Journal of Investigative Medicine:
EB Symposium Manuscripts
Human Steroid Biosynthesis for the Oncologist
Auchus, Mary Louise MD; Auchus, Richard J. MD, PhD
From the Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, MI.
Received September 19, 2011, and in revised form October 20, 2011.
Accepted for publication October 20, 2011.
Reprints: Richard J. Auchus, MD, PhD, MEND/Internal Medicine, University of Michigan, 5560A, MSRBII, 1150 W Medical Center Dr, Ann Arbor, MI 48109. E-mail: firstname.lastname@example.org.
Dr. Richard Auchus is supported by a Clinical Scientist Award in Translational Research from the Burroughs-Wellcome Fund (1005954).
This article is supported in part by a grant from the National Center for Research Resources (R13 RR023236).
Abstract: In 2005, results from the Arimidex, Tamoxifen Alone or in Combination (ATAC) trial ushered in a new era of endocrine therapy for hormone-responsive malignancies. This study demonstrated that, compared with tamoxifen (a selective estrogen receptor modulator), anastrozole (aromatase inhibitor [AI]) prolonged time to recurrence and disease-free survival for postmenopausal women with breast cancer. The advantage was even greater for those with estrogen receptor–positive (ER+) tumors, and anastrozole was better tolerated than tamoxifen. Since then, AIs have become first-line adjuvant therapy for ER+ breast cancer in postmenopausal women.
In late 2010, a trial comparing abiraterone acetate (a 17-hydroxylase/17,20-lyase [CYP17A1] inhibitor) plus prednisone versus prednisone alone in men with castration-resistant prostate cancer (CRPC) previously treated with docetaxel chemotherapy was terminated early because of the survival benefit in the abiraterone acetate arm. This result not only validated a new therapy for CRPC but also, with the antecedent phase I-II abiraterone studies, shattered our understanding of the molecular mechanisms underpinning CRPC development and progression.
Aromatase inhibitors and CYP17A1 inhibitors will be widely used by oncologists, yet fellowship programs provide little training in steroid biosynthesis, compared with training in the biology of standard chemotherapies. Consequently, these drugs might be used without an appreciation of their caveats and pitfalls. The purpose of this review was to acquaint practicing oncologists with the fundamental principles and pathways of steroid biosynthesis, to improve their understanding of how and why these drugs work, and to alert these physicians to potential problems related to the drugs’ mechanisms of action.
The hormonal dependence of breast and prostate cancers has been exploited for decades as a therapeutic strategy. Dramatic and lifesaving tumor regression or stabilization was first achieved with surgical oophorectomy in breast cancer1 and orchiectomy in prostate cancer,2 but recurrences were common despite elimination of all gonad-derived androgens or estrogens, respectively. Recognizing that the adrenal glands provide a source of androgen precursors, surgical adrenalectomy was added to ovariectomy for breast cancer,3 and later chemical adrenalectomy with aminoglutethimide proved equivalent.4 Efforts to provide more complete and less invasive hormone ablation strategies in prostate cancer led to the use of estrogens such as diethylstilbestrol (DES) and progestins,5 later replaced by long-acting gonadotropin-releasing hormone (GnRH) agonists such as leuprolide acetate.6 Androgen receptor (AR) antagonists such as bicalutamide and nilutimide provided the next contribution to therapy in prostate cancer,7 whereas in breast cancer, the antiestrogen tamoxifen, which is actually a selective estrogen receptor modulator or SERM, became the reigning standard of care for many years8 until dethroned by the aromatase inhibitors (AIs) in the past decade.9 Abiraterone acetate, a 17-hydroxylase/17,20-lyase (CYP17A1) and thus androgen biosynthesis inhibitor, has been recently approved for the treatment of castration-resistant prostate cancer (CRPC).10 Consequently, the evolution of treatment has generally progressed from surgery to receptor antagonists to hormone synthesis inhibitors. Because these therapies should theoretically all achieve the same purpose, why are the enzyme inhibitors gaining favor over time?
To understand how these drugs work and why they might provide more complete hormone ablation than other therapies, a basic understanding of steroid biosynthesis is essential. Unfortunately, oncology training programs rarely provide more than a rudimentary introduction to steroidogenesis in their curricula. In this article, we will develop a logical and clinically relevant framework to understand steroid biosynthesis in normal and pathologic states. These basic principles will then illustrate why these drugs are more effective in some patient populations than in others, when these drugs should be combined with other agents, and how resistance develops. A comprehensive review of human steroid biosynthesis has recently appeared,11 and the reader is directed to this reference for any details not covered herein.
