A 12-year-old Chinese girl with Cushing syndrome and virilization due to adrenocortical carcinoma
Lap Ming Wong1,*, Chak Ho Li1, On Kei Angel Chan2, Chi Chung Shek2 and Ngai Shan Kwong1
1 Department of Pediatrics and Adolescent Medicine, Tuen Mun Hospital, Hong Kong, P.R. China
2 Department of Pathology, Queen Elizabeth Hospital, Hong Kong, P.R. China
Abstract
A Chinese adolescent girl presented with secondary amenor- rhea. During follow-up, she gradually developed Cushingoid features and virilization. After a series of endocrine investiga- tions, including urinary steroid profiling, a diagnosis of adre- nocortical carcinoma was made. The treatment and prognosis of the disease are discussed.
Keywords: adrenocortical carcinoma; Cushing syndrome; urinary steroid profiling; virilization.
Introduction
Adrenocortical carcinoma (ACC) is extremely rare in Chinese subjects. Patients usually present with features of hormonal disturbance, with virilization and Cushing syndrome being the most common (1). The diagnostic approach involves confirmation of the abnormal hormonal secretion pertaining to a physiological disorder, followed by imaging studies to localize the lesion. In this report, we describe the diagnostic work-up for a Chinese adolescent girl presenting with viril- ization and Cushing syndrome.
Case report
A 12-year-old girl, the younger of twin sisters, was initially referred to our clinic for headache and secondary amenorrhea that had lasted for 4 months. There were no precipitating or relieving factors for the headache and no other associated symptoms. She had no other systemic complaints or a his- tory of drug or herb intake. Physical examination, including neurological examination, was normal. A CT-scan of the brain was performed and no focal lesion was detected.
During follow-up, she gradually developed acne of increas- ing severity over the forehead, deepening of her voice, obe- sity (mainly involving the trunk) and pink striae over the lower limbs. She remained amenorrheic for 6 months after her first visit. Physical examination showed that her height was 155.3 cm and body weight was 47.4 kg, with a body mass index of 19.6 kg/m2. Her blood pressure was 105/67 mm Hg and she had a pulse rate at 72/min. Extensive acne was noted over her forehead, chest and back. Fine hair was noted over her chest and along the linea alba. Her voice was deepened, although no prominent Adam’s apple was evident. Moreover, buffalo lumps, truncal obesity and pink striae were evident over the medial sides of both thighs and legs. The abdomen was not distended and no mass was palpable. Concerning pubertal stage, her breasts were at stage 3, her pubic hair was at stage 5 and axillary hair was at stage 3 of the Tanner stag- ing. Her clitoris was prominent, measuring 1 cm in length and 0.6 cm in diameter.
Complete blood counts were normal. Renal and liver func- tion tests were normal, with serum potassium of 4.1 mmol/L. Thyroid function tests and serum prolactin levels were nor- mal. Basal follicle-stimulating hormone and luteinizing hor- mone were 0.6 and <0.1 IU/L, respectively. Serum estradiol was 113 pmol/L (30.8 pg/mL). Tumor markers, including a-feto-protein, ß-human chorionic gonadotropin and CA125 were not higher than normal. A urinary pregnancy test was negative.
To investigate possible virilization, serum testosterone was measured and was high at 15.32 nmol/L (4.42 ng/ml) (refer- ence range 0.1-2.46 nmol/L, 0.03-0.71 ng/mL) but dehydro- epiandrosterone sulfate (DHEAS) was 5.2 umol/L (1.91 µg/ mL) (reference range 0.7-6.1 µmol/L, 0.26-2.25 µg/mL). A standard-dose short synacthen test (using Cortrosyn 250 µg) was performed. Basal and stimulated cortisol were 815 nmol/L (29.54 µg/dL) and 899 nmol/L (32.58 ug/dL), respectively. Basal and stimulated 17x-hydroxyprogesterone were 2.7 nmol/L (0.89 µg/L) and 4.0 nmol/L (1.32 ug/L), respectively. This confirmed that the girl had hyperandro- genism, but no evidence of the simple virilizing form of con- genital adrenal hyperplasia.
