VIRILIZATION OF A FEMALE INFANT BY A MATERNAL ADRENOCORTICAL CARCINOMA
Lilah F. Morris, MD1; Steven Park, BA1; Timothy Daskivich, MD2; Bernard M. Churchill, MD2; C. V. Rao, PhD3; Zhenmin Lei, MD, PhD4; Dorothy S. Martinez, MD5; Michael W. Yeh, MD1
ABSTRACT
Objective: To describe a possible mechanism underly- ing the partial virilization of a 46,XX infant by a functional maternal adrenocortical carcinoma (ACC).
Methods: We performed immunocytochemical stain- ing of tumor sections for luteinizing hormone (LH)/human chorionic gonadotropin (hCG) receptors. In addition, related reports in the literature are discussed.
Results: A previously healthy mother developed a large cortisol- and androgen-producing stage III adre- nal tumor that did not interfere with conception or early morphogenesis. The tumor eluded detection until after delivery of a partially virilized 46,XX female infant with ambiguous genitalia. Immunohistochemical staining of tumor sections revealed overexpression of the LH/hCG receptor. Virilization of the genetically female fetus may have resulted from hCG-stimulated steroid secretion by the ACC.
Conclusion: Because hypercortisolism and hyper- androgenism are associated with menstrual disturbances
Submitted for publication July 18, 2010 Accepted for publication November 15, 2010
From the 1Endocrine Surgical Unit, Department of General Surgery, David Geffen School of Medicine at the University of California at Los Angeles, Los Angeles California, 2Department of Urology, Division of Pediatric Urology, David Geffen School of Medicine at the University of California at Los Angeles, Los Angeles, California, 3Florida International University College of Medicine, Miami, Florida, 4Division of Research, Department of Obstetrics/Gynecology and Women’s Health, University of Louisville Health Sciences Center, Louisville, Kentucky, and 5Department of Medicine, Division of Endocrinology, David Geffen School of Medicine at the University of California at Los Angeles, Los Angeles, California.
Address correspondence to Dr. Michael W. Yeh, Endocrine Surgical Unit, Department of General Surgery, University of California at Los Angeles, 10833 Le Conte Avenue, 72-228 CHS, Los Angeles, CA 90095. E-mail: myeh@ mednet.ucla.edu.
Published as a Rapid Electronic Article in Press at http://www. endocrine practice.org on February 16, 2011. DOI:10.4158/EP10209.CR Copyright @ 2011 AACE.
and spontaneous abortion, pregnancy in patients with functional adrenal tumors is uncommon. Rarely, maternal steroid excess from a functional adrenal tumor has caused 46,XX disordered sex differentiation. This unusual case demonstrates the influence of hCG on the functionality of an ACC and demonstrates the rare phenomenon of viriliza- tion of a female infant by a functional maternal adrenal tumor. (Endocr Pract. 2011;17:e26-e31)
Abbreviations:
ACC = adrenocortical carcinoma; ACTH = adrenocor- ticotropic hormone; DHEA = dehydroepiandrosterone; DHEA-S = dehydroepiandrosterone sulfate; DSD = disordered sex differentiation; hCG = human chorionic gonadotropin; LH = luteinizing hormone
INTRODUCTION
Virilization of a female infant from transplacental pas- sage of maternal androgenic steroids is most commonly associated with ingestion of virilizing drugs. Rarely, func- tional maternal adrenal tumors can cause 46,XX disordered sex differentiation (DSD). Classically, this phenomenon is characterized by a pathologic increase in androgen levels in female fetuses, causing the external genitalia to assume a male phenotype. We present the first reported case of 46,XX DSD in a fetus, caused by a functional maternal adrenocortical carcinoma (ACC) in a patient who was asymptomatic before pregnancy. In uncovering a poten- tial mechanism of augmented tumor functionality during pregnancy, we demonstrate high expression of the lutein- izing hormone (LH)/human chorionic gonadotropin (hCG) receptor in this tumor (1,2).
CASE REPORT
A 20-year-old previously healthy woman presented during the postpartum period because of depressed mood, facial swelling, generalized weakness, acne, and prominent
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stretch marks. She denied having any of these symptoms before or during pregnancy. She had had regular menstrual periods and had no difficulty conceiving.