THE BIG PICTURE
All steroid hormones derive from cholesterol, and in normal human physiology, only a few tissues convert 27-carbon cholesterol to 21-carbon pregnenolone, the first committed intermediate in steroidogenesis. The adrenal cortex, Leydig cells of the testis, theca and granulosa cells of the ovary, and trophoblasts of the placenta are the only cells in the body capable of synthesizing enough pregnenolone to contribute to circulating concentrations of steroids.12 Subsequent conversions within the steroid-producing cells yield either active hormones or hormone precursors, and the exact products depend on which downstream enzymes are expressed in those cells (Fig. 1, A and B). These steroids enter the circulation to act on target cells, but extensive metabolism occurs outside the steroidogenic tissues. Consequently, circulating concentrations of steroids only partially reflect their biologic activity, and different cells each experience a unique hormonal milieu depending on the balance of enzymes and other factors present in each cell.13 For example, circulating testosterone (T) is actually 3 potential hormones. T binding to AR elicits androgenic effects in some tissues such as spermatic tubules, stimulating sperm production. In the prostate, 5α-reductase irreversibly converts T to dihydrotestosterone (DHT), which, unlike T, uniquely mediates formation of the prostate and the male external genitalia in fetal life, as well as development of prostatic hyperplasia.14 Conversely, aromatase activity in breast tissue metabolizes T to the potent estrogen estradiol (E2), which, if excessive, causes gynecomastia (Fig. 1C).
THE FIRST STEP IS THE HARDEST
The conversion of cholesterol to pregnenolone is generally the slowest, most complex, and acutely regulated step in steroid production.15 The side chain cleavage enzyme (P450scc or CYP11A1) uniquely catalyzes this transformation, which really involves 3 chemical steps, at a maximum rate of roughly 7 turnovers per minute—pathetically slow for an enzyme. In addition, access of cholesterol to CYP11A1 is restricted topologically within the specialized mitochondria of steroidogenic cells. The mobile pool of cholesterol capable of entering steroid biosynthesis resides on the outer mitochondrial membrane, whereas CYP11A1 and its cofactor protein ferredoxin reductase (FdxR) are attached to the inner mitochondrial membrane (Fig. 2). In the mitochondrial matrix, electrons from reduced nicotinamide adenine dinucleotide phosphate (NADPH) channel from FdxR to a soluble iron-sulfur protein ferredoxin (Fdx) and then to CYP11A1. This reaction uses 2 electrons and 1 molecule of oxygen in each of 3 cycles to cleave cholesterol to pregnenolone. Every pulse of luteinizing hormone (LH) yields a corresponding pulse of T via the induction of intracellular cyclic adenosine monophosphate (cAMP), which “opens the gate” for cholesterol entry to the steroidogenic pathway. The familiar cosyntropin stimulation test also elicits a sharp rise in cortisol in 30 minutes due to cAMP elevation and cholesterol mobilization. How does this rapid mobilization of cholesterol occur?
The protein that drives cholesterol from the outer to inner mitochondrial membranes is the steroidogenic acute regulatory (StAR) protein16 (Fig. 2), whose mechanism of action is incompletely understood. The x-ray crystal structure of the StAR homolog MLN64 contains a binding pocket for 1 molecule of cholesterol,17 suggesting that StAR physically carries cholesterol across the intermembranous space; however, other evidence suggests that StAR acts while residing on the outer membrane.18 Phosphorylation of StAR is required for the activation and termination of its action,19 reflective of its transient nature. Some steroidogenic tissues such as the placenta do not express StAR yet still produce abundant steroids, possibly using MLN64 instead. In model cells, StAR coexpression increases pregnenolone production 7-fold above that observed using the CYP11A1 catalytic system alone.20
Conceivably, additional tissues, including cancer cells, might convert cholesterol to pregnenolone, and evidence supporting this mechanism of T synthesis in CRPC progression has been found in some21,22 but not all studies.23 Nevertheless, for a cell to convert cholesterol to pregnenolone, the minimum requirements include expression of CYP11A1, FdxR, and Fdx; sufficient cholesterol, oxygen, and NADPH content in a permissive mitochondrial environment; and ideally, StAR and its phosphorylation machinery. Of course, the quantities of pregnenolone synthesis required for local de novo T production sufficient to stimulate CRPC growth are many orders of magnitude lower than those required to raise circulating steroid concentrations, challenging the limits of detection by modern assay methods.
STEROIDOGENESIS IS DIRECTIONAL
An important concept in steroid biosynthesis is that most steps are irreversible and that classes of endogenous steroid hormones are defined both by their biologic activities and their chemical structures. These structures, in turn, are determined by the activities of those enzymes catalyzing their biosynthesis, and the nomenclature is mercifully helpful for the novice in most cases. Most of these enzymes are cytochromes P450, and their naming is thus CYP followed by number, letter, and number (CYP17A1, CYP3A4, etc).24 In addition, the 5α-reductase reactions are irreversible (Fig. 1B).
