Studies of Androgens and Their Precursors in Adrenocortical Virilizing Carcinoma1
JOSÉ M. SAEZ, BERNADETTE LORAS, ANNE M. MORERA, AND JEAN BERTRAND
Unité de Recherches Endocriniennes et Métaboliques chez l’Enfant, I.N.S.E.R.M., Hôpital Debrousse, 69-Lyon, 5e, France
ABSTRACT. A boy with adrenocortical car- cinoma has been studied. The initial urinary 17- ketosteroid excretion was between 1700 and 2100 mg/day. Peripheral plasma levels of pregneno- lone, 17-hydroxypregnenolone,dehydroepiandros- terone (DHA), androstenediol, testosterone (T) and the sulfate conjugates of these steroids were elevated. Plasma levels of androstenedione (A) were also high. The levels of these steroids in adrenal vein plasma were still higher except in the case of unconjugated T. The MCR and the blood production rates of T and A were elevated but were lower than their urinary production rates. The urinary production rates of DHAS
and DHA were 2000 and 5100 mg/day, respec- tively. These results, considered in association with the specific activities of several urinary metabolites after injection of tracers (3H-T +14C-4, 3H-DHAS+14C-DHA and 3H-DHAS +14C-4) suggest that: 1. Urinary androsterone was diluted by precursors that did not pass through the plasma A pool. 2. Urinary T glucuronide was derived in part from precursors other than plasma A and T. 3. An undefined precursor which did not contribute to plasma DHA and DHAS con- tributed to urinary DHAG. 4. Some of plasma 4 was converted into plasma 11-hydroxyandros- tenedione. (J Clin Endocr 32: 462, 1971)
F OR MANY YEARS it has been realized that androgen secretion from adrenal tumors can give rise to clinical manifestations of virilization but it is only recently that the exact nature of the androgens concerned has been investigated. It has been established that dehydro- epiandrosterone (DHA)? and DHA sul- fate, testosterone (T) and its sulfate, an- drostenedione (4), 11-hydroxyandrostene-
Received August 28, 1970.
1 Presented in part at the Seventh Acta Endo- crinologica Congress, Stockholm, June 1969.
2 The following trivial names and abbreviations have been used: pregnenolone =38-hydroxypregn- 5-en-20-one; 17-hydroxypregnenolone =38,17a-dihy- droxypregn-5-en-20-one; androstenediol = androst- 5-ene-38,178-diol; 16-hydroxy-DHA =38,16a-dihy- droxyandrost-5-en-17-one; 7-keto-DHA =36-hy- droxyandrost-5-ene-7, 17-dione; 11 -hydroxyandros- tenedione = 118-hydroxyandrost-4-ene-3,7-dione; 11-hydroxyandrosterone =3,118-dihydroxy-5a-an- drostan-17-one; 11-ketoandrosterone = 3a-hydroxy- 5a-androstane-11,17-dione; 11-hydroxyetiocholan- olone =3a,118-dihydroxy-58-androstan-17-one; 11- ketoetiocholanolone = 3a-hydroxy-56-androstane- 11,17-dione; pregnenediol = pregn-5-ene-38,20a- diol; pregnenetriol =pregn-5-ene-38,17a,20a-triol; pregnanediol =58-pregnan-3a,20a-diol; pregnane- triol =58-pregnan-3a,17a,20a-triol; S =sulfate es- ter; G =glucuronoside; o’p’-DDD = 1,1-dichloro-2- (O-chlorophenyl)-2-(p-chlorophenyl)-ethane.
dione and 7-keto-DHAS are secreted by these tumors (1-4). However, our knowl- edge concerning the secretion and meta- bolism of androgen and their precursors by normal and pathological adrenal glands is still limited (5-8).
In the present study, we determined the concentrations of unconjugated and con- jugated C-19 and C-21 steroids in periph- eral blood and in the adrenal vein of a child with adrenocortical carcinoma. The metab- olism and the production rates of T, A, DHA and DHAS were also studied. The effects of o’,p’-DDD therapy on plasma concentrations of androgens are also re- ported.
