Abstract
In the 21st century, there has been a significant increase in the use of testosterone replacement therapy (TRT) for men with symptoms of hypogonadism and a desire for more energy, muscle mass, etc. The TRT guidelines as defined by the American Urological Association have made all urologists familiar with the associated risks of polycythemia or infertility. However, there is a longer history and more persistent use of androgenic anabolic steroids (AAS) in men who are body building and trying to improve muscle mass. The goal of this mini review is to share and educate physicians on the additional risks of hepatic masses with the use of AAS and their pathophysiology.
Introduction
Within the average urologist's practice, testosterone replacement therapy (TRT) for men with hypogonadism is becoming more common. Before starting TRT, patients are warned of the common risks, which include polycythemia and infertility. 1 Patients are also counseled that there is unknown risk regarding cardiovascular events. 1 At our institution, patients with further questions regarding the risks of TRT are referred to the 2018 American Urological Association TRT guidelines, which elaborate on our developing understanding of the relationship between testosterone and cardiovascular disease, as well as with prostate cancer, in more detail.1,2
Given their widespread use, it is also important for the urologist to understand the nuances of the hormones utilized in TRT relative to the overarching class of androgenic anabolic steroids (AAS). The AAS are synthetic derivatives of testosterone and are available to patients in various forms requiring different routes of administration (i.e., oral pills, topical gels, injectables, etc.). 3 Due to their convenience, oral forms are popular among those body building and seeking to increase muscle mass; however, to achieve sufficient oral bioavailability, testosterone derivatives are alkylated at the 17α position. 3
Several of these C-17 alpha alkyl derivatives are used as performance-enhancing drugs and have been associated with additional risks, including hepatic growths and other forms of liver dysfunction. 3 In this review article, we will examine the relationship between androgens and hepatic cells, specifically the formation of hepatic adenomas, as well as what that means for the average urologist. We begin with the case presentation of a 59-year-old male with a long history of hypogonadism on TRT and intermittent use of nandrolone decanoate who was found to have a 9 cm androgen-related hepatic adenoma.
Patient Presentation
This patient first presented to our institution in mid-2019. He was 57 years old at the time and complained of symptoms consistent with hypogonadism since 2002. Initially, he tried to manage his symptoms with diet, but he continued to have bothersome symptoms. At an outside facility, he was started on testosterone cypionate at a dose of 100 mg weekly with some resolution in his symptoms. During this time, he was also treated with nandrolone decanoate 50 mg weekly for joint pain intermittently for up to 1–2 years at a time. In addition, he noted that he had used performance-enhancing anabolic steroids for muscle gain in his 20–30s. At this point, he decided to transition his care to an infertility specialist at our institution.
His symptoms of hypogonadism included decreased energy, reduction in muscle mass, body composition changes with increased abdominal fat, decreased quality of erections, difficulty maintaining erections during intercourse, etc. Other medical problems include increased body mass index (BMI) of 38 kg/m2 and fatty liver. He reports no known family history of prostate cancer or cirrhosis. At his initial consult, his testosterone level was 415 ng/dL. He reported that it could be as low as 55 ng/dL when he held his testosterone in the past.
Other hormone levels, including dehydroepiandrosterone-sulfate, prolactin, and estradiol, were unremarkable. Notably, his liver enzymes were within normal limits; specifically, aspartate aminotransferase was 25 IU/L and alanine aminotransferase was 33 IU/L. At this initial visit, his prostate-specific antigen was 3.79 ng/mL and on digital rectal exam, a 0.5 cm prostatic nodule was noted. The risks of testosterone therapy, including the hormone's relationship with prostate cancer, were reviewed with the patient at this time. He expressed understanding of the risks and wished to proceed with TRT.
