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Yokoyama M, Kijima T, Takada‐Owada A, Sakamoto K, Suzuki I, Nishihara D, Nakamura Y, Ishida K, Kamai T. A case of estrogen-secreting adrenocortical carcinoma: Comprehensive immunohistochemical analysis of disorganized steroid genesis. IJU Case Rep 2021; 4:318-321. [PMID: 34497994 PMCID: PMC8413203 DOI: 10.1002/iju5.12336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 05/17/2021] [Accepted: 06/10/2021] [Indexed: 12/05/2022] Open
Abstract
INTRODUCTION Adrenocortical carcinoma rarely secretes estrogens, and little is known regarding the mechanism of intra-tumor estrogen production. We report an estrogen-secreting adrenocortical carcinoma in a postmenopausal woman, where comprehensive immunohistochemical analyses of the resected tumor revealed disorganized steroidogenesis. CASE PRESENTATION A 68-year-old woman presented with postmenopausal vaginal bleeding and was found to have a left adrenal tumor. Serum estradiol and testosterone were elevated but they normalized after resection of the tumor, suggestive of adrenocortical carcinoma with disorganized steroidogenesis. Immunohistochemical analyses revealed that the tumor expressed aromatase which converts androgens into estrogens. Furthermore, the tumor lacked 17βHSD2, which converts estradiol to estrone, suggesting that estradiol accumulated as the final product of the tumor's steroidogenic pathway. CONCLUSION The capability of adrenocortical carcinoma to produce estrogen can be demonstrated by comprehensive immunohistochemical analyses of steroidogenic enzymes, such as those reported here.
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Affiliation(s)
- Megumi Yokoyama
- Departments ofUrologyDokkyo Medical UniversityShimotsugaTochigiJapan
| | - Toshiki Kijima
- Departments ofUrologyDokkyo Medical UniversityShimotsugaTochigiJapan
| | - Atsuko Takada‐Owada
- Department ofDiagnostic PathologyDokkyo Medical UniversityShimotsugaTochigiJapan
| | - Kazumasa Sakamoto
- Departments ofUrologyDokkyo Medical UniversityShimotsugaTochigiJapan
| | - Issei Suzuki
- Departments ofUrologyDokkyo Medical UniversityShimotsugaTochigiJapan
| | - Daisaku Nishihara
- Departments ofUrologyDokkyo Medical UniversityShimotsugaTochigiJapan
| | - Yasuhiro Nakamura
- Division of PathologyTohoku Medical and Pharmaceutical UniversitySendaiMiyagiJapan
| | - Kazuyuki Ishida
- Department ofDiagnostic PathologyDokkyo Medical UniversityShimotsugaTochigiJapan
| | - Takao Kamai
- Departments ofUrologyDokkyo Medical UniversityShimotsugaTochigiJapan
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Jeong Y, Cho SC, Cho HJ, Song JS, Kong JS, Park JW, Ku YH. Estrogen-secreting adrenocortical carcinoma. Yeungnam Univ J Med 2018; 36:54-58. [PMID: 31620613 PMCID: PMC6784621 DOI: 10.12701/yujm.2019.00017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 08/09/2018] [Accepted: 09/11/2018] [Indexed: 11/17/2022] Open
Abstract
Adrenocortical carcinoma is a rare type of endocrine malignancy with an annual incidence of approximately 1–2 cases per million. The majority of these tumors secrete cortisol, and a few secrete aldosterone or androgen. Estrogen-secreting adrenocortical carcinomas are extremely rare, irrespective of the secretion status of other adrenocortical hormones. Here, we report the case of a 53-year-old man with a cortisol and estrogen-secreting adrenocortical carcinoma. The patient presented with gynecomastia and abdominal discomfort. Radiological assessment revealed a tumor measuring 21×15.3×12 cm localized to the retroperitoneum. A hormonal evaluation revealed increased levels of estradiol, dehydroepiandrosterone sulfate, and cortisol. The patient underwent a right adrenalectomy, and the pathological examination revealed an adrenocortical carcinoma with a Weiss’ score of 6. After surgery, he was treated with adjuvant radiotherapy. Twenty-one months after treatment, the patient remains alive with no evidence of recurrence.
