Two patients with metastatic adrenal cortical carcinoma were treated with cisplatin and etoposide. Both achieved a partial remission after only one cycle. One patient had a "nonfunctioning" tumor that had previously regressed on mitotane whereas the second patient presented with classical Cushing's syndrome. Although the latter patient's urinary <em>17</em>-<em>ketosteroids</em> normalized while receiving mitotane, the tumor itself failed to regress objectively. Cisplatin plus etoposide appears to be an active combination for the treatment of metastatic adrenal cortical carcinoma.

We studied nine patients with anorexia nervosa: five were "undernourished" and four were "well-nourished". The undernourished patients had significantly higher plasma growth hormone (GH) levels in a fasting state and higher GH rebounds following glucose administration. In four of these patients, GH levels decreased to normal after weight restoration. Decreased urinary follicle stimulating hormone (FSH) in three and plasma luteinizing hormone in six patients were not related to nutritional status; however, positive correlation was found between duration of illness and urinary FSH. Other results included decreased plasma testosterone in the one male, elevated plasma cortisol in five, and decreased <em>17</em>-<em>ketosteroid</em> excretion in five patients. The results support elevated GH as secondary to starvation of anorexia nervosa and not an independent hypothalamic-pituitary disturbance. Other endocrine findings indicate hypothalamic-pituitary malfunction is not confined to GH.

To determine the adrenal contribution to elevated plasma androgens in 31 young hyperandrogenemic women with acne and/or hirsutism, we compared their responses to ACTH with those of 14 normal women. Each subject was given a low dose (10 micrograms/m2) of synthetic ACTH-(1-24) (Cortrosyn) after administration of 1.5 mg dexamethasone the night before the test. Thirty and 60 min responses of plasma <em>17</em> alpha-hydroxypregnenolone (<em>17</em>-Preg), <em>17</em> alpha-hydroxyprogesterone, (<em>17</em>-prog), dehydroepiandrosterone (DHEA), androstenedione, 11-deoxycortisol, and cortisol were measured. Eighteen (58%) patients had increased responses of at least one <em>17</em>-<em>ketosteroid</em> or adrenal androgen precursor. All patients had cortisol responses within the range of those of the 14 normal subjects. Nine patients (29%) had evidence of steroid biosynthetic enzyme deficiencies, either mild congenital adrenal hyperplasia or the heterozygote state; after ACTH, 4 of these patients had elevated <em>17</em>-prog in the range of values in heterozygote carriers of 21-hydroxylase deficiency, 2 had elevated levels of 11-deoxycortisol compatible with 11 beta-hydroxylase deficiency, and 3 had elevated levels of <em>17</em>-Preg and DHEA, suggestive of 3 beta-hydroxysteroid dehydrogenase deficiency. Another 9 subjects (29%) had <em>17</em>-<em>ketosteroid</em> (DHEA and/or androstenedione) hyperresponsiveness to ACTH with associated elevated <em>17</em>-Preg responses. As a group, their patterns suggested relatively deficient 3 beta-hydroxysteroid dehydrogenase and relatively hyperactive C lyase without impairment of cortisol secretion. This pattern resembles exaggerated adrenarche, and we postulate that these 9 patients have hyperplasia of the zona reticularis. Neither basal levels of plasma androgens (free testosterone and DHEA sulfate) nor menstrual history predicted which patients would have abnormal ACTH responses. Although 5 of 11 (45%) patients with acne alone had abnormal responses to ACTH, 10 of 14 patients with acne and hirsutism (71%) had abnormal responses to ACTH. We conclude that an adrenal contribution is found in about half of hyperandrogenemic women with acne and/or hirsutism. This adrenal androgen hyperresponsiveness is heterogeneous. Some patients may have mild forms of congenital adrenal hyperplasia. However, functional androgenic hyperresponsiveness to ACTH, which resembles an exaggeration of adrenarche, is the most common abnormality found. Such findings may provide an explanation for the clinical observation of exacerbations of acne with stress.