Case Report
A boy aged 7 yr and 6 months was referred to the hospital in January 1967 with a history of virilization and abdominal distention.
Physical examination revealed a child with musculature developed to adult male propor- tions, a deep voice, facial acne and a light beard growth. His height was 138 cm, weight 35 kg, and his bone age 13 yr. His penis was pigmented and of adult size. Both testes were small and the prostate palpable. An abdominal mass was felt in the right hypochondrium. X-ray examina-
tion of the abdomen revealed a calcified mass above the right kidney. The endocrine studies carried out at that time (see Results) supported the diagnosis of an adrenocortical virilizing tumor.
Laparotomy was carried out on February 24, 1967. A right-sided adrenocortical tumor was found and removed. It weighed 2100 g. The histology was that of a malignant carcinoma.
Following operation he remained well for 7 months, at which time the urinary 17-KS were slightly increased. At the end of November 1967, the urinary 17-KS were 100 mg/day. In December 1967, a second laparotomy was per- formed. A mass adherent to the inferior vena cava was found and removed from the right supra-adrenal area. The tumor weighed 25 g. Histologically, the tumor was quite similar to the one removed 9 months previously. Follow- ing operation, the urinary 17-KS decreased to normal values, but 12 months later increased again to 100 mg/day. In March 1968, the uri- nary 17-KS reached 400 mg/day. At this time both hepatic arteriography and scanning of the liver after 198Au administration suggested the existence of a metastatic deposit in the right lobe of the liver. On March 24, 1968, a third laparotomy was performed and the right lobe of the liver and the right kidney were removed. Macroscopically, the right lobe of the liver con- tained 3 metastases, each measuring 3 ×2, 5 ×3 cm. Histologically, these tumors resembled the primary tumor. No metastases were found in the kidney. In the first week after operation the urinary 17-KS returned to normal values. Two weeks after operation, chemotherapy was insti- tuted with 5-fluorouracil 300 mg/day for 10 days and o’,p’-DDD 6 g daily, which was continued.
He remained well until September 1968. At this time, the patient exhibited drug toxicity with anorexia, nausea and vomiting. Physical examination revealed bilateral gynecomastia and an increase in the size of the testes. The urinary 17-KS were very low and urinary excre- tions of estrone, estradiol and estriol were each less than 3 ug/day. Urinary FSH excretion lay between 5 and 40 mouse units.
On October 3, 1968, all therapy was stopped and it was followed by a sharp rise in urinary 17-KS and especially in 17-ketogenic steroids (KGS). Two months later, gynecomastia had disappeared, but ascites had developed, and x-ray examination revealed several metastatic nodules in both lungs. Chemotherapy was re- sumed with cyclophosphamide 600 mg/week and o’,p’-DDD 5 g/day. This therapy pro- duced a temporary decrease in the excretion of urinary steroids, but during the following weeks
his general condition deteriorated. He died on May 14, 1969. Permission for autopsy was refused by the parents.
Materials
1,2-3H-T (SA 30 Ci/mmole), 14C-A (SA 50 mCi/mmole), 14C-DHA (SA 40 mCi/mmole) and 3H-DHAS (SA 5 Ci/mmole), obtained from New England Nuclear Corporation, were chro- matographed before use.
The following systems were used for paper chromatography. I. Hexane : methanol : water (100:90:10). II. Hexane : benzene : methanol : water (66:33:80:20). III. Toluene:isooctane: methanol:water (75:25:80:20). IV. Benzene: methanol: water (100:50:50).
Radioactivity was measured with a Packard Tri-Carb liquid scintillation spectrometer, model 3320.
Gas liquid chromatography (GLC) was carried out in an F and M apparatus model 402 flame ionization detector. Glass columns, 8 feet by } inch, were packed with either 2.5% SE-30 or XE-60 on gas-chrom Q (100-120 mesh).
