Gonadotropin-releasing hormone-agonist as a neoadjuvant therapy for Sertoli-Leydig cell tumors of the ovary

Dexamethasone suppression test versus selective ovarian and adrenal vein catheterization in identifying virilizing tumors in postmenopausal hyperandrogenism - a systematic review and meta-analysis

OBJECTIVE

The diagnostic accuracy of tests in identifying virilizing tumors in postmenopausal hyperandrogenism is limited. This systematic review compares the dexamethasone suppression test against selective ovarian and adrenal vein sampling of androgens in distinguishing neoplastic from non-neoplastic causes of postmenopausal hyperandrogenism.

METHODS

Diagnostic test accuracy studies on these index tests in postmenopausal women were selected based on pre-established criteria. The true positive, false positive, false negative, and true negative values were extracted and meta-analysis was conducted using the hierarchical summary receiver operator characteristics curve method.

RESULTS

The summary sensitivity of the dexamethasone suppression test is 100% (95% CI 0-100%) and that for selective venous sampling is 100% (95% CI 0-100%). The summary specificity of the dexamethasone suppression test is 89.2% (95% CI 85.3-92.2%) and that for selective venous sampling is 100% (95% CI 0.3-100%).

CONCLUSION

There is limited evidence for the use of dexamethasone suppression test or selective venous sampling in identifying virilizing tumors in postmenopausal hyperandrogenism.

Gonadotropin-Releasing Hormone Analogue Stimulation Test Versus Venous Sampling in Postmenopausal Hyperandrogenism

Postmenopausal hyperandrogenism can be due to excessive androgen secretion from adrenal or ovarian virilizing tumors or nonneoplastic conditions. The etiology of postmenopausal hyperandrogenism can be difficult to discern because of limited accuracy of current diagnostic tests. This systematic review compares the diagnostic accuracy of the gonadotropin-releasing hormone (GnRH) analogue stimulation test against selective ovarian and adrenal vein sampling of androgens in distinguishing neoplastic from nonneoplastic causes of postmenopausal hyperandrogenism. Diagnostic test accuracy studies on these index tests in postmenopausal women were selected based on preestablished criteria. The true positive, false positive, false negative, and true negative values were extracted and meta-analysis was conducted using the hierarchical summary receiver operator characteristics curve method. The summary sensitivity of the GnRH analogue stimulation test is 10% (95% confidence interval [CI], 1.1%-46.7%) and that for selective venous sampling is 100% (95% CI, 0%-100%). Both tests have 100% specificity. There is limited evidence for the use of either test in identifying virilizing tumors in postmenopausal hyperandrogenism.

Postmenopausal hyperandrogenism of ovarian origin: A clinicopathologic study of five cases

In postmenopausal women presenting with virilization and elevated testosterone levels, laparoscopic salpingo-oophorectomy should be considered after exclusion of adrenal causes. A clinicopathological study was conducted among those women who presented with features of hyperandrogenism in our postmenopausal clinic over a period of 2 years. Relevant past medical and surgical histories were elicited. Basic hormonal evaluation and radiological imaging were done. Laparoscopic bilateral salpingo-oophorectomy was done. Six weeks postoperatively, serum testosterone was undetectable with significant clinical improvement. There was no recurrence of symptoms during the follow-up period of 2 years. Treatment of postmenopausal women with hyperandrogenism and virilization with laparoscopic bilateral salpingo-oophorectomy is effective if she has no pronounced ovarian enlargement or adrenal tumor on imaging. An extensive endocrine testing and a detailed search for metastatic disease may be unnecessary.

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.

Treatment of high risk Sertoli-Leydig cell tumors of the ovary using a gonadotropin releasing hormone (GnRH) analog

Sertoli-Leydig cell tumors are rare ovarian neoplasms. We report two unusual cases with bilateral SLCTs suggesting evidence of genetic predisposition and at high risk of recurrence. To reduce this risk, we exploited the use of GnRH analog to lower gondadotropin and potentially directly inhibit the tumors through expressed GnRH receptors. We used it as maintenance antitumor therapy for 2 years after completion of chemotherapy, to cover the period of risk for recurrence. Both patients remain in complete remission at >2 years after completing leuprorelin therapy. Of note, both patients carry DICER1 mutations, frequently found in pleuropulmonary blastoma syndrome.

Cetrorelix suppression test to assess the source of androgen overproduction in postmenopausal hirsutism

A 75-year-old woman presenting with recent onset hirsutism and severely elevated serum androgen levels was evaluated to assess the source of excessive androgen production. Commonly recommended hormonal stimulation and suppression tests, and the usually employed imaging techniques were non-diagnostic. In this report, we describe a new suppression test based on the use of the GnRH receptor antagonist, cetrorelix, to determine whether androgen production was LH-dependent. Cetrorelix, administered in a daily dose of 250 microg subcutaneously, suppressed serum LH within 24 h and reduced serum androgen levels to normal within 48-72 h, indicating that androgen overproduction was of ovarian origin. This diagnosis was confirmed by laparoscopic ovariectomy.

CONCLUSION

The cetrorelix suppression test is a simple procedure that provides valuable information regarding the source of androgen excess in postmenopausal hirsutism.

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.

Sertoli-Leydig cell tumor - a rare androgen secreting ovarian tumor in postmenopausal women. Case report and review of literature

Sertoli-Leydig cell tumors (SLCT) constitute only 1-0.5% of all primary ovarian neoplasms. We report a SLCT in a postmenopausal woman aged 69 years. The physical examination revealed severe hirsutism. Basal hormonal evaluation showed high plasma testosterone and estradiol values, with suppressed plasma gonadotropins. Computer tomograph scan revealed a right ovarian tumor mass of 4,3/3 cm, confirming an androgen secreting ovarian tumor. The histopathological and immunocytochemical examination established the diagnosis of well differentiated Sertoli-Leydig cell tumor. The tumor was positive for cytokeratin KL 1 and S-100 protein and, in isolated tumor cells, positive for alpha-fetoprotein. Postsurgical evolution was favorable; controls after 6 months and 3,5 years showed marked reduction of hirsutism, normal plasma testosterone values and gonadotropins in normal postmenopausal range. We discuss the complex aspects of etiology and pathogenesis, the clinical and hormonal settings, the role of immunocytochemical markers in diagnosis, as well as the therapy and the prognostic features of this ovarian tumor.

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.