Clinical and biochemical studies of a patient with a corticosterone-secreting adrenocortical tumour

Close examination of steroidogenesis disorders in a DOC- and progesterone-producing adrenocortical carcinoma

We report a case of hypertension, hypokalemia, and amenorrhea accompanying an adrenocortical carcinoma. A 27-year-old woman was admitted to our hospital because of a left adrenal incidentaloma. She presented with hypertension, hypokalemia, and amenorrhea; her plasma renin activity was low, but her plasma aldosterone concentration was normal, as were cortisol and androgens. By contrast, her serum concentrations of deoxycorticosterone (DOC), 18-hydroxydeoxycorticosterone, and progesterone were high, and her urinary steroid profile showed elevated secretion of 17-deoxysteroids and 11-deoxysteroids (progesterone, DOC, 11-dehydrocorticosterone, and 11-deoxycortisol), and 3beta-hydroxy 5-en steroids (pregnenolone, 17-hydroxypregnenolone, and DHEA). Decreased ratios of metabolites of (1) 17-OHpregnenolone to pregnenolone and 17-OHprogesterone to progesterone, (2) corticosterone to DOC and cortisol to 11-deoxycortisol, and (3) progesterone to pregnenolone, 17-OHprogesterone to 17-OHpregnenolone and androstenedione to DHEA suggested the impairment of 17alpha-hydroxylase, 11beta-hydroxylase, and 3beta-HSD activities, respectively. After the tumor was removed, levels of all adrenal steroids were normalized. Based on the Weiss criteria, the tumor was diagnosed as an adrenocortical carcinoma, and immunohistochemical analysis of steroidogenic enzymes revealed disorganized steroidogenesis in the tumor tissue. With adrenocortical carcinomas, heterogeneity of individual steroid producing enzymes within tumor cells can lead to hypersecretion of various steroid intermediates, even when steroid end products are within the normal range.

Adrenal adenoma with excess secretion of corticosterone and 18-hydroxycorticosterone

A 64-year-old man with sudden onset of quadriplegia due to marked hypokalemia was referred to our clinic with suppressed plasma renin activity in the presence of a low aldosterone level. Computerized tomography demonstrated a left adrenal adenoma, shown on adrenal scintigraphy to be functioning. The elevated basal level of plasma corticosterone and its increased response to 1-24 adrenocorticotropic hormone suggested the tumor produced corticosterone. The surgical specimen was a benign adrenocortical adenoma with excess content of corticosterone and 18-hydroxycorticosterone.

Diurnal variation of plasma corticosterone in depression

Hypersecretion of cortisol is associated with depression. Because corticosterone may show greater responsiveness than cortisol to exogenous ACTH in depression and it has behavioural effects in rodents, we determined whether depression is also associated with hypersecretion of corticosterone. Both cortisol and corticosterone were significantly elevated in depression, with greatest differences from control subjects during the afternoon and evening. The ratio of corticosterone/cortisol was constant and similar throughout the day in both depressed patients and controls. We conclude that there is no disproportionate endogenous hypersecretion of corticosterone in depression.

Hypermineralocorticism without elevation of plasma aldosterone: deoxycorticosterone-producing adrenal adenoma and hyperplasia

Two female patients were admitted for evaluation of hypertension and hypokalaemia. Plasma renin activity was suppressed and plasma aldosterone levels were within the normal value in a 52-year-old woman and below the normal value in the other patient, a 62-year-old woman. Plasma 11-deoxycorticosterone (DOC) levels were as high as 1.13 and 1.47 nmol/l, respectively. Adrenal scintigram and abdominal CT scan clearly showed a right adrenal tumour in the 52-year-old woman. After adrenalectomy plasma DOC level decreased to the normal level of 0.12 nmol/l, and her blood pressure and serum potassium became normal. Abdominal CT scan revealed no finding of adrenal tumour in the older woman. These results indicate that these two patients had hypermineralocorticism with elevation of plasma DOC. One patient had a DOC-producing adrenal adenoma, and the other probably had bilateral adrenal hyperplasia.

Hypermineralocorticoidism due to adrenal carcinoma: plasma corticosteroids and their response to ACTH and angiotensin II

A 47-year-old female presented with hypertension, hypokalaemia, low plasma renin, high plasma aldosterone and was found to have a left adrenal tumour 4 cm in diameter by computerized tomography. Detailed biochemical studies showed high plasma levels of 11-deoxycorticosterone and corticosterone in addition to aldosterone and 18-hydroxycorticosterone. Basal 11-deoxycorticosterone levels were particularly high. Corticosterone, 18-hydroxycorticosterone and aldosterone concentrations were abnormally sensitive to infusions of ACTH and angiotensin II. Plasma cortisol and assays for sex hormones were normal although there was evidence that cortisol derived from the neoplasm. At operation a well-differentiated adrenocortical carcinoma weighing 50 g (56 X 30 X 36 mm) was removed. There was no evidence of metastases following surgery. Adrenal function returned to normal. Review of the literature suggests that adrenocortical carcinoma should be suspected in patients who otherwise have typical features of Conn's syndrome, but whose tumours are more than 3 cm in diameter. Measurement of steroids such as 11-deoxycorticosterone in addition to aldosterone is recommended since abnormally high values may also help to distinguish between hyperaldosteronism due to adenoma and carcinoma. Previously reported cases of isolated aldosterone production by a carcinoma cannot be substantiated.

