Selective ovarian vein sampling to localize a Leydig cell tumor

From diagnosis to treatment of androgen-secreting ovarian tumors: a practical approach

About 5% of all ovarian tumors develop some form of hormonal activity. Only 1% of ovarian tumors will secrete androgens causing clinical hyperandrogenism. Most androgen-secreting neoplasms (ASN) derive from sex cord or stroma cells of the ovary and may affect both premenopausal and postmenopausal women. Typically, a patient will present reporting symptoms of rapidly increasing hyperandrogenization such as: hirsutism, acne, frontal/male pattern balding, and in severe cases even virilization. Sertoli-Leydig Cell Tumors are the most frequent ASN and constitute about 0.5% of all ovarian neoplasms. Typically affecting women under 30 years of age, these tumors are usually unilateral and benign. They are also the most common tumor in postmenopausal women suffering with hyperandrogenism. Other tumors originating from the sex-cord stroma are also known to develop in this population, but the incidence of these is much lower. Approaching suspected hyperandrogenemia and its related symptoms in a clinical setting can be a significant diagnostic challenge. When evaluating a patient for hyperandrogenism, it is important to assess the severity of symptoms but most of all it is critical to assess the time of onset and dynamics of symptom progression. Diagnostic tools including laboratory tests and imaging studies should also be engaged. When deriving a differential diagnosis for androgen-secreting ovarian tumors, adrenal gland tumors should be considered as well as typical endocrine pathologies including polycystic ovary syndrome, congenital adrenal hyperplasia, Cushing's disease, and acromegaly. Treatment options for an androgen-secreting ovarian tumors is mainly surgical, but in exceptional cases can involve pharmacotherapy alone.

An Occult Leydig Cell Tumour in a Postmenopausal Woman Presenting with Alopecia and Hirsutism: A Case Report

Progressive hirsutism and moderate to severe male-pattern balding in women requires exclusion of an adrenal or ovarian tumour, especially in the presence of significantly elevated androgen levels. We present the case of a 68-year-old woman who was referred to an endocrinology clinic with insidious onset excessive facial hair growth and loss of scalp hair. Her testosterone levels were significantly elevated at 13 nmol/L (normal range: 0.1-1.4 nmol/L), although dehydroepiandrosterone sulphate and 17-hydroxyprogesterone levels were normal, suggestive of an ovarian source of androgens. Repeated radiologic investigations, including pelvic ultrasound, and abdominal and pelvic computed tomography, could not identify the obvious source of androgens. Based on strong clinical suspicion of an ovarian tumour, she underwent an elective salpingo-oophorectomy, which detected an occult Leydig cell tumour on histopathological analysis. Post-operatively, her hyperandrogenic features significantly improved and testosterone levels normalized.

An Occult Leydig Cell Tumour in a Postmenopausal Woman Presenting with Alopecia and Hirsutism: A Case Report

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Ovarian Blood Sampling Identifies Junction Plakoglobin as a Novel Biomarker of Early Ovarian Cancer

Ovarian cancer is the most lethal gynecologic malignancy. Early detection would improve survival, but an effective diagnostic test does not exist. Novel biomarkers for early ovarian cancer diagnosis are therefore warranted. We performed intraoperative blood sampling from ovarian veins of stage I epithelial ovarian carcinomas and analyzed the serum proteome. Junction plakoglobin (JUP) was found to be elevated in venous blood from ovaries with malignancies when compared to those with benign disease. Peripheral plasma JUP levels were validated by ELISA in a multicenter international patient cohort. JUP was significantly increased in FIGO serous stage IA+B (1.97-fold increase; p < 0.001; n = 20), serous stage I (2.09-fold increase; p < 0.0001; n = 40), serous stage II (1.81-fold increase, p < 0.001, n = 23) and serous stage III ovarian carcinomas (1.98-fold increase; p < 0.0001; n = 34) vs. normal controls (n = 109). JUP plasma levels were not increased in early stage breast cancer (p = 0.122; n = 12). In serous ovarian cancer patients, JUP had a sensitivity of 85% in stage IA+B and 60% in stage IA-C, with specificities of 76 and 94%, respectively. A logistic regression model of JUP and Cancer Antigen 125 (CA125) revealed a sensitivity of 70% for stage IA+B and 75% for stage IA-C serous carcinomas at 100% specificity. Our novel ovarian blood sampling – proteomics approach identified JUP as a promising new biomarker for epithelial ovarian cancer, which in combination with CA125 might fulfill the test criteria for ovarian cancer screening.