Methods
1. Urinary Steroids. Total urinary 17-ketoste- roids (17-KS) and 17-ketogenic steroids (KGS) were determined by a modification (9) of the method described by Appleby et al. (10). The urinary Porter-Silber chromogens were mea- sured by the method of Glenn and Nelson (11).
Preliminary separation of urinary steroids in the unconjugated, sulfate and glucuronide frac- tions was achieved by a modification (7) of the method described by Crepy et al. (12). The glucuronides were hydrolyzed by ß-glucuroni- dase and the sulfates by solvolysis (13). Further steps in purification were group fractionation with digitonin and Girard T reagent. The re- sulting alpha and beta ketonic and nonketonic fractions were purified as follows:
The alpha ketonic fraction was submitted to paper chromatography in system I. Androster- one and etiocholanolone were eluted separately and quantitated as free steroids by GLC. Tes- tosterone was purified and measured as pub- lished elsewhere (14). The more polar 11-oxo- 17-ketosteroids were eluted together and mea- sured as the trimethylsilyl ethers by GLC.
From the alpha nonketonic fraction pregnane- diol and pregnanetriol were isolated and eluted separately after chromatography in system II. Their final measurement was by GLC.
The beta ketonic fraction was chromatog- raphied in system I for 10 hr. DHA was eluted and quantitated as free by GLC. The more
polar area corresponding to 7-keto-DHA and 16-hydroxy-DHA was eluted. The separation, further purification and measurement of these compounds were carried out as described else- where (15).
Beta nonketonic fraction. Pregnenediol, andros- tenediol and pregnenetriol were isolated from this fraction after chromatography in system II. All 3 steroids were quantitated as free by means of GLC.
Estrogens. Estrogens were isolated from the phenolic fraction obtained after hydrolysis of the glucuronides. The 3 main estrogens, estrone, estradiol and estriol, were separated by chroma- tography of the phenolic fraction in system III. The estrone and estradiol were rechromato- graphed separately in system II and the estriol in system IV. Thereafter, the samples were acetylated and submitted to thin-layer chroma- tography using CHCI3 for the solvent system. The areas corresponding to estrone acetate, estradiol diacetate and estriol triacetate were eluted separately and measured by GLC.
2. Plasma steroids. Androsterone, etiocholan- olone and DHA in both glucuronide and sulfate fractions, and 11-hydroxyandrostene- dione were measured by GLC. All the other steroids were quantitated by double isotopic dilution. The method used has already been described (2, 15).
3. Production rates. The metabolic clearance rates (MCR) of T and A were measured after single intravenous injection of 5.77 uCi of 3H-T and 1.99 uCi of 14C-A. Plasma T and A were isolated as described by Rivarola et al. (16). The urine was collected from the time of the injec- tion of the tracer for 48 hr, and pooled. From an aliquot of this pool both androsterone and T isolated from the sulfate and glucuronide fractions were purified by the method described elsewhere (14).
The urinary production rates of DHA and DHAS were determined after the simultaneous iv injection of 7.4 uCi of 3H-DHAS and 2.84 uCi of 14C-DHA (investigation A). The urine was collected for 4 days and pooled. The specific activity of several urinary metabolites was measured on an aliquot of this pool (see Re- sults). In addition to the preliminary purifica- tion reported above, each urinary metabolite was repurified in 3 or more chromatographic systems before measurement of the specific activity.
In another study, 1.99 uCi of 14C-A and 10.5 uCi of 3H-DHAS were injected (investigation B). As in the preceding investigation, the urine
was collected for 4 days, and the specific ac- tivity of several metabolites measured.
The secretion rates of cortisol, corticosterone and aldosterone were measured by methods published elsewhere (17).
Results
All the investigations reported except for some of the plasma androgen and urinary group steroid assays were carried out at the time of the initial hospitalization, prior to removal of the tumor.
