Ovarian steroidogenesis in an adrenalectomized girl with 21-hydroxylase deficiency

Bilateral Adrenalectomy in Congenital Adrenal Hyperplasia: A Systematic Review and Meta-Analysis

CONTEXT

Management of congenital adrenal hyperplasia (CAH) involves suppression of the hypothalamic-pituitary-adrenal axis using supraphysiological doses of exogenous glucocorticoids. This can pose a challenge, with Cushing syndrome a frequent complication of adequate suppression. Bilateral adrenalectomy, with subsequent replacement of glucocorticoids and mineralocorticoids at physiological doses, has been proposed as an alternative therapeutic strategy.

OBJECTIVE

To review the outcomes after bilateral adrenalectomy for CAH.

DATA SOURCES

A systematic search of PubMed/MEDLINE and Web of Science, identifying relevant reports published up to 10 January 2018.

STUDY SELECTION

Case reports or case series were included if they reported individual patient data from patients with CAH who had undergone bilateral adrenalectomy.

DATA EXTRACTION

Information regarding the following was extracted: first author, country, sex, age at adrenalectomy, year of adrenalectomy, diagnosis, molecular abnormality, pre- and postoperative biochemistry, pre- and postoperative medications, pre- and postoperative body mass index, indication for adrenalectomy, surgical technique, gross and microscopic adrenal characteristics, follow-up duration, and short- and long-term postoperative outcomes.

DATA SYNTHESIS

We identified 48 cases of bilateral adrenalectomy for CAH, with patients aged from 4 months to 56 years at surgery. The most common indication for surgery was the inability to control hyperandrogenism/virilization and/or Cushing syndrome (n = 30; 62%). Most patients (n = 34; 71%) reported symptomatic improvement postoperatively, with some cases of short-term (n = 5; 10%) and long-term (n = 13; 27%) adverse outcomes.

CONCLUSIONS

Bilateral adrenalectomy for CAH appears to be a reasonable therapeutic option for carefully selected patients who have had unsatisfactory outcomes with conventional medical management.

Ectopic adrenal rests in congenital adrenal hyperplasia as a cause of androgen excess after adrenalectomy detected by pelvic venous sampling

BACKGROUND

Patients with classic congenital adrenal hyperplasia (CAH) due to CYP21 deficiency are treated with supraphysiological doses of glucocorticoids to suppress elevated androgen production. This implies also side effects of high-dose glucocorticoids, possibly leading to iatrogenic Cushing's syndrome. Bilateral adrenalectomy has been suggested as the ultimate therapy in severe cases, when insufficient androgen suppression was obtained despite high glucocorticoid doses. Usually, ACTH levels rise after bilateral adrenalectomy, and this could imply an increased risk for the development of ectopic adrenal rests. In female CAH patients ovarian adrenal rests are not commonly detected by conventional radiological techniques.

METHODS

We report the case of an adult female CAH patient who underwent bilateral adrenalectomy in early puberty because of poorly controlled CAH.

RESULTS AND CONCLUSIONS

Several years after surgery, she developed secondary amenorrhea and hair loss as a result of androgen overproduction in ovarian adrenal rests that appeared to be detectable only by pelvic venous sampling. After unilateral oophorectomy androgen levels normalized.

Adrenal steroid concentrations in children seven to seventeen years of age

During puberty, serum steroid concentrations change dramatically. The objective of this study was to determine the adrenal steroid concentrations in children from 7 to 17 years of age. Tanner stage was determined in each child by physical examination. 11-Deoxycortisol, pregnenolone, 17-hydroxypregnenolone, 17-hydroxyprogesterone and testosterone were quantified by liquid chromatography-tandem mass spectrometry (LC-MS/MS). Androstenedione and dehydroepiandrosterone sulfate were measured by immunoassay. The median and central 95% of the steroid concentrations were determined for age, gender, and Tanner stage. Except for 11-deoxycortisol, all of the steroids exhibited an increase in concentration after age 7-9 years in both boys and girls. 11-Deoxycortisol, which is made exclusively in the adrenal cortex, declined with age and Tanner stage. This suggests that a rise in gonadal function and decreased efficiency of 11beta-hydroxylase with age may contribute to an increase in the remaining steroids. Testosterone concentrations increased more dramatically in boys, but increases were seen with each Tanner stage in girls.

Ovarian adrenal rest tissue in congenital adrenal hyperplasia--a patient report

We report a young girl who died in an Addisonian crisis due to previously undiagnosed congenital adrenal hyperplasia (CAH), in whom ovarian adrenal rest tissue was detected at postmortem histopathological examination. This is a very rare complication in female patients with CAH with only two previously reported cases.

