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Home , Pregnanediol, Testosterone sulfate

Metabolism of testoterone and related in metastatic interstitial cell carcinoma of the testis.

M B Lipsett, … , C W Bardin, L M Fishman

J Clin Invest. 1966;45(11):1700-1709. https://doi.org/10.1172/JCI105476.

Research Article

Find the latest version: https://jci.me/105476/pdf Journal of Clinical Investigation Vol. 45, No. 11, 1966

Metabolism of and Related Steroids in Metastatic Interstitial Cell Carcinoma of the Testis * M. B. LIPSETT,t G. A. SARFATY, H. WILSON, C. WAYNE BARDIN, AND L. M. FISHMAN (From the Endocrinology Branch, National Cancer Institute, Bethesda, Md.)

Interstitial cell carcinoma of the testis is a singu- production rate has been shown to be a conse- larly rare -producing cancer. Of the seven quence of metabolism of reported cases (1-7), urinary 17- (17- sulfate. KS) excretion was high in the four cases in which it was measured. Abelson, Bulaschenko, Trom- Methods mer, and Valdes-Dapena (7) fractionated the uri- Routine methods were used to analyze the following: nary 17-ketosteriods and corticoids in one recently urinary 17-KS (8), urinary 17-hydroxycorticoids (9), reported case. There is, however, no comprehen- plasma Silber-Porter chromogens (10), and plasma tes- tosterone (11). sive study of either the production of Gas-liquid chromatography. We carried out gas-liquid or related steroids by this tumor. We have had chromatography (GLC) in a Glowell Chromolab gas the opportunity to study a patient with metastatic chromatograph utilizing a 'Sr ionization detector oper- interstitial cell carcinoma, and we have examined ating at 1,050 v. The coiled glass columns, 6 feet by i inch several related steroids. From i.d., were packed with 2% SE-30 on chromosorb W. the androgens and Trimethylsilyl derivatives were prepared as noted previ- these data, we have concluded that interstitial cell ously (12). carcinoma resembles virilizing adrenal carcinoma in Fractionation of urinary steroids. Urinary steroid sul- its pattern of biosynthesis of C-19 steroids and 21- fates and glucuronides were separated by thin layer deoxypregnane analogues. The high testosterone 1 chromatography in system TN (13) after an ether- ethanol extraction (14). Glucuronides and sulfates were * Submitted for publication April 6, 1966; accepted hydrolyzed separately either with 8-glucuronidase (Keto- July 27, 1966. dase) or by solvolysis (15). In the subsequent dis- Presented in part at the 47th Meeting of the Endo- cussion, steroid sulfates are defined as those steroids crine Society, New York, 1965. having the mobility of steroid monosulfates in TN and t Address requests for reprints to Dr. Mortimer B. hydrolyzed by solvolysis. Glucuronides are defined as Lipsett, Endocrinology Branch, National Cancer Insti- those steroids having the mobility of steroid glucuronides tute, Bethesda, Md. 20014. in TN and released by j8-glucuronidase. Further steps 1 The chemical names for the steroids used in this in purification were chromatography on the silica-alumina paper are as follows: 17,8-hydroxy-androst-4-en-3-one column (16) and group fractionation with Girard re- (testosterone) ; 17a-hydroxy-androst-4-en-3-one (epites- agent T and digitonin. For isolation of individual me- tosterone); 3a-hydroxy-5,B-androstan-17-one (etiocholano- tabolites, the resulting ketonic and nonketonic alpha lone); 3a-hydroxy-5a-androstan-17-one (); and beta fractions of differing polarity were then chro- 3a,11,8-dihydroxy-51-androstan-3-one (11-hydroxyetiocho- matographed in the appropriate systems listed below. lanolone); 3a-hydroxy-58-androstan-3,11-dione (ll-keto- Paper chromatography systems (after Bush) were as ) ; 3a,11'B-dihydroxy-Sa-androstan-17-one follows: Al-ligroin: methanol: H20 (100: 90: 10); B1 (1l-hydroxy-androsterone); 3,B-hydroxy-androst-5-en-3- -ligroin: toluene: methanol: H20 (75:25:70:30); B1 one (dehydroepiandrosterone, DHA); androst-4,en-3,17- -ligroin: toluene: methanol: H20 (50:50: 70: 30); B4 dione (); 3fi,16a-dihydroxy-5-androstan- 17-one (16-hydroxy DHA); androst-5-en-3,8,17P-diol (an- 3,20-dione () ; 3ac,11P,17a,21 -tetrahydroxy-5#9- drostenediol); pregn-5-en-3p8,20a-diol (pregnenediol); pregnan-20-one (); 3a,17a,21-trihy- pregn-5-en-3fi,17a,20a-triol (pregnenetriol) ; 5,6-pregnan- droxy-5fi-pregnan-11,20-dione () ; 3a, 3a,20a-diol (); 5P-pregnan-3a,17a,20a-triol 11P,17a,21-tetrahydroxy-5a-pregnan-20-one (allotetrahy- (); 3a,17a-dihydroxy-5p8-pregnan-20-one drocortisol) ; 3a,17a,21 -trihydroxy-5Sf-pregnan-20-one (17-hydroxypregnanolone); 3a,17a,20a-trihydroxy-59- (tetrahydro substance S); 3-hydroxyestratrien-1,3,5 (10)- pregnan-l1-one (11-ketopregnanetriol); 5a-androst-16-en- 17-one (); 1,3,5 (10-estratriene-3,17P-diol (estra- 3cr-ol (); llB,17a,21-trihydroxy-pregn-4-en- diol); 1,3,5 (10)-estratriene-3,16a,17P-triol (). 1700 METABOLISM IN TESTICULAR INTERSTITIAL CELL CARCINOMA 1,701 NFON-KETONIC A (Mg. per Day)

SULFATES

5-1PTROLt - F TRIOL 3.7 1.2

I~~~~~ 0.2 0.4 0.6 0.8 1.0 02 0.4 0.6 0.8 1.0

R T VS CHOLEcSTANE n eisll Testic. Carc FIG. 1. GAS-LIQUID CHROMATOGRAMS OF NONKETONIC-3P8-. Glu- curonides and sulfates were separated before hydrolysis, and each column fraction was treated with Girard's reagent T and digitonin. 5-A'diol = 5-; 5-P'diol = 5-pregnenediol; and 5-P'triol = 5-pregnenetriol.