1. Total urinary steroids. The total urinary 17-KS before the first operation varied be- tween 1700 and 2100 mg daily. During the same period, the urinary excretion of KGS and 17-OHCS lay between 32 and 65 mg/24 hr, and between 2 and 4 mg/24 hr, respec- tively (Fig. 1). Fractionation of urinary steroids at the time of the first hospitaliza- tion showed that all steroids measured were tremendously increased except for preg- nanediol and the estrogens (Table 1).
2. Plasma steroids (Table 2).3 Peripheral plasma concentrations of unconjugated steroids were markedly increased for the age of the patient. This increase was most important for DHA. The tumoral origin of pregnenolone, DHA and A was demon- strated by the higher concentration of these steroids in the adrenal vein plasma than in the peripheral plasma. In contrast, the T concentration was similar in adrenal and peripheral plasma. This last-mentioned result suggests that the tumor did not se- crete and that all the plasma T derived from the peripheral conversion of its pre- cursors. A testicular origin of T is unlikely, because, three weeks after the first opera- tion, the plasma concentration of T went down to 0.041 ug/100 ml, while that of DHAS and A decreased to 5.5 and 0.030 ug/100 ml, respectively.
Plasma concentrations of steroid sulfates were even more increased than those of the
3 Some of the results for peripheral and adrenal plasma concentrations reported here have already been published (15).
SURGERY
1
2
3
2100
1
1
1900
1
1700-
Cyclophosphamide 600mg/week
5-Fluorouracil 300 mg/1 mm
500
8
O,p-DDD g/day
4
Dexamethasone 1 mg/day
400
17-KS
KGS
mg/day
100
F-
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F
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A
MJ
J
A
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D J
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1967
1968
1969
unconjugated steroids. The higher con- centrations in adrenal venous plasma than in peripheral plasma, for all the steroid sulfates measured except those of andros- terone and etiocholanolone, indicated their secretion by the tumor (Table 2). In No- vember 1967, at the time of the first recur- rence, although the plasma steroid con- centrations were much lower, a similar pattern was observed (Table 2).
In October 1968, after five months of o’,p’-DDD and dexamethasone therapy, the plasma concentrations of T and A were increased for the age of the patient, but concentrations of DHA and its sulfate were normal (Table 3).4 After two months with- out any therapy, 4, DHA and DHAS con- centrations rose sharply, while the increase
of T was less important. Thereafter, in spite of antimitotic therapy, a continuous rise in plasma concentrations of A, DHA and DHAS was observed but the levels of T did not change significantly (Table 3).
4. Metabolism of T and A. The MCRs of T and A were 1165 and 2164 1/day, re- spectively. These values are similar to those found in adult males (18). However, if the results are corrected for body surface area (1.16 m2), then the MCRs of both steroids are about twice those found in nor- mal adult males. A similar increased MCR of both T and A has been reported in pa- tients with large endocrine tumors by Bar- din et al. (8) and Lipsett et al. (19).
The blood production rates of both T and A at 14 and 16.4 mg/day, respectively, were considerably increased for the age of the patient. As expected, the urinary produc-
4 At this point in time, an increase in testicular size and a urinary output of FSH similar to that ob- tained in normal adult occurred and led us to think that some of the T had its origin in the testis.
| Sulfates | Glucu- ronides | |
|---|---|---|
| DHA | 283 | 70 |
| Androsterene | 8 | 15 |
| Etiocholanolone | 19 | 88 |
| 11-Ceto-androsterone | + | 10 |
| 11-Ceto-etiocholanolone | + | 19 |
| 11-Hydroxyandrosterone | + | 26 |
| 11-Hydroxyetiocholanolone | + | 3 |
| Androstenediol | 27 | 28 |
| Pregnenodiol | 12 | 0.1 |
| Pregnenetriol | 4 | 0.1 |
| Pregnanediol | + | 0.2 |
| Pregnanetriol | + | 9 |
| 16-hydroxy-DHA | 99 | 2 |
| 7-Keto-DHA | 17 | 1 |
| Testosterone* | 0.21 | 0.14 |
| Estrone* | + | 0.002 |
| Estradiol* | t | 0.001 |
| Estriol* | + | 0.001 |
* These are the only values which have been cor- rected for losses during isolation.
t Not investigated.
tion rates at 37.4 and 72 mg/day, respec- tively, were still higher.