Four months earlier, she had given birth to a 46,XX infant (weighing 1.45 kg and having ambiguous genitalia) by normal spontaneous vaginal delivery at 32 weeks of gestational age. The baby had clitoromegaly, fused mid- line labioscrotal folds, and persistence of a urogenital sinus in conjunction with an ultrasonographically normal uterus and ovaries (Fig. 1). The mother had received regular pre- natal care, which had revealed gestational hypertension. The infant’s laboratory studies at birth demonstrated nor- mal levels of 17-hydroxyprogesterone (210 ng/dL; nor- mal, ≤360), deoxycortisol (218 ng/dL; normal, ≤235), and estrogen. Further hormonal studies in this infant were not performed; she was born at an outside hospital and was not referred to our institution until she was 4 months old. Her clitoromegaly resolved, and she reached all normal devel- opmental milestones. At 1 year of age, she underwent a one-stage corrective surgical procedure that created a vagi- nal opening from her persistent urogenital sinus.
On examination of the mother, she had hypertension despite taking 4 antihypertensive medications and had pro- nounced cushingoid features, including moon facies, a buf- falo hump, and prominent purple striae on her abdomen and in her axillary creases. A low-dose dexamethasone suppres- sion test demonstrated nonsuppressibility of cortisol, with undetectable adrenocorticotropic hormone (ACTH) levels. She had substantially elevated morning cortisol, renin, and dehydroepiandrosterone sulfate (DHEA-S), with normal urine and plasma metanephrines (Table 1). These factors were measured while the patient was taking ketoconazole, an ACTH and glucocorticoid synthesis inhibitor, likely leading to artificially deflated values. Computed tomogra- phy revealed a large, hypervascular right adrenal mass with caval invasion.
After appropriate blood pressure optimization, the mother underwent open surgical resection of her adre- nal tumor. Pathology examination demonstrated an ACC (10.5 by 6.5 by 5.5 cm and weighing 300 g) involving the renal hilum (stage III) with negative surgical margins. Postoperatively, the patient recovered rapidly, her cortisol levels normalized, and clinical manifestations of Cushing syndrome regressed. She received adjuvant mitotane therapy in escalating doses. Five months later, the patient developed recurrent Cushing syndrome and was found to have bulky metastatic disease in the thorax. She suc- cumbed to her disease 11 months after diagnosis.
MATERIALS AND METHODS
Sections (5 um thick) cut from paraffin-embedded tumor tissue blocks were immunostained for LH/hCG receptors by the avidin-biotin immunoperoxidase method, as previously described (3,4). The polyclonal antibody
raised against a synthetic N-terminal amino acid sequence of 15 to 38 of LH/hCG receptors was used at a dilution of 1:350. For the immunostaining controls, the same dilution of LH/hCG receptor antibody was preincubated overnight at 4℃ with excess corresponding receptor peptide and then applied to the tumor tissue sections.
RESULTS
Immunostaining of ACC samples demonstrated over- expression of LH/hCG receptors in the adrenal cortex (Fig. 2 A), with no expression in the stained control (Fig. 2 B).
DISCUSSION
Although rare, the presence of ACC during pregnancy has been reported. One large study found that all these tumors secreted cortisol alone or cortisol and another ste- roid hormone (5). In a review of 67 reported cases of preg- nancy with Cushing syndrome, 7 cases involved ACC (6). The mother in our current report presented with elevated aldosterone, cortisol, and DHEA-S. Her elevated cortisol level, in the setting of undetectable ACTH, was nonsup- pressible on an overnight low-dose dexamethasone test. Her elevated renin activity level argues against excess mineralocorticoid activity. Hence, we conclude that she had glucocorticoid-induced hypertension.