-toluene: methanol: H20 (100: 50: 50) ; and C-toluene- . The three classical urinary estrogens were ethyl acetate: methanol: Hs0 (90: 10: 50: 50). isolated from the phenolic fraction as suggested by Engel Thin layer silica gel systems were as follows: T4-ben- (18). Tritiated estrone, , and estriol 2 were zene: ethyl acetate (40: 60); T6-benzene: ethyl acetate added to the phenolic extract to correct for losses oc- (60: 40); TE-benzene: ethanol (90: 10); and TN- curring after P-glucuronidase hydrolysis. We separated ethyl acetate: ethanol: ammonia (50: 50: 10). estriol from estrone and estradiol by partitioning between 3a-Hydroxyketonic steroids. Etiocholanolone and an- petroleum -ether-benzene and water. Estrone and estra- drosterone were quantified as the trimethylsilyl ethers by diol were chromatographed on thin layer silica gel plates GLC of the appropriate fractions after chromatography in TE, and estriol was chromatographed in 100%o ethyl in Al and T6. The 11-oxo-17- were measured acetate. All samples were acetylated and chromato- as the free steroids by GLC after chromatography in B1 graphed on thin layer silica gel. Chloroform was used to and T4. develop the chromatograms. After saponification, paper 33a-Hydroxy nonketonic steroids. Androstenol was chromatography was performed as follows: estrone, Bi; measured by GLC of the least polar nonketonic alpha estradiol, Bi; and estriol, C. Subsequent thin layer fraction (17). Pregnanediol and pregnanetriol were iso- chromatography of estrone and estradiol in T6 and es- lated from appropriate nonketonic alpha fraction by chro- triol in T4 was performed. Gas-liquid chromatography matography in T4 and estimated by GLC as the free ster- of these fractions resulted in single clean peaks for es- oids. We could not identify li-ketopregnanetriol by trone and estriol. Estradiol could- not be identified. GLC after chromatography in T4. 16-Hydroxy DHA. Since this steroid has been found AY-3fi-Hydroxy nonketonic steroids. Androstenediol, only rarely in urine, its identity was assured by the cor- pregnenediol, and pregnenetriol were measured by GLC respondence of the isolated material with authentic stand- directly after column chromatography and Girard and ard3 in paper, thin layer, and gas-liquid chromatography digitonin fractionation. Figure 1 is an example of the as the free steroid and the acetate. The color changes chromatograms obtained from two such fractions. The produced by the Allen reagent and the sulfuric acid clearly defined peaks, well separated from contaminants, spectra were identical for the presumptive and authentic permitted accurate measurements. 16-hydroxy DHA. Cortisol metabolites. Cortisol and its metabolites, tetrahydrobortisol, tetrahydrocortisone, and allotetrahy- 2 We wish to thank Dr. Mortimer Levitz, New York drocortisol, were measured together as phenylhydrazine University Medical School, -for a gift of estriol-'H, chromogens after silica-alumina column fractionation and 3We wish to thank Dr. D. Fukushima, Institute for thin layer chromatography in TE. Tetrahydro sub- Steroid Research, New York, and Dr. A. Colas, Uni- stance was sought in another column fraction after pa- versity of Oregon Medical School, Portlan4 for gifts of per chromatography in B4. 16-hydroxy DHA. - 1702 LIPSETT, SARFATY, WILSON, BARDIN, AND FISHMAN

