“Androgen-Secreting Tumors of the Ovary”

Renato PasqualiDiv. of Endocrinology

St. Orsola-Malpighi Hospital

University Alma Mater Studiorum

Bologna

Mediterranean School of Oncology (MSO)Rome, July 10 2010

WHO 2003 histological classification including most ovarian androgen secreting tumors.

Sex cord stromal tumorsGranulosa stromal cell tumorsThecoma-fibroma group

thecoma, fibroma, cellular fibroma,

fibrosarcoma, stromal tumor with

minor sex cord elements,sclerosing

stromal tumors, signet-ring stromal

tumors, unclassified tumors

Sertoli stromal cell tumorsSertoli-Leyding cell tumor group (androblastomas)

well differentiated or with intermediate differentiation

Variant with heterolgous elementPoorly differentiated

(sarcomoid)

Variant with heterologous element

Stromal Leyding cell tumor

Retiform

Sex cord stromal tumor of mixed or unclassified type

Sex cord tumor with anular tubules

Gynandroblastomas

Sex cord stromal tumor, unclassified

Steroid cell tumors (stromal luteoma)

Leyding cell tumor group hilar cell tumor,

nonhilar cell type,

not otherwise specified

Steroid cell tumor, not otherwise specified (well differentiated, malignant)

Androgen-Secreting Tumors (AST) of the Ovary

Sertoli-Leyding cell tumors account for < 1% of all solid ovarian tumors

- Prevalence is higher in the 2°-4° decades of life

- Size often large

Hilus cell tumors occur more frequently after menopause

- Small size

Granulosa-theca cell tumor produce E2 (occasionally T)

Rapidly progessing symptoms/signs of androgen excess suggest the presence of and AST, unless proved otherwise

The progression is usually more from defeminizing signs (loss of body size contour, decrease in breast size) than from

the androgenic signs

Androgen-Secreting Tumors of the Ovary (OAST)

The ovarian tumors secrete large amounts of testosterone or

its precursor androstenedione

As the tumor continues to growth, more and more testosterone

is produced

With all OAST testosterone is typically high:

- production and secretion directly from the tumor

- secretion of large amounts of androstenedione, that is

converted to testosterone in peripheral tissues

Testosterone produced by OAST may be suppressed

by a GnRH agonist (however, its use for diagnostic

purposes has low sensitivity and specificity)

ORIGIN OF CIRCULATING ANDROGENS IN WOMEN

* Percentages indicate the relative amounts of androgens originating from sources to the left of the arrows

DHEAS

DHEA

Testosterone

4-Androstenedione (A4)

2%

5%

25%

50%

4-Androstenedione (A4)

Testosterone

DHEA

DHEAS

OvaryOvary

AdrenalAdrenal

50%

25%

95%

98%

Steroid concentrations (ng/mL) in peripheral and ovarian venous plasma of

premenopausal and postmenopausal women

.01

.1

1

10

100*

*

*

*

* P< 0.05 vs Postmenopausal value

E2 and TESTO in postmenopausal women.Blood lovels, PR and MCR are shown for women at various

phases of perimenopause

Jonston CC et al, JCEM 1985.

Estradiol Testosterone

Perimenopausal stage

Perimenopausal stage

Perimenopausal stage

Plasma concentrations

Production rates

Metabolic clearance rates

Therefore, plasma levels are influenced by the PR rather than the MCR

Differential diagnosis of clinical hyperandrogenism

Diagnosis Frequency%

Age of onset Time of onset Menses Virilization

PCOS > 95 13-25 Years +/- Very rare

CAH 1-2 Congenital Birth, Adolescence,

Adulthood

+ +/-

Adrenal tumor < 1 Any time Weeks/Months

+ +

Ovarian tumor < 1 Any time Weeks/Months

+ +

Cushing s. < 1 Any time Months/Years + +/-

Hypertecosis < 1 Pre- and post-

menopause

Months/Years +No in

menopause

+

Modified from Conall Dennedy et al, EJE, 2010

Screening for an ovarian tumor Clinical:

- Adult age- History of androgen-related signs/symptom- Changes in behaviour

Physical exam- Body habitus (fat distribution, ecc)- Signs of androgen excess (hirsutism, alopecia, etc.)- Gynecological exam

Labotatory exams- Androgen blood levels (and other sex hormones)- metabolic parameters- Functional tests

Imaging techniques (and others)- US, MRI (CT scan, venous sampling)

Somatic tissues affected by androgens

Androgen• Muscle• Larynx• Beard• Distribution of sexual hair• Bone and cartilage• Immune system• Nervous system• Heart• Red cells• Brain (behavioral functions)

NB: some of these effects can also be dependent on

estrogens

In the presence of high androgen levels somatic effects should always be investigated

Changes in body composition and sexual symptoms are problably the most important features of severe androgen excess in adult women and may help diagnosis

Relialability of blood androgen measurement are influenced

by:• Methods• Reference normal range• Factors know to alter serum T concentrations• Ovarian vs adrenal source of androgens (DD

between ovarian and adrenal androgen secreting tumors)• Low-normal testosterone levels do not exclude

and ovarian-secreting tumor (measure androstenedione!)