He was continued on his current dose of testosterone cypionate and nandrolone decanoate. Subsequent biopsy demonstrated Gleason 3 + 4 disease. The patient was then referred to an oncologic urologist for consideration of surgical intervention and underwent a staging work-up with bone scan and computed tomography (CT) abdomen/pelvis. Throughout his evaluation for prostate cancer, the patient maintained his regiment of TRT. He reported significant improvement in his hypogonadism symptoms and wished to continue testosterone therapy.
Bone scan and CT were negative for bony metastases; however, on CT, he was noted to have multiple, ill-defined hypodense lesions at the hepatic dome with minimal rim enhancement (Fig. 1). Given his history of known prostate cancer, it was initially read as concerning for hepatic metastases. A magnetic resonance imaging (MRI) abdomen was performed to further characterize the liver lesions, and a more accurate impression was obtained (Fig. 2). The study revealed a single hypervascular mass in the lateral aspect of the right lobe measuring 8.9 cm in the longest dimension without evidence of portal vein or intrahepatic vein invasion. Due to its appearance, there was suspicion for a primary neoplasm rather than metastasis, specifically intrahepatic cholangiocarcinoma or hepatocellular carcinoma (HCC).
Axial CT images post-contrast—initially read as multiple, ill-defined hypodense lesions at the hepatic dome with minimal rim enhancement. The largest of these was described as a confluent lesion that measured approximately 2.7 cm in diameter. A separate, more ill-defined lesion also measuring 2.7 cm was noted further inferiorly in the right lobe. CT, computed tomography.
MRI T1 weighted images—the study revealed a single mass in the lateral aspect of the right lobe measuring 8.9 × 6.2 × 4.3 cm (AP, transverse, craniocaudal). It was noted to be predominantly T1 and T2 isointense with a few T2 hyperintense areas. No capsular retraction was seen. On administration of contrast, the mass was noted to be heterogeneously hypervascular with retention of contrast at each time point. AP, anteroposterior; MRI, magnetic resonance imaging.
At this point, the patient was referred to a hepatologist. The patient denied any symptoms of liver disease, including jaundice, scleral icterus, or abdominal pain. Blood work showed that his testosterone level was 614 ng/dL (free testosterone was 135 pg/dL) and gamma-glutamyl transferase was mildly elevated to 68 IU/L. The remainder of his hepatic function panel were within normal limits. Additional cancer markers carcinoembryonic antigen, cancer antigen 19–9, and alpha-fetoprotein were also unremarkable. Based on his lab values, he had a calculated Model for End-Stage Liver Disease score of 8.
Based on subsequent discussion with radiology, the mass' appearance was concerning for HCC; however, given that the patient has no prior history of cirrhosis, it was recommended for the patient to first undergo biopsy of the mass. He subsequently underwent ultrasound-guided biopsy of the mass that showed features of a hepatic adenoma that was androgen-related due to the clinical history of prior testosterone use in this male patient and beta-catenin activated. On microscopic evaluation, the neoplasm comprised hepatocytes with near-normal nucleus:cytoplasm ratio and without cytologic atypia along with scattered thin-walled unpaired hepatic arterial blood vessels.
There was no increased mitotic activity or significant nuclear pleomorphism. Characteristic histologic findings of focal nodular hyperplasia were not identified. Pseudoglandular growth pattern that can be seen in HCC as well as androgen-related hepatocellular adenoma was also not identified. On immunohistochemical (IHC) staining, nuclear expression of beta-catenin was not seen; however, staining for glutamine synthetase showed strong and diffuse cytoplasmic positivity in the tumor cells with a homogenous staining pattern.
Diffuse and strong cytoplasmic glutamine synthetase staining of lesional cells in a hepatic adenoma is representative of beta-catenin activation even in the absence of nuclear expression of beta-catenin. 3 Notably, there was no uninvolved hepatic parenchyma within this biopsy specimen to compare the glutamine synthetase staining between tumoral and background nontumoral tissue.