Bilateral laparoscopic adrenalectomy as a treatment for classic congenital adrenal hyperplasia attributable to 21-hydroxylase deficiency

OBJECTIVE

Current medical therapy for congenital adrenal hyperplasia (CAH) attributable to a complete 21-hydroxylase deficiency is not optimal. Difficulties in adequate adrenal androgen suppression are common, causing short adult stature, infertility, and hyperandrogenism. We report the use of laparoscopic bilateral adrenalectomy as a definitive therapy for this condition and argue that it is superior to conventional medical therapy in selected patients.

METHODS

Participants were 2 adult females with classic, salt-wasting CAH and a history of poor adrenal control were selected for adrenalectomy: case 1 was a 22-year-old woman with mild hirsutism and primary amenorrhea; case 2 was a 28-year-old woman with severe hirsutism, acne, and amenorrhea. Preoperative and postoperative hormonal profiles were performed. Both underwent laparoscopic bilateral adrenalectomy with a mean follow-up of 37 months.

RESULTS

Bilateral laparoscopic adrenalectomy was performed in both patients with no complications and an uneventful recovery. Maintenance medications of glucocorticoid and mineralocorticoid replacement were reduced compared with preoperative doses. Three years postoperatively, however, rising adrenal steroid precursor levels in case 1, presumably caused by adrenal rests, prompted an increase in replacement therapy dose. Hirsutism and acne improved in both patients, and regular menstruation began 5 months (case 1) and 2 months (case 2) postoperatively. Pregnancy 3 years postoperatively was successful in case 2, who delivered a unaffected infant, full-term via Cesarian section.

CONCLUSIONS

Surgical adrenalectomy should be considered in females with classic CAH attributable to 21-hydroxylase deficiency and a history of poor hormonal control. Adrenalectomy may prove to be superior to current medical therapy for these patients.

Congenital adrenal hyperplasia: epidemiology, management and practical drug treatment

Congenital adrenal hyperplasia (CAH) owing to 21-hydroxylase deficiency is a common disorder, and is characterised by a defect in cortisol biosynthesis with or without a defect in aldosterone synthesis and androgen excess. The classic form, also known as the severe form, occurs in 1:15,000 births worldwide, while the nonclassic or mild form occurs in approximately 1:1,000 births worldwide and is much more common (up to 1:20) in certain ethnic groups. In classic 21-hydroxylase deficiency, glucocorticoids are given in doses sufficient to suppress adrenal androgen secretion, and mineralocorticoids are given to normalise electrolytes and plasma renin activity. The management of CAH may be complicated by iatrogenic Cushing's syndrome, inadequately treated hyperandrogenism, or both. Prenatal treatment may decrease virilisation of the affected female foetus, but the efficacy and safety of treating CAH prenatally remains to be fully defined. Close clinical monitoring of growth and development is essential to optimise treatment outcome. New treatment approaches are currently under investigation in the most severely affected patients, while nonclassic CAH does not always require treatment.

Bilateral laparoscopic adrenalectomy: a new treatment for difficult cases of congenital adrenal hyperplasia

PURPOSE

In difficult cases of congenital adrenal hyperplasia (CAH), often the child may have normal cortisol levels and elevated androgen levels, or normal androgen levels and elevated cortisol levels, but not normal levels of both. Because bilateral adrenalectomy removes the source of the abnormal androgen production, the authors felt that in some cases it might be more efficacious than conventional medical therapy.

METHODS

Three children with CAH and suboptimal response to medical management underwent bilateral laparoscopic adrenalectomy. Parents were counseled extensively regarding the experimental nature of this treatment and the potential long-term complications.

RESULTS

All children recovered quickly after a mean hospital stay of 1.8 days. Pathologic examination of the removed adrenal glands showed persistent cortical hyperplasia. Follow-up at 6 months indicated marked reduction in abnormal androgen production, which allowed lowering of the steroid dosing to physiologic levels.

CONCLUSION

In children with CAH refractory to medical management, bilateral laparoscopic adrenalectomy can be performed safely with almost trivial morbidity. Although early results are very encouraging, the anticipated long-term beneficial effects on growth, short stature, and adult infertility will require years to assess.