The terminal steps of steroidogenesis and the peripheral conversions are mediated by the many hydroxysteroid dehydrogenases (HSDs) (Fig. 1, A and B), and these reactions are reversible, although each enzyme has a strong directional preference in intact cells.25,26 Thus, pairs of enzymes drive steroid flux in opposite directions, one from hydroxysteroid to ketosteroid and another back from ketosteroid to hydroxysteroid. An example is 17βHSD3, the critical enzyme for converting androstenedione (AD) to T in Leydig cells. Boys with 17βHSD3 deficiency are born with ambiguous genitalia from T and DHT deficiency in utero.27 Conversely, 17βHSD2 oxidizes T almost completely to AD in peripheral tissues, attenuating the androgenic activity of T in cells containing this enzyme.28 One caveat regarding the reversibility of these transformations is that the two 3βHSD-isomerase enzymes,29 by virtue of their second (Δ5→Δ4-isomerase) activity, also mediate irreversible reactions (Fig. 1C). The many human HSD enzymes are each encoded by separate genes with characteristic tissue-specific expression profiles, catalytic activities, and substrate preferences.30 The function of only a few of these enzymes is known with certainty, particularly those expressed in peripheral tissues, and many of these enzymes are poor catalysts for HSD reactions. Consequently, a cancer cell might contain several 17βHSD isoforms competing for steroid substrates, and the final biologic potency of an entering steroid will be determined by the net result of these activities.
Another mechanism of terminating steroid action is conjugation, similar to the phase 2 conjugation reactions of drug metabolism, including glucuronidation and sulfation. For steroids, free hydroxyl groups are sulfated or glucuronidation by sulfotransferases (SULTs) and uridine diphosphate glucuronyltransferase (UGT) enzymes, respectively, which also have a number, letter, and number nomenclature (SULT2A1, UGT2B17).31 The UGT enzymes include UGT1A1, a major bilirubin conjugating enzyme; low UGT1A1 activity causes Gilbert disease and predisposes to irinotecan toxicity.32 Glucuronylation is generally an irreversible process, which tags the steroid for excretion in the urine by organic anion transporters, whereas sulfation increases protein binding and prolongs circulating half-life. At least some steroid sulfates are desulfated in specific tissues, such as estrone sulfate conversion to estrone in breast cancer cells.33
YOU CAN GO YOUR OWN WAY
The classic pathways have been constructed based on the dominant enzyme activities and hormone concentrations observed in normal adrenal and gonadal tissues, reinforced by changes in flux observed in enzyme deficiency states. Nevertheless, minor pathways also exist, but we hide these “under the rug” because their contributions are insignificant during normal physiology. For example, 21-deoxycortisol (progesterone hydroxylated in the 17- and 11-positions) is made in the normal adrenal but is not part of a mainstream pathway and generally not measured by clinical laboratories. Elevated 21-deoxycortisol, however, is a more specific marker steroid for 21-hydroxylase deficiency than the customary 17-hydroxyprogesterone,34 and 21-deoxycortisol is used as a second-tier newborn screening test in some states.
In addition, more than 1 pathway might converge at the same product. Although pathway A might be the major route to steroid X in tissues whose primary job is to export X as a circulating hormone, other tissues might use pathway B or C. How is dehydroepiandrosterone (DHEA) converted to T and DHT, as must occur to explain hirsutism in women? Well, textbooks usually say DHEA → AD → T → DHT (enzyme sequence 3βHSD, 17βHSD, SRD5A), with these reactions occurring mainly in the liver and the skin. There is no reason why DHEA should not be converted to androst-5-ene-3β,17β-diol (A5diol) via 17βHSD first and then by 3βHSD to T, and this sequence is probably dominant in the normal testis35 (Fig. 1B). Furthermore, we have recently shown that CRPC specimens and cell lines predominantly use the sequence DHEA → AD → 5α-androstane-3,17-dione (5αdione) → DHT (enzyme sequence 3βHSD, SRD5A1, 17βHSD), entirely bypassing T36 (Fig. 3). Even more bizarre, a complex alternate or “backdoor” pathway to DHT in the tammar wallaby pouch young testis involves 5α-reduction of 17-hydroxyprogesterone before the 17,20-lyase reaction of CYP17A1.37,38 In this pathway, the testis exports the 5α-reduced androgens androsterone and 5α-androstane-3α,17β-diol, that latter of which is oxidized to DHT in the target tissues to mediate male prostate and genital differentiation in that species.39 The lesson is that alternate routes might bypass blocks in classic pathways, as long as enzymes capable of catalyzing these reactions are expressed in the tissue and cells of interest.
FEEDBACK MECHANISMS OR LACK THEREOF
Under normal circumstances, tropic hormones regulate steroid production, and the product steroid then suppresses its own production in a classic negative feedback loop. In the adrenal, adrenocorticotropin (ACTH) stimulates production of cortisol and dehydroepiandrosterone sulfate (DHEAS), yet only cortisol provides negative feedback on ACTH (Fig. 4A). Similarly, LH stimulates androgen production by the Leydig cells of the testis (mainly T; Fig. 4B) and theca cells of the ovary (mainly AD), and these androgens suppress LH production. In the ovary, follicle-stimulating hormone (FSH) acts on the granulosa cells surrounding the developing oocyte to induce aromatase production, thus allowing conversion of AD and T to E2 (Fig. 4C), and FSH also induces small amounts of E2 production in the testes. E2 and even progesterone also suppress LH production, whereas FSH negative feedback is mainly due to inhibin B, which is a protein hormone derived from the Sertoli cells of the testes and granulosa cells of the ovary.