obtained at 50, 60, and 70 minutes of the infusion. The plasma was separated, and 400 dpm of testosterone-14C and 50 #g of testosterone were added. Testosterone ex- tracted from the plasma was purified through five chro- STANDARD 16a -OH-DH'A matography systems. The specific activities and the 2 ug 'H/f'C ratios agreed within 5% during the last three chromatographies, in which the testosterone was mea- sured successively as the acetate, the free alcohol, and androstenedione. We determined the production rates of DHA and DHA sulfate with 20.45 Ac of DHA sulfate-8H and 2.77 juc of DHA-14C injected intravenously over a 5-minute pe- riod. Urine was collected for 3 days, processed as de- scribed above, and the specific activity of the DHA sul- fate and DHA glucuronide was measured. 16a-OH-DHA FROM Specific activities of DHA, 16-hydroxy DHA, and GLUCURONIDE FRACTION OF URINE EXTRACT androstenediol. The appropriate fractions containing J.AT. a DHA, 16-hydroxy DHA, and androstenediol were chro- matographed on 45-cm thin layer silica gel plates in T4, and they were then chromatographed in systems Al, B1, and Bi, respectively. The DHA was chromatographed on T6, and the 16-hydroxy DHA and androstenediol were chromatographed in T4. Specific activities of the DHA and 16-hydroxy DHA were determined at this point, the mass being measured with the Allen reagent and by FIG. 2. GAS-LIQUI CHROMATOGRAM OF 16a-HYDROXY GLC. Agreement between the two estimates was good. DHA. Comparison of authentic standard and steroid iso- Figure 2 demonstrates the purity of the 16-hydroxy lated from urine. DHA; comparable tracings were obtained for andros- tenediol and DHA. The mass of androstenediol was measured by GLC only. The coefficient of variation of Radioactivity counting. Radioactivity measurements estimates of mass by GLC averages 7% in our hands. were made on a Packard liquid scintillation spectrometer, This is the largest error associated with the determina- model 314EX, with discriminator and gain settings to tion of the specific activities calculated in this paper. give an efficiency of 45% for 14C and 19% for 'H. Suffi- cient counts were accumulated to give a standard error Results of no more than 2%. Preparation of tracers. Testosterone-7a-3H,4 dehydro- 17-Ketosteroids and corticoids. The 17-KS ex- -4-1'C,5 and dehydroepiandrosterone sul- cretion varied between 200 and 400 mg daily dur- fate-7a-3H 5 were chromatographed before use. DHA ing the control period and was not suppressed by sulfate was extracted with ether shortly before infu- sion into the patient. -8H was prepared either , 8 mg daily, or fluoxy- by the Wilzbach technique and purified by column, paper, mesterone, 40 mg daily (Figure 3). The adminis- and thin layer chromatography of the free steroid and tration of human chorionic gonadotropin (HCG) its acetate (19). in doses of 4,000 international units (IU) daily for Production rates. To measure testosterone produc- 5 days was associated with an increase in 17-KS tion rate, we injected 10.0 ,uc of testosterone-8H in sa- line intravenously and determined the specific activity of excretion to an average level of 690 mg per day. testosterone in urinary (16). Since chemotherapy could not be delayed further, Epitestosterone production rate was estimated similarly a subsequent control period was not obtained; after injection of 5 uc of epitestosterone-8H and isola- hence, the decreased excretion of 17-KS after tion of epitestosterone from a 3-day urine collection. cessation of HCG could conceivably be attributed Blood testosterone production rate was measured by the to the lack of re- metabolic clearance technique (20); a Bowman infu- the chemotherapy. However, sion pump was used for the constant infusion. It was sponse of the tumor to the chemotherapeutic regi- found subsequently that 26% of the testosterone infused mens that were tried makes this an unlikely pos- via the venoclysis set was absorbed by the tubing, and sibility. appropriate corrections were made. Blood samples were Urinary 17-hydroxycorticoid excretion averaged 4 Nuclear-Chicago Corp., Des Plaines, Ill. 22 mg per day. Since the excretion of - 5 New England Nuclear Corp., Boston, Mass. triols, which are also measured by the method em- ANDROGEN METABOLISM IN TESTICULAR INTERSTITIAL CELL CARCINOMA 1703

DECADRON GDAILY jCG40U40 U ILILY ACTINOMYCIN D FLUOXY- MESTRONE 4MG DAILY 111 800 a, I~~~~~~~~~~~~ 7- 7 I7 N. 6001- o0 7 7 400F 7 a

200 X/ x X/ /,/ O/ //,/ 0// // 'I / / / /I / // / /y DAYS FIG. 3. EFFECT OF EXOGENOUS HORMONES AND ACTINOMYCIN D ON 17-KETOSTEROID EXCRETION. HCG = human chorionic gonadotropin. ployed, was increased to 6 mg per day, urinary entirely from the blood testosterone compartment. corticoid excretion was actually within the nor- If a significant fraction of the urinary testosterone mal range. Plasma Silber-Porter chromogen lev- glucuronide had been derived from a testosterone els were normal. compartment other than the plasma testosterone Testosterone. Total excretion of testosterone compartment, the production rate estimated by ranged between 500 and 1,500 ,ug per day, or some urinary isotope dilution would have been larger 10 to 30 times normal. These values are not cor- than that measured by the metabolic clearance rected for losses, and the recovery was probably technique (22, 23). between 40 and 50%. When the sulfates and glu- Origin of plasma testosterone. It could not be curonides were separated before hydrolysis, the ex- established from these data whether the plasma cretion of testosterone isolated from the sulfate testosterone resulted from "secretion" by the tu- fraction was 690 Jng per day. mor or peripheral production from precursors. Plasma testosterone concentration was 1.96 ,g The high urinary excretion of DHA sulfate sug- per 100 ml. The metabolic clearance rate of tes- gested that this conjugate could serve as a precur- tosterone was 2,700 L per day, about three times sor of the plasma testosterone. To examine this, the normal clearance rate (21), indicating ex- we isolated testosterone glucuronide from urine tensive extrahepatic clearance of testosterone. and measured its specific activity after the intra- As the tumor at autopsy was six times as large as venous infusion of DHA sulfate-8H and DHA-14C the liver, it was the likely site of the extrahepatic (Table I). It is apparent that the specific ac- metabolism. Other studies in this patient likewise tivity of testosterone glucuronide was the same as suggest active participation of the tumor in metab- olism of plasma steroids. TABLE I The testosterone production rate calculated by Specific activity of urinary testosterone glucuronide and urinary DHA sulfate after administration the urinary isotope dilution method from the spe- of DHA sulfate-3H and DHA-14C* cific activity of urinary testosterone glucuronide was 53 mg per day, or ten times normal. When % testosterone glucuronide de- the blood testosterone production rate was esti- Testosterone -DHA rived from mated as the product of the metabolic clearance glucuronide sulfate DHA sulfates rate and the plasma level (20), the value was 48 dpm/pg 3H 1.2 1.1 100 mg per day. The reasonable agreement between 14C 0.65 0.72 90 these two production rates indicates that the uri- nary testosterone glucuronide originated almost * DHA = dehydroepiandrosterone. 1704 LIPSETT, SARFATY, WILSON, iBARDIN,: AND FISHMAN

