and all three androgens were simultaneously elevated in 56% of the cases. Serum androgen levels became subnormal in all ACT-AS patients after the tumor was removed. In nontumor androgen excess alone, the most commonly elevated androgen was androstenedione (93%), while all three androgens (T, A, and DHEAS) were elevated in only 22% of the cases. Free testosterone values above 6.85 pg/mL (23.6 pmol/L) had the best diagnostic value for ACT-AS (sensitivity 82%; CI, 57%–96%; specificity 97%, CI, 91%–100%) (Table 31.3). The large overlap of androstenedione, testosterone, and DHEAS levels between ACT-AS and androgen excess groups suggests that thoughtful consideration should be employed when choosing hormone studies for this evaluation (11).
The heterogeneity of hormone secretion patterns in the adrenocortical tumor group reveals the complexities of hormone level screening for adrenocortical tumors: 7 of 44 patients (15.9%) had tumors secreting androgens alone, 2 of 44 (4.5%) had tumors secreting androgens and estrogens, 28 of 44 (63.6%) had tumors secreting both androgens and cortisol, and 7 of 44 (15.9%) had tumors secreting androgens, cortisol, and estrogens. Compound S or 11-desoxycortisol was increased (≥10 ng/mL or 28.9 nmol/L) in 23 of 27 ACT-AS patients (85%); 20 of 21 patients with malignant tumors, and 3 of 6 patients with apparently benign tumors, although 11-desoxycortisol was normal and inferior to 6 ng/mL (17.3 nmol/L) in 35 of 35 nontumor androgen excess patients (100%). Youden’s index displayed that a 11-desoxycortisol level above 7 ng/mL (20.2 nmol/L) has a sensitivity of 89% (95% CI, 71%–98%) and a specificity of 100% (95% CI, 90%–100%) for the detection of ACT-AS (11,12).
When clinical signs of androgen excess reach the point of virilization or the free testosterone level is above 6.85 pg/mL (23.6 pmol/L), follow-up testing with a 11-desoxycortisol (>7 ng/mL), DHEAS (>3.6 μg/mL), and 24-hour urinary cortisol (>45 μg per day) are the most sensitive and specific for the detection of an androgen-secreting adrenocortical tumor. Careful consideration of the sensitivity and specificity, diurnal variation, and age-related variation of potentially measureable androgens will aid in choosing the most useful measurements (Table 31.3).