Use of a long-acting gonadotropin-releasing hormone agonist for treatment of steroid cell tumors of the ovary

Ovarian steroid cell tumors: what do we know so far?

Steroid cell tumors (SCT) of the ovary are rare, which has limited advances in the understanding of this enigmatic neoplasm. In this review, we summarize currently known clinicopathologic information on SCT. SCT are frequently hormonally active, leading to elevated serum and/or urine levels of androgenic hormones or their metabolites, and associated symptomatology, including virilization. The reported age at diagnosis is broad and has ranged from as young as 1 year old to 93 years old, although most patients were between ages 20 and 40 years. Most tumors are stage I and unilateral. The tumors are usually well circumscribed with a solid or solid to cystic cut surface. The tumors in one series reportedly ranged in size from 1.2 to 45 cm (average 8.4 cm). MRI is a useful imaging modality, typically showing a well delineated mass with contrast enhancement and lipid content on T2 and T1 weighted images, respectively. Microscopically, SCT display polygonal to epithelioid cells with abundant eosinophilic to vacuolated/clear cytoplasm and display an immunoprofile that is consistent with sex cord-stromal differentiation. Most cases are benign, without any recurrences after primary resection, but a subset - probably less than 20% of cases -are clinically malignant. Pathologic criteria that can specifically predict patient outcomes remain elusive, although features that correlate with adverse outcomes have been proposed based on retrospective studies. The molecular characteristics of SCTs are similarly under characterized, although there is some evidence of an enrichment for hypoxia-signaling gene mutations in SCT. In malignant SCT, the tumors generally show greater global genomic instability, copy number gains in oncogenes, and occasional BAP1 mutation. Future studies involving multi-institutional cohort and unbiased molecular profiling using whole exome/transcriptome sequencing are needed to help advance our molecular understanding of SCTs.

Recurrent ovarian steroid cell tumour not otherwise specified: A case report

Steroid cell tumors not otherwise specified are one of the rare virilizing ovarian tumors. Most of the tumors are benign. This case report illustrates the challenge in managing steroid cell tumor not otherwise specified, which starts from determining its malignant potential, surveillance, and adjuvant treatment option.

A large ovarian steroid cell tumor-not otherwise specified with a unique combination of benign and malignant features as a challenging cause of oligomenorrhea and hirsutism in a 21-year-old Syrian female: a case report

Background

Ovarian steroid cell tumors represent a rare category of sex cord-stromal tumors that constitute less than 0.1% of all ovarian tumors. These neoplasms are classified into three main subtypes according to the cell of origin: Leidyg cell tumors, stromal luteomas, and steroid cell tumors not otherwise specified (SCTs-NOS). The latter subtype is defined as a neoplasm of an uncertain lineage that mostly affects middle-aged women, whereas it’s rare in younger ages.

Case presentation

We report a case of a 21-year-old virgin female who presented to our hospital with complaints of mild abdominal pain, hirsutism, and oligomenorrhea for more than a year. Before her current admission, the patient had attended an external gynecologic clinic where she had been prescribed oral contraceptives to regulate her periods. Nevertheless, on presentation to our institution, physical examination revealed abdominal tenderness with a palpable pelvic mass and mild hirsutism in the thigh. Ultrasonography demonstrated a large left ovarian mass measuring 154 × 104 mm, and compressing the uterus. Therefore, a unilateral salpingo-oophorectomy was performed, and interestingly, pathologic examination of the large aforementioned mass alongside with immunohistochemical correlation revealed the diagnosis of a large ovarian steroid cell tumor-not otherwise specified with a unique combination of benign and malignant features.

Conclusions

Although ovarian steroid cell tumors represent a rare category, they must be considered in the differential diagnosis for mild virilization symptoms in young females due to the importance of early diagnosis and management. In this manuscript, we aimed to present the first case report from Syria that highlights the crucial role of detailed morphological examination for challenging cases despite the difficulties in differential diagnosis, and the absence of ancillary techniques. Furthermore, we managed to discuss a brief review of diagnostic methods, histological characteristics, and treatment recommendations.