Factors know to alter serum T concentrations (preanalytical and analytical)

Physiological factors (puberty, etc) Pulsatile release during the day Diurnal rhythm: am > pm Menstrual cycle: luteal > follicular Seasons (no variantion in T but freeT shows 30%

difference: summer < winter) Age: in women with/without PCOS: 20s > 40s Analytical factors Cross-reactivity with other androgens Interference with endogenous antibodies Poor performance in the female range: < 8 nmol/L

Barth J, Clin Endocrinol, 2007

Position statement: Utility, limitations, and pitfalls in measuring testosterone:

an Endocrine Society position statement

Adult females Most commercial assays are adequate for identifying, but not accurately quantifying elevated T in women.…these assays frequently fail to detect moderate HA The need for defining an accurate lower range for T

in women has become significant …conventional RIAs are unreliable in this range, whereas … LC/ MS-MS appears capable of yielding meaningful data. In defining normal ranges, care must be taken to exclude subjects with PCOS, or other HA forms.

Rosner W, et al. JCEM. 2007; 92:405-13.

METHOD COMPARISON: IMMUNOASSAYS vs LC-MS/MS

Deming Regression

CORTISOLCORTICOSTERONE11-DESOXYCORTISOLANDROSTENEDIONEDESOSSICORTICOSTERONETESTOSTERONE17OH-PROGESTERONEDHEAPROGESTERONE

RANGE

ng/ml

LC-MS/MS METHOD

ACCURACY %

<1 ng/ml

99,9

>1ng/ml

99,2 – 99,6

N=33

Ferriman e Gallwey, modified by Hatch et al, Am J Obstet Gynecol 1981

HIRSUTISM SCORE according to Ferriman & Gallway:

a semiquantitative method

Comparison of blinded simultaneous Ferriman-Gallwey scores

Wild RA, J Clin Endocrinol Metab. 2005 Jul;90:4112-4

Agreement analysis demonstrated that patient self scores, physician scores, and research nurse scores were quite discrepant. Therefore the modified F-G map scoring system has not too much variation to be clinically useful.

Screening for an ovarian tumor

Clinical Clinical sensitivity * specificity *

US exam (ta or tv) probably low probably lowMRI probably low probably lowVenus sampling NA NA

* No sufficient data

* No studies

A diagram to investigate syndromes of severe hyperandrogenism in adult women

Hyperandrogenism

Define:- Signs of androgen excess (hirsutism onset and degree)- Changes in the phenotype- Sexual behavior

Measure androgens (T, D4A, DHEAS, 17OHP, E2,E1) and gonadotropins)

Perform tests to exclude adrenal soringin (dex test, etc) Perform GnRG analogue test (if appropriate)

Perform ovarian imaging (tvUS, MRI)Venous sampling (??)

SURGERY

Pathophysiology of ovarian androgen secreting tumors

Lessons from case reports

Lobo RA, Endocr Clin NA, 1991

Blood and glandular vein TESTO in 7 pts with neoplastic ovarian HA

Androgen secreting tumors and androgen production and regulation

Buserelin diminishes blood TESTO in the face of androgen-producing tumor

Copyright ©1997 The Endocrine Society Barnes, R. B. et al. J Clin Endocrinol Metab 1997

CASE REPORT: Long-term suppression of T after treatment with nafarelin in

a woman with a presumed T secreting ovarian tumor

An adult woman with severe HA. CT scan showed bilateral medullary nephrocalcinosis, normal adrenal glands, and a normal left ovary, without vuisualization of the right ovary A hysterectomy and bilateral oophorectomy was recommended for a presumed ASOT, however, the patient was unwilling to have surgery.The patient agreed to a trial of GnRHa to test the suppression of ovarian androgen production. An initial nafarelin stimulation test to determine tumor sensitivity showed a marked elevation in17-OHP, Δ4A, and T. Long-term treatment resulted in a marked suppression of androgens

Friedman Am J Obstet Gynecol 1985

Case report: Testosterone in a pt with an arrhenoblastoma after no treatment, dex suppression, ovarian suppression, and,

finally, unilateral oophorectomy

Case reports

A steroid-cell tumor of the ovary resulting in massive androgen excessA 30-year-old woman with an ovarian steroid-cell tumor secreting markedly elevated levels of T (28.3 nmol/l), DHEAS (19.7 μmol/l), Δ4A (> 34.7  nmol/l) and 17-OHP (100.5 nmol/l) (Stephens JW, et al. Gynecol Endocrinol 2008).