Congenital adrenal hyperplasia due to 21-hydroxylase deficiency

More than 90% of cases of congenital adrenal hyperplasia (CAH, the inherited inability to synthesize cortisol) are caused by 21-hydroxylase deficiency. Females with severe, classic 21-hydroxylase deficiency are exposed to excess androgens prenatally and are born with virilized external genitalia. Most patients cannot synthesize sufficient aldosterone to maintain sodium balance and may develop potentially fatal "salt wasting" crises if not treated. The disease is caused by mutations in the CYP21 gene encoding the steroid 21-hydroxylase enzyme. More than 90% of these mutations result from intergenic recombinations between CYP21 and the closely linked CYP21P pseudogene. Approximately 20% are gene deletions due to unequal crossing over during meiosis, whereas the remainder are gene conversions--transfers to CYP21 of deleterious mutations normally present in CYP21P. The degree to which each mutation compromises enzymatic activity is strongly correlated with the clinical severity of the disease in patients carrying it. Prenatal diagnosis by direct mutation detection permits prenatal treatment of affected females to minimize genital virilization. Neonatal screening by hormonal methods identifies affected children before salt wasting crises develop, reducing mortality from this condition. Glucocorticoid and mineralocorticoid replacement are the mainstays of treatment, but more rational dosing and additional therapies are being developed.

Bilateral ovarian steroid cell tumor in congenital adrenal hyperplasia due to classic 11beta-hydroxylase deficiency

An 8.7 year-old patient, raised as a boy, presented with premature appearance of pubic hair and accelerated growth since 2 years of age and ambiguous genitalia noted at birth. There was first degree consanguinity between his parents. A similar problem was reported in a cousin. Examination of the external genitalia revealed complete scrotal fusion, a 5 cm long phallus, urogenital sinus at base of phallus with no gonads palpable. Pigmentation was increased. His blood pressure was 150/100 mm Hg. Pubic and axillary hair were at stage 3. Bone age was 17 years. Adrenal ultrasound was normal. Pelvic ultrasound showed relatively enlarged uterus and ovaries with normal echogenicity. Karyotype was 46,XX. Hormone profile was compatible with congenital adrenal hyperplasia (CAH) due to 11beta-hydroxylase deficiency (11-deoxycortisol: 11.5 nmol/l [400 ng/dl] [normal: 0.6-4.5 nmol/l [20-155 ng/ml]], androstenedione: 17.4 nmol/l [5 ng/ml] [normal: 0.1-1.2 nmol/l [0.03-0.35 ng/ml]]). Prednisolone and antihypertensive drugs were started. The patient underwent bilateral salpingo-oophorectomy and hysterectomy at 9.1 years. Histopathological examination of both ovaries revealed steroid cell tumor. The type of the tumor was "not otherwise specified" (NOS). Basal hormone levels and ACTH test performed 10 months after the operation and 7 days off treatment reconfirmed the diagnosis of 11beta-hydroxylase deficiency. Steroid cell tumors are extremely rare forms of steroid hormone-reducing ovarian neoplasms in childhood and may coexist with or imitate virilizing CAH.

Prophylactic adrenalectomy of a three-year-old girl with congenital adrenal hyperplasia: pre- and postoperative studies

Long term follow-up studies of children with congenital adrenal hyperplasia have documented less than desirable outcomes, including reduction in final adult height, obesity, virilism, and decreased fertility. We have proposed that children with the most severe forms of congenital adrenal hyperplasia would be better off if their adrenals were removed at an early age. We report here on our experience with prophylactic bilateral adrenalectomy in a 3-yr-old girl with a double null mutation of the CYP21 gene. The results of sodium balance studies, performed preoperatively on our patient and her unaffected fraternal twin sister, and hormonal data are presented as well. In contrast to her twin, who markedly increased her sodium retention in response to ACTH, our patient showed increased natriuresis, suggesting a deleterious effect of her adrenals on sodium homeostasis. Adrenalectomy was carried out at the time of necessary genital repair. No surgical or postsurgical complications were encountered.

Precocious puberty due to a lipid-cell tumour of the ovary

A 4-year-old girl with a lipid cell tumour of the ovary showed isosexual precocious pseudopuberty. The endocrine activity of the tumour led to elevated plasma levels of dehydroepiandrosterone sulphate, oestradiol, testosterone and androstenedione. After tumour resection the clinical signs of abnormal hormonal stimulation disappeared within 10 months. The girl developed precocious puberty again 2 years later without any sign of relapse. Therapy with luteinizing hormone releasing hormone agonist was effective although premature activation of the hypothalamic-pituitary-gonadal axis could not clearly be demonstrated by hormonal investigations.