Virilizing ovarian dermoid cyst with leydig cells

Removal of an atypical ovarian dermoid cyst: a case report

Ovarian dermoid cysts, also known as mature teratomas, are benign embryonal tumors with a slow growth rate. They are the consequence of ectodermal components becoming trapped along with their closure sites and account for the most common germinative ovarian tumor in reproductive-aged women. These patients may have a reduced risk of morbidity if they receive an accurate diagnosis and extensive follow-up care. These cysts are often evaluated using one of the following imaging techniques: computed tomography, magnetic resonance imaging, pelvic ultrasonography, or transvaginal ultrasound. Laparoscopy and laparotomy are the 2 surgical procedures typically used to remove persistent or exceptionally large cysts. Leakage of cyst contents during surgery is a common postoperative complication that can seldom, but occasionally, results in chemical peritonitis. We discuss a case of a significant dermoid cyst that developed in an older woman and was successfully removed via laparoscopic surgery. This instance is instructive for other physicians who may encounter a similar pathology.

Dermoid Cyst Spillage Resulting in Chemical Peritonitis: A Case Report and Literature Review

A dermoid cyst, also called a mature teratoma, is a benign tumor of the ovary derived from pluripotent germ cells. It is often asymptomatic; however, it can be expressed by several complications, including infection, adnexal torsion, and rupture. Rarely ovarian dermoid cysts can also transform into malignant degeneration. A ruptured teratoma is a rare and life-threatening complication and may arise spontaneously. However, cystic rupture is often secondary to surgical procedures such as ovarian cystectomy, leading to acute peritonitis and surgical emergency. Herein, we report a case of acute peritonitis in a female resulting from ovarian dermoid cyst spillage. Her clinical picture and radiological imaging were consistent with a ruptured ovarian cyst leading to chemical peritonitis, and a histopathological examination confirmed an ovarian dermoid cyst.

An adolescent female with a testosterone-secreting ovarian teratoma: a case report

Ovarian neoplasms constitute 1% of childhood tumors. The majority of them are teratomas and usually are asymptomatic or present with paraneoplastic syndromes. Our case is a 16-year-old female who presented with chronic abdominal pain, virilization and oligomenorrhea and found to have a complex cystic mass of the left ovary, more likely cystic teratoma on abdomen and pelvis CT. Further work-up revealed significantly elevated serum total and free testosterone. The patient subsequently underwent left salpingo-oophorectomy confirming the radiological findings. Within two week after surgery, serum testosterone normalized and the patient started having regular menstrual cycles. In summary, ovarian teratomas should be include in the differential diagnosis of abdominal pain and menstrual abnormalities in female adolescents. Further studies are needed to determine the role of ovarian-sparing surgery in this patient population.

Postmenopausal women with hyperandrogenemia: Three case reports

BACKGROUND

Diagnosing hyperandrogenemia in postmenopausal women is very difficult. It occasionally manifests as excessive hair growth or with no clinical manifestations, and is therefore often misdiagnosed or missed altogether. Ovarian steroid cell tumors that cause hyperandrogenemia in women account for approximately 0.1% of all ovarian tumors. Due to the low incidence, corresponding imaging reports are rare, so ovarian steroid cell tumors lacks typical imaging findings to differentiate it from other ovarian tumors. Therefore, we summarized its clinical and imaging characteristics through this case series, and elaborated on the differential diagnosis of steroid cell tumors.

CASE SUMMARY

We report three cases of postmenopausal women with hyperandrogenemia. Only 1 patient showed virilization symptoms, the other two patients were completely asymptomatic. All patients underwent total hysterectomy + bilateral adnexectomy. Histological results showed one case of Leydig cell tumor and two cases of benign, non-specific steroid cell tumor. After the operation, the androgen levels of all patients returned to normal, and there was no clinical recurrence since follow-up.

CONCLUSION

Although virilization caused by increased serum testosterone levels is an important clinical feature of ovarian steroid cell tumors, it is often asymptomatic. A solid, slightly hypoechoic, round or oval mass with uniform internal echo, richer blood flow in the solid part, and low resistance index are typical imaging features of ovarian steroid cell tumors. Diagnosis of ovarian steroid cell tumors after menopause is challenging, but surgery can be used for both diagnosis and clear treatment.