To investigate Cushingoid features, early morning and midnight cortisol levels were measured using an indwelling catheter; these were 759 nmol/L (27.51 µg/dL) and 776 nmol/L (28.13 µg/dL), respectively. Free cortisol in a 24-h urine sam- ple was high at 1798 nmol/day (651.68 µg/24 h) (reference range 100-379 nmol/day, 36.25-131.37 µg/24 h). An over- night 1-mg dexamethasone suppression test was performed. Midnight and early next morning cortisol were 819 nmol/L (29.68 µg/dL) and 862 nmol/L (31.24 µg/dL), respectively. Midnight and early next morning adrenocorticotrophic
*Corresponding author: Lap Ming Wong, Department of Pediatrics and Adolescent Medicine, Tuen Mun Hospital, Tsing Chung Koon Road, Tuen Mun, New Territories, Hong Kong, P.R. China Phone: +852-24685392, Fax: +852-24569111, E-mail: lmwong888@hotmail.com
hormone (ACTH) were both <1.1 pmol/L (5 pg/mL). This confirmed that the patient had Cushing syndrome.
Before dynamic function tests were performed, a 24-h sample was collected for urinary steroid profiling (USP), which revealed a significant increase in the excretion of free cortisol (779 ug/day; reference range 3-44), cortisol metabolites (36,260 µg/day; reference range 1034-10,388) and androgen metabolites (9422 ug/day; reference range 59- 6863). Mineralocorticoid metabolites were within the refer- ence range (398 ug/day; reference range 110-545) (Figure 1). Tetrahydro-11-deoxycortisol (2212 µg/day; reference range 7-61) and two uncommon metabolites, 5-pregnene- 3a,160,20c-triol (412 ug/day; reference range <30) and 5-pregnene-3,16a,20c-triol (39 ug/day; reference range <3), were grossly elevated. CT of the abdomen (Figure 2) and thorax showed a predominantly hypodense heteroge- neous mass in the posterior part of the left adrenal gland of 5.4 cm×3.6 cmx5 cm in size. Multiple hypo-enhancing hypodense nodules, the largest one 1.2 cm, were found in the liver and were suggestive of metastases. The right adrenal gland, the lung and the mediastinum were normal. Whole- body 18F-2-fluoro-2-deoxy-D-glucose positron emission tomography combined with a CT (PET-CT) scan revealed no metastases other than those in the liver.
A CT-scan-guided adrenal biopsy confirmed an adrenal cortical neoplasm. Analysis of a peripheral blood sample
revealed two heterozygous mutations in exon 7 of the TP53 gene, R249S (AGG>AGT) and P250S (CCC>TCC).
USP for the twin sister revealed no abnormal increase in free cortisol or cortisol metabolites, or presence of uncom- mon steroid metabolites. After counseling, genetic screening was offered to other family members.
Discussion
Adrenocortical tumors are very rare in Chinese children. According to the International Incidence of Childhood Cancer published by the International Agency for Research on Cancer, ACC incidence is 1.5 per million in Sao Paulo, Brazil, although this is almost more than three times the rate in most other regions (2). In an international study on adreno- cortical tumors in a sample of 254 patients, the female/male ratio was 1.6. Approximately 60% of these patients were less than 4 years of age, while 10% were 13 years or older, with a median age of 3.2 years at presentation (1). Almost 90% of the patients had abnormal hormone secretion. Virilization alone occurred in 55.1%, and in combination with over- production of other hormones (including Conn’s syndrome and/or feminization) in 29.2%. Isolated Cushing syndrome occurred in 5.5%. A non-hormonal secreting tumor was found in 10.2% (1).