Gonadotropin-releasing hormone analogs: Mechanisms of action and clinical applications in female reproduction

Extra-hypothalamic GnRH and extra-pituitary GnRH receptors exist in multiple human reproductive tissues, including the ovary, endometrium and myometrium. Recently, new analogs (agonists and antagonists) and modes of GnRH have been developed for clinical application during controlled ovarian hyperstimulation for assisted reproductive technology (ART). Additionally, the analogs and upstream regulators of GnRH suppress gonadotropin secretion and regulate the functions of the reproductive axis. GnRH signaling is primarily involved in the direct control of female reproduction. The cellular mechanisms and action of the GnRH/GnRH receptor system have been clinically applied for the treatment of reproductive disorders and have widely been introduced in ART. New GnRH analogs, such as long-acting GnRH analogs and oral nonpeptide GnRH antagonists, are being continuously developed for clinical application. The identification of the upstream regulators of GnRH, such as kisspeptin and neurokinin B, provides promising potential to develop these upstream regulator-related analogs to control the hypothalamus-pituitary-ovarian axis.

Direct evidence on the efficacy of GnRH agonist in recurrent steroid cell tumor-not otherwise specified

Background

Steroid cell tumor (SCT) not otherwise specified (NOS) is rare and recurrence and metastasis rarely occurs; therefore, reports regarding its treatment are limited. We report a case of recurrent SCT-NOS treated with gonadotropin releasing hormone agonist (GnRHa) and successful.

Case

A 50-year-old woman underwent a staging laparotomy and diagnosed as SCT-NOS. Multiple liver tumors and intraperitoneal dissemination were detected 5 years 10 months after the initial surgery. As the immunohistochemical analysis showed positive staining for GnRH receptor, GnRHa was attempted. After the first cycle the serum testosterone level was normalized and after six cycles CT scan confirmed reduction of the tumor size.

Conclusion

Some ovarian SCT-NOS have GnRH receptors; thus, GnRHa may have a reducing effect for these tumors without major adverse event.

Hyperandrogenism in a Postmenopausal Woman Secondary to Testosterone Secreting Ovarian Stromal Tumor with Acoustic Schwannoma

Androgen-secreting ovarian neoplasms are rare ovarian tumors that present with hirsutism and virilization which may manifest as severe alopecia, deepening of voice, and clitoromegaly. Most often, ovarian tumors are found to be very small or even undetectable. In such cases, bilateral salpingo-oophorectomy should be performed after ruling out other causes of high androgens. We present a 63-year-old postmenopausal woman with clinically and radiologically undetectable testosterone-secreting ovarian tumor, which was later on detected on biopsy.

Gonadotropin-releasing hormone analog therapeutics

Dysregulation at any level of the hypothalamic-pituitary-gonadal (HPG) axis results in, or aggravates, a number of hormone-dependent diseases such as delayed or precocious puberty, infertility, prostatic and ovarian cancer, benign prostatic hyperplasia, polycystic ovarian syndrome, endometriosis, uterine fibroids, lean body mass, as well as metabolism and cognitive impairment. As gonadotropin-releasing-hormone (GnRH) is an essential regulator of the HPG axis, agonist and antagonist analogs are efficacious in the treatment of these conditions. GnRH analogs also play an important role in assisted reproductive therapies. This review highlights the current and future therapeutic potential of GnRH analogs and upstream regulators of GnRH secretion.

Metastatic Malignant Ovarian Steroid Cell Tumor: A Case Report and Review of the Literature

We report a case of malignant ovarian steroid cell tumor not otherwise specified (NOS) in a 47-year-old female who presented with hirsutism, virilization, and amenorrhea. At the time of laparotomy, the tumor had already spread to the pelvic cul-de-sac. She underwent a total hysterectomy, bilateral salpingo-oophorectomy, and tumor resection with no residual disease. She received three cycles of bleomycin, etoposide, and cisplatin (BEP) and is now free of disease 24 months after surgery. Literature review of ovarian steroid cell tumors NOS including clinicopathological features and clinical management was performed.

Recurrent ovarian steroid cell tumor, not otherwise specified managed with debulking surgery, radiofrequency ablation, and adjuvant chemotherapy

Steroid cell tumors, not otherwise specified, are infrequently encountered ovarian neoplasms, which constitute <0.1% of all ovarian tumors. Most of these tumors are unilateral, and almost one-third of all cases are reportedly malignant. However, because most of these tumors are diagnosed in the early stage, and do not recur or metastasize, little is known about their response to therapies such as chemotherapy or radiation. Here, we present a rare case of recurrent steroid cell tumor, not otherwise specified that showed a complete response after debulking surgery, radiofrequency ablation, and adjuvant chemotherapy.

