Diagnostic relevance of urinary steroid profiles on ovarian granulosa cell tumors: two case reports

A 49-year-old European, postmenopausal woman who was diagnosed with stage T1a ovarian GCT had recurrence 7 years after primary surgery and five cycles of chemotherapy: epirubicin + cisplatin. On admission, the results of her neurological examination were normal. A physical examination revealed two cystic masses above her vagina on the left and slightly to the right that varied from 6 to 10 cm in diameter. The results of the rest of her physical examination were normal. She had given birth to three children. In January 2011, magnetic resonance imaging (MRI) depicted a large pelvic mass with inhomogeneous signal intensity (87×108×70 mm), a diffuse peritoneal metastasis (68×35 mm) with ascites, a parailiacal pathological lymph node (15×10 mm), and an inguinal pathological lymph node (62×32 mm) from the left side of her pelvis (Fig. 1). A laboratory examination did not reveal elevated levels of serum tumor markers and hormones: carcinoembryonic antigen (CEA), 1.6 ng/ml; carbohydrate antigen-125 (CA-125), 18.45 U/ml; carbohydrate antigen-15-3 (CA-15-3), 20 U/ml; carbohydrate antigen-19-9 (CA-19-9), 0.6 U/ml; alpha-fetoprotein (AFP), 2.3 μg/l; follicle-stimulating hormone (FSH), 23.1 U/l; luteinizing hormone (LH), 38.9 U/l; progesterone (P), 2 nmol/l; 17β-estradiol (E₂), 64 pmol/l; testosterone (T), 0.92 nmol/l; and androstenediol (A), 7.74 nmol/l. She underwent abdominal hysterectomy with bilateral salpingo-oophorectomy and omentectomy 3 months later. A histologic examination revealed recurrence of GCT. Immunohistochemical staining gave positive results for alpha-inhibin. After the operation (OP), she was given three cycles of chemotherapy: bleomycin, etoposide, and cisplatin (BEP). Two months later she underwent metastasectomy through laparotomy and she was given three cycles of third line chemotherapy: cyclophosphamide and doxorubicin (CAP I). Despite surgeries and chemotherapies, in August 2014 a computed tomography (CT) scan showed significant progression of the recurrent GCT, local tumor recurrence, the presence of diffuse peritoneal carcinosis, ascites, and inguinal pathological lymph node (Fig. 2). A laboratory examination did not reveal elevated levels of serum tumor markers: CEA, 1.3 ng/ml; CA-125, 13 U/ml. Then she was given three cycles of re-induction of epirubicin + cisplatin chemotherapy. Three months later in February 2015, CT demonstrated 25% regression of the tumor (Fig. 2). Then, she refused further parenteral chemotherapy. From April 2016 she received oral anastrozole (Arimidex®) therapy. During the treatments, before and after the OP, 13 24-hour urinary samples were collected at different time points. Her urine samples were stored at −20 ^○C until analysis. We performed sample pre-treatment, and the extraction method we used is based on Shackleton and Whitney’s extraction method [7]. After the sample preparation processes the concentrations (μg/24 hours) of the following urinary androgen, progesterone (P), and corticoid metabolites were determined by gas chromatography-mass spectrometry (GC-MS)/selected ion-monitoring (SIM): androsterone (An), etiocholanolone (Et), dehydroepiandrosterone (DHEA), 11β-hydroxyandrosterone (11-OH-An), 16-hydroxy-DHEA (16-OH-DHEA), pregnanediol (PD), pregnanetriol (PT), pregnenediol (Δ5-PD), androstenetriol (Δ5-AT), tetrahydro-11-deoxycortisol (THS), 11-keto-pregnanetriol (11-O-PT), tetrahydrocortisone (THE), tetrahydro-11-dehydrocorticosterone (THA), tetrahydrocorticosterone (THB), allo-tetrahydrocorticosterone (aTHB), tetrahydrocortisol (THF), allo-tetrahydrocortisol (aTHF), α-cortolone (α-CL), β-cortolone (β-CL), and α-cortol (α-C). All components were detected in all samples. The interventions and treatments of patient 1, the collection of urine samples, and the levels of the urinary steroid metabolites are shown in Fig. 3.

A 55-year-old European, postmenopausal woman was diagnosed with stage T1a ovarian GCT in October 2011. On admission, the results of her neurological examination were normal. Her physical examination was otherwise unremarkable. A CT scan depicted a large, single pelvic mass with inhomogeneous signal intensity (164×113×146 mm) and ascites. A laboratory examination did not reveal an elevated level of CA-125 (11 U/ml) tumor marker. She underwent laparotomy and the entire tumor was removed. The pathologic diagnosis was GCT. No further treatment was given. On clinical and radiological examination 11 months later, she was found to be free of the disease. After the OP, during the oncological follow-up, six 24-hour urinary samples were collected at different time points. Her urinary concentrations (μg/24 hours) of An, Et, DHEA, 11-OH-An, 16-OH-DHEA, PD, PT, Δ5-PD, Δ5-AT, THS, 11-O-PT, THE, THA, THB, aTHB, THF, aTHF, α-CL, β-CL, and α-C were determined by GC-MS/SIM. All components were detected in all samples. The interventions and treatments of patient 2, the collection of urine samples, and the levels of the urinary steroid metabolites are shown in Fig. 4.