TABLE II 146 dpm per ,ug. Had both steroids been derived Specific activities of , DHA glucuronide, exclusively from the same precursors, their spe- and DHA sulfate after infusion of DHA sulfate-3H and DHA-14C cific activities would have been equal. Thus, 80%o of the urinary testosterone sulfate must have been Specific activity diluted by unlabeled testosterone sulfate. Production rate DHA Testos- In view of the significance of the sulfoconjugates glucu- DHA terone DHA ronide sulfate sulfate DHA sulfate in steroid biosynthesis (25) and the demonstration that an adrenocortical carcinoma could synthesize dpmAg mg/24 hr 3H 10.3 1 18.9 2,270 testosterone sulfate (26), it may be reasonably 14C 7.5 0.72 1.04 286 assumed that the testosterone sulfate was syn- thesized by the tumor. The data of Table II sup- port this assumption. After the infusion of DHA that of DHA sulfate with respect to tritium and sulfate-3H, the specific activity of 3H of the tes- was 90%o of the specific activity of DHA with re- tosterone sulfate was 18 times as great as that of spect to 14C. This means that plasma DHA sul- DHA sulfate. If urinary DHA sulfate is derived fate must have been the unique precursor of es- entirely from plasma DHA sulfate, the testosterone sentially all of the urinary testosterone glucuronide sulfate must have been synthesized from infused and hence, of the plasma testosterone, for if DHA sulfate-3H that was selectively metabolized there had been a precursor of testosterone not de- by the tumor before equilibration with plasma rived from DHA sulfate, the urinary testosterone DHA sulfate had occurred. Siiteri and MacDon- glucuronide would have been diluted by this other ald (27) used a similar explanation to account for source, and its specific activity would have been similar apparently anomalous findings after infu- lower than that of DHA sulfate. The good agree- sion of labeled DHA sulfate. It is not easy to in- ment between the specific activities of 5H and '4C voke this explanation for the finding that the 14C is additional evidence that the plasma DHA sulfate specific activity of testosterone sulfate was twice was the precursor of the urinary testosterone glu- the 14C specific activity of DHA sulfate, since free curonide and thus the source of the plasma testos- plasma DHA is rapidly metabolized. terone. Production rates of DHA and DHA sulfate. This conclusion is supported by considering the An attempt was made to use the two compart- conversion of DHA sulfate to urinary testosterone ment model of Gurpide, MacDonald, Vande Wiele, glucuronide after the infusion of DHA sulfate-3H. and Lieberman (28) to calculate secretion rates, By reverse isotope dilution, it was found that production rates, and rates of conversion of DHA 0.03%o of the DHA sulfate-3H was converted to and DHA sulfate. From the data of Table II, we urinary testosterone glucuronide. Since about 1o% calculated that the production rate of DHA sul- of plasma testosterone is metabolized to urinary fate was 2,270 mg per day and that of DHA was testosterone glucuronide (24), and since plasma 286 mg per day. The calculation of secretion and DHA sulfate was the precursor of plasma testos- conversion rates was not possible due to the excess terone in this subject, the production of plasma of tritium in the DHA glucuronide. testosterone could be estimated at 68 mg per day The reason for this finding has been alluded to. from the production rate of DHA sulfate (Table The analysis of Gurpide and co-workers (28) was II) (2,270 x 0.0003 X 100). The difference of predicated on a two compartment model, although 30%o from the experimental values may be due to it seems probable that in this patient the tumor the assumed rate of metabolism of plasma testos- acted as a third compartment. If, as suggested terone to urinary testosterone glucuronide. earlier, the tumor was removing DHA sulfate Origin of urinary testosterone sulfate. After from plasma and secreting DHA, then plasma administration of testosterone-3H, the specific ac- DHA and urinary DHA glucuronide could con- tivities of urinary testosterone sulfate and glu- tain an excess of tritium. There would then be curonide were measured. Testosterone sulfate no way to estimate secretion and conversion rates. had a specific activity of 31.2 dpm per /Lg, whereas If injected DHA sulfate-8H was metabolized by testosterone glucuronide had a specific activity of the tumor before equilibration with plasma DHA ANDROGEN METABOLISM IN TESTICULAR INTERSTITIAL CELL CARCINOMA 1705