A rare occurrence of a malignant ovarian steroid cell tumor not otherwise specified: A case report and literature review

Steroid cell tumors not otherwise specified (NOS) are a rare subgroup of sex cord-stromal tumors. The tumors can occur at any age, although the mean age of occurrence is 43 years old. The majority are benign, but have the capability of producing one or more steroids associated with virilization. The present study reports the case of a 29-year-old female who presented to the Second Xiangya Hospital suffering from lower back and leg pain that had persisted for five months. The patient had regular menstrual cycles and no virilization symptoms were present. Laboratory investigations revealed normal hormone levels. Multiple areas of bone destruction and a right ovarian mass were confirmed via positron emission tomography/computed tomography. The patient underwent an exploratory laparotomy, and a mass measuring ~6 cm in diameter was subsequently identified in the right ovary. A right salpingo-oophorectomy and pelvic washings for cytology were performed. Histopathological studies confirmed the diagnosis of a malignant steroid cell tumor NOS of the right ovary. The patient underwent eight cycles of chemotherapy (docetaxel, 120 mg and nedaplatin, 80 mg). The patient continued to have relatively good health, with no deterioration of the condition for one year and a half, however, the disease progressed and the patient succumbed to brain metastases six months later.

Effect of gonadotropin-releasing hormone agonist on ES-2 ovarian cancer cells

OBJECTIVE

Gonadotropin-releasing hormone (GnRH) receptor is found in the ovarian tissue, including epithelial ovarian cancer (EOC), suggesting that GnRH agonists may have direct action on EOC.

MATERIALS AND METHODS

Ovarian clear cell cancer (ES-2) cells were treated with low-dose GnRH agonist with/without low-dose paclitaxel (1 μM D-Lys(6) with/without 0.5 μM or 1.0 μM paclitaxel). Growth and behavior of ES-2 cells were evaluated.

RESULTS

Use of either D-Lys(6) or paclitaxel or a combination of the two did not affect the morphology and growth pattern of ES-2 cells. However, ability of migration and invasion of ES-2 cells was significantly decreased in either use of D-Lys(6) or paclitaxel and more apparent with the combination. Type I GnRH receptor expression of ES-2 was not altered significantly by the combination.

CONCLUSION

GnRH agonist might modify the ES-2 ovarian cancer cells, and its role might be independent, additional or synergistic, suggesting the potential role of the use of GnRH agonist in the management of clear cell type of the ovarian cancer. However, the results of this study were derived using ES-2 ovarian cancer cells, and might not be valid in other cell types of ovarian cancers.

A case of ovarian steroid cell tumor, not otherwise specified, treated with surgery and gonadotropin releasing hormone agonist

Steroid cell tumors account for less than 0.1% of all ovarian tumors. There are three steroid cell tumor subtypes: steroid cell tumor not otherwise specified (NOS), stromal luteoma and Leydig cell tumor. Steroid cell tumor, NOS, is the most common type and has malignant potential. This report describes a case of an ovarian steroid cell tumor, NOS. A 35-year-old woman visited hospital with the complaint of metrorrhagia. Physical examination revealed increased pubic hair. Transvaginal ultrasound indentified a 4.9 × 3.4 cm, well-circumscribed and solid left ovarian tumor. After laparoscopic left oophorectomy, the tumor was revealed as an ovarian steroid cell tumor, NOS. During the laparoscopic surgery, tumor ruptured. Complete surgical staging was performed and no evidence of metastasis was found. Gonadotropin releasing hormone agonist was administered monthly for 6 months. The patient has had no evidence of recurrence for 43 months.

Steroid cell tumor of the ovary in a pregnant woman whose androgenic symptoms were masked by pregnancy

INTRODUCTION

Ovarian steroid cell tumors are very rare sex cord-stromal tumors, and most of them are unilateral and almost one-third of the cases are malignant.

CASE REPORT

Here, we present a pregnant woman, who diagnosed with steroid cell tumor of the ovary and underwent surgical staging.

DISCUSSION

We will discuss the clinical presentation of the case, management options and follow-up strategies.

