Direct laparoscopic venous sampling to diagnose a small Sertoli-Leydig tumor

Ovarian Steroid Cell Tumor Masquerading as Steroid-Unresponsive Congenital Adrenal Hyperplasia

Objective

Ovarian neoplasms in children are rare. The objective of this report is to emphasize the importance of considering those neoplasms in the differential diagnosis of hyperandrogenism even with negative diagnostic imaging.

Methods

We report the case of a 12-year-old girl who presented with virilization and elevated 17 hydroxyprogesterone (17-OHP) and who was subsequently diagnosed with an ovarian neoplasm.

Results

The patient was initially seen for hirsutism and deepening of the voice. Elevated 17-OHP, androstenedione, and testosterone prompted the initial diagnosis of nonclassic congenital adrenal hyperplasia due to 21-hydroxylase deficiency, but those levels failed to suppress on corticosteroid therapy. Ultrasound, computed tomography scan, and magnetic resonance imaging of the abdomen and pelvis were normal. Genetic testing for congenital adrenal hyperplasia was negative. Bilateral selective adrenal and ovarian venous sampling confirmed the ovarian origin of her hyperandrogenism. A unilateral salpingo-oophorectomy revealed a steroid cell tumor. Postoperatively there was normalization of testosterone and 17-OHP.

Conclusion

This report highlights the utility of selective adrenal and ovarian sampling when suspecting a primary androgen-secreting neoplasm, even in the setting of elevated 17-OHP levels and negative imaging studies, as early diagnosis can prevent manifestation of irreversible symptoms of virilization

The clinical features and reproductive prognosis of ovarian neoplasms with hyperandrogenemia: a retrospective analysis of 33 cases

The aim of this study is to review the natural course, clinical features, and reproductive prognosis of ovarian tumors associated with hyperandrogenemia. We retrospect 33 patients of ovarian tumors with hyperandrogenemia. Thirty cases (91%) were sex cord-stromal tumors. Sertoli-Leydig cell tumors, Leydig cell tumors, and steroid cell tumors were the most common types. It is not possible, to predict the pathological subtypes based on androgen levels alone. Most of these tumors were solid masses, with an average diameter of 3.9 cm. These tumors are soft or fragile, no clear boundary with normal tissue, thus excision is superior to exfoliation. The average disease course of the top three tumors was 32.6, 35.4, and 67.7 months, respectively. Among 11 married women with a desire to get pregnant, nine cases resumed menstrual periods after surgery and became pregnant naturally. Hyperandrogenemia might predict a better prognosis. The asynchronism of hyperandrogenemia and undetectable tumor may cause irreversible change and emotional depress, the methods of early diagnosis need further study.

Rare case of occult testosterone-producing ovarian tumor that was diagnosed by selective venous hormone sampling

CASE

A 32 year old woman was referred because of secondary amenorrhea, hirsutism, and voice deepening.

OUTCOME

The blood testosterone level was markedly high. A transvaginal ultrasound revealed a small region in the left ovary, but whether or not it was a tumor was unclear. Therefore, selective ovarian venous sampling was performed. Consequently, the testosterone level was selectively increased in a blood sample that was taken from the left ovarian vein, the tumor was successfully localized, and a laparoscopic left oophorectomy was performed. Although the left ovary appeared to be normal at laparoscopy, the androgen-secreting tumor was located within it. The tumor was diagnosed as a Leydig cell tumor by histopathological analyses.

CONCLUSION

This report demonstrates that selective blood sampling from ovarian veins before an operation is effective in localizing an androgen-producing ovarian tumor that is difficult to diagnose by imaging studies.

Ovarian Sertoli-Leydig cell tumor: a report of seven cases and a review of the literature

The aim of this study was to investigate the clinicopathologic features, treatment and outcome of seven patients with an ovarian Sertoli-Leydig cell tumor (SLCT). Five patients presented with feminization, two with accompanying virilization. One presented with amenorrhea alone. Three of the five patients showing feminization symptoms had endocrine-related diseases. Histologically, five tumors were well differentiated, the other two were poorly differentiated. The latter two patients were misdiagnosed as having an ovarian epithelial carcinoma or granulosa cell tumor from frozen sections. Immunohistochemistry showed that the tumors were calretinin-positive in two patients and one was inhibin-positive. Four patients underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy(TAH/BSO) and two were treated by unilateral salpingo-oophorectomy. Among them, two patients received adjuvant chemotherapy. Six patients were free of disease in a follow-up of 2-34 years and one achieved a pregnancy. The remaining patient recurred 4 years later. Feminization as well as virilization might provide important clues for a preoperative diagnosis. Histological misdiagnosis is probable in poorly differentiated tumors. Conservative surgery including retention of fertility can be considered. However, the tendency for recurrence in poorly differentiated tumors should be considered.

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.

Combined adrenal and ovarian venous sampling to localize an androgen producing tumor

A postmenopausal woman presented with hirsutism and elevated serum testosterone levels. A 1-cm adrenal adenoma was noted on computed tomography. Combined adrenal and ovarian venous sampling was performed to localize an androgen producing tumor to the left ovary. The patient underwent a bilateral salpingo-oophrectomy and was spared an unnecessary adrenalectomy.

