URINARY STEROIDS IN 10 CASES OF ADRENAL CARCINOMA, WITH SPECIAL REFERENCE TO PREGNANE-3a, 17a,20a-TRIOL-11-ONE
TO THE EDITOR:
It has been pointed out in previous publications (1-3) that “pregnane- triolone” (pregnane-3a,17a,20a-triol-11-one) is excreted in the urine of cases of congenital adrenal hyperplasia (female pseudohermaphrodism and macrogenitosomia praecox) and also in a few cases of Cushing’s syndrome, in some of which adrenal hyperplasia was verified by histologic examina- tion (4, 5). By contrast, no pregnanetriolone was found in the urine of 254 normal adult males and females and 5 patients with adrenocortical tumor (6).
These findings led us to postulate the feasibility of a test based on pregnanetriolone excretion, for differential diagnosis between adrenal tumor and adrenal hyperplasia. However, since the number of cases of adrenal tumor studied with pregnanetriolone determinations was limited, we were careful to suggest that more such cases should be studied before any generalization could be made.
Recently we received through the courtesy of Dr. Roy Hertz of the Endocrinology Branch, National Cancer Institute, Bethesda, Maryland, samples of urine from 10 patients with adrenal carcinoma. We analyzed these urines for pregnanetriolone, pregnanetriol and hydrocortisone. The methods used are described elsewhere (2, 3).1 Analyses for 17-ketosteroids (17-KS) and corticosteroids were performed at the National Cancer In- stitute, and results pertaining to 5 patients (V.G., G.T., V.F., R.S. and P.V.) together with a description of the cases have been published by Dr. Hertz and collaborators (7). Clinical data concerning the other 5 patients (G.H., J.B., L.S., T.R. and J.H.) and the respective excretions of 17-KS and corticosteroids were kindly communicated to us by Dr. M. B. Lipsett of the National Cancer Institute.
In Table 1 the urinary steroid data on the 10 patients with adrenal can- cer are summarized. Mean excretions in normal adults and in patients with congenital adrenal hyperplasia (female pseudohermaphrodism and macro- genitosomia praecox) are listed for comparison. The following features seem to be noteworthy :
1. None of the adrenal cancer patients excreted pregnanetriolone in quantities detectable by our method, the sensitivity of which was in most cases between 0.1-0.2 mg. per twenty-four hours.2
1 In all cases reported in the present communication, hydrolysis of urine was carried out with @-glucuronidase (Ketodase).
2 In previous publications (1, 2) the sensitivity of the estimation was indicated as
| Patient, Sex & Age | Clinical observations relating to hormonal effects | Pregnane- triolone (mg./24 hrs.) | Pregnane- triol (mg./24 hrs.) | Hydro- cortisone (mg./24 hrs.) | Corti- coids (mg./24 hrs.) | 17-KS (mg./24 hrs.) |
|---|---|---|---|---|---|---|
| G.H. (m.) 16 mo. | Phallus slightly enlarged; no other viriliz- ing signs | <0.04 | < 0.20 | <0.02 | 0.5 | 100-160 |
| V.G. (f.) 28 yrs. | Cushing's syndrome | <0.15 | 5.6 | 1.90 | 48.0 | 150 |
| J.B. (m.) 36 yrs. | Cushing's syndrome +virilization | <0.10 | 4.5 | 1.04 | 30-50 | 100-150 |
| G.T. (m.) 33 yrs. | Cushingoid appearance | <0.20 | < 1.0 | <0.1 | 11.5 | 11.3 |
| V.F. (f.) 45 yrs. | Cushing's syndrome +hirsutism | <0.16 | 1.09 | <0.08 | 18.0 | 34.0 |
| L.S. (f.) 55 yrs. | Virilizing syndrome with hirsutism | <0.10 | 3.36 | 0.48* | 5-10 | 40- 50 |
| R.S. (m.) 30 yrs. | Slightly Cushingoid | <0.11 | 13.0 | 0.71* | 47.0 | 55.0 |
| P.V. (f.) 30 yrs. | Cushing's syndrome +virilization | <0.13 | 6.1 | 0.57 | 43.5 | 36.4 |
| T.R. (m.) 59 yrs. | No clinical evidence of hormonal effects | <0.20 | 6.7 | 0.32 | 5-10 | 80-150 |
| J.H. (f.) 18 yrs. | No clinical evidence of hormonal effects | <0.14 | 5.8 | 0.53* | 3- 8 | 3- 10 |
| Normal adults (mean excretion) Congenital adrenal hyperplasia (mean excretion) | <0.05 1-5 | 0.1-1.5 5-20 | ≤0.03 | 5- 15 | 8- 20 | |
| <0.03 | 1-10 | 30- 60 | ||||
* Hydrocortisone was not completely separated from additional substances showing either blue or pink fluorescence, and the values should not be regraded as quantitative.
2. Excretion of pregnanetriol was elevated above “normal” in most of the patients, and was normal in a few others. No correlation was found be- tween the occurrence of virilization and the concentration of pregnanetriol in the urine. Neither could 17-KS excretion be correlated with the develop- ment of a virilization syndrome.
3. Hydrocortisone was excreted in increased quantities in some of the patients showing clinical signs of Cushing’s disease, but the increment was also observed in patients without clinical signs of excessive adrenocortical activity. Conversely, excretion of hydrocortisone within the “normal” range was found in patients showing some of the characteristic signs and symptoms of Cushing’s disease.