Current and future applications of GnRH, kisspeptin and neurokinin B analogues

Reproductive hormones affect all stages of life from gamete production, fertilization, fetal development and parturition, neonatal development and puberty through to adulthood and senescence. The reproductive hormone cascade has, therefore, been the target for the development of numerous drugs that modulate its activity at many levels. As the central regulator of the cascade, gonadotropin-releasing hormone (GnRH) agonists and antagonists have found extensive applications in treating a wide range of hormone-dependent diseases, such as precocious puberty, prostate cancer, benign prostatic hyperplasia, endometriosis and uterine fibroids, as well as being an essential component of in vitro fertilization protocols. The neuroendocrine peptides that regulate GnRH neurons, kisspeptin and neurokinin B, have also been identified as therapeutic targets, and novel agonists and antagonists are being developed as modulators of the cascade upstream of GnRH. Here, we review the development and applications of analogues of the major neuroendocrine peptide regulators of the reproductive hormone cascade: GnRH, kisspeptin and neurokinin B.

An asymptomatic ovarian steroid cell tumor with complete cystic morphology: A case report

Steroid cell tumors of the ovary are extremely rare, accounting for only 0.1% of all ovarian tumors. Of these, steroid cell tumors, not otherwise specified (NOS) constitute about 56% of all steroid cell tumors. Most steroid cell tumors secrete steroid hormones, and only about 10% to 15% of patients are asymptomatic. The morphology of steroid cell tumors, NOS is predominantly reported to be solid, and a review of case reports from 1979 until now revealed only 5 cases that were mainly cystic tumors. The present case, in a patient who had undergone a previous hysterectomy and surgery for a peritoneal inclusion cyst, is reported due to its rarity and its unusual presentation, together with a brief review of the literature. The tumor showed no clinical signs and symptoms typical of a steroid hormone secreting tumor and had an atypical morphology, being primarily multi-septate cystic with a minor solid portion.

An ovarian steroid cell tumor causing virilization and massive ascites

Steroid cell tumors, not otherwise specified (NOS), are rare ovarian sex cord-stromal tumors with malignant potential. The majority of these tumors produce several steroids, particularly testosterone. Various virilizing symptoms such as hirsutism, temporal balding, and amenorrhea are common in these patients; however massive ascites is an infrequent symptom. A 52-year-old woman with the sudden onset of virilization and massive ascites presented for treatment at Severance Hospital. After clinical evaluation, the patient underwent an exploratory laparotomy and a complete surgical staging procedure. She recovered from the surgery uneventfully and was discharged from the hospital five days after surgery. We present here an unusual case of an ovarian steroid cell tumor, NOS, and a brief review of the literature regarding these types of tumors.

Hypothyroidism and hyperlipidemia with a virilizing ovarian steroid cell tumor, not otherwise specified

Steroid cell tumors, not otherwise specified, are rare ovarian sex cord-stromal tumors with malignant potential. The majority of these tumors produce steroids, with testosterone being the most common. A 44-year-old woman with hypothyroidism and hyperlipidemia presented with abrupt onset of oligomenorrhea, progressive virilization as acne, hirsutism and clitoromegaly, and a non-palpable pelvic mass. The preoperatively elevated serum testosterone level returned to normal after salpingo-oophorectomy, and then menstrual flow became regular.

Vaginal Expulsion of a Submucosal Myoma During Treatment with Long-Acting Gonadotropin-Releasing Hormone Agonist

OBJECTIVE

Gonadotropin-releasing hormone agonist (GnRH agonist) therapy has been useful as an adjunct before myomectomy or hysterectomy for uterine myoma.

CASE REPORT

A 26-year-old woman without sexual exposure was diagnosed with a submucosal myoma and treated with long-acting GnRH agonist. This patient exhibited heavy menstruation and severe anemia for 2 years and consulted our outpatient department. Transabdominal ultrasound demonstrated a 3.5-cm submucosal myoma within the endometrial cavity. The patient showed a marked suppression of serum estradiol concentrations throughout the treatment (< 20 pg/mL at the second dose injection). The volume of the uterus and uterine myoma decreased to two-thirds of the original size at the end of the second dose injection. However, a sudden onset of severe abdominal cramping pain occurred on the 76th day and a ping-pong sized mass was expelled from the vagina. She visited our outpatient department for evaluation, where ultrasound failed to detect the previous submucosal uterine myoma. A 3-year follow-up has been uneventful.

CONCLUSION

Spontaneous expulsion of submucosal myomas might occur after the administration of GnRH agonist; hence, it may be an acceptable alternative for symptomatic females without sexual exposure.

Steroid cell tumors, not otherwise specified (NOS), in an accessory ovary: a case report and literature review

BACKGROUND

Accessory ovaries are uncommon congenital abnormalities of the female reproductive tract. Steroid cell tumors at accessory ovaries are proportionately even rare.