The feedback mechanisms of the hypothalamic-pitu- itary-adrenal axis suggest incompatibility of pregnancy with the presence of a functional adrenal tumor. Although in polycystic ovary syndrome the cause of anovulation is androgen excess, studies of patients with Cushing syn- drome demonstrate that hypercortisolemia is responsible for menstrual disturbances (7,8). One study found that 80%
| Hormone | Value | Reference range |
|---|---|---|
| Plasma | ||
| Adrenocorticotropic hormone (pg/mL) | <5 | 5-27 |
| Cortisol (ug/dL) | ||
| Midnight | 15 | <5 |
| 5 AM | 32 | 9-22 |
| Renin activity (ng/mL/h) | 21.9 | 0.5-4 |
| Aldosterone (ng/dL) | 36.8 | 3-16 |
| Dopamine (pg/mL) | <20 | 0-20 |
| Epinephrine (pg/mL) | <10 | 10-200 |
| Norepinephrine (pg/mL) | 114 | 80-520 |
| Free metanephrine (mmol/L) | <0.15 | 0-0.49 |
| Free normetanephrine (mmol/L) | 0.37 | 0-0.89 |
| Dehydroepiandrosterone (ng/ml) | 373 | 130-980 |
| Dehydroepiandrosterone sulfate (ng/ml) | 5,880 | 400-3,600 |
| Bioavailable testosterone (ng/dL) | 20 | 1.1-14.3 |
| Androstenedione (ng/dL) | 167 | 60-245 |
| Urine (24-hour collection) | ||
| Metanephrine (ug/24 h) | 65 | 30-350 |
| Normetanephrine (ug/24 h) | 127 | 50-650 |
| Cortisol (ug/24 h) | 33.8 | <45 |
| Dehydroepiandrosterone (ug/24 h) | 4,206 | 21-2,710 |
| Testosterone (ug/24 h) | 15 | 5-38 |
| 17-Ketosteroids (mg/24 h) | 5.7 | 6-15 |
of women of reproductive age with Cushing syndrome experience amenorrhea or oligomenorrhea (7). In 6 prior cases of 46,XX DSD caused by a maternal adrenal tumor, 3 patients had more than 1 spontaneous abortion, and 3 patients reported difficulty conceiving (9-14) (Table 2).
In order to develop ambiguous genitalia, the infant described in our report must have experienced androgen exposure before the 13th week of gestation. The fetal adrenal gland exhibits ACTH-responsive maximal cor- tisol production at 8 to 9 weeks of gestational age (15). Between weeks 8 and 12, dihydrotestosterone causes vir- ilization of the external genitalia, and excess androgen exposure can induce the formation of a common urogenital sinus (16,17). In human studies, the degree of labioscro- tal fusion is directly related to the amount of steroid given to the mother between gestational weeks 8 and 12. After
week 12, androgen excess produces only clitoral and labial hypertrophy (10,16,18).
These various timing constraints and the clinical manifestations observed in this case led us to the follow- ing inferences: (1) The tumor likely arose before preg- nancy but did not secrete sufficient amounts of cortisol to interfere with conception or to cause early fetal loss and (2) adrenal androgen production from the tumor was suf- ficiently high between gestational weeks 8 and 12 to cause labioscrotal fusion.
In light of the large size of the tumor at excision, we postulate that the tumor mass increased at a different rate than its peak functionality. Our consideration of this sce- nario motivated us to identify possible mechanisms under- lying what must have been an exquisitely timed androgen surge. Because peak hCG secretion occurs at 9 weeks of
A.
B.
gestation, we theorize that hCG levels may have triggered a dramatic increase in DHEA-S, leading to the infant’s vir- ilization (9,10).
Adrenocortical tumors have previously been shown to hypersecrete androgens acutely in response to hCG administration. Fuller et al (10) reported on a 33-year- old patient whose functional adrenal tumor was identified when her daughter was born with virilization. The patient was administered 5,000 IU hCG before and after resec- tion of her tumor (6 months after delivery). In response to hCG injection, DHEA-S increased to 9 times the base- line value preoperatively, whereas levels remained static in response to administration of hCG 2 weeks after resec- tion of the adrenal tumor. High basal levels of testosterone, dihydrotestosterone, and dehydroepiandrosterone (DHEA) increased by 20% to 50% in response to hCG (10). Mürset et al (9) reported a 40% increase in testosterone excretion after hCG administration. In vitro studies involving ACC cells in culture found that exposure to hCG induced a sig- nificant increase in DHEA but not testosterone (1).
Placental aromatase protects both the mother and the fetus against the effect of maternal androgens and high
levels of DHEA-S secreted by the fetal adrenal gland (18,19). Fetal aromatase deficiency, a possible cause of 46,XX DSD (20), was excluded in the current case because of the infant’s normal estrogen levels.
Pabon et al (4) demonstrated that the DHEA-secreting zona reticularis in the human adrenal gland contains LH/ hCG receptors. In vitro studies have demonstrated that the addition of LH or hCG to cultures of some human adre- nal tumors led to increased production of cyclic adenosine monophosphate and secretion of cortisol or androgens (2). Overexpression of the LH/hCG receptor in our patient’s tumor may explain the overproduction of androgen by the tumor in concert with the hCG surge (Fig. 2).