The specific activities of several urinary metabolites after injection of 14C-A and 3H-T are given in Table 4. The 14C specific activity of TG was higher than that of androsterone isolated from both glucuro- nide and sulfate fractions. These findings, together with the results of blood and urinary production rates, suggest, first, that one or several precursors were con- verted to urinary androsterone without going through the A plasma pool, and, second, that a part of the urinary TG was derived from precursors other than the plasma T and 4. The 3H specific activity of urinary TS was several times lower than that of urinary TG. Therefore, TS must have been diluted by precursors other than
| February 1967 | November 1967 | |||
|---|---|---|---|---|
| Adrenal vein | Periph- eral vein | Periph- eral vein | ||
| Unconjugated | ||||
| Pregnenolone | 94.3 | 12.9 | 2.81 | |
| 17-Hydroxypreg- nenolone | - | 7.9 | 1.31 | |
| DHA | 247 | 23.8 | 3.10 | |
| Androstenediol | - | 13.4 | 0.61 | |
| Androstenedione | 2.03 | 0.76 | 0.32 | |
| Testosterone | 1.02 | 1.21 | 0.13 | |
| 11-Hydroxyan- drostenedione | - | 40 | . . | |
| Cortisol | -- | 19 | ||
| Sulfates | ||||
| Pregnenolone | 98 | 69 | 13 | |
| 17-Hydroxypreg- nenolone | 59 | 14 | ... | |
| DHA | 14,770 | 7,680 | 237 | |
| Androstenediol | 655 | 304 | 15 | |
| Testosterone | 6.8 | 1.8 | 0.22 | |
| Androsterone | 94 | 99 | ... | |
| Etiocholanolone | 52 | 50 | ||
| Glucuronides | ||||
| DHA | 235 | 227 | - | |
| Androsterone | - | 22 | - - | |
| Etiocholanolone | 37 | 43 | --- - | |
plasma T. TS was itself secreted by the tumor (Table 2) and may have been such a precursor.
5. Metabolism of DHAS, DHA and 4. The specific activities of several urinary metabolites after injection of 3H-DHAS and 14C-DHA (investigation A) and 3H- DHAS and 14C-4 (investigation B) are given in Table 5. In experiment A, in the urinary DHAG the specific activities for both 3H and 14C were lower than those
| Dates | Treatment | Plasma (ug/100 ml) | Urine (mg/day) | ||||
|---|---|---|---|---|---|---|---|
| DHAS | DHA | A | T | 17-KS | KGS | ||
| Oct. 1, 1968 | o',p'-DDD Dexametha- sone | 13 | 0.36 | 0.25 | 0.81 | 0.7 | 2.7 |
| Dec. 12, 1968 | No | 211 | 1.83 | 7.45 | 1.21 | 48 | 127 |
| Apr. 4, 1969 | o',p'-DDD Cyclophos- phamide Dexamethasone | 418 | 5.98 | 13.99 | 1.29 | 187 | 281 |
| May 12, 1969 | No | 1781 | 7.63 | 14.89 | 1.35 | 532 | 233 |
found in DHAS. However, the 3H/14C ratios were similar in both conjugates.
The specific activities of 3H and 14C in androstenediol G were similar to those found in DHAG, but, in contrast, those of androstenediol S were lower than those of DHAS.
The specific activity for tritium in androsterone G was similar to that of DHAG, but its 14C specific activity was the highest found in any of the steroids iso- lated.