BACKGROUND

Adrenal tumors that secrete androgens exclusively are extraordinarily rare. The aim of this study was to characterize patients with pure androgen-secreting adrenal tumors.

METHODS

A retrospective chart review from January 1946 through November 2002 identified 11 female patients with pure androgen-secreting adrenal tumors.

RESULTS

The mean age was 23.4 years (range, 1-52). The most common presenting symptoms were hirsutism, acne, and clitoral enlargement. Elevated <em>17</em>-<em>ketosteroids</em> were found in seven of nine tested patients. Computed tomogram, ultrasound, or both localized tumors in six of seven patients. All tumors were surgically resected, one laparoscopically, all without complications. Five of the 11 tumors were malignant. Mean weight and mean maximal diameter for benign and malignant tumors were 44 g and 4.2 cm and 232 g and 9.8 cm, respectively. Mean hospital stay was 8.5 days, with excess androgen production resolved in all patients. Recurrence and disease-related death occurred in only one patient who had pulmonary metastases at diagnosis. The remaining patients had no recurrence of tumor at mean follow-up of 11.7 years (range, 0.5-32 years).

CONCLUSIONS

Pure androgen-producing tumors are extremely rare. Approximately 50% are benign, and surgical resection provides excellent treatment if the tumors are not metastatic at the time of diagnosis.

Seven patients with Cushing's syndrome were treated with trilostane (WIN 24,540) 4 alpha,5-epoxy-<em>17</em> beta-hydroxy-3-oxo-5 alpha-androstane-2 alpha-carbonitrile), an inhibitor of adrenal steroid biosynthesis. Trilostane treatment reduced steroid biosynthesis and it also improved biochemical manifestations of the disease in all of the patients treated. The average cortisol secretory rate decreased significantly with treatment, from 47.1 to 23.4 mg/24 h (P less than 0.005), and urinary <em>17</em>-hydroxycorticosteroids decreased from 15.7 to 8.7 mg/24 h (P less than 0.01). Urinary free cortisol excretion decreased from 277 to 88 microgram/24 h (P less than 0.01), and 0800 h plasma cortisol levels declined from 25.0 to 12.0 microgram/dl (P less than 0.05). Conversely, dehydroepiandrosterone sulfate excretion in urine increased from 1.3 to 5.8 mg/24 h (P less than 0.0025) and in plasma increased from 162 mg/24 h (P less than 0.025). Plasma and urinary free dehydroepiandrosterone increased 2-fold. Urinary <em>17</em>-<em>ketosteroid</em> excretion increased from 18 to 43 mg/24 h (P less than 0.001). A significant reduction in urinary excretion of tetrahydroaldosterone, tetrahydrodeoxycorticosterone, and 18-hydroxytetrahydrodeoxycorticosterone was observed with treatment. Inhibition of steroid biosynthesis was accompanied by a 2-fold increase in PRA and no change in serum cholesterol levels. Mean arterial blood pressure decreased with treatment from 109 to 97 mm Hg (P less than 0.005), and fasting blood sugar decreased from 1<em>17</em> to 98 mg/dl (P less than 0.005), accompanied by rise in plasma potassium levels from 3.8 to 4.3 milliequivalents/liter (P less than 0.025). Two patients on long term therapy also showed an improvement in clinical features of their disease. There were no significant treatment-related carcinoma, simultaneously producing both an excessive amount of cortisol and ACTH, is described. It is concluded that trilostane is an effective inhibitor of 3 beta-hydroxysteroid dehydrogenase enzyme system in human adrenal gland; it inhibits biosynthesis of cortisol and it is useful in the treatment of Cushing's syndrome.

