | 2.9 | 111 |
| A4-Androstenedione (50-180 ng./dl.) | 33 | 62 |
| Estradiol (10-60 pg./ml.) | 81 | 38 |
| Estrone (15-65 pg./ml.) | 377 | 48 |
| 17a-Hydroxyprogesterone (10-100 ng./dl.) | 151 | 41.4 |
Accepted for publication July 2, 1985.
3.3c
2c
NUMBER OF CELLS
58 % >2c
DNA FLUORESCENCE
breast tenderness (42 per cent), areolar pigmentation (27 per cent), obesity (27 per cent), feminizing hair changes (23 per cent), penile atrophy (20 per cent), high blood pressure (16 per cent), increased skin pigmentation (12 per cent), varicocele (11 per cent) and acne (8 per cent). Since the majority of these lesions are large, most can be detected easily on plain films of the abdomen or an IVP. However, CT scans of the abdomen provide considerably more information in regard to the size, shape, consistency and extent of the mass.
The majority of these neoplasms have been reported as carcinoma (86 per cent), although at least 10 were originally reported as benign.1 Difficulty in establishing benignity versus malignancy by histological means is demonstrated by the fact that a number of these cases, subsequently, have been found to have metastases, thus, proving the malignant character of this tumor. This difficulty in the histological differentiation of adrenocortical tumors has been encountered in other adrenal neoplasms associated with hyperfunction. Indeed, our case confirms the dilemma, since some pathologists thought the lesion was benign, whereas others thought it was malignant. For this reason flow cytometry determination of the DNA content of the tumor was performed, which revealed the pres- ence of an aneuploid population of cells at 3.3c, with 58 per cent of the cells being hyperdiploid (in S + G2 + M phase of the cell cycle). Previous investigations of human solid tumors by flow cytometry have clearly shown a tendency for chromo- some changes manifested by a deviation from the normal ploidy number.8-10 These altered (cancer) cells have enlarged, hyper- chromatic nuclei because of abnormally increased DNA con- tent, and irregular coarsely textured chromatin that is believed to reflect a change in the chromatin structure. Thus, flow cytometric determination of the DNA content of individual cell nuclei has become an objective quantitative method of deter- mining malignancy. In general, less differentiated, more ag- gressive tumors will exhibit cells with aneuploid DNA content, as in our case.
Most feminizing adrenal tumors secrete increased amounts of androstenedione, which are converted in the periphery to estrogen. Therefore, serum and urinary estrogen levels are increased as well as estrone, estradiol and estriol. The amount of estrogen excretion generally correlates with the degree of
malignancy but more importantly elevation postoperatively indicates either persistent or recurrent disease. In addition, urinary neutral 17-ketosteroids and dehydroepiandrosterone levels frequently are elevated as are urinary pregnanetriol and tetrahydro-s. Likewise, in about half of the patients serum 17- hydroxycorticosteroids are elevated, whereas serum luteinizing hormone, follicle-stimulating hormone and testosterone levels usually are low.
In general, the prognosis with this neoplasm is grave. In their first review Gabrilove and associates reported that 27 per cent (14 of 52) of the patients either had metastases at the time of diagnosis or the neoplasm was unresectable.1 In addition, more than half of the patients died within 11/2 years and 80 per cent died within 3 years of the onset of symptoms. Other than complete surgical removal there is little to offer the patient. Radiation therapy has not been proved effective in inoperable adrenal carcinoma. However, 1,1-dichloro-2-[0-chlorophenyl]- 2[p-chlorophenyl]-ethane has been shown by Hutter and Kayhoe,3 and by Lubitz and associates11 to have a response rate of 34 to 61 per cent and a steroid response rate of 70 to 85 per cent. In these series there was no specific mention of the outcome in those patients with feminizing neoplasms and the mean duration of response was 10 months.3,11
In conclusion, feminizing adrenal neoplasms should be con- sidered in the differential diagnosis of men with gynecomastia. The best radiological test to detect and stage this neoplasm is an abdominal CT scan. Although the prognosis is grave the best survival lies in early diagnosis followed by radical adre- nalectomy. To aid in the determination of malignancy, flow cytometry measurement of the DNA content of the tumor seems to be a valuable addition to the pathologist’s armamen- tarium.
REFERENCES
1. Gabrilove, J. L., Sharma, D. C., Wotiz, H. H. and Dorfman, R. I .: Feminizing adrenocortical tumors in the male. A review of 52 cases including a case report. Medicine, 44: 37, 1965.
2. Gabrilove, J. L., Nicolis, G. L., Hausknecht, R. U. and Wotiz, H. H .: Feminizing adrenocortical carcinoma in a man. Cancer, 25: 153, 1970.
3. Hutter, A. M., Jr. and Kayhoe, D. E .: Adrenal cortical carcinoma. Results of treatment with o,p’DDD in 138 patients. Amer. J. Med., 41: 581, 1966.
4. Huvos, A. G., Hadju, S. I., Brasfield, R. D. and Foote, F. W., Jr .: Adrenal cortical carcinoma. A clinicopathologic study of 34 cases. Cancer, 25: 354, 1970.
5. Didolkar, M. S., Bescher, R. A., Elias, E. G. and Moore, R. H .: Natural history of adrenal cortical carcinoma: a clinicopatholog- ical study of 42 patients. Cancer, 47: 2153, 1981.
6. King, D. R. and Lack, E. E .: Adrenal cortical carcinoma: a clinical and pathologic study of 49 cases. Cancer, 44: 239, 1979.
7. Vindelov, L. L .: Flow microfluorometric analysis of nuclear DNA in cells from solid tumors and cell suspensions. A new method for rapid isolation and staining of nuclei. Virch. Arch. B Cell. Path., 24: 227, 1977.
8. Böhm, N. and Sandritter, W .: DNA in human tumors: a cytopho- tometric study. Curr. Top. Path., 60: 151, 1975.
9. Barlogie, B., Göhde, W. and Drewinko, B .: Flow cytometric analysis of DNA content for ploidy determination in human solid tumors. J. Histochem. Cytochem., 27: 505, 1979.
10. Barlogie, B., Göhde, W., Johnston, D. A., Smallwood, L., Schumann, J., Drewinko, B. and Freireich, E. J .: Determination of ploidy and proliferative characteristics of human solid tumors by pulse cytophotometry. Cancer Res., 38: 3333, 1978.
11. Lubitz, J. A., Freeman, L. and Okun, R .: Mitotane use in inoperable adrenal cortical carcinoma. J.A.M.A., 223: 1109, 1973.