In experiment B, the specific activity for 3H in androsterone G was similar to that in DHAG and in androstenediol G, thus con- firming the results of experiment A. The 11-ketoandrosterone and the 11-hydroxy- androsterone from the a-ketonic fraction were subjected to intense purification (paper chromatography in 3 systems, TLC in 3 systems). An additional proof of the purity of these compounds was afforded by the presence of a single peak on GLC. The actual quantities isolated were 2.2 mg for 11-ketoandrosterone and 6.1 mg for 11- hydroxyandrosterone. In the latter com- pound there were 42 cpm of 3H with a background of 14 cpm, but, when the poor ratio of 3H/14C is taken into account, the possibility of error in this value is high.
The production rate of DHAS calculated from the specific activity of the 3H in urinary DHAS was 2100 and 2388 mg/24
| dpm/µg | ||
|---|---|---|
| He | 14C | |
| Sulfates | ||
| Testosterone | 10.5 | Unmeasurable |
| Androsterone | 25 | 23.2 |
| Glucuronides | ||
| Testosterone | 171 | 34.4 |
| Androsterone | 31 | 30.4 |
hr in experiments A and B, respectively. If the production is calculated from the 3H specific activity of unconjugated DHA in the urine, the production rate amounts to 2000 and 2032 mg/24 hr, respectively.
The production of unconjugated DHA calculated from the 14C specific activity of urinary DHAG was 5100 mg/24 hr but, if calculated from the specific activity of the unconjugated DHA in 14C, a value of about half of this is obtained.5
6. Cortisol, corticosterone and aldosterone secretion rates. In spite of the total lack of clinical evidence of any excess of gluco- and
5 The specific activities obtained for unconju- gated DHA in both investigations A and B must be accepted with certain reservations, since, during the 4 days in which urine was collected, the speci- mens were not deep-frozen. Some spontaneous hydrolysis of urinary sulfates or glucuronides can- not be excluded.
| dpm/mg | ||||||
|---|---|---|---|---|---|---|
| Experiment A | Experiment B | |||||
| Hs | 14C | 3H /14C | He | 14C | 3H/14C | |
| DHA unconjugated* | 2,046 | 544 | 3.76 | 2,867 | ||
| DHAG* | 1,356 | 310 | 4.37 | 1,721 | ||
| DHAS* | 1,955 | 446 | 4.38 | 2,439 | ||
| Androstenediol G* | 1,308 | 300 | 4.36 | 1,627 | ||
| Androstenediol S* | 1,701 | 378 | 4.50 | 2,200 | ||
| Androsterone G* | 1,282 | 752 | 1.70 | 1,738 | 15,860 | 0.109 |
| Testosterone G | - | - | <855 | 17,940 | 0.047 | |
| 11-Ketoandrosterone G | - | - | - | 976 | ||
| 11-Hydroxyandrosterone G | - | - | <20 | 992 | ||
| Tracers injected | 2.60 | 5.21 | ||||
* Samples were recrystallized with added carrier.
mineralocorticoids, the secretion rates of cortisol, corticosterone and aldosterone at 29, 8.8 and 0.45 mg/day, respectively, were increased two to four times when consider- ing the age of the patient.
Discussion
Proof of direct adrenal secretion of a steroid hormone depends upon the simul- taneous measurement of the compound in the suprarenal vein and in a peripheral vein. This method has already been used to demonstrate the tumoral secretion of several C-19 and C-21 steroids (1-5). In our own case, the levels of all the uncon- jugated steroids and steroid sulfates mea- sured in the adrenal vein were higher than those in peripheral plasma with exceptions only for unconjugated T and for etio- cholanolone sulfate, both of which showed similar levels in the two situations (Table 2). Absence of unconjugated T from tumor tissue (15) has confirmed that this com- pound was not, in fact, secreted by the tumor. Mahesh et al. (4) have also sug- gested an absence of direct secretion of T in two cases of adrenal tumor but, in both their subjects, the plasma levels of the hor- mone in suprarenal vein were more than twice those found in peripheral blood. Nevertheless, Lipsett et al. (20) have used isotope techniques to demonstrate absence of tumoral secretion of T in a case of metastatic interstitial cell carcinoma of the testis with high levels of plasma T.