CASE

This 30-year-old woman had an accessory ovarian tumor attached to the infundibulum of the right fallopian tube which was solid and gross pathologically and microscopically showed the appearances of steroid cell tumor, NOS, a benign entity.

CONCLUSION

We report the first case of an accessory ovarian steroid cell tumor, NOS, which attached to the infundibulum of fallopian tube.

Steroid cell tumour not otherwise specified during pregnancy: a case report and diagnostic work-up for virilisation in a pregnant patient

Steroid cell tumours not otherwise specified are rare ovarian tumours, which can cause foetal and maternal virilisation. This is the first case report that describes a steroid cell tumour not otherwise specified during pregnancy. Differential diagnosis, a diagnostic work-up and treatment are discussed.

Diagnosis and localization of testosterone-producing ovarian tumors: imaging or biochemical evaluation

OBJECTIVE

In the testosterone-secreting ovarian tumor (TSOT), the role of whole-body positron emission tomography (WBPET) with (fluorine-18)-2-deoxyglucose scanning (FDG) and/or [(11)C]acetate is unclear, although it presents a rationale that these functional tumors would be more active and have increased use of glucose and oxygen consumption than normal tissues.

CASE

A 52-year-old woman had a history of steroid cell tumors of the right ovary (IIA) and she received staging surgery including total hysterectomy, salpingo-oophorectomy, and lymph node sampling. Reelevated serum levels of T (5.24 ng/ml) were noted 52 months later. The patient received serial preoperative examinations including WBPET with FDG and acetate, ultrasound, computerized tomography (CT), and magnetic resonance imaging (MRI) to evaluate her recurrence. A suspicious mass on the liver was found on ultrasound, CT, and MRI. The ultrasound-guided biopsy was performed three times, and each of them failed to provide any pathological confirmation. Functional imaging studies showed an abnormal uptake in WBPET using [(11)C]acetate but were negative using FDG. Because of the size of the tumor, the patient's hesitatancy toward an operation, and good previous response to gonadotropin-releasing hormone (GnRH) agonist treatment, the patient received a six-cycle GnRH agonist treatment. Serum T levels returned to normal limits after administration of the first dose of GnRH agonist. At follow-up, serum hormone levels were all within the normal ranges consistent with menopause, but the size of the metastatic tumor was constant. The tumor was then completely excised pathologically proven to be a metastatic TSOT.

CONCLUSIONS

Recurrent TSOT might be successfully detected using WBPET with [(11)C]acetate. In addition, GnRH agonist could be tried in patients with TSOT if initial responses were excellent and surgical intervention could not be performed.

Hemoperitoneum is an initial presentation of recurrent granulosa cell tumors of the ovary

Ovarian sex cord-stromal tumors account for less than 5% of all ovarian carcinoma, of which granulosa cell tumors account for 70%. These tumors have a propensity for indolent growth and late recurrence; they may even occur 25 years after initial treatment. We report a 44-year-old woman with hemoperitoneum (acute abdomen) after initial treatment 10 years earlier for granulosa cell tumor of the ovary. This case re-emphasizes the need for long-term follow-up in patients with stromal cell tumors of the ovary and considers the possibility of recurrence when presented with acute abdomen after conservative treatment.

Managing a patient with presumed testosterone-secreting ovarian tumor

We report the case of a 70-year-old woman who was presumed to have right ovarian testosterone-secreting tumor and was treated with long-acting gonadotropin-releasing hormone agonist therapy plus add-back hormone replacement therapy. The patient presented with various medical problems including hypertension, intracranial hemorrhage, myocardial infarction, unstable angina pectoris, and poor control of diabetic mellitus and had exhibited rapid symptoms of androgen excess such as progressive hirsutism and bilateral temporal balding for half a year. Tumor survey was negative except for an elevated testosterone level. Renal vein catheterization successfully detected a right ovarian androgen-secreting tumor. Because the patient was deemed medically unable to tolerate surgery, she received an alternative treatment consisting of 6 months of gonadotropin-releasing hormone-agonist (GnRH-a) and add-back hormone replacement therapy (HRT). Serum testosterone levels returned to normal limits after administration of the first dose of GnRH-a. A follow-up tumor survey was negative. The patient has been alive and free of disease for 8 months after six doses of GnRH-a. We conclude that this strategy might be used as urgent therapy in a medically compromised patient with presumed ovarian androgen-secreting tumor.