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Affiliation(s)
- You Jeong
- Department of Internal Medicine, Korea Cancer Center Hospital, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Sung Chul Cho
- Department of Internal Medicine, Korea Cancer Center Hospital, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Hee Joon Cho
- Department of Internal Medicine, Korea Cancer Center Hospital, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Ji Soo Song
- Department of Internal Medicine, Korea Cancer Center Hospital, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Joon Seog Kong
- Department of Pathology, Korea Cancer Center Hospital, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Jong Wook Park
- Department of Urology, Korea Cancer Center Hospital, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Yun Hyi Ku
- Department of Internal Medicine, Korea Cancer Center Hospital, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
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Takeuchi T, Yoto Y, Ishii A, Tsugawa T, Yamamoto M, Hori T, Kamasaki H, Nogami K, Oda T, Nui A, Kimura S, Yamagishi T, Homma K, Hasegawa T, Fukami M, Watanabe Y, Sasamoto H, Tsutsumi H. Adrenocortical carcinoma characterized by gynecomastia: A case report. Clin Pediatr Endocrinol 2018; 27:9-18. [PMID: 29403152 PMCID: PMC5792817 DOI: 10.1297/cpe.27.9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 08/19/2017] [Indexed: 01/14/2023] Open
Abstract
We present a 4-yr-old boy with adrenocortical carcinoma (ACC), diagnosed due to the appearance of gynecomastia as the presenting symptom. Six months prior to admission, an acute growth spurt along with the development of bilateral breast swelling was observed. He did not present any features of virilization, including enlargement of the testes, increase in testis volume, and penis size. Laboratory investigations showed gonadotropin-independent hypergonadism, with low LH/ FSH levels and elevated estradiol/testosterone levels. Abdominal computed tomography revealed a large heterogeneous mass adjacent to the right kidney and below the liver. Pathological investigations of the biopsy specimen demonstrated that the tumor was an ACC. Pre- and post-operative combination chemotherapy with mitotane was administered and surgical resection was carried out. Post-surgery, the elevated estradiol/testosterone concentrations reverted to within the reference range. Urinary steroid profile and tissue concentration analysis of estradiol and testosterone indicated the presence of estrogen in the ACC tissue. An investigation for TP53 gene aberrations revealed the presence of a germline point mutation in exon 4 (c.215C>G (p.Pro72Arg)). In ACC, the most common symptom is virilization, and feminization, characterized by gynecomastia, is very rare. However, a diagnostic possibility of ACC should be considered when we encounter patients who have developed gynecomastia without the influence of causative factors such as obesity or puberty, and do not present with the typical signs of virilization.
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Affiliation(s)
- Takako Takeuchi
- Department of Pediatrics, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Yuko Yoto
- Department of Pediatrics, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Akira Ishii
- Department of Pediatrics, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Takeshi Tsugawa
- Department of Pediatrics, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Masaki Yamamoto
- Department of Pediatrics, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Tsukasa Hori
- Department of Pediatrics, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Hotaka Kamasaki
- Department of Pediatrics, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Kazutaka Nogami
- Department of Pediatrics Hematology and Oncology, Hokkaido Medical Center for Child Health and Rehabilitation, Sapporo, Japan
| | - Takanori Oda
- Department of Pediatrics Hematology and Oncology, Hokkaido Medical Center for Child Health and Rehabilitation, Sapporo, Japan
| | - Akihiro Nui
- Department of Pediatric Surgery, Hokkaido Medical Center for Child Health and Rehabilitation, Sapporo, Japan
| | - Sachiko Kimura
- Department of Pathology, Hokkaido Medical Center for Child Health and Rehabilitation, Sapporo, Japan
| | - Takuya Yamagishi
- Maternal-Child Screening Division, Health Science Section, Sapporo City Institute of Public Health, Sapporo, Japan
| | - Keiko Homma
- Clinical Laboratory, Keio University Hospital, Tokyo, Japan
| | - Tomonobu Hasegawa
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Maki Fukami
- Department of Molecular Endocrinology, National Center for Child Health and Development, Tokyo, Japan
| | - Yoko Watanabe
- Inspection Department, ASKA Pharma Medical Co., Ltd, Kawasaki, Japan
| | - Hidehiko Sasamoto
- Inspection Department, ASKA Pharma Medical Co., Ltd, Kawasaki, Japan
| | - Hiroyuki Tsutsumi
- Department of Pediatrics, Sapporo Medical University School of Medicine, Sapporo, Japan
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Hatano M, Takenaka Y, Inoue I, Homma K, Hasegawa T, Sasano H, Awata T, Katayama S. Feminizing Adrenocortical Carcinoma with Distinct Histopathological Findings. Intern Med 2016; 55:3301-3307. [PMID: 27853073 PMCID: PMC5173498 DOI: 10.2169/internalmedicine.55.5912] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
We herein present a 60-year-old man with adrenocortical carcinoma who had gynecomastia. An endocrinological examination revealed increased levels of serum estradiol and dehydroepiandrosterone-sulfate (DHEA-S) and reduced levels of free testosterone. Magnetic resonance imaging showed an adrenal tumor with heterogeneous intensity. Iodine-131 adosterol scintigraphy showed an increased uptake at the same site. Because feminizing adrenocortical carcinoma was suspected, right adrenalectomy was performed; the pathological diagnosis was adrenocortical carcinoma. The results of immunostaining indicated a virilizing tumor. Aromatase activity was identified on RT-PCR. As disorganized steroidogenesis is pathologically present in adrenocortical carcinoma, this diagnosis should be made with caution.