Abundance
1.4e+07
A, B and C: internal standards
10
9: Tetrahydro-11-deoxycortisol+ 5-pregnene-3a, 16a.,20c-triol
1: Androsterone
1.3e+07
2: Aetiocholanolone
10: Tetrahydrocortisone
3: Dehydroepiandrosterone
12
11: 5-pregnene-30,16x,20c-triol
1.2e+07
4: 11-oxo-aetiocholanolone
12: Tetrahydrocortisol
5: 11-hydroxyandrosterone+17-hydroxypregnenolone
13: 5%-Tetrahydrocortisol
1.1e+07
6: 11-hydroxyaetiocholanolone
14: a-Cortolone
15: B-Cortolone+ß-Cortol
1e+07
7: Pregnanediol
16: a-Cortol
8: Pregnanetriol
17: Cortisol
9 000 000
2
8 000 000
7 000 000
7
6 000 000
6
11
13
5
5 000 000
A
8
14
4 000 000
9
15
4
3 000 000
B
2 000 000
1
C
3
U
16
1 000 000
17
Time — > 14.00
16.00
18.00
20.00
22.00
24.00
26.00
28.00
30.00
32.00
34.00
Se:8 Im:8
[A]
Study Date:24/11/2009 Study Time: 10:10:30
MRN
1L
CONTRAST
[P]
060
Work-up for patients presenting with endocrine disturbance requires a carefully designed protocol, especially when use of a pharmacological agent may affect the hormonal environ- ment for subsequent testing. In our patient, baseline blood and urine samples were collected before dynamic function tests were carried out. To test for virilization, testosterone and DHEAS levels were measured to assess the hyperandrogenic state. A standard-dose short synacthen test served to rule out the simple virilizing form of congenital adrenal hyperplasia. To test for Cushing syndrome, early morning and midnight serum cortisol were measured to assess possible loss of diurnal rhythm. Free cortisol was measured in 24-h urine to screen for hypercortisolism. The overnight dexamethasone suppres- sion test served to confirm Cushing syndrome (3). USP using gas chromatography-mass spectrometry is a useful tool in the diagnosis and monitoring of ACC. In a single analysis, USP can demonstrate the pattern and quantity of excretion of corti- sol, mineralocorticoid and androgen metabolites, which reflect the biosynthetic activities of the adrenal cortex. When there is hyperactivity in more than one of these biosynthetic path- ways, the diagnosis of ACC should be considered after ACTH- dependent Cushing syndrome has been ruled out. Besides, elevated excretion of unusual steroid metabolites such as 5-pregnene-3x,16a,20a-triol and 5-pregnene-3ß,160,20x- triol, which are products of aberrant steroidogenesis, or the reappearance of neonatal steroid metabolites after regression of the adrenal fetal zone, such as 16x-hydroxypregnenolone,
are highly suggestive of ACC (4). Positive findings in this test should prompt the clinician to arrange for an early imaging study, which usually takes a few months for an appointment in the public sector, or to review a previously negative radiologi- cal examination as soon as possible.
Imaging to define the extent of the tumor is important in disease staging, planning for possible surgical interven- tion and as a prognostic indicator. CT or MRI scanning of the abdomen and the chest is performed to define the size of the tumor, to detect possible invasion into adjacent struc- tures (including major blood vessels) and metastases to the liver or the mediastinum. As ACC has an active metabolism, whole-body PET-CT has a role in detecting distant metasta- sis beyond the abdomen and thorax, and in detecting tumor recurrence (5).
Owing to detailed hormonal work-up, including USP, together with sophisticated imaging studies, pre-operative fine-needle biopsy of ACC is no longer justified, as it is asso- ciated with needle-track metastasis (6). In our patient, the tumor had multiple liver metastases that were inoperable, and a biopsy was performed to obtain histological evidence before starting chemotherapy and oral mitotane (3).