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.

Case report: an identical twin with Sertoli-Leydig cell tumor

Our report details the workup and management of a 43-year-old woman with an identical twin who presented with 2 years of virilization and secondary amenorrhea. Serum total testosterone was elevated. An MRI did not identify adnexal or adrenal pathology. Subsequent ovarian vein sampling demonstrated unilateral testosterone elevation. The patient underwent laparoscopic unilateral oophorectomy resulting in the diagnosis of Sertoli-Leydig cell tumor (SLCT). Although SLCT is a rare sex-cord ovarian tumor, it is associated with endometrial hyperplasia and malignancy. Our goals are to review the workup of androgen-secreting tumors and discuss the clinical importance of the DICER1 mutation in the context of SLCT. In this case, an identical twin underwent DICER1 testing which was one of the essential steps in her clinical management.

Ectopic adrenal rests in congenital adrenal hyperplasia as a cause of androgen excess after adrenalectomy detected by pelvic venous sampling

BACKGROUND

Patients with classic congenital adrenal hyperplasia (CAH) due to CYP21 deficiency are treated with supraphysiological doses of glucocorticoids to suppress elevated androgen production. This implies also side effects of high-dose glucocorticoids, possibly leading to iatrogenic Cushing's syndrome. Bilateral adrenalectomy has been suggested as the ultimate therapy in severe cases, when insufficient androgen suppression was obtained despite high glucocorticoid doses. Usually, ACTH levels rise after bilateral adrenalectomy, and this could imply an increased risk for the development of ectopic adrenal rests. In female CAH patients ovarian adrenal rests are not commonly detected by conventional radiological techniques.

METHODS

We report the case of an adult female CAH patient who underwent bilateral adrenalectomy in early puberty because of poorly controlled CAH.

RESULTS AND CONCLUSIONS

Several years after surgery, she developed secondary amenorrhea and hair loss as a result of androgen overproduction in ovarian adrenal rests that appeared to be detectable only by pelvic venous sampling. After unilateral oophorectomy androgen levels normalized.

"Occult" ovarian Leydig cell tumor: when laboratory tells more than imaging

Hyperandrogenism is a common finding in premenopausal age and is generally caused by polycystic ovarian syndrome or other benign disease. Androgen-secreting tumors represent only 0.2 % of the causes of hyperandrogenism and usually present with severe clinical features, abrupt onset, and very high androgens levels. We describe here three cases of occult ovarian Leydig cell tumors suspected on the basis of severe clinical features of hyperandrogenism rapidly worsening, with elevated serum total testosterone levels, in which bilateral ovariectomy was performed and tumor was confirmed by post-operative histology. In all three cases, imaging was negative for ovarian tumor. Moreover, in one case the confounding concomitant finding of bilateral adrenal masses posed an additional challenge. Our experience highlights that testosterone levels represent the most helpful marker in the diagnosis of androgen-secreting ovarian tumor. In the absence of imaging findings, bilateral ovariectomy should be indicated, if supported by unequivocal clinical and laboratory data.