sulfate occurred, then one of the criteria of the TABLE IV urinary isotope dilution method was not fulfilled, Specific activities of sulfates of DHA, andros- and DHA namely, that the tracer be metabolized identically tenediol, 16-hydroxy with the unlabeled steroid. Thus, even calculation Andros- 16-Hy- of production rates would be theoretically un- DHA tenediol droxy DHA sound. The divergence between the true and cal- dpm/mg culated blood production rates would depend on 3H 1,070 1,060 1,080 1l4C 720 700 730 such incalculable factors as how much tracer was metabolized by the tumor and the fate of this tracer. Nevertheless, the internal consistency of fraction was excreted as the sulfate, although in the testosterone production rate calculated from the case of 16-hydroxy DHA, the glucuronide al- the dilution of testosterone-3H and that estimated most equaled the sulfate. Dehydroepiandrosterone from the conversion of DHA sulfate to urinary was excreted in amounts similar to those noted in testosterone glucuronide suggests that DHA sul- adrenal carcinoma. The urinary levels of preg- fate production rates cannot have been greatly nenediol, pregnenetriol, and androstenediol were overestimated. many times the normal values. Similar findings Epitestosterone. The production rate of epi- have been described in adrenocortical carcinoma testosterone estimated from the specific activity (30). A high excretion of 16-hydroxy DHA has of urinary epitestosterone glucuronide after the in- been described previously in a patient with adreno- jection of epitestosterone-3H was 495 ug per day, cortical carcinoma (31). or two to three times normal. We have shown The origin of the androstenediol sulfate and the previously (29) that epitestosterone is not a 16-hydroxy DHA sulfate was examined by com- peripheral metabolite of DHA or testosterone, and paring their specific activities to that of DHA sul- these data suggest that increased synthesis of fate after the infusion of DHA sulfate-3H and these steroids is not accompanied by a propor- DHA-14C (Table IV). Their specific activities tionate increase in epitestosterone synthesis. were the same within the limits of error of mea- Excretion of M6 steroids. The excretion of sev- surement, which made it likely that the plasma eral steroids retaining the A5-3,8-hydroxy function DHA sulfate was the sole precursor of the urinary is presented in Table III. As expected, the larger androstenediol sulfate and 16-hydroxy DHA sul- fate. Roberts and associates (32) reported similar TABLE III findings in a subject with adrenocortical carci- Urinary steroid excretion noma. Excretion of 3a-hydroxysteroids. Urinary an- Normal (sulfate drosterone and etiocholanolone levels were greatly Glucu- plus ronide Sulfate Total glucuronide) elevated, although they totaled only 9% of the mg/24 hr* DHA sulfate production. These are uncorrected Androstenol 1.2 t 1.2 1-2 figures, however, and the true excretion may be DHA 3.5 45.0 48.5 0.2-2.0 16-Hydroxy DHA 5.0 6.8 11.8 0.1-0.2 twice the estimated values. The metabolites of Androstenediol 0.2 8.8 9.0 0.1-0.2 17-hydroxyprogesterone, pregnanetriol and 17- Pregnenediol 0.4 5.6 6.0 0.1-0.4 Pregnenetriol 1.2 3.7 4.9 0.2-0.4 hydroxypregnanolone, were excreted in increased Pregnanediol 2.1 t 2.1 0.4 amounts (Table III). Pregnanediol excretion Pregnanetriol 6.0 t 6.1 0.5 17-Hydroxypregnanolone 2.8 t 2.8 0.2 was increased proportionately less than the metabo- Androsterone 65 7.3 72.3 1-3 lites of other biosynthetic intermediates, suggest- Etiocholanolone 119 1.8 120.8 2-4 ing that either was efficiently utilized 1l-Ketoetiocholanolone 1.4 0 1.4 0.5 1 1-Hydroxyetiocholanolone 3.1 0 3.1 0.4 by the tumor, or that biosynthesis occurred pre- 1 1-Hydroxyandrosterone 4.5 2.2 6.7 0.5 Estrone 0.075 dominantly via the pathway from 17-hydroxypreg- Estradiol <0.013 nenolone to 17-hydroxyprogesterone, thus bypass- Estriol 0.029 ing progesterone.