This pathology findings of androgen-related, beta-catenin activated hepatic adenoma carried with it high risk features for malignant progression, necessitating exclusion of HCC. He was subsequently evaluated by a hepatobiliary surgeon for resection. A repeat MRI showed a stable heterogeneous mass, and the patient then underwent right lobe hepatectomy. The final pathology of the mass revealed a 2.5 × 2 × 1.6 cm focus of well-differentiated HCC within the 9 × 6.5 × 4.5 cm hepatic adenoma involving segment VIII in the right lobe of the liver, demonstrating malignant transformation with a nodule-within-a-nodule appearance (Figs. 3–5) and a trabecular growth pattern.
Cut surface of the hepatic mass demonstrating a “nodule in nodule” appearance of a smaller well-circumscribed focus of HCC (red circle) within a larger tan-colored unencapsulated hepatic adenoma (yellow circle). HCC, hepatocellular carcinoma.
IHC staining of both the hepatic adenoma and well-differentiated HCC components showed no nuclear expression of beta-catenin but demonstrated strong and diffuse cytoplasmic staining for glutamine synthetase in both components of this large hepatic mass, thus supportive of beta-catenin or Wnt signaling pathway activation. By definition, a beta-catenin activated adenoma demonstrates nuclear positivity for beta-catenin on IHC staining, strong and diffuse glutamine synthetase IHC staining, or molecular sequencing findings showing a beta-catenin mutation. The beta-catenin protein plays a significant role by activating the Wnt signaling pathway, with strong and diffuse glutamine synthetase IHC staining representing Wnt signaling or beta-catenin activation.
Glypican-3 IHC staining was negative in both the hepatic adenoma and HCC components, as is often documented in up to one-half of cases of well-differentiated HCCs. Glypican 3 staining performs better in poorly differentiated HCCs than it does in well-differentiated HCC cases, and tumors arising in noncirrhotic livers are less frequently positive than HCCs arising in a background of cirrhosis. Reticulin staining exhibited areas of loss of the normal reticulin framework and thickened hepatocyte trabeculae greater than three layers in thickness in the smaller nodular HCC component, whereas the surrounding larger hepatic adenoma comprised hepatocyte pates that were less than three layers in maximum thickness without associated reticulin loss.
Intratumoral steatosis was noted focally (<10% of sampled tumor) in the hepatic adenoma. There was no tumor necrosis, intralesional steatohepatitis, or pigmentation or myxoid differentiation identified. No lymphovascular invasion or extracapsular extension was seen, and the parenchymal resection margins were negative for HCC and hepatic adenoma.
The patient has since recovered well and had an uneventful radical prostatectomy. Given his degree of bother with his hypogonadism symptoms and joint pain, he has opted to continue TRT and nandrolone decanoate at this time. The patient will be followed closely with monitoring for recurrence.
Discussion
Hepatic adenomas are solid, benign lesions of the liver that typically range in size from a few millimeters to several centimeters. Though generally solitary, they can be multifocal in 30–40% of cases. 4 With an estimated incidence of <5 cases per 1,000,000 people in the general population, they are more rare than other benign liver tumors such as liver angiomas and focal nodular hyperplasia. 4 They are most often seen in young women taking oral contraceptives with a median age of 38 years and a female/male ratio of 8:1. 4
Risk factors include hormonal exposure with estrogen or androgenic steroids as well as obesity, metabolic syndromes, glycogen storage diseases, and vascular hepatic disorders.4–6 Obesity (defined as BMI greater or equal to 30 kg/m2) and its role in the development and progression of hepatic adenomas has been a subject of growing interest in recent decades, as the prevalence of obesity has been increasing substantially. Several potential mechanisms for this relationship have been postulated, such as the increased exposure of hepatocytes to estrogen due to aromatase activity within adipose tissue. 6
Although they are usually asymptomatic, complications of hepatic adenoma include hemorrhage after rupture (15–20%) and malignant transformation into HCC (less than 5, although risk of malignant transformation is greater in men than in women).4,7 To minimize these risks, surgical resection is generally warranted for larger tumors, especially those larger than 5 cm.