Large ovarian tumors in adolescents, a systematic review of reported cases, diagnostic findings and surgical management

The purpose of this study was to analyze the published cases regarding large ovarian masses in adolescents, in order to find useful clinical implications for the diagnosis and management of the condition. The methodology employed a systematic review of reported cases of large/giant ovarian tumor in adolescence. The main objective was to assess the imagery findings, histology of the tumor, and the type of surgery performed. Our study included 58 patients with the tumor diameters ranged between 11 and 42 cm, with a median value of 22.75 cm and a mean diameter of 24.66 ± 8.50 cm. The lesions were benign in 47 cases (81%), borderline in 2 cases (3.4%), and malign in 9 cases (15.6%). We found no statistically significant difference (p > 0.05) between the size of the tumors and the ovarian markers levels. At the same time, a statistically significant difference was identified (p=<0,001) between elevated levels of the serum markers and the malignant tumor type (OR = 12.45; CI₉₅ = 2.55-94.77). The main types of surgery performed were cystectomy (35 cases), oophorectomy (4 cases), salpingo-oophorectomy (18 cases). Open laparotomy was performed in 46 cases on tumors with a median diameter of 25 ± 8.8 cm, while laparoscopy was done in 12 cases on tumors with a median diameter of 23.7 ± 7.6 cm. For optimal surgical management, it is advisable to assess first the imagery findings and tumor markers. Then, the laparoscopic approach should be considered as a feasible option, especially in cases where there are no predictive factors for a malign disease.

Dermoid Cysts of the Maxillofacial Region: Case Series

The maxillofacial region can be affected by a number of subcutaneous pathologic conditions that include developmental, inflammatory, infective and neoplastic entities. Many of these lesions present as a soft to firm painless swelling. Differential diagnosis of such lesions requires thorough knowledge of maxillofacial pathology as well as anatomy to come to a correct diagnosis and provide effective treatment. Misdiagnosis and improper treatment can lead to other complications and morbidity. The commonly encountered lesions include dermoid cysts, branchial cysts, lipoma and thyroglossal cyst. Dermoid cysts are dysontogenetic cysts rarely involving the maxillofacial region (1.6-7% of all dermoid cysts of the body). The most common site of involvement in the maxillofacial region is near the frontozygomatic suture followed by cervical region. Some lesions have a deep component which may involve the cranial or orbital cavities. This is a retrospective study of the cases managed at our center from 2001 to 2017. Of the 12 cases in our study, all but one was involving the floor of the mouth. There were 11 males and 1 female. Swelling was the only symptom. The patients age ranged from 16 to 34 years (Table 2). The cysts were present for a period ranging from 6 months to 5 years at the time of reporting. All cases were managed with enucleation. The patients are on follow-up with no report of recurrence. The period of follow-up was 1 to 16 years. There were no complications postoperatively.

Virilism and Ectopic Expression of HSD17B5 in Mature Cystic Teratoma

Mature cystic teratoma (MCT) is rarely involved in the overproduction of steroid hormones in contrast to sex cord stromal tumors. A 31-year-old woman visited our hospital with hirsutism, hoarseness, and hair loss from the scalp. Serum testosterone and free-testosterone levels were 7.3 ng/ml and 2.3 pg/ml, respectively, which were markedly in excess of the age adjusted female standard levels. Basal blood levels of steroid hormones and serum levels of 17-hydroxyprogesterone at 1 h after intravenous injection of adrenocorticotropic hormone demonstrated that 21-hydroxylase deficiency was not the underlying cause of her virilization. A subsequent chromosomal test with G-banding revealed a karyotype of 46XX. Magnetic resonance imaging revealed a mass in the left ovary, which was subsequently diagnosed as MCT. Detailed pathological analysis of the tumor indicated that it was comprised of skin components, sweat glands, with hair and fat texture, glandular epithelium and fibrous connective tissue, consistent with the characteristic composition of MCT. Immunohistochemical analysis demonstrated marked immunoreactivity of 17beta-hydroxysteroid dehydrogenase (HSD17B5), an enzyme that can convert androstenedione to testosterone. Following surgical removal of the tumor, testosterone and free testosterone levels were markedly decreased (0.3 ng/ml and 0.4 pg/ml, respectively) and other symptoms abated. In conclusion, this is the first report of an ovarian MCT associated with clinical virilization caused by the ectopic production of testosterone possibly because of an overexpression of intratumoral HSD17B5.