Selective venous sampling for androgen-producing ovarian pathology

OBJECTIVE

Multiple diagnostic modalities may be needed to establish the source of excessive androgen production in women. The role of selective venous catheterization in this process has not been established fully.

DESIGN

A study of hyperandrogenaemic subjects and literature review.

PATIENTS

Four hyperandrogenaemic women and an additional 132 previously reported cases with available testing data and a pathological diagnosis were evaluated.

MEASUREMENTS

Serum androgens, diagnostic imaging and ovarian venous effluent sampling. Criteria to distinguish ovarian tumours from other ovarian conditions and to localize the lesion(s) were evaluated.

RESULTS

Basal peripheral testosterone levels >or= 4.51 nmol/l (>or= 130 ng/dl) discriminated ovarian tumours from benign causes of hyperandrogenism (sensitivity: 93.8%, 95% CI 85.0-98.2; specificity: 77.8%, 95% CI 66.4-86.7). Single lesions produced higher ipsilateral testosterone concentrations (612.6 +/- 162.0 nmol/l; 17 653 +/- 4670 ng/dl) compared to contralateral values (26.4 +/- 5.2 nmol/l; 761 +/- 150 ng/dl). In women with peripheral testosterone >or= 4.51 nmol/l, a right-to-left (R:L) ovarian testosterone ratio >or= 1.44 correctly identified all 18 women with right-sided tumours and misclassified two with bilateral lesions; 12 out of 14 women with left-sided or bilateral lesions had a lower R:L value. When this criterion was combined with a left-to-right (L:R) ovarian testosterone effluent ratio of > 15 to identify left-sided tumours, overall 66% of women were correctly categorized.

CONCLUSIONS

Peripheral testosterone concentrations identified ovarian androgen-producing tumours, and venous sampling could correctly localize 66% of these, suggesting a role for sampling when imaging studies are not revealing.

Selective ovarian vein sampling can be crucial to localize a Leydig cell tumor: an unusual case in a postmenopausal woman

Leydig cell tumors of the ovary are very rare, frequently associated with symptoms of virilization in postmenopausal patients. It is sometimes difficult to localize the tumor precisely even with modern imaging techniques. A 62-year-old patient presented with recent onset of rapidly progressive virilization including increased hirsutism, progressive balding, deepening voice and enlargement of the clitoris. Initial laboratory examination revealed a total serum testosterone level of 1330 ng/dL. Serum dehydroepiandrosterone sulfate, androstenedione and 17 hydroxyprogesterone levels were all within normal limits. Extensive pre-operative evaluations included transvaginal ultrasound, abdominal computed tomography and magnetic resonance imaging failed to localize the tumor. Therefore, selective ovarian venous hormonal sampling (SOVHS) was performed and they revealed that the total serum testosterone level was significantly higher in the left than in the right ovarian vein (7000 ng/dL vs. 225 ng/dL). A total abdominal hysterectomy and bilateral salpingo-oophorectomy was performed. Microscopic examination of the left ovary revealed a Leydig cell tumor. In conclusion, when the precise location of the tumor is not determined pre-operatively, SOVHS may be valuable to make accurate diagnosis.

Virilizing ovarian tumor in a 14-year-old female with a prior familial multinodular goiter

A 14-year-old female presented with intermittent abdominal pain, deepening of voice and amenorrhoea for 4 months. Twelve months earlier she had had a thyroidectomy because of familial multinodular goiter and had, subsequently, received substitution with L-thyroxine. At the time of admission, a high serum testosterone level was detected. The dexamethasone suppression test confirmed the hormonal autonomy and magnetic resonance imaging (MRI) visualized a solid tumor within the left ovary. The pathological diagnosis after left salpingo-oophorectomy was Sertoli-Leydig cell tumor. The patient has remained disease-free for 6 years.

Low leptin level in an obese hyperandrogenic woman--potential marker for androgen-secreting tumor

Hyperandrogenism in postmenopausal women is due to ovarian hyperthecosis or an androgen-secreting ovarian/adrenal tumor. Making the correct diagnosis might be complicated due to the possible existence of an adrenal neoplasm secreting testosterone only, ectopic ovarian tissue or ectopic luteinizing hormone/human chorionic gonadotropin receptors in the adrenals, as well as the relatively low sensitivity of imaging techniques (computed tomography, magnetic resonance imaging) and vein catheterization for this type of pathology. We present the case of an obese postmenopausal woman with metabolic syndrome, hyperandrogenism (high testosterone levels, suppressed gonadotropins), adrenal macronodular hyperplasia and Leydig-cell ovarian tumor. At presentation she had low leptin levels despite high body fat content. After a catheter study left adrenalectomy was carried out but hyperandrogenism persisted. Then, bilateral oophorectomy with hysterectomy was performed and a small Leydig-cell tumor was found in the left ovary. Postoperatively, testosterone and gonadotropin levels were normal (postmenopausal) and leptin level became elevated without change in body mass index or body fat content. In conclusion, we speculate that low leptin levels in obese hyperandrogenic women might be a marker for androgen-secreting tumors.