With the introduction of oral contraceptives in the 1970s, the incidence of hepatic adenomas increased significantly to ∼1–4 cases per 100,000 women.4,5 Taken orally, these medications are absorbed through the gastrointestinal tract and are metabolized through the liver, where they may alter the risk of developing tumor. Several studies have described the role of sex steroid receptors in activating the signaling pathways involved in pathogenesis of hepatic adenomas, demonstrating expression of estrogen receptors in between 26% and 73% of hepatic adenomas. 8
Hepatic adenomas that develop in men are generally associated with the use of anabolic androgenic steroids for body-building or therapeutic purpose in patients with Fanconi's anemia 4 (although hepatic adenomas have also been described in women with hyperandrogenism 9 ). These are usually seen in patients who have been on long-term anabolic androgenic steroids (typically 5–15 years), although there have been cases of hepatic tumors discovered within 2 years of starting steroids. 10 The AAS are synthetic derivatives of testosterone and come in various forms.3,10 The relationship between AAS and hepatic adenomas has become evident in more recent decades. 11
Notably, reports of hepatic adenomas/tumors in men on non-oral TRT such as gels or injections are much rarer in incidence. 12 Currently, with regard to non-oral TRT, there is no association or causation. Androgen-induced hepatic adenomas are still relatively rare, so, unlike with estrogen and progesterone, the role of androgens and their receptors in the pathogenesis of hepatic adenomas is not entirely understood. There is some consensus that the hormone molecules bind to intracellular androgen steroid receptors, which are then translocated to the nucleus where they bind to androgen response elements on DNA.
This thereby activates a cascade of signaling pathways inducing hepatocyte growth, which, once unregulated, leads to development of hepatic tumors. 10 Prior studies have found a correlation between liver tumor development and androgen receptor expression with high proportions of biologically active receptors in cells of hepatic adenomas compared with normal liver cells.13,14 Other theories suggest that AAS induce the growth of hepatic adenomas after the aromatization of androgen to estrogen, similar to men developing gynecomastia and other estrogen-related symptoms while receiving exogenous sex steroids. 15 Whatever the mechanism, studies have shown that hepatic adenomas do often regress after the discontinuation of estrogens or androgenic steroids.16,17
The pathology of hepatic tumors associated with AAS usually describes hepatic adenoma, well-differentiated HCC, or hepatic adenoma with areas of malignant transformation, with the latter being seen in the case of this patient. 10 Among hepatic adenomas, there are five different molecular subtypes that have been described based on mutations in oncogenes or tumor suppressor genes, leading to dysregulation of signaling pathways: HNF1A-inactivated subtype, inflammatory subtype, β-catenin-mutated exon 3 subtype, β-catenin-mutated exon 37 or 8 subtype, sonic hedgehog subtype, and finally, unclassified hepatic adenomas. 4
The various subgroups are associated with different complication risks, thereby impacting clinical management; for example, the sonic hedgehog subtype is associated with an increased risk of bleeding and the beta-catenin-mutated subtype is associated with a 40% higher incidence of malignant transformation than other molecular subtypes.4,8 On subtyping, androgen-related hepatic adenomas are most commonly beta-catenin mutated (∼50%), inflammatory (∼20%), unclassified (∼20%), or HNF1-alpha inactivated (∼10%).4,8
In this particular case, beta-catenin activation and Wnt signaling activation are demonstrated by the positivity for glutamine synthetase with a homogenous staining pattern. As previously mentioned, this patient's pathologic finding of beta-catenin activation is associated with an increased risk of malignant transformation. The beta-catenin/Wnt signaling pathway is responsible for liver zonation, liver embryogenesis, amino acid metabolism, and hepatic regeneration and when uncontrollably activated, plays a key role in many types of cancer, such as colorectal cancer, HCC, breast cancer, and medulloblastoma. 4
The key principle in clinical management of hepatic adenoma is risk reduction. Generally, the first step is to discontinue offending agents such as oral contraceptive pills and AAS, which has been shown to cause regression of hepatic adenomas smaller than 5 cm5. Therefore, women with asymptomatic hepatic adenomas of this size can be monitored with repeat contrast-enhanced MRI in 6 months. If at that time, the lesion is noted to have increased in size by more than 20% or has become larger than 5 cm, then surgical resection is recommended given that lesions larger than 5 cm are associated with a greater risk of hemorrhage. 5
Per some guidelines, men with hepatic adenomas of any size are recommended to undergo surgical resection due to an increased risk of malignant degeneration. 5 In a cohort study of 218 patients, men were noted to have a higher rate of malignant transformation of hepatic adenomas than women (47% vs. 4%). 7 This is consistent with the fact that a majority of androgen-related hepatic adenomas are beta-catenin mutated, which itself is associated with a greater risk of malignant degeneration.