On the basis of the paradigms described, damage to the pituitary (tumor, trauma, radiation) will lower LH, FSH, and ACTH production and therefore reduce production of T, E2, cortisol, DHEAS, and all the precursor steroids and metabolites as well. Surgical removal of the adrenal glands raises ACTH, which can be lowered with exogenous cortisol replacement. Gonadectomy will cause LH and FSH to rise, and androgen or estrogen replacement lowers LH but not FSH because inhibin B remains absent. Similarly, natural menopause occurs when all follicles and thus granulosa cells are depleted, and estradiol production falls, whereas LH and, more specifically, FSH rise. Long-acting GnRH agonists act by desensitizing the pituitary gonadotropes and suppressing LH (and FSH) and therefore T and E2 synthesis. Supraphysiologic doses of exogenous androgens and estrogens or progestins also lower LH, T, and E2 production—less so—but directly exert hormone actions on the body. For example, high-dose DES, a potent estrogen, is used to treat prostate cancer by increasing negative feedback on the gonadal axis, which suppresses LH and thus T production. The estrogenic action of DES, however, causes gynecomastia in a high proportion of patients and predisposes to thrombotic events, limiting its utility. Similarly, dexamethasone or prednisone suppress ACTH and thus both cortisol and DHEAS synthesis. Steroid receptor antagonists relieve the negative feedback of these hormones and cause a rise in the tropic hormones from the pituitary and subsequently the endogenous steroids themselves.
T AND DHT IN PROSTATE CANCER
On the basis of the preceding discussion, several strategies to block T and DHT synthesis and/or action can be envisioned, and most of these have already found application in clinical practice (Fig. 5). Surgical orchiectomy, DES, leuprolide acetate, and bicalutamide are all successful examples of different strategies to block testicular T production or action, and dutasteride inhibits conversion of T to DHT by 5α-reductase enzymes. The problem with AR antagonists is that most are partial agonists or incomplete antagonists, and up-regulation of LH and thus T might overcome the blockade, prompting the development of more potent compounds such as MDV3100.40 Gonadal suppression strategies fail to address the abundant DHEAS and DHEA derived from human adrenal gland, which are only 3 or 2 steps upstream of T (Fig. 3), with redundant pathways mediating these transformations.13 Adrenal androgen elimination in CRPC probably explains the additional therapeutic benefit of ketoconazole,41 a CYP17A1 inhibitor, and dexamethasone or prednisone, which suppress ACTH and thus adrenal DHEA(S) production.42
Similarly, abiraterone is a potent and specific CYP17A1 inhibitor, explaining its recent success in treating CRPC.10,43,44 Despite its ideal molecular target and potency, abiraterone is not used as monotherapy. Like AR antagonists, inhibition of T synthesis will remove negative feedback and increase LH production in an effort to restore homeostasis. The mechanism of abiraterone action involves irreversible binding to the heme iron in the active site of CYP17A1, so inhibition continues even after the drug has been completely cleared from the circulation, until new enzyme is synthesized. Consequently, abiraterone is used with GnRH agonist, to maintain LH suppression and prevent the synthesis of new CYP17A1 protein in the testis. When studied in noncastrated men with prostate cancer, abiraterone alone lowers T only transiently to castrate levels,45 and therefore abiraterone is unlikely to be effective as monotherapy in prostate cancer.
In the pivotal abiraterone trial, all participants received prednisone 5 mg twice daily as well, which was generally started during docetaxel treatment. Because abiraterone also ablates adrenal CYP17A1 activity, prednisone might seem unnecessary for efficacy, but CYP17A1 inhibition also blocks cortisol synthesis and induces a syndrome of 17-hydroxylase deficiency46,47 (17OHD; Fig. 5). Biglieri et al.48 described the clinical and biochemical consequences of 17OHD, a rare form of congenital adrenal hyperplasia, nearly a half-century ago. Loss of negative feedback from cortisol deficiency causes ACTH to rise, activating StAR, driving cholesterol into steroidogenesis, and flooding the available downstream enzymes with pregnenolone (Fig. 6). The block at CYP17A1 leaves only pathways involving 3βHSD2, 21-hydroxylase (CYP21A2), and 11β-hydroxylase (CYP11B1) and limits steroidogenesis to corticosterone and its precursor 11-deoxycorticosterone (DOC). Steroid flux in the adrenal of a patient with 17OHD resembles that of the rodent adrenal, which also lacks CYP17A1 and makes corticosterone as the principal glucocorticoid. In 17OHD, circulating corticosterone concentrations rise more than 100 times normal to more than 10,000 ng/dL (∼1 μM) in a new steady state,47 which prevents glucocorticoid insufficiency in most patients.46 To make this much corticosterone, however, DOC production also rises markedly, and at these concentrations (>10 nM), DOC is a potent mineralocorticoid receptor (MR) agonist, inducing volume expansion with kaluresis and suppressing plasma renin activity (Fig. 6). Consequently, the clinical presentation of complete 17OHD is sexual infantilism regardless of chromosomal sex, hypertension, and hypokalemia.48
In the phase 1 to 2 trials of abiraterone, prednisone was omitted,43,44 and hypertension and hypokalemia were commonly observed. Both DOC and corticosterone rose markedly, as is seen in genetic 17OHD.49 These consequences were treated effectively with addition of either MR antagonist to block the action of DOC on MR (eplerenone in these studies) or corticosteroid to prevent the ACTH rise and thus lower DOC production. Thus, prednisone cotherapy with abiraterone acetate serves 2 purposes: to limit synthesis of new adrenal CYP17A1, which might overcome of the blockade in DHEAS synthesis in between abiraterone acetate doses, and to prevent accumulation of DOC with its propensity to cause hypertension and hypokalemia. This triple regimen is the evolution of the “total androgen blockade” concept proposed by Labrie50 upon considering all potential androgen sources and peripheral steroid metabolic pathways. It is possible that smaller prednisone doses and other glucocorticoids might accomplish the same purposes, but other regimens have not been studied.