Fast intraoperative testosterone assay confirms the location of an ovarian virilizing tumor in a young girl

The detection of testosterone-producing ovarian tumors in childhood and adolescence by imaging techniques only can be difficult because of the tumors' radiological structure and sometimes diminutive size. We describe an 11.5-year-old girl with a 9-month history of voice deepening, mild hirsutism, minor acne, increased growth velocity, weight gain, and clitoromegaly. Laboratory investigation revealed an extremely elevated serum testosterone level without any additional endocrine abnormalities. Abdominal ultrasound and MRI showed a sparsely noticeable solid mass in the center of the right ovary. At laparotomy, blood was selectively drawn from the right and the left ovarian veins. Rapid testosterone measurement revealed a 70-fold higher testosterone concentration in the right ovarian vein within 45 min. Based on this finding, a right salpingo-oophorectomy was performed. The patient's postoperative testosterone level declined within 24 h. The histopathological diagnosis was Leydig cell tumor. In conclusion, the implementation of a fast intraoperative testosterone assay enabled the localization and curative therapy of a Leydig cell tumor. This technique seems to be a good alternative to preoperative selective venous blood sampling when body imaging does not unveil the tumor's site.

Malignant ovarian Sertoli-Leydig cell tumor localized with selective ovarian vein sampling

Sertoli-Leydig cell tumors (SLCT) are rare, comprising less than 0.5% of ovarian neoplasms. They are most often diagnosed in premenopausal women and may produce androgens, resulting in hirsuitism, voice deepening, frontal balding, terminal hair growth, and clitoromegaly. SLCT are malignant in 15%-20% of cases. We discuss a 25-year-old patient with persistent hyperandrogenemia. Noninvasive imaging cannot conclusively differentiate between SCLT and other diagnoses such as polycystic ovary syndrome, ovarian hyperthecosis, idiopathic hyperandrogenism, idiopathic hirsuitism, and 21-hydroxylase-deficient nonclassic adrenal hyperplasia. Selective ovarian vein sampling revealed a 15-fold greater testosterone production from the right ovary compared with the left, which guided appropriate surgical management.

Leydig cell tumour of the ovary localised with positron emission tomography/computed tomography

Androgen-producing ovarian tumours can lead to assessment difficulties because of their small size. We present a case of virilising steroid cell ovarian tumour in a 41-year-old woman localised with Fluorine-18-Deoxyglucose Positron Emission Tomography/Computed Tomography ((18)FDG-PET/CT). Although the biochemical evaluation pointed to an ovarian source of androgen, diagnostic attempts to localise the source of hyperandrogenism with transvaginal ultrasound (US), and magnetic resonance imaging (MRI) of pelvis failed. Additional evaluation with (18)FDG-PET/CT showed an increased uptake in the right ovary. A laparoscopic right oophorectomy was performed and histopathology examination revealed a 1.2-cm Leydig cell tumour. The patient showed regression of clinical signs.

Use of F 18-fluoro-D-glucose-positron emission tomography-computed tomography to localize a hilar cell tumor of the ovary

OBJECTIVE

To describe provocative testing and alternative imaging strategies used to localize an androgen-producing tumor in a 58-year-old woman with severe hirsutism.

DESIGN

Case report.

SETTING

Clinical Research Center.

PATIENT(S)

A 58-year-old woman who was seen for evaluation of severe hirsutism.

INTERVENTION(S)

Serum androgen levels were measured at baseline, 4 hours after administration of 2000 IU of hCG, and 11 days after administration of 3.75 mg of leuprolide acetate (LA). Magnetic resonance imaging and F 18-fluoro-D-glucose-positron emission tomography-computed tomography (FDG-PET/CT) were performed.

MAIN OUTCOME MEASURE(S)

Description of preoperative provocative testing and imaging.

RESULT(S)

In response to hCG, T rose from 243 to 288 ng/dL then decreased to 233 ng/dL after LA administration. The FDG-PET/CT scan demonstrated focal hypermetabolism in the right pelvis, corresponding to a soft-tissue density on the noncontrast CT scan. Magnetic resonance images were correlated with the PET/CT, and the right ovary was identified. Right salpingo-oophorectomy was performed, and final pathologic examination revealed a hilar cell tumor with ovarian cortical hyperplasia.

CONCLUSION(S)

This case demonstrates the utility of provocative testing in the evaluation of a patient with severe hirsutism and illustrates the value of FDG-PET/CT when traditional imaging is nondiagnostic.

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.