Coincidental diagnosis of an occult hilar steroid cell tumor of the ovary and a cortisol-secreting adrenal adenomaA 49-year-old woman persistence of severe hyperandrogenism after removal of a left adrenal adenoma (UFC normalized but serum T still very high (3.04 ng/mL). Selective catheterization of ovarian veins revealed a gradient of T concentration in the right ovary (steroid cell tumor of hilar type) (Gorgojo JJ, Fertil Steril. 2003)

Ectopic bioactive LH production from a pancreatic endocrine tumor (positive scintigraphy with [111In]octreotide and abdominal imaging) in a 33y woman with rapidly developing symptoms/signs of HA and markedly elevated serum androgen and LH levels leading to hyperthecosis and bilateral ovarian luteinized granulosa-thecal cell tumors After surgery, Symptoms and signs of HA resolved Immunohistochemistry, in situ hybridization, and electron microscopy studies confirmed LH synthesis by the tumor cell. Rare ectopic LH production from nonpituitary endocrine tumors should be considered in the DD of HA, particularly when associated with elevated LH levels

(Piatidis G, JCEM, 2005)

Case report: Ectopic bioactive LH secretion by a pancreatic

endocrine tumor, manifested as luteinized granulosa-thecal cell tumor of the ovaries.

Case reportLow leptin and ovarian androgen-secreting tumor

An obese postmenopausal woman with MetS, HA (high T but low LH), adrenal macronodular hyperplasia and Leydig-cell ovarian tumor.

She had low leptin levels despite high body fat content.

After a catheter study left adrenalectomy was carried out but HA persisted. Then, bilateral oophorectomy and a small Leydig-cell tumor was found in the left ovary.

Postoperatively, T and gonadotropin levels were normal (postmenopausal) and leptin level became elevated without change in BMI or body fat content.

Low leptin levels in obese HA women might be a marker for androgen-secreting tumors

(Cvijovic G et al, Gynecol Endocrinol. 2007)

TestosteroneAndrogen receptor

Testosterone, acting through its own receptor, interferes with insulin signalling in peripheral tissues.

Skeletal muscle cellsAndrogens may interfere with insulin signalling by amplifying phosphoryla- tion of mTOR, ribosomal S6-kinase (S6K), and consequently increasing Ser636/639 phosphorylation of IRS-1

Adipose tissueIn cultured subcutaneous adipocytes, Tselectively induces metabolic insulin resistance via the AR (this defect does not involve PI3K, but the impaired phosphory-lation of the downstream mediator PKC

IRS-1 SerP Reduced whole-body insulin sensitivity:INSULIN RESISTANCE

From: Corbould A, Diab Metab Res Rev, 2008

Abdominal obesity

Testosterone

Changes in scheletal muscle

• N° of less sensitive type Iib cells

• Inhibition of muscle glycogen

synthase

Testosterone impairs muscle insulin sensitivity in female rats through the modification of muscle morphology and

glycogen synthase expression and activity

Holmäng et al.,Am J Physiol 1990; Rincon et al.,Diabetes 1996; Holmäng et al.,Am J Physiol 1992

*

*

* *

Evidence that androgens impair insulin action and increase visceral adiposity in women while reducing

subcutaneous fat: female to male transsexuals studies

Elbers et al., Clin Endocrinol 2003; Elbers et al., JCEM 1997

p< 0.05

p< 0.01

p< 0.01

p< 0.001

Evidence that androgens impair insulin action and increase visceral adiposity in women: effect of

antiandrogen treatment

Moghetti et al., JCEM, 1996; Gambineri et al. JCEM, 2006

0 150 300 750 900

0

2

4

6

8

10

12

IS

I

-50

-40

-30

-20

-10

0

V

AT

(cm

2 )

□ Changes () at 6 months

■ Changes () at 12 months

PLAC MET FLUT MET+FLUT

*

*

Antiandrogens

Insulin and hyperandrogenemiaInsulin and hyperandrogenemiaOvary

- Direct stimulation of androgen secretion (stimulatory effect onthe P450c17 enzyme)- Increase of LH ovary receptor number

Pituitary- Sensitization ol LH secreting pituitary cells to GnRH stimulation

Proteins- Decrease of SHBG levels- Decrease of IGF binding proteins

Metabolism- Decrease of androgen clearance- Decrease of the aromatase activity- Increase of the 5-reductase activity