An alternative explanation for the discordance between virilization of an infant and little or weak maternal virilization is that this ACC grew exponentially as part of its normal growth course, uninfluenced by hCG. Although this scenario cannot be tested, it can explain the absence of maternal virilization in this case. In 3 cases of complete masculinization of female infants from benign adrenal tumors, the mothers had long histories of virilizing symp- toms and difficulty conceiving (9,11,14). Two other reports describe mothers who experienced virilization only during or after pregnancy (12,13). In each case, the observation of poor penile development and cryptorchidism led to the finding of 46,XX DSD in the offspring between 14 months and 15 years of age.
Two other cases described children with lesser degrees of virilization whose mothers experienced virilizing symp- toms during or after pregnancy. Fuller et al (10) reported on an infant with an enlarged clitoris and partial labial fusion, whereas Miyata et al (12) described a genetically female child born with severe hypospadias and undescended testes.
Grumbach and Ducharme (16) reviewed 14 cases in which maternal steroid ingestion during pregnancy caused 46,XX DSD. They found 3 cases in which the mother experienced no virilizing symptoms, noting a “striking dis- parity” between virilizing signs in the mother and the fetus in all cases.
CONCLUSION
This report describes an unusual case of a maternal ACC with LH/hCG receptor overexpression, causing virilization of a female infant. Although several studies have demonstrated overproduction of adrenal androgens in response to administration of hCG, more research is needed to characterize the adrenal LH/hCG receptor and the downstream processes associated with it.
DISCLOSURE
The authors have no multiplicity of interest to disclose.
| Reference | Maternal virilizing symptoms | Htn | Cushing features | Testosterone (x normal) | DHEA-S (x normal) | Andro- stenedione (x normal) | History of spontaneous abortion? | Difficulty conceiving? | Term delivery | Extent of virilization in offspring | Tumor size (cm) | Estimated time between tumor inception and resectionª |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Mürset et al (9), | Excessive body | ... | ... | 3.8 | 122.6 | 2.5 | No | Yes | 41 WGA | Complete | 6.5 by 5 | 7 y |
| 1970 | hair, poor | by 3 | ||||||||||
| breast | ||||||||||||
| development, | ||||||||||||
| deep voice, | ||||||||||||
| baldness | ||||||||||||
| Fuller et al (10), | Excessive | … | ... | 2.8 | 4.4 | 1.9 | 2 | No | ... | Partial | 8 by 6 | 7 y |
| 1983 | facial hair | by 5 | ||||||||||
| van de Kamp et | Low-pitched | Yes | ... | WNR | 3.2 | WNR | Several | Yes | 32 WGA | Complete | ... | 17 y |
| al (11), 1984 | voice, | |||||||||||
| excessive | ||||||||||||
| hair | ||||||||||||
| Miyata et al (12), | Excessive hair, | ... | Yes | 1.9-2.3 | 1.4-2.5 | 1.5 | ... | ... | ... | Complete | 10.5 by 8.5 | 4 y |
| 1989 | clitoral | (DHEA) | by 5.5 | |||||||||
| hypertrophy | ||||||||||||
| Kirk et al (13), | Excessive | ... | ... | 1.5 | 1.5 | 4.4 | Several | No | Yes | Complete | 9 by 6 | 15 y |
| 1990 | facial hair, | by 6 | ||||||||||
| male | ||||||||||||
| escutcheon, | ||||||||||||
| clitoral | ||||||||||||
| hypertrophy | ||||||||||||
| Alvarez-Nava et al (14), 2004 | Yes | Yes | ... | 4.1 | ... | ... | ... | Yes | 34 WGA | Complete | ... | 6 y |
| Morris et al | None | Yes | Yes | 1.4b | 1.63b | WNRb | No | No | 32 WGA | Partial | 10.5 by 6.5 | 16 mo |
| (current | by 5.5 | |||||||||||
| report) |
Abbreviations: DHEA = dehydroepiandrosterone; DHEA-S = dehydroepiandrosterone sulfate; Htn = hypertension; WGA = weeks of gestational age; WNR = within normal range.
a Estimates based on the time between first symptoms and time of diagnosis. In some cases, review of prior imaging studies demonstrated evidence of tumor.
b Studies during treatment with ketoconazole.
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