* These values are not corrected for losses during isolation, Excretion of il-oxo-steroids. Of considerable t Not searched for. t Normal values have not been measured in this laboratory. interest were the increased urinary titers of the 1706 LIPSETT, SARFATY, WILSON, BARDIN, AND FISHMAN three 11-oxo-17-ketosteroids. The excretion of equally compatible with production pe- 6.7 mg per 24 hours of 11-hydroxyandrosterone ripherally from any of the C10O2 precursors. represented a thirteenfold increase above normal. tince synthesis of this steroid presumably required Discussion an 11,8-hydroxylating system in the tumor, the The rarity of interstitial cell carcinoma has pre- general question of 11,8-hydroxylation was ex- cluded adequate study of its steroid synthetic ac- amined. As pregnanetriol excretion was elevated tivity. The 17-KS excretion ranged from 20 to and we could infer 17-hydroxyprogesterone syn- 1,000 mg daily in four reported cases (1, 4, 5, 7) thesis, we attempted to measure 11-ketopregnane- and in our case, and it was thus within the range triol in the urine. However, none was found in usually found with adrenocortical carcinoma (34). this subject's urine, indicating that 11,-hydroxyla- Although the steroid biosynthetic activity of the tion of 17-hydroxyprogesterone did not occur to interstitial cell tumor was not suppressed by ex- any measurable extent. ogenous androgen as is the normal interstitial cell To ascertain whether the urinary 17-hydroxy- (35), the response to HCG demonstrated that the corticoids were metabolites of cortisol produced tumor was not completely autonomous. Occa- by the tumor or by the adrenal cortex, we mea- sional adrenocortical carcinomas have similarly sured tetrahydrocortisol, tetrahydrocortisone, al- shown ACTH responsiveness, but there has been lotetrahydrocortisol, and cortisol together. Dur- a uniform inability to suppress their steroid out- ing a control period, the 24-hour excretion was 7.8 put with exogenous corticoids (34). mg; this was decreased to 3.8 mg by the daily ad- This patient and the patient described the by Abel- ministration of 8 mg of dexamethasone. Thus, son and co-workers (7) had a high plasma con- titers of cortisol metabolites paralleled adrenocor- centration of testosterone, the characteristic se- tical function, whereas the excretion of 11-hy- cretory product of the Leydig cell. Since this droxyandrosterone measured simultaneously was patient's remaining testis was atrophic, it seems unchanged by dexamethasone. Hence, it seems unlikely that it could have accounted for a sig- that the tumor demonstrated some substrate speci- nificant fraction of the plasma testosterone. in a that has ficity 11-hydroxylation, conclusion In spite of a high metabolic some precedence in a similar Savard and clearance rate of study by testosterone, the level associates (33) of a benign interstitial cell tumor. plasma was maintained at 1.96 jug per 100 ml, due to a high testosterone Tetrahydro substance S was not detected in the blood production rate. An unexpected conclusion urine of this patient. In view of the probable ex- was that almost all of this testosterone had its cess of 17-hydroxyprogesterone produced by the origin from plasma DHA sulfate, and the close tumor, it must be concluded that the tumor did agreement between the specific -activities of tritium not possess a 21-hydroxylating system and differs and carbon in urinary DHA in sulfate and in urinary this regard from many adrenocortical tumors. testosterone glucuronide left no alternative. This Estrogens. The excretion of estrone, estradiol, conclusion was strengthened by the estimate of and estriol was measured in four consecutive 24- testosterone production obtained from the inde- hour urines. The average excretion of estrone pendent measurement of DHA sulfate production was 75 ,ug per 24 hours; estriol, 29 ,ug per 24 and its conversion to testosterone glucuronide. hours; and estradiol, less than 13 ,ug per 24 hours. This emphasizes the hazards of assuming syn- Other patients with interstitial cell carcinoma thesis of a steroid by a tumor when such a steroid have had an increased excretion of estrogens de- can be synthesized peripherally from other steroid termined either by bioassay (4, 7) or chemically precursors. (5). The agreement between the two methods of es- The failure to find estradiol may have been timating testosterone production rates is of con- due to the relatively small samples used and the siderable interest in view of prior studies demon- large losses before the measurement of estrogen. strating that, in general, only a small moiety of It cannot be assumed from these high levels that plasma testosterone is due to hepatic testosterone the tumor produced estrogens, since the data are synthesis from other precursors (23, 35, 36). ANDROGEN METABOLISM IN TESTICULAR INTERSTITIAL CELL CARCINOMA 1707 This phenomenon most probably reflects rapid Schriefers (40) demonstrated that a homogenate conjugation of the newly synthesized testosterone. of a benign interstitial cell tumor could 1 1/-hy- This has not been invariable, however, and in one droxylate both androstenedione and deoxycorti- patient it was shown that all of the testosterone costerone. synthesized peripherally from androstenedione ap- Although we have suggested that the 3,8-hy- peared in the plasma as free testosterone (23). droxysteroid dehydrogenase activity of the tumor Thus, variability in rates of conversion to glucuro- was limited, it should be pointed out that the evi- nide of testosterone synthesized in the liver could dence for any 3,8- dehydrogenase have a decisive role in determining plasma testos- activity of the tumor is limited. It is known that terone levels. Had the production rates not been the liver also possesses this enzyme system so that measured by both techniques, it would have been progesterone or 17-hydroxyprogesterone could concluded that plasma DHA sulfate could not have have been synthesized there from their respective been the source of plasma testosterone. A5-3,8-hydroxy precursors. The finding that The measurement of urinary metabolites of tends to refute this possibility is the synthesis of known intermediates of biosynthetic sequences 11,/-hydroxyandrostenedione, since if androstene- permits an informed guess about in vivo syn- dione were synthesized only in the liver, 11,8-hy- thetic activity. Thus, the excretion of large droxylation would not be expected. amounts of pregnenediol, pregnenetriol, andros- The resemblance of this tumor to adrenocortical tenediol, and DHA reflected the production of carcinoma in its functional aspect is striking. The proportionately increased amounts of their re- high production rate of DHA sulfate and the ex- spective precursors, , 17-hydroxy- cretion of greatly increased amounts of DHA and pregnenolone, and DHA. A subsequent inference other A5 steroids are in the usual pattern of func- is that tumor 3,8-hydroxysteroid dehydrogenase tional adrenal carcinoma (37). Many adrenal car- activity was limited, since these steroids were not cinomas likewise demonstrate a decreased activity converted to the