In our own case, despite the absence of direct secretion of T, the plasma produc- tion rate was very high. An increased con- version of A to T has been found in some previously reported cases of adrenal tumor (8) but, even if this increased conversion were applicable to our case, only 20% of the plasma T would have its precursor in the plasma A pool.
Recently, Gurpide et al. (20-22) have made theoretical and practical studies with a multicompartmental model to calculate the secretion rates and production rates of DHAS, DHA, 4 and T, following the in-
jection of several tracers and measurement of the specific activities of several urinary metabolites. Using the data of Tables 4 and 5, we calculated the urinary produc- tion rates for these four steroids but we were unable to calculate the secretion and the conversion rates. After injection of 3H- DHAS and 14C-DHA, the specific activities of both isotopes in urinary DHAG were lower than those in urinary DHAS, in spite of the fact that the tumor was actually secreting important amounts of DHAS. In the same experiment, the 14C specific ac- tivity in urinary androsterone glucuronide was higher than that in DHAS, although A was secreted by the tumor.
Possible reasons for the discrepancies be- tween the results of Gurpide and his col- leagues and our own findings must be dis- cussed. In the analysis of Gurpide et al., it was assumed, first, that plasma DHAS, DHA and A were the common intermedi- ates for all precursors of urinary DHAS, DHAG and androsterone glucuronide, re- spectively, and, second, that in the metab- olism of these steroids there is no spatial compartmentalization. It seems probable that in this patient the tumor was removing DHA from the blood stream and secreting DHAS, thus making it possible for both plasma and urinary DHAS to contain an excess of 14C compared with DHAG. On the other hand, formation of DHAG in the liver or in other peripheral tissue from other precursors than DHA or DHAS could also explain the lower specific ac- tivities for both isotopes in the DHAG ex- creted in the urine. Either 17-hydroxypreg- nenolone or its sulfate could have been such precursors (6, 7) and both were, in fact, secreted by the tumor (Table 2).
The principal urinary metabolite of 11- hydroxyandrostenedione is 11-hydroxyan- drosterone (23, 24). Thus, a high urinary excretion of this metabolite suggests an in- creased secretion of 11-hydroxyandros- tenedione. This was confirmed in our pa- tient by demonstration of high levels of this steroid in plasma and in the tumor it-
self (15). However, some of this resulted probably from 118-hydroxylation of the circulating plasma 4 (Table 5).
Treatment of adrenal carcinoma with o’,p’-DDD gives rise to a reduced excretion of urinary steroids in 70% of cases (33). However, it has been shown that o’,p’- DDD can alter the peripheral metabolism of certain steroids (26-28) and, as a result, the quantity of steroids excreted in the urine cannot give a true indication of the response of the tumor to treatment. Bardin et al. (8) have studied the response of plasma androgens to o’,p’-DDD in four women with adrenal cancer and in only two of these cases was there a lowering of plasma T and 4. In our case, after five months of treatment with o’,p’-DDD, and despite the appearance of pulmonary me- tastases, the urinary steroid excretion was very low, as were the plasma levels of DHA and its sulfate. In contrast, the plasma levels of T and A were increased.4 After two months without treatment, all the plasma androgens had risen abruptly, but the type of secretion of the tumor had probaby changed from what had existed before in that the ratio of DHA/A in the plasma which had heretofore always greatly ex- ceeded unity now achieved a value of less than 1, and this was maintained to the end. Likewise, the urinary excretion of 17-KS, although increased, was less than that of the KGS. We are unable to state whether this change in the pattern of tumoral secretion was a result of treatment or whether it was due to a process of spontaneous evolution in the tumor (29).
