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

Background Granulosa cell tumor of the ovary is the most frequent sex cord stromal tumor and represents 2 to 5% of all primary ovarian cancers. Ovarian granulosa cell tumor is a malignant tumor with slow progression and in some cases this tumor is hormonally active. The recurrence of granulosa cell tumor often happens after 5 years. Case presentation We describe two cases of postmenopausal women with adult-type granulosa cell tumors of the ovary. Patient 1 is a 49-year-old European woman with a recurrent tumor; patient 2 is a 55-year-old European woman without recurrence of tumor. Urinary steroid profiles of patient 1 were monitored during a 5-year period starting from before an operation (13 samples). In patient 2, the urinary steroid profiles were monitored during a 3-year period starting from after an operation (six samples). The 24-hour urinary samples were examined and the urinary concentration of 20 androgen, progesterone, and corticoid metabolites was quantitatively determined by gas chromatography-mass spectrometry with selected ion-monitoring mode. Conclusions Based on these cases a correlation could be observed between increased levels of the urinary steroids and the recurrence of ovarian granulosa cell tumor; therefore, we concluded that a urinary steroid profile could be a more effective method to follow-up such patients compared to the traditional serum hormones determinations supplemented with conventional tumor markers.


Background
Granulosa cell tumor (GCT) of the ovary is a malignant tumor originating from the sex-cord stromal cells of the ovary and represents approximately 5% of all primary ovarian cancers [1][2][3]. Approximately 4% occur before puberty (juvenile GCT) and the majority of the cases are the adult type of GCT (occur in people of reproductive age and postmenopausal age) [4]. In some cases these tumors are hormonally active, they often express steroid hormone receptors [3,5]. The natural history of GCT is generally long with slow progression, and recurrence often happens after 5 years of follow-up [6]. We report two cases of adult GCT of the ovary and describe the changes experienced in urinary steroid profiles which could help in following-up the presence, progression, and recurrence of this tumor.

Patient 2
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,

Discussion
GCT is hormonally active, so the qualitative and quantitative determination of steroid hormones has an important role in the follow-up and the diagnostics of this tumor. The urinary steroid profile is a feasible method, which allows us to measure several steroid groups in parallel and it is a noninvasive procedure.
In the first case, 1 month before the OP, in the first sample the urinary concentrations of An, Et, 11-OH-An, 16-OH-DHEA, Δ5-AT, PT, Δ5-PD, THE, aTHF, and α-CL were higher than the same age and same sex reference values. A laboratory examination did not reveal elevated levels of serum tumor markers and hormones. At 2 and 4 months after the OP, during the BEP chemotherapy (samples 2 and 3), the urinary levels of all metabolites were lower than the reference values. Six months after the OP (after BEP chemotherapy and metastasectomy, before CAP I chemotherapy) the urinary concentrations of An, Et, 11-OH-An, 16-OH-DHEA, Δ5-AT, PT, Δ5-PD, THE, THA, THB, THF, aTHF, α-CL and α-C were higher than the reference values (sample 4). After CAP I chemotherapy, a laboratory examination did not reveal elevated levels of serum tumor markers; however, in samples 5 to 8 (10 months, 15 months, 20 months, and 2 years 6 months after OP) the urinary concentrations of An, 11-OH-An, and Δ5-AT were higher than the reference values. In sample 9 (2 years 11 months after OP and before epirubicin + cisplatin chemotherapy) the urinary concentrations of An, Et, DHEA, 11-OH-An, 16-OH-DHEA, Δ5-AT, PT, Δ5-PD, THE, aTHF, and α-CL were found to be higher than the reference values again. In addition, a CT examination revealed that the tumor had progressed considerably. The elevated urinary hormone levels of the previous samples (samples 5 to 8) might have already indicated this progress. After epirubicin + cisplatin chemotherapy in sample 10 (4 years 1 month after OP), the urinary concentrations of six metabolites (An, 11-OH-An, Δ5-AT, PT, THE, and α-CL) were higher than the reference values; however, CT showed regression of the tumor. In sample 11 (4 years 6 months after OP and after epirubicin + cisplatin chemotherapy), the urinary concentrations of An, Et, DHEA, 11-OH-An, 16-OH-DHEA, Δ5-AT, PT, THE, THF, aTHF, α-CL, and β-CL were found to be higher than the reference values again. Under the anastrozole treatment in samples 12 and 13 (5 years 2 months and 5 years 5 months after OP), only the urinary concentration of THE was higher, the urinary concentrations of other metabolites were lower than the reference values. In all urine samples the concentrations of PD, THS, and 11-O-PT were lower than the reference values.
To summarize, before the OP the concentrations of urinary metabolites of serum androgens, pregnenolone, and 17-hydroxyprogesterone were elevated. The concentrations of the urinary metabolites of P, 21-deoxycortisol, and 11deoxycortisol were low. These changes were found after further treatments (surgery and chemotherapies), so they referred to the presence of the recurrent GCT. The elevated levels of the urinary metabolites of cortisol and cortisone referred to the effects of the stress. The chemotherapy and the aromatase inhibitor (anastrozole) treatments amended the steroid metabolism.
In case 2 the urinary concentrations of the metabolites are presented in Fig. 4. After the OP, during a 3-year follow-up period in all urine samples (samples 1 to 6) the concentrations of 20 steroid metabolites were lower than the reference values.
The obtained urinary steroid concentrations, as patient 2 was free of the GCT after an OP, corresponded to the postmenopausal state of women without ovaries.

Conclusions
Our results suggest that the recurrence of GCT changes urinary steroid profiles, which was indicated by the differences between the urinary steroid levels of the two patients. To confirm that the presence of a GCT can be identified based on a urinary steroid profile, we plan to carry out further multicenter clinical trials.