Pure primary hyperaldosteronism due to adrenal cortical carcinoma

A 47-year-old woman is described who had pure primary hyperaldosteronism due to an adrenal cortical carcinoma. This may represent the first such case in which modern laboratory tests allowed specific diagnosis and exclusion of hypersecretion of other adrenal steroids, and also the first reported case in which modern localizing procedures have been utilized. Other interesting facets of the case include calcification of the tumor, visualization with 131l iodomethylnorcholesterol , metaplastic histologic changes, and coexistent bilateral renal artery fibromuscular disease.

Experimental evidence for biosynthesis of steroids in metastatic tissue originating from a primitive adrenocortical carcinoma

1. Cortisol, cortisone, 11-deoxycortisol and deoxycorticosterone were synthesized in large amounts in vitro by a metastatic tissue from an adrenocortical carcinoma. 2. Both 11 beta- and 21-hydroxylase were very active. 3. A secreting metastasis can be thus responsible for a biological relapse. 4. A metastasis originating from another secreting adrenocortical carcinoma was found to be non-secreting.

Increased excretion of 18-hydroxycorticosterone in patients with adrenal adenomas and hypertension

Two female patients, 54 and 34 years old, each presented with an adrenal adenoma and hypertension. Blood pressure fell after removal of the tumors. The first patient had high urinary 18-hydroxycorticosterone and periodically elevated 18-hydroxy-deoxycorticosterone excretions. The second patient had elevated 18-hydroxycorticosterone and free cortisol excretions. Urinary aldosterone, aldosterone metabolites and plasma aldosterone were not increased. Plasma renin activity was suppressed and serum potassium levels were normal. After surgery, no elevated steroid values were found. Elevated 18-hydroxycorticosterone excretion may be an indicator of yet unknown hypertensinogenic mechanisms. The role of 18-hydroxycorticosterone in the etiology of hypertension is still unknown.

Mineralocorticoid hypertension due to a nasal spray containing 9 alpha-fluoroprednisolone

The finding of hypokalemia and of low plasma renin activity (PRA) in a hypertensive patient suggests a diagnosis of primary hypermineralocorticoidism. Medications containing compounds with mineralocorticoid-like activity (licorice, carbenexolone) may also cause the same syndrome. Recently, we carried out detailed studies on 10 patients with severe hypertension and hypokalemic alkalosis, suppressed PRA and low aldosterone levels. Plasma levels of cortisol and ACTH were suppressed in most of the cases. Measurement of deoxycorticosterone and corticosterone (and in some patient of 18-hydroxydeoxycorticosterone and 18-hydroxycorticosterone) was not significantly higher than normal. Therapeutic trials of dexamethasone and aminoglutethimide were ineffective. In contrast, spironolactone and amiloride treatment resulted in substantial but incomplete amelioration of both hypertension and hypokalemia. All of the patients share a common history of chronic rhinitis and habitual use of large doses of nasal spray containing 9 alpha-fluoroprednisolone and vasoconstrictor agents. Withdrawal resulted in a complete remission of hypokalemia in one to two weeks in all patients. The hypertension and depressed levels of PRA, aldosterone and cortisol took longer to return to normal, varying from case to case; in all but one patient, the values returned to normal within two months. This report reveals another cause of factitious mineralocorticoid excess which may be considered in the differential diagnosis of hypokalemic hypertensive syndromes.

Corticosterone-secreting tumours: with and without renal artery stenosis

Two cases of corticosterone-secreting adrenal adenomata are reported. Both patients were middle-aged females in whom the clinical course spanned several years before the diagnosis was made. Severe hypertension and recurrent hypokalaemia refractory to standard treatments were outstanding features. The importance of measuring the production rates of all mineralocorticoids when a tumour is suspected is emphasized by Case 1 where the production rate of corticosterone alone was elevated. Bilateral renal artery stenosis was responsible for unsuppressed plasma renin activity in Case 2.

The pathology of adrenocortical neoplasia: a correlated structural and functional approach to the diagnosis of malignant disease

The structural and functional characteristics of nine functioning adrenocortical tumors (four adenomas and five carcinomas) causing Cushing's syndrome or virilization were studied. All tumors that we considered to show histologic evidence of malignant disease and that subsequently metastasized or recurred also showed in cell culture at least one significant functional or behavioral difference from benign tumors. No single defect was common to all carcinomas, but predominant changes included secretion of precursor steroids, such as 11-deoxycortisol (S) and a blunted or absent response to ACTH. All adenomase examined were normal in these respects in comparison with nondiseased cortical cells in culture. In carcinomas whose functions deviated only minimally from normal the presence of highly differentiated ultrastructural characteristics did not, however, confer a better prognosis.

The control of aldosterone secretion and its relationship to the diagnosis of hyperaldosteronism

Current concepts of the control of aldosterone secretion in man have been reviewed with particular reference to the role of the kidney. On the basis of these concepts, it is concluded that hyperaldosteronism is most conveniently diagnosed by repeated estimation of plasma potassium, which is usually persistently or intermittently reduced in this disease. Occasional cases fail to show hypokalaemia. Distinction between primary and secondary hyperaldosteronism is made by means of measurement of plasma renin concentration. Subnormal values are usually obtained in the first instance and supranormal values in the second.