corresponding &4-3-ketosteroids. of 3/3-hydroxysteroid dehydrogenase and, in some, This pattern, too, is characteristic of adrenocortical this enzyme appears to be absent. The occurrence carcinoma (37). of 11,8-hydroxylation of androstenedione and the The excretion of individual 11-oxo-17-keto- simultaneous lack of 1 1,8-hydroxylation of C-21 steroids was measured by Abelson and associates pregnane derivatives have also been described in (7), and the excretion of each was increased. The adrenocortical carcinoma (37). The interstitial findings in our case are similar, but the largest in- cell carcinoma synthesized small amounts, if any, crease was in the excretion of 11-hydroxyandros- of testosterone, the important secretory product terone. This steroid is the principal metabolite of of the interstitial cell; similarily, some adrenal 11,8-hydroxyandrostenedione (38). Since sup- cancers that synthesize several corticoids fail to pression of the adrenal cortex did not decrease the synthesize the characteristic adrenal cortical se- excretion of 11-hydroxyandrosterone, we have cretory product, cortisol. concluded that 11,8-hydroxyandrostenedione was A singular point of difference between the two synthesized by the tumor. cancers is the development of an 11,8-hydroxylat- In three cases of benign interstitial cell tumor ing system in the interstitial cell carcinoma. As (33, 39, 40) 11-hydroxyandrosterone was also ex- far as we are aware, 11,3-hydroxylation has not creted in increased amounts. Savard and associ- been shown to occur in any normal mammalian ates (33) suggested that the 11/3-hydroxylating testis. Thus, this interstitial cell cancer is an ex- system showed substrate specificity, since they ception to the generalization that the development were unable to demonstrate 11,8-hydroxylation of of neoplasia is not accompanied by the appearance progesterone. Our findings support this sug- of new enzymes. Rather, the activity of normal gestion, since we were unable to find 11-ketopreg- enzyme systems may be greatly reduced or disap- nanetriol in spite of an abundant supply of the pear, as so often happens to 11,8-hydroxylation in substrates for 11ft-hydroxylation, 17-hydroxy- adrenocortical carcinoma. progesterone, and 17-hydroxypregnenolone. It These comparisons rest on the unequivocal iden- should be noted, however, that Smith, Breuer, and tification of the tumor in this case as an interstitial 1708 LIPSETT, SARFATY, WILSON, BARDIN, AND FISHMAN cell carcinoma. This question will be considered References in detail by Horner and Evans (41), but it should 1. Masson, P. Deux cancers Leydigiens de l'homme. be stated that there was no disagreement among Rev. canad. Biol. 1943, 2, 168. experienced pathologists regarding the origin of 2. Gharpure, V. V. A case of malignant interstitial-cell the cancer. One could, however, make a convinc- tumour of the testis in man. J. Path. Bact. 1950, 62, 113.' ing argument that biochemical and morphologic 3. Ohlsen, A. S., and G. Rhnn. Leydig-cell carcinoma. criteria have equal validity. With report of a case. Acta chir. scand. 1957, 112, 411. 4. Largiader, F. Maligner Tumor der Leydigschen Summary Zwischenzellen des Hodens. Frankfurt. Z. Path. Steroid studies in a patient with metastatic in- 1960, 70, 630. 5. Ward, J. A., S. Krantz, J. Mendeloff, and E. Halti- terstitial cell carcinoma have been described. The wanger. Interstitial-cell tumor of the testis: re- patient excreted large amounts of 17-ketosteroids, port of two cases. J. clin. Endocr. 1960, 20, 1622. comprising both the li-deoxy- and the l1-oxy- 6. Short, M., and J. I. Coe. Malignant interstitial cell steroids. The tumor responded to human chori- tumor of the testis: a case report. J. Urol. (Balti- onic but was not suppressed by ex- more) 1963, 89, 851. gonadotropin 7. Abelson, D., H. Bulaschenko, P. R. Trommer, and ogenous androgen. A. Valdes-Dapena. Malignant interstitial-cell tu- The plasma testosterone level was four times mor of the testis treated with o,p'-DDD. Metabo- normal, and it was demonstrated that plasma de- lism 1966, 15, 242. sulfate was the source of the 8. Peterson, R. E., and C. E. Pierce. Determination of hydroepiandrosterone urinary neutral 17-ketosteroids in Lipids and the plasma testosterone. The dehydroepiandrosterone Steroid Hormones' in Clinical Medicine, F. W. sulfate production rate was 2,270 mg per day. Sunderman and F. W. Sunderman, Jr., Eds. Evidence was presented that the tumor secreted Philadelphia, Lippincott, 1960. 9. Wilson, H., and M. B. Lipsett. Use of periodate testosterone sulfate as well. oxidation in the clinical analysis of urine corti- The excretion of metabolites of the biosynthetic coids. Analyt. Biochem. 1963, 5, 217. precursors of testosterone demonstrated that there 10. Peterson, R. E., A. Karrer, and S. L. Guerra. Eval- was a low activity of tumor de- uation of Silber-Porter procedure for determina- 3,8-hydroxysteroid tion of plasma hydrocortisone. Analyt. Chem. 1957, hydrogenase. The steroid synthetic activity of 29, 144. this cancer resembled closely that of adrenocorti- 11. Kirschner, M. A., M. B. Lipsett, and D. R. Collins. cal cancer. Plasma ketosteroids and testosterone in man: a study of the pituitary-testicular axis. J. clin. Invest. 1965, 44, 657. Appendix 12. Kirschner, M. A., and M. B. Lipsett. Gas-liquid chromatography in the quantitative analysis of uri- Case report nary 11-deoxy-17-ketosteroids. J. clin. Endocr. J.A.T. (NIH, 05-84-62) was a 67-year-old white man 1963, 23, 255. who had a left orchiectomy for a testicular mass in 1963. 13. Sarfaty, G. A., and M. B. Lipsett. Separation of In June 1964 an abdominal mass was noted; this was bi- free and conjugated 11-deoxy-17-ketosteroids by opsied 3 months later, and he was referred from the thin-layer chromatography. Analyt. Biochem. 1966, Savannah U. S. Public Health Service Hospital to the 15, 184. Endocrinology Branch, National Cancer Institute. On 14. Edwards, R. W. H., A. E. Kellie, and A. P. Wade. admission, the only significant physical finding was a The extraction and conjugation of urinary ster'oid 15- X 15-cm lower abdominal mass. conjugates. Mem. Soc. Endocr. 1953, 2, 53. The routine laboratory studies including hematology, 15. Burstein, S., and S. Lieberman. Hydrolysis of keto- steroid hydrogen sulfates by solvolysis procedures. liver function tests, protein-bound iodine, and total gonado- 3. biol. Chem. 1958, 233, 331. tropin excretion were within normal limits. The biopsy 16. Korenman, S. G., H. Wilson, and M. B. Lipsett. 9pecimen of the tumor and the material obtained at au- Testosterone production rates in normal adults. topsy were reported as interstitial cell carcinoma by J. clin. Invest. 1963, 42, 1753. pathologists at the National Institutes of Health and the 17. Wilson, H., M. B. Lipsett, and S. G. Korenman. Armed Forces Institute of Pathology. The clinical and Evidence that 16-androsten-3a-ol is not a periph- pathological aspects of this case will be reported by eral metabolite of testosterone in man. J. clin. Homer and Evans (41). Endocr. 1963, 23, 491. ANDROGEN METABOLISM IN TESTICULAR INTERSTITIAL CELL CARCINOMA 1709