Insulin excess may exert a central role in the induction of hyperandrogenism in PCOS women

CYP21 enzymes

Clinical presentationPts Age,

yBMI Waist

(cm)Hirsutism

(F-G)T2D Alopecia

(Ludwig scale)Sex disturbancies

1 (B.G.) 68 31.6 104 >20 NO Male pattern 3 ==

2 (G.G.) 68 32,8 106 7 (face) NO 0 Increased libido (for 6 y)

3 (Z.D.) 58 26,3 87 9 NO Female patter 1I Highly Increased libido (for 2 y), clitoridomegaly

4 (T.G.) 60 30,4 101 14 YES * Male pattern 3 Increased libido

5 (M.M.) 62 27,2 88 13 NO 0 =0

m±DS 63±5 29,5±2,8

97,2±9,0

== ==

Main features: - old age,- abdominal overweight/obesity, - alopecia, hirsutism - increased libido

* Data reported in a further slide

Case 2 (GG) Sertoli-Leydig ovarian tumor (left ovary, well differentiated (max diameter: 16 mm)

20X 40X

Case 1 (BG) Leydig cell ovarian tumor (right ovary, well differentiated)

Sertolcells

Leydigcells

40X20X

Case 4 (TG) Leydig cell tumor (left ovary, well differentiated, with stromal hyperplasia)

20X 40X

Case 5 (MM) Sertoli-Leydig tumor (left ovaio, well differentiated, 3 cm, with endometriod aspects)

10X 40X20X

Sertoli cell with lipid deposits

Anthropometry at baseline and after surgeryin pts with ovarian androgen secreting tumors

Hirsutism scoreBMI

0

5

10

15

20

25

30

35

1 2

kg/m

2

Basal After0

2

4

6

8

10

12

14

16

1 2Basal After

Waist circumference

0

20

40

60

80

100

120

1 2

cm

Basal After

Metabolic parameters at baseline and after surgeryin pts with ovarian androgen secreting tumors

Glicemia

0

20

40

60

80

100

120

140

Basal After

mg

/dL

Basal After

GlucoseInsulina

0,0

2,0

4,0

6,0

8,0

10,0

12,0

14,0

16,0

pre post

mcU

I/mL

Insulin

AfterBasal

0

50

100

150

200

250

300

mg

/dL Basal

After

HOMA-IR

0,00

0,50

1,00

1,50

2,00

2,50

3,00

3,50

4,00

4,50

pre post

HOMA-IR

Basal After

GluAUC

0

5000

10000

15000

20000

25000

pre post

GlucoseAUC

Basal After

InsAUC

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

pre post

InsulinAUC

Basal After

>2.7 insulin-resistance

0,0

1,0

2,0

3,0

4,0

5,0

6,0

7,0

pre post

Testo

ste

ron

e (n

g/m

L)

0

5

10

15

20

25

30

pre post

FA

I

0

100

200

300

400

500

600

700

pre post

An

dro

ste

ne

dio

ne

(n

g/d

L)

Hormonal parameters at baseline and after surgeryin pts with ovarian androgen secreting tumors

Androstenedione

FAI

Basal After

Basal After

Testosterone

Basal After

0,0

10,0

20,0

30,0

40,0

50,0

60,0

70,0

80,0

90,0

100,0

LH FSH

mIU

/mL

Before

After

FSHLH FSH

Case report: IMPROVEMENT OF METABOLIC CONTROL AFTER BILATERAL OOPHORECTOMY FOR LEYDIG CELL

TUMOR IN A POST-MENOPAUSAL DIABETIC WOMEN

HbA1c ()Fasting insulin (g/mL)

Total testosteroneng/mL

Conclusions Ovarian androgen-secreting tumor are rare entities Their prevalence is higher in postmenopause Changes in sexual behavior and body shape may

be the most relevant clinical features Testosterone levels often exceed 1.5-2,0 ng/ml

(high levels of other androgens and estrogens

may occur) Surgery is the preferred therapeutic choice Whether metabolic disturbances may be related to

very high testosterone levels requires further

investigation.

Acknowledgments

Div. of Endocrinology,

S. Orsola-Malpighi Hosp.

Alessandra Gambineri

Valentina Vicennati

Paola Altieri

Uberto Pagotto

Carla Cavazza

Giulia Forlani

C.R.B.A. (Center for applied biological research)

Rosaria De Iasio

Federica Tomassoni

Alessandra Munarini

Flaminia Fanelli

University Alma Mater StudiorumBologna, Italy