In considering other targets, only 3 enzymes besides CYP17A1 are required for T synthesis (Fig. 3). CYP11A1 and 3βHSD inhibitors would block synthesis of all steroid hormones and cause adrenal insufficiency as well. A 17βHSD inhibitor, acting on the final step, might seem ideal, but many enzymes catalyze this reaction besides testicular 17βHSD3, so the exact target(s) are unknown. Although AKR1C3 (17βHSD5) is highly expressed in many CRPC specimens,51 inhibition of this enzyme might select for clones that express alternative 17βHSD isoenzymes. In contrast, CYP17A1 is the ONLY enzyme that converts pregnenolone to DHEA, so this target leaves no alternative pathway to T open. The relative contributions of the de novo steroidogenesis from cholesterol all the way to T and DHT versus terminal metabolism of adrenal-derived DHEA(S) within the CRPC tumor to androgens is debated and likely to vary among specific tumors.52 Regardless of origin, complete blockade is of all CYP17A1 activity will ablate all sources of T and DHT production, but the complete endocrinologic consequences of these manipulations must be considered to optimize patient outcomes.
ESTROGENS IN BREAST CANCER
Similarly, steroidogenesis in the ovary of reproductive-age women derives from feedback-regulated axes as in the male, but steroid and germ cell production in the female is cyclical, adding to complexities beyond the scope of this article. Because E2 is the major hormone providing negative feedback, inhibition of aromatase will increase LH and FSH production, which increases aromatase expression in an effort to overcome the blockade (Fig. 4C). When AIs are administered to premenopausal women, E2 decreases only transiently, and subsequently, a new steady state is reached. In contrast, the postmenopausal ovary makes little or no estrogen, and E2 derives from androgen precursors (DHEAS, AD) of ovarian and adrenal origin.53 The aromatase enzyme in postmenopausal women is expressed mainly in adipose tissues, including those of the breast,54 but also in breast cancers themselves.55 Because LH and FSH, which are already elevated in postmenopausal women, do not regulate aromatase expression in these tissues, the potent, irreversible AIs used clinically are very effective in suppressing E2 synthesis in postmenopausal women and treating ER+ breast cancers in these women.56
In contrast, the use of AIs in premenopausal women (and men) with ER+ breast cancer would be ineffective, unless combined with therapy to prevent overcoming the blockade. Such treatments might include surgical or chemical oophorectomy and suppression of LH and FSH with high-dose progestins or long-acting GnRH agonists. Preliminary reports have demonstrated the feasibility of “total estrogen blockade” in premenopausal women with ER+ breast cancers using leuprorelin and anastrazole.57 Whether such combination therapies will prove effective in this population remains unknown.
Because AI therapy in women who have ceased menses for more than 12 months—and thus are clinically menopausal—effectively suppresses E2 and eliminates most negative feedback on the gonadotropes, LH and FSH might rise even higher. This gonadotropin surge, which mimics the midcycle surge, induces ovulation and/or menses in some women.58 Often only 1 cycle is experienced, but this phenomenon, which is rather distressing to patient and physician alike, also brings into question whether the menopausal status has been correctly assigned. Will such patients still benefit from AI therapy? In general, patients with a single episode of menses on an AI can be considered postmenopausal, although serum estradiol measurements before and during AI therapy are required in this setting.59 As long as serum estradiol remains low, AI therapy remains an option.
Similar to the tumor progression typically observed in CRPC, tumor progression eventually occurs in most cases of metastatic breast cancer treated with AIs. The mechanisms responsible for the escape from control are being studied vigorously in several groups. Serum concentrations of E2 remain markedly reduced at progression in nearly all cases,60,61 although intratumoral concentrations of E2 might be sufficient to activate ER yet elude detection in the most sensitive assays. Furthermore, the steroids accumulating above the AI blockade are androgens, and AR is expressed in many breast cancers.62 Could these tumors be converting from estrogen-dependent to androgen-dependent growth mechanisms? In addition, androgen metabolites such as androstanediols also accumulate, and some of these compounds activate ER, thwarting the intention of the treatment.63 In either case, strategies similar to those used in CRPC might be effective salvage therapies, by blocking all androgen and estrogen production, and some trials testing this hypothesis are underway.