18. Engel, L. L. The chemical estimation of steroid hor- 30. Wilson, H., M. B. Lipsett, and D. W. Ryan. Urinary mone metabolites. Recent Progr. Hormone Res. excretion of A5-pregnenetriol and other 3f8-hydroxy- 1950, 5, 335. A' steroids by subjects with and without endo- 19. Wilson, H., and M. B. Lipsett. Metabolism of epites- crine disease. J. clin. Endocr. 1961 21, 1304. tosterone in man. J. clin. Endocr. 1966, 26, 902. 31. Okada, M., D. K. Fukushima, and T. F. Gallagher. 20. Tait, J. F. Review: the use of isotopic steroids for Isolation and characterization of 3p-hydroxy-A5- the measurement of production rates in vivo. J. steroids in adrenal carcinoma. J. biol. Chem. 1959, clin. Endocr. 1963, 23, 1285. 234, 1688. 21. Horton, R., J. Shinsako, and P. H. Forsham. Tes- 32. Roberts, K. D., L. Bandi, H. I. Calvin, W. D. tosterone production and metabolic clearance rates Drucker, and S. Lieberman. Evidence that ster- with volumes of distribution in normal adult men oid sulfates serve as biosynthetic intermediates. IV. and women. Acta endocr. (Kbh.) 1965, 48, 446. Conversion of sulfate in vivo to urinary 22. Tait, J. F., and R. Horton. Some theoretical con- Cn and C21 steroidal sulfates. Biochemistry 1964, siderations on the significance of the discrepancy 3, 1983. in urinary and blood production rate estimates of 33. Savard, K., R. I. Dorfman, B. Baggett, L. L. Field- steroid hormones particularly in those of testos- ing, L. L. Engel, H. T. McPherson, L. M. Lister, terone in young women. Steroids 1964, 4, 365. D. S. Johnson, E. C. Hamblen, and F. L. Engel. 23. Korenman, S. G., and M. B. Lipsett. Is testosterone Clinical, morphological, and biochemical studies of glucuronoside uniquely derived from plasma tes- a virilizing tumor in the testis. J. clin. Invest. tosterone? J. clin. Invest. 1964, 43, 2125. 1960, 39, 534. 24. Camacho, A. M., and C. J. Migeon. Studies on the 34. Lipsett, M. B., R. Hertz, and G. T. Ross. Clinical origin of testosterone in the urine of normal adult and pathophysiologic aspects of adrenocortical subjects and patients with various endocrine dis- carcinoma. Amer. J. Med. 1963, 35, 374. orders. J. clin. Invest. 1964, 43, 1083. 35. Horton, R., and J. F. Tait. Androstenedione pro- 25. Calvin, H. I., R. L. Vande Wiele, and S. Lieberman. duction and interconversion rates measured in Evidence that steroid sulfates serve as biosyn- peripheral blood and studies on the possible site thetic intermediates: in vivo conversion of preg- of its conversion to testosterone. J. clin. Invest. nenolone-sulfate-S' to dehydroisoandrosterone sul- 1966, 45, 301. fate-S'. Biochemistry 1963, 2, 648. 36. Korenman, S. G., and M. B. Lipsett. Direct periph- 26. Dixon, W. R., J. G. Phillips, and N. Kase. In vitro eral conversion of dehydroepiandrosterone to tes- production of testosterone sulfate from proges- tosterone glucuronoside. Steroids 1965, 5, 509. terone-4-1'C in an adrenal tumor. Steroids 1965, 37. Lipsett, M. B., and H. Wilson. Adrenocortical can- 6, 81. cer: steroid biosynthesis and metabolism evaluated 27. Siiteri, P. K., and P. C. MacDonald. The utilization by urinary metabolites. J. clin. Endocr. 1962, 22, of circulating dehydroisoandrosterone sulfate for es- 906. trogen synthesis during human pregnancy. Steroids 38. Bradlow, H. L., and T. F. Gallagher. Metabolism 1963, 2, 713. of ll-hydroxy-A'-androstene-3,17-dione in man. 28. Gurpide, E., P. C. MacDonald, R. L. Vande Wiele, J. biol. Chem. 1957, 229, 505. and S. Lieberman. Measurement of the rates of se- 39. Camin, A. J., R. I. Dorfman, J. H. McDonald, and cretion and of peripheral metabolism of two inter- I. M. Rosenthal. Interstitial cell tumor of the convertible compounds: dehydroisoandrosterone- testis in a seven-year-old child. Amer. J. Dis. dehydroisoandrosterone sulfate. J. clin. Endocr. Child. 1960, 100, 389. 1963, 23, 346. 40. Smith, E. R., H. Breuer, and H. Schriefers. A study 29. Korenman, S. G., H. Wilson, and M. B. Lipsett. of the steroid metabolism of an interstitial-cell tu. Isolation of 17a-hydroxyandrost-4-en-3-one (epi- mor of the testis. Biochem. J. 1964, 93, 583. testosterone) from human urine. J. biol. Chem. 41. Horner, C. E., and G. Evans. Personal communica- 1964, 239, 1004. tion.