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Affiliation(s)
- Masako Hatano
- Department of Endocrinology and Diabetes, Saitama Medical University, Japan
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Uruc F, Urkmez A, Yuksel OH, Sahin A, Verit A. Androgen secreting giant adrenocortical carcinoma with no metastases: A case report and review of the literature. Can Urol Assoc J 2015; 9:E644-7. [PMID: 26425231 DOI: 10.5489/cuaj.2867] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Functional adrenocortical carcinoma (ACC) is a very rare disease with a poor prognosis. Over half (60%) of ACCs bigger than 6 cm synthesize hormones; hormone-secreting ACCs generally include virilization, feminization or Cushing syndrome. Besides, 82% of ACCs are metastatic at the time of diagnosis. While a 48-year-old female patient was examined for abdominal pain and flushing, we detected a non-metastasizing mass (23 × 18 × 16 cm) in the adrenal lodge. The mass was extracted en bloc during open exploration and its histopathology was reported as ACC. We review the literature and report the largest androgen-producing, clinically silent ACC mass cited in the literature so far.
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Affiliation(s)
- Fatih Uruc
- Fatih Sultan Mehmet Research and Training Hospital, Department of Urology, Içerenkoy/Atasehir, Istanbul, Turkey
| | - Ahmet Urkmez
- Fatih Sultan Mehmet Research and Training Hospital, Department of Urology, Içerenkoy/Atasehir, Istanbul, Turkey
| | - Ozgur Haki Yuksel
- Fatih Sultan Mehmet Research and Training Hospital, Department of Urology, Içerenkoy/Atasehir, Istanbul, Turkey
| | - Aytac Sahin
- Fatih Sultan Mehmet Research and Training Hospital, Department of Urology, Içerenkoy/Atasehir, Istanbul, Turkey
| | - Ayhan Verit
- Fatih Sultan Mehmet Research and Training Hospital, Department of Urology, Içerenkoy/Atasehir, Istanbul, Turkey
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Abstract
Feminizing adrenal tumors (FAT) are extremely rare tumors prevailing in males. Clinical manifestations are gynecomastia and/or other hypogonadism features in adults. They are rarer in pediatric population and their main manifestation is peripheral sexual precocity. In women genital bleeding, uterus hypertrophy, high blood pressure and/or abdomen mass may be the only manifestations. On the biological point, estrogen overproduction with or without increase in other adrenal hormones are the main abnormalities. Radiological examination usually shows the tumor, describes its limits and its eventual metastases. Adrenal and endocrine origins are confirmed by biochemical assessments and histology, but that one is unable to distinguish between benign and malignant tumors, except if metastases are already present. Immunostaining using anti-aromatase antibodies is the only tool that distinguishes FAT from other adrenocortical tumors. Abdominal surgery is the best and the first line treatment. For large tumors (≥10 cm), an open access is preferred to coeliosurgery, but for the small ones, or when the surgeon is experienced, endoscopic surgery seems to give excellent results. Surgery can be preceded by adrenolytic agents such as ortho paraprime dichloro diphenyl dichloroethane (Mitotane), ketoconazole or by aromatase inhibitors, but till now there is not any controlled study to compare the benefit of different drugs. New anti-estrogens can be used too, but their results need to be confirmed in malignant tumors resistant to classical chemotherapy and to conventional radiotherapy. Targeted therapy can be used too, as in other adrenocortical tumors, but the results need to be confirmed.
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Affiliation(s)
- Farida Chentli
- Department of Endocrine and Metabolic Diseases, Bab El Oued Teaching Hospital, University of Medicine, Algiers, Algeria
| | - Ilyes Bekkaye
- Department of Endocrine and Metabolic Diseases, Bab El Oued Teaching Hospital, University of Medicine, Algiers, Algeria
| | - Said Azzoug
- Department of Endocrine and Metabolic Diseases, Bab El Oued Teaching Hospital, University of Medicine, Algiers, Algeria
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Fancellu A, Pinna A, Porcu A. Feminizing Adrenocortical Carcinoma with Distant Metastases: Can Surgery be Considered? Clin Pract 2014; 4:651. [PMID: 25332762 PMCID: PMC4202184 DOI: 10.4081/cp.2014.651] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 06/12/2014] [Indexed: 02/08/2023] Open
Abstract
Functioning adrenocortical carcinomas are rare diseases with dismal prognosis. A 41-year-old man presenting with gynecomastia had a giant feminizing adrenocortical carcinoma at stage IV. Although surgical resection was controversial, we removed the primary tumor to reduce the mass effects. He lived for 12 months with an acceptable quality of life. Gynecomastia may be the first sign of feminizing adrenal malignancies. Surgery may ameliorate the quality of life in selected patients with metastatic disease.