SUMMARY AND CONCLUSIONS
Endocrine therapy has been a mainstay for the treatment of breast and prostate cancer for decades, and enzyme inhibitors have taken center stage as first-line therapies in recent years. Treatment strategies to eliminate production of key steroids must consider the optimal targets, alternate pathways that might bypass the blockade, and the endocrine consequences of deranged steroid flux. In many instances, combination therapies with other agents are necessary to prevent adverse effects of upstream steroids and/or physiologic adaptations, which might overcome the blockades. Every new drug brings its unique challenges, which derive from the basic physiology of how the biochemical machinery in different tissues orchestrates the synthesis of steroid hormones. Armed with an understanding of these fundamental concepts and principles of steroid biosynthesis, the practicing oncologist will be prepared to avoid these pitfalls and optimally manage the prostate and breast cancer patients on these treatments.
The authors thank Drs. Nima Sharifi and Michael McPhaul for many productive discussions.
1. Boyd S. On oophorectomy in cancer of the breast. BMJ. 1900; 2: 1161–1167.
2. Huggins C. Prostatic cancer treated by orchiectomy; the five year results. JAMA. 1946; 15: 576–581.
3. Huggins C, Dao TL. Adrenalectomy and oophorectomy in treatment of advanced carcinoma of the breast. JAMA. 1953; 18: 1388–1394.
4. Santen RJ, Worgul TJ, Samojlik E, et al.. A randomized trial comparing surgical adrenalectomy with aminoglutethimide plus hydrocortisone in women with advanced breast cancer. N Engl J Med. 1981; 305: 545–551.
5. Susan LP, Roth RB, Adkins WC. Regression of prostate cancer metastasis by high doses of diethylsilbestrol phosphate. Urology. 1976; 7: 598–601.
6. The Leuprolide Study Group. Leuprolide versus diethylstilbestrol for metastatic prostate cancer. The Leuprolide Study Group. N Engl J Med. 1984; 311: 1281–1286.
7. Schellhammer PF, Sharifi R, Block NL, et al.. A controlled trial of bicalutamide versus flutamide, each in combination with luteinizing hormone–releasing hormone analogue therapy, in patients with advanced prostate carcinoma. Analysis of time to progression. CASODEX Combination Study Group. Cancer. 1996; 78: 2164–2169.
8. Osborne CK. Tamoxifen in the treatment of breast cancer. N Engl J Med. 1998; 339: 1609–1618.
9. Baum M, Budzar AU, Cuzick J, et al.. Anastrozole alone or in combination with tamoxifen versus tamoxifen alone for adjuvant treatment of postmenopausal women with early breast cancer: first results of the ATAC randomised trial. Lancet. 2002; 359: 2131–2139.
10. de Bono JS, Logothetis CJ, Molina A, et al.. Abiraterone and increased survival in metastatic prostate cancer. N Engl J Med. 2011; 364: 1995–2005.
11. Miller WL, Auchus RJ. The molecular biology, biochemistry, and physiology of human steroidogenesis and its disorders. Endocr Rev. 2011; 32: 81–151.
12. Miller WL. Lessons from congenital lipoid adrenal hyperplasia. Curr Opin Endocrinol Diabetes. 1998; 5: 155–161.
13. Labrie F. Intracrinology. Mol Cell Endocrinol. 1991; 78: 113–118.
14. Griffin JE. Androgen resistance—the clinical and molecular spectrum. N Engl J Med. 1992; 326: 611–618.
15. Miller WL. Early steps in androgen biosynthesis: from cholesterol to DHEA. Baillieres Clin Endocrinol Metab. 1998; 12: 67–81.
16. Clark BJ, Wells J, King SR, et al.. The purification, cloning and expression of a novel luteinizing hormone–induced mitochondrial protein in MA-10 mouse Leydig tumor cells. Characterization of the steroidogenic acute regulatory protein (StAR). J Biol Chem. 1994; 269: 28314–28322.
17. Tsujishita Y, Hurley JH. Structure and lipid transport mechanism of a StAR-related domain. Nat Struct Biol. 2000; 7: 408–414.
18. Bose H, Lingappa VR, Miller WL. Rapid regulation of steroidogenesis by mitochondrial protein import. Nature. 2002; 417: 87–91.
19. Arakane F, King SR, Du Y, et al.. Phosphorylation of steroidogenic acute regulatory protein (StAR) modulates its steroidogenic activity. J Biol Chem. 1997; 272: 32656–32662.
20. Lin D, Sugawara T, Strauss JF III, et al.. Role of steroidogenic acute regulatory protein in adrenal and gonadal steroidogenesis. Science. 1995; 267: 1828–1831.
21. Montgomery RB, Mostaghel EA, Vessella R, et al.. Maintenance of intratumoral androgens in metastatic prostate cancer: a mechanism for castration-resistant tumor growth. Cancer Res. 2008; 68: 4447–4454.
22. Cai C, Chen S, Ng P, et al.. Intratumoral de novo steroid synthesis activates androgen receptor in castration resistant prostate cancer and is upregulated by treatment with CYP17A1 inhibitors. Cancer Res. 2011; 71: 6503–6513.
