THE FEMINIZING SYNDROME IN MALE SUBJECTS WITH ADRENOCORTICAL NEOPLASMS

Feminizing adreno-cortical carcinomas in male adults. A dire prognosis. Three cases in a series of 801 adrenalectomies and review of the literature

We describe the clinical presentation, biochemical features, diagnostic criteria, clinical course and differential diagnosis in three cases of feminizing adreno-cortical carcinoma (FACC) with a review of the literature.

PATIENTS

From 1970 throughout December 2003 among a series of 801 adrenalectomies, three had been performed for FACC.

RESULTS

Age at presentation was 74, 63 and 23 years. Estradiol hypersecretion was observed in 3/3 patients, 17 OH progesterone was elevated in 2/3 patients and both of them had a diminution of testosterone, delta 4 androstenedione was elevated in 1/3 patients. Imaging studies suggested malignancy in 3/3 patients by the presence of necrosis, heterogeneity, calcifications, size of the tumor and compression of adjacent organs. All patients were stage III at presentation and had a Weiss score >or=6. Size and weight of the tumors were 30, 20, 15cm and 3750, 480 and 275g respectively. All 3 patients received mitotane and cortisone post-operatively and at follow up (7, 3 and 2 years) all 3 died of the disease.

CONCLUSIONS

Feminizing adreno-cortical carcinomas in adults are exceedingly rare (1-2% of adreno-cortical carcinomas). Tumors are huge and even after surgery for cure their prognosis is worse than for other varieties of adreno-cortical carcinomas either secreting or non secreting. Early diagnosis and treatment may improve overall prognosis.

Adrenocortical tumors: clinical symptoms and biochemical diagnosis

Patients who are suspected clinically to suffer from hypersecretory disorders of their adrenal(s) should undergo an appropriate endocrinological investigation to confirm or exclude the presence of such disorders prior to any radiological investigation. In those patients in whom an adrenal mass is found 'incidentally' on imaging clinical symptoms of hormonal activity should be carefully followed up. Asymptomatic patients should be screened biochemically for latent hormonal hypersecretion syndromes including pheochromocytoma (urine catecholamine excretion), hypercortisolism (overnight dexamethason suppression test) and aldosteronism (blood pressure and serum potassium). These investigations are mandatory in all patients scheduled for surgery. The decision to refer patients with inactive adrenal tumors to surgery is, in the absence of valid biochemical markers of malignancy, mainly influenced by tumor size but remains arbitrary. Patients who are not at first treated by surgery should be operated if follow-up indicates a progression in tumor size.

Feminizing Adreno-Cortical Carcinoma: Report of a Case

A case of feminizing adreno-cortical carcinoma is reported and features of these tumours are commented on. The differential diagnosis of gynaecomastia and its investigation are discussed. The features of adrenal carcinoma are also discussed, the literature is reviewed and treatment is outlined.