Approach to the Mechanism of Androgen Overproduction in a Case of Krukenberg Tumor Responsible for Virilization during Pregnancy*

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Abstract
Virilization may occur during pregnancy as the result of an ovarian Krukenberg tumor. Mechanism of the androgen overproduction in this exceptional condition is still poorly understood. A new case is reported in which only in the postpartum clinical, endocrine, and endoscopic studies led to the diagnosis of an ovarian Krukenberg tumor secondary to a gastric carcinoma. In the mother, basal hormonal studies were done 1 and 4 weeks after delivery, then after gastric and ovarian surgery. Three months after delivery, ovarian steroid response to hCG (priming dose, 5000 IU; then 1500 IU every other day for 12 days) and a study of progesterone (P) metabolism at a steady state after a constant infusion of [3H]P and cold P (92 μg/min → blood production rate (BPR) of 152 mg/day designed to reproduce the BPR of P usually seen in pregnancy) were successively performed. Hormones were measured by specific RIAs after chromatographical purification. Basal hormonal levels were normal in the child. In the mother, on the 5th day postpartum, mean hormone levels (in nanograms per dl) were: testosterone (T), 4181; androstenedione (Δ4), 8876; 17α-hydroxyprogesterone (17-OHP), 9746; P, 1075; estrone (E1), 195; and estradiol (E2), 151. One month later, levels were normal for the follicular phase: T, 40; Δ4, 146; P, 52; E2, 9; and E2, 4.5. At both times, dehydroepiandrosterone was normal (703–750). Hormone levels increased progressively during hCG stimulation but their time course was different between hormones. At the end of the test, T, 144; Δ4, 746; 17-OHP, 789; P, 723; E,, 37; and E2) 20. The MCR of P was decreased, 1450 liters/day (normal, 2020). Conversion ratios between products and precursor during constant infusion were normal. From these data, obtained in four different conditions (postpartum period, hCG stimulation, progesterone infusion, and after oophorectomy), the following can be concluded: adrenal production of dehydroepiandrosterone was normal; the ovarian overproduction of androgens likely resulted from the excessive reductive metabolism of both placental and ovarian P along the Δ4 steroid biosynthetic pathway by an hypertrophic stromal compartment; and hCG stimulation seems to be the necessary stimulus for this condition. The enhancement by T on its own peripheral production is also discussed.

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