23. Hofland J, van Weerden WM, Dits NF, et al.. Evidence of limited contributions for intratumoral steroidogenesis in prostate cancer. Cancer Res. 2010; 70: 1256–1264.
24. Nelson DR, Kamataki T, Waxman DJ, et al.. The P450 superfamily: update on new sequences, gene mapping, accession numbers, early trivial names of enzymes, and nomenclature. DNA Cell Biol. 1993; 12: 1–51.
25. Khan N, Sharma KK, Andersson S, et al.. Human 17β-hydroxysteroid dehydrogenases types 1, 2, and 3 catalyze bi-directional equilibrium reactions, rather than unidirectional metabolism, in HEK-293 cells. Arch Biochem Biophys. 2004; 429: 50–59.
26. Mizrachi D, Auchus RJ. Androgens, estrogens, and hydroxysteroid dehydrogenases. Mol Cell Endocrinol. 2009; 301: 37–42.
27. Geissler WM, Davis DL, Wu L, et al.. Male pseudohermaphroiditism caused by mutations of testicular 17β-hydroxysteroid dehydrogenase 3. Nat Genet. 1994; 7: 34–39.
28. Wu L, Einstein M, Geissler WM, et al.. Expression cloning and characterization of human 17β-hydrosteroid dehydrogenase type 2, a microsomal enzyme possessing 20α-hydroxysteroid dehydrogenase activity. J Biol Chem. 1993; 268: 12964–12969.
29. Simard J, Sanchez R, Durocher F, et al.. Structure-function relationships and molecular genetics of the 3β-hydroxysteroid dehydrogenase gene family. J Steroid Biochem Mol Biol. 1995; 55: 489–505.
30. Labrie F, Luu-The V, Lin SX, et al.. Role of 17β-hydroxysteroid dehydrogenases in sex steroid formation in peripheral intracrine tissues. Trends Endocrinol Metab. 2000; 11: 421–427.
31. Turgeon D, Carrier JS, Levesque E, et al.. Relative enzymatic activity, protein stability, and tissue distribution of human steroid-metabolizing UGT2B subfamily members. Endocrinology. 2001; 142: 778–787.
32. Iyer L, King CD, Whitington PF, et al.. Genetic predisposition to the metabolism of irinotecan (CPT-11). Role of uridine diphosphate glucuronosyltransferase isoform 1A1 in the glucuronidation of its active metabolite (SN-38) in human liver microsomes. J Clin Invest. 1998; 101: 847–854.
33. Pasqualini JR, Chetrite G, Blacker C, et al.. Concentrations of estrone, estradiol, and estrone sulfate and evaluation of sulfatase and aromatase activities in pre- and postmenopausal breast cancer patients. J Clin Endocrinol Metab. 1996; 81: 1460–1464.
34. Tonetto-Fernandes V, Lemos-Marini SH, Kuperman H, et al.. Serum 21-deoxycortisol, 17-hydroxyprogesterone, and 11-deoxycortisol in classic congenital adrenal hyperplasia: clinical and hormonal correlations and identification of patients with 11β-hydroxylase deficiency among a large group with alleged 21-hydroxylase deficiency. J Clin Endocrinol Metab. 2006; 91: 2179–2184.
35. Flück CE, Miller WL, Auchus RJ. The 17, 20-lyase activity of cytochrome P450c17 from human fetal testis favors the Δ5 steroidogenic pathway. J Clin Endocrinol Metab. 2003; 88: 3762–3766.
36. Chang KH, Li R, Papari-Zareei M, et al.. Dihydrotestosterone synthesis bypasses testosterone to drive castration-resistant prostate cancer. Proc Natl Acad Sci U S A. 2011; 108: 13728–13733.
37. Auchus RJ. The backdoor pathway to dihydrotestosterone. Trends Endocrinol Metab. 2004; 15: 432–438.
38. Wilson JD, Auchus RJ, Leihy MW, et al.. 5α-Androstane-3α,17β-diol is formed in tammar wallaby pouch young testes by a pathway involving 5α-pregnane-3α,17α-diol-20-one as a key intermediate. Endocrinology. 2003; 144: 575–580.
39. Wilson JD, Shaw G, Leihy ML, et al.. The marsupial model for male phenotypic development. Trends Endocrinol Metab. 2002; 13: 78–83.
40. Tran C, Ouk S, Clegg NJ, et al.. Development of a second-generation antiandrogen for treatment of advanced prostate cancer. Science. 2009; 324: 787–790.
41. Ryan CJ, Halabi S, Ou SS, et al.. Adrenal androgen levels as predictors of outcome in prostate cancer patients treated with ketoconazole plus antiandrogen withdrawal: results from a cancer and leukemia group B study. Clin Cancer Res. 2007; 13: 2030–2037.
42. Patel SR, Kvols LK, Hahn RG, et al.. A phase II randomized trial of megestrol acetate or dexamethasone in the treatment of hormonally refractory advanced carcinoma of the prostate. Cancer. 1990; 66: 655–658.
43. Attard G, Reid AH, Yap TA, et al.. Phase I clinical trial of a selective inhibitor of CYP17, abiraterone acetate, confirms that castration-resistant prostate cancer commonly remains hormone driven. J Clin Oncol. 2008; 26: 463–4571.