<em>17</em>β-Hydroxysteroid dehydrogenases (<em>17</em>β-HSDs) belong to a group of key enzymes involved in the biosynthesis of steroidal hormones by catalyzing the reduction of <em>17</em>-<em>ketosteroids</em> or the oxidation of <em>17</em>β-hydroxysteroids. From three members known in the early nineties, the <em>17</em>β-HSD functional family has grown to 15 members over the last 20 years. This growing number of <em>17</em>β-HSD isoforms questioned the importance of each member, especially in their implication in estrogen- and androgen-dependent diseases, such as breast and prostate cancers. One of the strategies used to address the physiological importance of <em>17</em>β-HSDs is to use potent and selective inhibitors. Furthermore, enzyme inhibitors could also be of therapeutic interest by reducing the level of estradiol (E2). Focusing on estrogens, we targeted <em>17</em>β-HSD types 1 and 7, two enzymes able to transform the weak estrogen estrone (E1) into the potent estrogen E2. The present review article gives a description of different classes of inhibitors of <em>17</em>β-HSD1 (C6-derivatives of E2, C16-derivatives of E2 as alkylating and dual action compounds, E2-adenosine hybrids, E2-simplified adenosine hybrids, and C16-derivatives of E1 or E2) and of inhibitors of <em>17</em>β-HSD7, all these inhibitors developed in our laboratory. The chemical structures and inhibitory activity of these steroidal inhibitors, their potential as therapeutic agents, and their use as tools to elucidate the role of these enzymes in particular biological systems will be discussed. Article from the Special issue on Targeted Inhibitors.

3-<em>Ketosteroid</em>-delta 1-dehydrogenase from Nocardia corallina catalyzes transhydrogenation of 3-keto-4-ene-steroid to 3-keto-1,4-diene-steroid e.g., progesterone to 1,4-androstadiene-3,<em>17</em>-dione. The reaction proceeded linearly at first and then soon slowed down owing to equilibration. The turnover number of this reaction was of the same magnitude as that of the dehydrogenation of 3-keto-4-ene-steroid. The pH optimum was 8.4, which is lower than that of the dehydrogenase reaction. The enzyme has a wide specificity for hydrogen acceptor steroids. The Km' and Kmax' values for these steroids and the values of the corresponding 3-keto-4-ene-steroids were compared. Kinetic studies of the steroid transhydrogenase reaction demonstrated a typical ping-pong mechanism. The enzyme oxidized 1,2-tritiated progesterone and transferred the tritium atoms to the reaction product, 4-androstene-3,<em>17</em>-dione, and water. Transhydrogenation in D2O resulted in the incorporation of a deuterium atom into the C2-position of 4-androstene-3,<em>17</em>-dione. The results indicate that the enzyme catalyzes C1, C2-trans axial abstraction of hydrogen atoms from progesterone, transfer of the 1 alpha-hydrogen to the C1-position of 1,4-androstadiene-3, <em>17</em>-dione and release of the 2 beta-hydrogen to water. Reaction schemes based on the experimental results are proposed. The enzyme also catalyzes the reduction of 3-keto-1,4-diene-steroids with reduced benzyl viologen.

Spironolactone, an aldosterone antagonist currently used in the treatment of hypertension, has numerous antiandrogenic side effects. Decreased production rates of testosterone in intact (N = 10) and hirsute (N = 6) women, respectively, were noted after short (7 days) or long-term (6 months) administration of the drug, 25 mg twice daily. A 50% diminution in the urinary <em>17</em>-<em>ketosteroid</em> excretion was also observed after 6 months of therapy. Assessment of the treatment was done by the patients: a reduction in hair growth rate was initially observed after 3 to 4 months, followed by the appearance of a more downy type of new growth and a decrease in diameter of the hair shaft. It is concluded that this beneficial effect is obtained by a decrease in the testosterone production rate and probably through competitive inhibition of spironolactone and/or canrenone with the androgen receptor in human hair follicles.