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Affiliation(s)
- Alessandro Fancellu
- Unit of General Surgery 2, Department of Clinical and Experimental Medicine, University of Sassari , Italy
| | - Antonio Pinna
- Unit of General Surgery 2, Department of Clinical and Experimental Medicine, University of Sassari , Italy
| | - Alberto Porcu
- Unit of General Surgery 2, Department of Clinical and Experimental Medicine, University of Sassari , Italy
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Farida C, Ilyes B, Smina Y, Sabrina S, Soumeya FN, Said A. Feminizing adrenal tumors: Our experience about three cases. Indian J Endocrinol Metab 2013; 17:509-513. [PMID: 23869312 PMCID: PMC3712386 DOI: 10.4103/2230-8210.111669] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Feminizing adrenal tumors (FATs) are very rare as they account for less than 2% of all the adrenal neoplasms. Their prognosis is deemed to be very poor. We aimed to present a mono centre (adult and pediatric) experience over a long period of time (January 1980 to Jun 2012). During the study period, we observed only three cases in men aged 22 (2 cases) and 45 (1 case). They all consulted for a painful gynecomastia, decreased libido and impotency. Estradiol was high in two cases at presentation, and after a relapsing tumor in the third one. All had big adrenal tumors (5.9, 6, and 17 cm), and a mixed secretion composed by high estradiol and cortisol. The pathological study argued for malignancy in two cases. But, only one had diffuse metastasis and died 4 years after diagnosis; the others diagnosed one and three years ago are still alive without any metastasis or relapsing.
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Affiliation(s)
- Chentli Farida
- Department of Endocrine, and Metabolic Diseases, Bab El Oued Hospital, 5boulevard Said Touati, Algiers, Algeria
| | - Bekkaye Ilyes
- Department of Endocrine, and Metabolic Diseases, Bab El Oued Hospital, 5boulevard Said Touati, Algiers, Algeria
| | - Yahiaoui Smina
- Department of Endocrine, and Metabolic Diseases, Bab El Oued Hospital, 5boulevard Said Touati, Algiers, Algeria
| | - Souidi Sabrina
- Department of Endocrine, and Metabolic Diseases, Bab El Oued Hospital, 5boulevard Said Touati, Algiers, Algeria
| | - Fedala Nora Soumeya
- Department of Endocrine, and Metabolic Diseases, Bab El Oued Hospital, 5boulevard Said Touati, Algiers, Algeria
| | - Azzoug Said
- Department of Endocrine, and Metabolic Diseases, Bab El Oued Hospital, 5boulevard Said Touati, Algiers, Algeria
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Saito T, Tojo K, Furuta N, Ono K, Sasano H, Utsunomiya K. Feminizing adrenocortical carcinoma with selective suppression of follicle-stimulating hormone secretion and disorganized steroidogenesis: a case report and literature review. Intern Med 2011; 50:1419-24. [PMID: 21720063 DOI: 10.2169/internalmedicine.50.4968] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We report a 61-year-old male with gynecomastia, poor libido and erectile dysfunction. Endocrinological studies showed high levels of estradiol and dehydroepiandrosterone sulfate. Although luteinizing hormone (LH) level was within the normal limit, the concentration of follicle-stimulating hormone (FSH) was under the normal limit. Delayed response of LH and poor response of FSH to gonadotropin-releasing hormone administration were detected. Magnetic resonance imaging of the abdomen revealed a left adrenal tumor. Although the surgically-resected tumor was diagnosed as a high grade ACC based on Weiss's criteria of adrenocortical malignancy, no metastasis was detected. Since estrogen levels normalized after resection, feminizing ACC was confirmed. While LH concentration increased slightly after operation, FSH level became transiently elevated over the normal limit, and finally reached the normal range. These data may suggest that FSH was suppressed selectively by hormone produced by ACC different from estrogen.
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Affiliation(s)
- Takatoshi Saito
- Division of Diabetes and Endocrinology, Department of Medicine, Jikei University School of Medicine, Japan.
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