The treatment approach depends on the extent of the disease. Surgical removal remains the most effective mode of therapy and should be considered in all patients. Complete tumor excision results in good long-term prog- nosis. However, rupture of the tumor pseudocapsule during surgery and invasion of the vena cava are associated with poor prognosis, even when the primary tumor is completely resected (7). For residual tumors, whether recurrent or meta- static, chemotherapy (cisplatin, etoposide and doxorubicin) combined with oral mitotane can be offered. In a study of 8 patients with recurrent tumor or advanced staging at presentation, chemotherapy combined with mitotane were offered. Five patients died of the disease while on treatment for 6-18 months (8).
An underlying constitutional genetic disorder has been discovered in almost half of the children with ACC and Li-Fraumeni syndrome is a notable example. A family with this syndrome had an ACC frequency of approximately 100 times that of the general population (9). Li-Fraumeni syn- drome is a well-known autosomal dominant entity whereby affected individuals have a propensity to develop primary cancers, such as brain tumor, breast cancer, osteosarcoma, leukemia, and ACC (9). The genetic basis of the syndrome has been identified as a mutation of the p53 gene in a family with multiple members affected by cancer (10).
In conclusion, ACC is a rare tumor that may present with secondary amenorrhea. Careful history and physical exami- nation are necessary to search for features of hormonal distur- bances such as virilization and Cushing syndrome. Diagnosis requires a high index of suspicion and a carefully designed endocrine work-up. USP is a useful tool for the diagnosis and monitoring of treatment response and is being increasingly used in the diagnostic work-up for ACC. Imaging studies serve to guide the disease management approach and prog- nosis. Complete surgical resection leads to good long-term prognosis. Chemotherapy combined with oral mitotane could
be offered for recurrence, residual disease or metastases, but the long-term outlook remains poor.
References
1. Michalkiewicz E, Sandrini R, Figueiredo B, Miranda EC, Caran E, et al. Clinical and outcome characteristics of children with adrenocortical tumors: a report from the International Pediatric Adrenocortical Tumor Registry. J Clin Oncol 2004;22:838-45.
2. Stiller CA. International variations in the incidence of childhood carcinomas. Cancer Epidemiol Biomarkers Prev 1994;3:305-10.
3. Fassnacht M, Allolio B. Clinical management of adrenocortical car- cinoma. Best Pract Res Clin Endocrinol Metab 2009;23:273-89.
4. Tiu SC, Chan AOK, Taylor N, Lee CY, Loung PY, et al. Use of urinary steroid profile for diagnosing and monitoring adrenocorti- cal tumours. Hong Kong Med J 2009;15:463-70.
5. Ahmed M, Al Sugair A, Alarifi A, Almahfouz A, Al-Sobhi S. Whole-body positron emission tomographic scanning in
patients with adrenal cortical carcinomas: comparison with conventional imaging procedures. Clin Nucl Med 2003;28: 494-7.
6. Schteingart DE, Doherty GM, Gauger PG, Giordano TJ, Hammer GD, et al. Management of patients with adrenal cancer: recom- mendations of an international consensus conference. Endocr Relat Cancer 2005;12:667-80.
7. Ribeiro RC, Figueiredo B. Childhood adrenocortical tumours. Eur J Cancer 2004;40:1117-26.
8. Zancanella P, Pianovski MA, Oliveira BH, Ferman S, Piovezan GC, et al. Mitotane associated with cisplatin, etoposide, and doxorubicin in advanced childhood adrenocortical carcinoma. J Pediatr Hematol Oncol 2006;28:513-24.
9. Ribeiro RC, Michalkiewicz EL, Figueiredo BC, DeLacerda L, Sandrini F, et al. Adrenocortical tumors in children. Braz J Med Biol Res 2000;33:1225-34.
10. Srivastava S, Zou Z, Pirollo K, Blattner W, Chang EH. Germ- line transmission of a mutated p53 gene in a cancer-prone family with Li-Fraumeni syndrome. Nature 1990;348:747-9.