Curiously, there is some evidence that HCC secondary to AAS usage may have a better prognosis than HCC secondary to cirrhosis or chronic hepatitis B and C (potentially due to the ability to withdraw the offending agent). 10 Nonetheless, patients with androgen-related HCC are at risk of death due to hepatic rupture or tumor metastasis and surgical resection of localized disease is indicated as it is for HCC of other etiologies.
Of note, in the majority of the case reports describing androgen-induced hepatic adenomas, the growths were specifically associated with C-17 alpha alkyl derivative AAS.10,12 In some cases, patients were counseled on cessation of steroid use after resection and were successfully transitioned to clinically prescribed TRT without issue. 15 It is important to make the distinction between the different forms of testosterone used in TRT as opposed to AAS in general. The TRT typically consists of testosterone modified by C-17 beta esterification, such as testosterone cypionate, enanthate, undecanoate, and propionate.1,3
This process maintains and increases the potency and duration of the virilizing effects of the hormone.10,16 Other forms of AAS include testosterone derivations that have undergone alkylation of the C-17 alpha position of testosterone, which drastically increases oral bioavailability by slowing the degradation of the drug by the liver. This subgroup of AAS includes methyltestosterone, danazol, epistane, fluoxymesterone, stanozolol, norethandrolone, and oxandrolone.8,18
Due to their slower clearance by the liver, C-17 alpha alkylated testosterones and their hepatotoxicity have been well documented in the literature as have their associations with prolonged cholestasis, peliosis hepatis, nodular regeneration, hepatic adenomas, and HCC.3,10 On the other hand, C-17 beta esterified testosterones have rarely been seen to cause liver injury and have, in fact, been previously described as a safe step-down therapy for patients with hepatic adenomas transitioning from oral AAS. 15
Conclusion
Ultimately, the cause for this patient's presentation of hepatic adenoma with area of malignant transformation cannot be clearly identified. Contributing factors could include obesity given his elevated BMI of 38 kg/m2 and metabolic syndrome in light of his fatty liver. The possibility that the patient had used a form of C-17 alpha alkylated testosterone in his 20s exists. As discussed in this article, the likelihood of TRT being the culprit is inordinately low.
Overall, TRT is a well-tolerated and efficacious treatment option for hypogonadism. In men on modern TRT, there are exceedingly few cases of hepatic adenoma reported and there is no evidence of direct correlation or causation in these men. 12 But the take-away message is to simply be aware, as there is no mention of hepatic adenoma in current TRT guidelines (i.e., American Urological Association, European Association of Urology, or Endourology). Surveillance imaging is not recommended given the risk of radiation exceeding the minimal benefit of finding a rare tumor.
If found incidentally, however, it is recommended for the patient to be referred to a hepatobiliary surgeon to discuss further management, which may include discontinuing to causative agent and beginning evaluation for surgical resection.
Footnotes
Authors' Contributions
E.H.: writing—review and editing; M.D.: resources; M.V.: writing—review and editing; B.J.M.: methodology, supervision.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received for this article.