A 16-year-old phenotypic female with XY genotype presented an unusual form of nonfamilial male pseudohermaphroditism. Seemingly a normal girl during childhood, the patient failed to undergo pubertal changes presenting with scant pubic hair, absent axillary hair, lack of breast development, retarded bone age and primary amenorrhea. Neither uterus nor adnexa were palpable above the blind-ending vagina. Serum testosterone and estradiol were barely detectable by radioimmunoassay, while LH and FSH reached castrate levels. Two small testes were removed from the pelvic sidewalls which, on biopsy, showed atrophy and hyalinization of seminiferous tubules, but clusters of Leydig cells without signs of hypertrophy or hyperplasia. Administration of testosterone resulted in urinary nitrogen retention and a decrease in serum LH and FSH. Radioimmunoassay of various serum or plasma steroids and gas chromatographic determination of urinary steroids prior to and following ACTH stimulation yielded results which permitted to rule out 20,22-desmolase, 3beta-hydroxysteroid dehydrogenase, <em>17</em>-hydroxylase and <em>17</em>beta-hydroxysteroid dehydrogenase deficiency. Low plasma dehydroepiandrosterone sulfate (DHEA-S) and androstenedione (delta4 A) concentrations, low urinary <em>17</em>-<em>ketosteroid</em> and particularly low dehydroepiandrosterone (DHEA) excretion and the minimal rise of plasma DHEA-S and delta4 A and of urinary DHEA in response to ACTH in conjunction with a normal response of other serum and urinary C-21 steroids are consistent with <em>17</em>,20-desmolase deficiency. Direct confirmation of this defect, however, seems impossible in the absence of in vitro studies of testicular steroidogenesis.

Gossypol acetic acid (GAA) displays anti-fertility and antioxidant behavior. The efficacies of different doses of gossypol acetic acid were investigated in male albino rats. Rats were allocated into four groups: control group and three GAA-treated groups (2-4), that were injected with GAA (5, 10, 20mg/kg BW, respectively), through inrtaperitonial injection. Treatment of GAA was found to elicit a significant decrease in sperm counting, sperm motility, serum levels of testosterone, luteinizing hormone and follicle-stimulating hormone, whereas, the activities of testicular <em>17</em>β-hydroxysteroid dehydrogenase and <em>17</em>-<em>ketosteroid</em> reductase were increased. The activities of serum transaminases and alkaline phosphatase and hepatic glutathione peroxidase; glutathione reductase, superoxide dismutase and glutathione S-transferase and the level of hepatic glutathione were elevated. While, the lipid peroxidation end product; malondialdehyde, nitric oxide, and lipid profile and the activity of hepatic cytochrome P450 were decreased in GAA-treated rats. The histological analysis of liver and testicular tissues showed sever hepatocyte damage in addition to abnormal localization of hepatocytic nuclei. Also, the testicular pathology of GAA-treated rats showed depressed spermatogensis, sertoli cell toxicity and degeneration of seminiferous tubules.

The effects of nicotine and cotinine, the major metabolite of nicotine, on testosterone production in rat testis were investigated. Rat Leydig cells were isolated and incubated with nicotine and cotinine. Nicotine produced a dose dependent increase in progesterone levels and a dose-dependent decrease in androstenedione and testosterone concentrations. Cotinine produced a dose-dependent increase in progesterone and androstenedione and a dose-dependent decrease in testosterone levels. The effects of nicotine and cotinine on rat testis mitochondrial cholesterol side chain cleavage enzyme and microsomal 3 beta-hydroxysteroid dehydrogenase-isomerase, <em>17</em> alpha-hydroxylase, <em>17</em>,20-lyase and <em>17</em>-<em>ketosteroid</em> reductase were examined. Nicotine competitively inhibited <em>17</em> alpha-hydroxylase (apparent Ki = 30 microM) and <em>17</em>,20-lyase (apparent Ki = 18 microM). Cotinine competitively inhibited <em>17</em>-<em>ketosteroid</em> reductase (apparent Ki = 46 microM). The addition of nicotine to preparations of rat testis microsomes yielded a Type II cytochrome P-450 binding spectrum. We conclude that nicotine and cotinine competitively inhibit multiple steps in testosterone biosynthesis.