Acknowledgments
The authors thank Professor J. Marion and Dr. J. Bernex for allowing us to study the patient.
We are grateful to Dr. D. M. Cathro for help in editing the manuscript.
References
1. Baulieu, E. E., J Clin Endocr 22: 501, 1962.
2. Saez, J. M., M. A. Rivarola, and C. J. Migeon, J Clin Endocr 27: 615, 1967.
3. Saez, J. M., S. Saez, and C. J. Migeon, Steroids 9: 1, 1967.
4. Mahesh, V. B., E. B. Greenblatt, and R. F. Coniff, Amer J Obstet Gynec 100: 1043, 1968.
5. Wieland, R. G., C. de Courcy, and H. Hirsch- mann, Steroids 2: 61, 1963.
6. Solomon, S., A. C. Carter, and S. Lieberman, J Biol Chem 235: 351, 1960.
7. Loras, B., and C. J. Migeon, Steroids 7: 459, 1966.
8. Bardin, C. W., M. B. Lipsett, and A. French, J Clin Endocr 28: 215, 1968.
9. Few, J. D., J Endocr 22: 31, 1961.
10. Appleby, J. E., G. Gibson, J. K. Normyberski, and R. D. Stubbs, Biochem J 60: 453, 1955.
11. Glenn, E. M., and D. H. Nelson, J Clin Endocr 13: 911, 1953.
12. Crepy, O., M. F. Jayle, and F. Meslin, Acta Endocr (Kobenhavn) 24: 233, 1957.
13. Burstein, S., and S. Lieberman, J Biol Chem 233: 331, 1958.
14. Saez, J. M., and C. J. Migeon, Steroids 10: 441, 1967.
15. Saez, J. M., B. Loras, A. M. Morera, and J. Bertrand, J Steroid Biochem 1: 355, 1970.
16. Rivarola, M. A., J. M. Saez, J. W. Meyer, M. E. Jenkis, and C. J. Migeon, J Clin Endocr 26: 1208, 1966.
17. Loras, B., H. Roux, A. Dazord, and J. Ber- trand, Rev Eur Clin Biol (to be published).
18. Baird, D. T., R. Horton, C. Longcope, and J. F. Tait, Perspect Biol Med 11: 384, 1968.
19. Lipsett, M. B., G. A. Sarfaty, H. Wilson, C. W. Bardin, and L. M. Fishman, J Clin Invest 45: 1700, 1966.
20. Gurpide, E., P. C. MacDonald, A. Chapde- laine, R. L. Van de Wiele, and S. Lieberman, J Clin Endocr 25: 1637, 1965.
21. MacDonald, P. C., A. Chapdelaine, O. Gon- zales, E. Gurpide, R. L. Van de Wiele, and S. Lieberman, J Clin Endocr 25: 1557, 1965.
22. Chapdelaine, A., P. C. MacDonald, O. Gon- zales, E. Gurpide, R. L. Van de Wiele, and S. Lieberman, J Clin Endocr 25: 1569, 1965.
23. Bradlow, H. L., and T. F. Gallagher, J Biol Chem 229: 505, 1957.
24. Goldzicher, J. W., and S. C. Beering J Clin Endocr 29: 171, 1969.
25. Hutter, A. M., and D. E. Kayhoe, Amer J Med 41: 581, 1966.
26. Southren, A. L., S. Tochimoto, K. Isurugi, C. G. Gordon, E. Krikun, and W. Stypulkow- ski, Steroids 7: 11, 1966.
27. Bledsoe, T., D. P. Island, R. L. Ney, and G. W. Liddle, J Clin Endocr 24: 1303, 1964.
28. Bradlow, H. L., B. Zumoff, T. F. Gallagher, and L. Hellman, Excerpta Med, Internat. Cong. Series 111: 153, 1966 (Abstract).
29. Gallagher, T. F., Cancer Res 17: 520, 1957.