44. Attard G, Reid AH, A’Hern R, et al.. Selective inhibition of CYP17 with abiraterone acetate is highly active in the treatment of castration-resistant prostate cancer. J Clin Oncol. 2009; 27: 3742–3748.
45. O’Donnell A, Judson I, Dowsett M, et al.. Hormonal impact of the 17α-hydroxylase/C(17,20)-lyase inhibitor abiraterone acetate (CB7630) in patients with prostate cancer. Br J Cancer. 2004; 90: 2317–2325.
46. Auchus RJ. The genetics, pathophysiology, and management of human deficiencies of P450c17. Endocrinol Metab Clin North Am. 2001; 30: 101–119.
47. Costa-Santos M, Kater CE, Auchus RJ. Two prevalent CYP17 mutations and genotype-phenotype correlations in 24 Brazilian patients with 17-hydroxylase deficiency. J Clin Endocrinol Metab. 2004; 89: 49–60.
48. Biglieri EG, Herron MA, Brust N. 17α-Hydroxylation deficiency in man. J Clin Invest. 1966; 15: 1945–1954.
49. Attard G, Reid AHM, Auchus RJ, et al.. Clinical and biochemical consequences of CYP17A1 inhibition with abiraterone given with and without exogenous glucocorticoids in castrate men with advanced prostate cancer. J Clin Endocrinol Metab. In press.
50. Labrie F. Endocrine therapy of prostate cancer: optimal form and timing. J Clin Endocrinol Metab. 1995; 80: 1066–1071.
51. Penning TM, Steckelbroeck S, Bauman DR, et al.. Aldo-keto reductase (AKR) 1C3: role in prostate disease and the development of specific inhibitors. Mol Cell Endocrinol. 2006; 248: 182–191.
52. Sharifi N, McPhaul MJ, Auchus RJ. “Getting from here to there”—mechanisms and limitations to the activation of the androgen receptor in castration-resistant prostate cancer. J Investig Med. 2010; 58: 938–944.
53. Judd HL, Shamonki IM, Frumar AM, et al.. Origin of serum estradiol in postmenopausal women. Obstet Gynecol. 1982; 59: 680–686.
54. Simpson ER, Mahendroo MS, Means GD, et al.. Aromatase cytochrome P450, the enzyme responsible for estrogen biosynthesis. Endocr Rev. 1994; 15: 342–355.
55. Santner SJ, Pauley RJ, Tait L, et al.. Aromatase activity and expression in breast cancer and benign breast tissue stromal cells. J Clin Endocrinol Metab. 1997; 82: 200–208.
56. Rugo HS. The breast cancer continuum in hormone-receptor–positive breast cancer in postmenopausal women: evolving management options focusing on aromatase inhibitors. Ann Oncol. 2008; 19: 16–27.
57. Recchia F, Candeloro G, Necozione S, et al.. Premenopausal hormone-responsive breast cancer with extensive axillary nodes involvement: total estrogen blockade and chemotherapy. Anticancer Res. 2011; 31: 671–676.
58. Smith IE, Dowsett M, Yap YS, et al.. Adjuvant aromatase inhibitors for early breast cancer after chemotherapy-induced amenorrhoea: caution and suggested guidelines. J Clin Oncol. 2006; 24: 2444–2447.
59. Ortmann O, Pagani O, Jones A, et al.. Which factors should be taken into account in perimenopausal women with early breast cancer who may become eligible for an aromatase inhibitor? Recommendations of an expert panel. Cancer Treat Rev. 2011; 37: 97–104.
60. Dixon JM, Renshaw L, Young O, et al.. Letrozole suppresses plasma estradiol and estrone sulphate more completely than anastrozole in postmenopausal women with breast cancer. J Clin Oncol. 2008; 26: 1671–1676.
61. Winer EP, Hudis C, Burstein HJ, et al.. American Society of Clinical Oncology technology assessment on the use of aromatase inhibitors as adjuvant therapy for postmenopausal women with hormone receptor–positive breast cancer: status report 2004. J Clin Oncol. 2005; 23: 619–629.
62. Moinfar F, Okcu M, Tsybrovskyy O, et al.. Androgen receptors frequently are expressed in breast carcinomas: potential relevance to new therapeutic strategies. Cancer. 2003; 98: 703–711.
63. Sikora MJ, Cordero KE, Larios JM, et al.. The androgen metabolite 5α-androstane-3β,17β-diol (3βAdiol) induces breast cancer growth via estrogen receptor: implications for aromatase inhibitor resistance. Breast Cancer Res Treat. 2009; 115: 289–296.
This article has been cited 2 time(s).
Annual Review of Physiology, Vol 75Estrogen and CancerAnnual Review of Physiology, Vol 75
American Journal of Human BiologyAndrogen activity and markers of inflammation among men in NHANES IIIAmerican Journal of Human Biology
steroid biosynthesis; breast cancer; prostate cancer; abiraterone acetate; aromatase inhibitor
© 2012 American Federation for Medical Research
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