The most prominent feature of the foregoing results is that in none of the 10 cases of adrenocortical carcinoma was pregnanetriolone excreted in the urine in quantities detectable by our method. This applied to all categories, regardless of whether the patients exhibited virilization, signs of Cushing’s disease, or no clinical evidence of hormonal effects. The claim is not being
0.04-0.05 mg. per twenty-four hours. In the present series, due to scarcity of material, smaller aliquots of the 24-hour urine pool had to be used, thus reducing the sensitivity. Similarly, the sensitivity of the pregnanetriol and hydrocortisone estimation was pro- portionately decreased.
made that all patients with adrenocortical cancer do not excrete increased quantities of pregnanetriolone. Nevertheless, the uniform results obtained in the present series would suggest that elevated excretion of pregnane- triolone in such cases might be regarded as exceptional.
Similarly, in another series of 5 cases of adrenocortical adenoma (1 with Cushing’s syndrome, 3 with virilization, and 1 without significant hormonal effects), pregnanetriolone was not found in the urine in amounts above 50 µg. per twenty-four hours. In 1 of these cases the sensitivity of the analyt- ical method was increased to the point of detecting 1-2 ug. of pregnane- triolone in a 24-hour urine specimen, but no pregnanetriolone was found (6).
Regarding the excretion of pregnanetriolone in cases of congenital adrenal hyperplasia, the present evidence based on analyses performed by us in 26 cases (1, 2, 3, 6) and confirmed by others (8-11) is that in all pa- tients with this condition appreciable quantities of pregnanetriolone are excreted in the urine. To the best of our knowledge not a single case of congenital adrenal hyperplasia has been reported in which the urine was analyzed for pregnanetriolone but none was found. Thus is seems that high excretion of pregnanetriolone in congenital adrenal hyperplasia is more or less a general phenomenon, although this would not exclude the possi- bility of exceptions.
Comparison of the data on pregnanetriolone excretion in patients with adrenal carcinoma on the one hand and congenital adrenal hyperplasia on the other, suggests that the latter condition may be distinguished by the occurrence of large amounts (usually milligram quantities in adult pa- tients) of pregnanetriolone in the urine, despite possible exceptions. One such case was observed by us, in which pregnanetriolone was found in de- tectable amounts in the urine of a woman with a virilizing syndrome not due to a tumor. In 10 other patients with similar clinical manifestations no pregnanetriolone was detectable (6). The single case in which pregnane- triolone was excreted may be regarded as an intermediary, not fully devel- oped form of female pseudohermaphrodism.
The distinction between Cushing’s syndrome due to adrenal carcinoma and that due to adrenal hyperplasia appears to be more difficult. In 6 pa- tients with Cushing’s syndrome, in 4 of whom adrenal hyperplasia was confirmed and in 2 of whom the presence of a tumor was excluded, pregnane- triolone was found in the urine in quantities ranging from 50 µg. to 400 µg. per twenty-four hours (6). Since in the cases of adrenal cancer producing Cushing’s syndrome described in the present publication, the urines were analyzed for pregnanetriolone at a comparatively low level of sensitivity. (100-200 µg. per twenty-four hours), it cannot be stated conclusively that pregnanetriolone was not present in the lower concentrations found in
cases of Cushing’s syndrome due to adrenal hyperplasia. Clarification of this problem may possibly be achieved by using a larger volume of urine for the analysis and by the introduction of a modification of the method for estimation of pregnanetriolone which allows for the quantitation of 2 ug. of the compound in a 24-hour urine specimen (6).
It follows that when the clinical status warrants a differential diagnosis between adrenal hyperplasia and adrenal tumor in a patient excreting uri- nary pregnanetriolone in detectable quantities, adrenal hyperplasia should be considered. Alternatively, if pregnanetriolone is not being excreted in detectable amounts, an adrenal tumor should be suspected. In this in- stance, high excretion of either 17-KS, pregnanetriol, or corticoids may be suggestive but not diagnostic of an adrenal tumor. On the other hand, the excretion of any of these compounds within normal limits should not be taken as evidence against the presence of adrenal neoplasia (cf. Patient G.T). The proposed test does not allow for the distinction between “idio- pathic” virilism and a tumor of the adrenal cortex, since in both conditions the excretion of steroids as measured by our method appears to be non- specific.
MICHAEL FINKELSTEIN, PH.D. JUDITH SHOENBERGER, M. Sc.
Hormone Research Laboratory,
Hebrew University-Hadassah Medical School, Jerusalem, Israel, November 20, 1958
Acknowledgments
We are greatly obliged to Drs. Roy Hertz and M. B. Lipsett of the National Cancer Institute, Bethesda, Maryland, for having made available to us the urine of the patients with adrenal cancer, together with their clinical histories and the data on 17-KS and cor- ticoid excretion. .
The pregnane 3a, 17a, 20a-triol-11-one used as reference was kindly donated by Ciba, Basel, through the courtesy of Drs. A. Wettstein, G. Anner and R. Neher. We also wish to express our gratitude to Dr. W. Klyne, Postgraduate Medical School, London, for the gift of pregnane-3x, 17a,20a-triol.
The authors are much indebted to Prof. B. Zondek for his kind interest in the inves- tigation.
This study was supported by the Max London Foundation and by the Hadassah Medical Organization Research Fund.
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JEM