Virilization in a Postmenopausal Female Due to Androgen Secreting Ovarian Dermoid Cyst

Virilizing ovarian dermoid cysts are very rare. The source of androgen in these cysts may be tumors such as Sertoli–Leydig cell tumor or Leydig cell hyperplasia. A 52-year-old postmenopausal female with virilization was found to have an ovarian dermoid cyst on ultrasound. Her serum testosterone levels were elevated. Leydig cell hyperplasia within the dermoid cyst was found to be the source of androgen in this patient.

Leydig cell tumour and mature ovarian teratoma: rare androgen-secreting ovarian tumours in postmenopausal women

Androgen-secreting ovarian tumours are extremely rare accounting for <5% of all ovarian neoplasms. They are more frequent in postmenopausal women and should be suspected in the case of a rapid onset of androgenic symptoms. We report 4 cases of postmenopausal women who presented with signs of virilisation. All patients revealed increased serum levels of testosterone, normal dehydroepiandrosterone-sulfate and negative pelvic ultrasound for adnexal masses. An androgen-secreting ovarian tumour was suspected and all of them were submitted to bilateral oophorectomy. Histology confirmed the diagnosis of Leydig cell tumours in 3 patients and mature teratoma in 1. A successful response to surgery, which includes a decline in serum androgen levels and signs of hyperandrogenism, was observed in our patients. This case series demonstrates that androgen-secreting ovarian neoplasms may not be detectable by imaging studies, but should be considered in the differential diagnosis of all postmenopausal women with signs of hyperandrogenism.

Sclerosing stromal tumour of the ovary presenting as precocious puberty: a rare neoplasm

A 7-year-old Indian girl presented with symptoms of excessive development of breasts, early menarche, growth of pubic hairs, accelerated growth and abdominal distension. On clinical examination, a large right abdominopelvic mass was palpable. MRI revealed a large, heterogeneous, solid and cystic tumour in the right adnexal region, suggestive of an ovarian neoplasm. The hormonal profile showed markedly elevated oestradiol and low follicle-stimulating hormone levels. Clinical diagnosis of precocious puberty with right ovarian mass was concluded. Right-sided salpingo-oophorectomy was performed. Histopathology showed features consistent with sclerosing stromal tumour of the ovary. Postoperatively, signs and symptoms of precocity gradually regressed and her serum oestradiol level came down to normal. This is the first reported case from India.

Leydig cell tumors in children: contrasting clinical, hormonal, anatomical, and molecular characteristics in boys and girls

OBJECTIVE

To analyze the clinical, hormonal, anatomical, and molecular characteristics of Leydig cell tumors, a very rare cause of progressive hyperandrogenism in children.

STUDY DESIGN

Description of a 9-year-old boy with isosexual precocious pseudopuberty, and of a 12-year-old girl with rapidly progressive virilization, both due to a pure Leydig cell tumor. Review of all cases of pediatric Leydig cell tumors published since 1999 (when the first somatic mutations of the luteinizing hormone receptor were described) and reporting hormonal and/or molecular data.

RESULTS

Boys (n = 24) are younger than girls (n = 12) at diagnosis (median 6.5 vs 13.0 years, P = .04). Plasma gonadotrophins are more often completely suppressed in boys (6 cases) than in girls (2 cases). Pure Leydig cell tumors are exceedingly rare in girls (2 cases), who most often have Sertoli-Leydig tumors. These tumors affect either testis equally (11 left, 13 right) but occur more often in the left ovary (8 left, 3 right). Activating mutations of the alpha-subunit of the G(s) stimulatory protein have not been found in either boys or girls and activating mutations of the luteinizing hormone receptor have only been found in boys.

CONCLUSIONS

Leydig cell tumors in children display clinical, hormonal, anatomical, and molecular sexual dimorphism.