Ovarian thecoma with androgenic manifestations in a postmenopausal woman

Demons-Meigs syndrome caused by a giant ovarian fibroma: A case report

Demons-Meigs syndrome is a very rare entity. It combines a benign ovarian "fibroma-like" tumor with ascites and hydrothorax. The notion of benignancy is the key point. CA-125 levels are most of the time normal, but high levels can be observed in rare cases which makes it difficult to have a diagnostic. We present here the case of a 43-year-old female patient who presented with abdominopelvic pain. Imaging discovered a 30 cm large intraabdominal mass with ascites and bilateral pleural effusion. Surgical resection of the tumor was performed, and pathology identified an ovarian fibroma. No postintervention complications were observed, with resorption of the ascites and hydrothorax.

Paraneoplastic Erythropoiesis in Patients With Ovarian Sertoli Leydig Cell Tumors: Retrospective Study From Tertiary Care Institute

To study the clinical, paraneoplastic hematological presentation of Sertoli Leydig cell tumor patients. This retrospective study involved women with Sertoli Leydig cell tumors treated at JIPMER from 2018 to 2021. We reviewed the hospital registry for the Sertoli Leydig cell tumor among all the ovarian tumors being treated in the department of obstetrics and gynecology. We retrieved the datasheets of patients with Sertoli Leydig cell tumor and studied their clinical and hematological presentation, their management, complications, and follow-up. We had 5 patients of Sertoli Leydig cell tumor of 390 ovarian tumors operated during the study period. The mean age at presentation was 31.6 years. All 5 patients had hirsutism and menstrual irregularity. One patient presented with symptoms of polycythemia along with these complaints. Elevated serum testosterone was seen in all (mean being 688 ng/ml). Mean preoperative hemoglobin was 15.84%, and mean hematocrit was 50.14%. Fertility-sparing surgery was performed in 3 of them and the rest had complete surgery. All patients were in Stage IA. Histologically, one had Pure Leydig cell, three had steroid cell tumor not otherwise specified and one was mixed Sertoli Leydig cell tumor. After the operation, the hematocrit and testosterone levels came down to the normal range. The virilizing manifestations regressed over 4-6 months. With a follow-up period ranging from 1 to 4 years, all 5 patients are alive, one patient had a disease recurrence in the ovary after 1 year of primary surgery. She is disease-free following the second surgery. The rest of the patients had no disease recurrence and are disease-free following surgery. Virilizing ovarian tumors can have paraneoplastic polycythemia which needs to be looked into while evaluating these patients. Similarly, while evaluating polycythemia in young females, an androgen-secreting tumor has to be ruled out as it is reversible and completely treatable.

Ovarian thecoma: A very unusual cause of postmenopausal bleeding

We describe a 67-year-old woman with postmenopausal bleeding having ceased estrogen plus progestogen therapy nine months before. Transvaginal ultrasonography showed endometrial thickening with normal ovarian appearance. Hormonal studies revealed high estradiol and inhibin B levels but normal androgens and adrenal hormones. Magnetic resonance image demonstrated a 13-mm left ovarian tumour. Hysterectomy and bilateral salpingo-oophorectomy were performed, and the pathological study revealed an 8 mm ovarian thecoma. This case illustrates a very unusual cause of postmenopausal bleeding. We suggest a study protocol and discuss the differential diagnosis of this case.

Comprehensive review of imaging features of sex cord-stromal tumors of the ovary

Sex cord-stromal tumors of the ovary (SCST) are uncommon ovarian tumors arising from sex cord and/or stromal cells of the ovaries. They may be nonfunctional and asymptomatic or functional presenting with hyperestrogenic, hyperandrogenic or cushingoid symptoms. They present in a wide age group of women, mostly in early stages and follow a nonaggressive clinical course after surgical resection. They differ from more prevalent epithelial ovarian tumors which tend to present in older women in advanced stages with poor prognosis. Some of SCSTs are associated with clinical syndromes. We will review imaging features on ultrasound, computed tomography and magnetic resonance imaging, epidemiology and clinical presentations of these tumors.

An ovarian Leydig cell tumor of ultrasound negative in a postmenopausal woman with hirsutism and hyperandrogenism: A case report

RATIONALE

The incidence of severe hyperandrogenism associated with masculinity in women is very low. While rare and difficult to diagnose, androgen secreting tumors should be suspected in women with hyperandrogenism and hirsutism, especially in the postmenopausal population. Herein we present one case of ovarian Leydig cell tumor (LCT) with markedly elevated serum testosterone levels and frank hirsutism.

PATIENT CONCERNS

A 60-year-old woman, presented with increased hair growth and androgenic alopecia and the hormonal laboratory examination showed that she had elevated serum testosterone level and normal dehydroepiandrosterone sulfate (DHEAS), androstenedione, 17- hydroxyprogesterone, cortisol and thyroid stimulating hormone (TSH).

DIAGNOSES

The diagnosis of possible testosterone secreting tumor was performed when pelvic computed tomography (CT) and magnetic resonance image (MRI) showed a right adnexal mass of 15mm×16mm indicative of sex cord- stromal tumors.

INTERVENTIONS

The patient received laparoscopic total abdominal hysterectomy and bilateral salpingo-oophorectomy.

OUTCOMES

After operation, testosterone got back to the normal level and clinical symptoms subsided.

LESSONS

It is common that postmenopausal androgen excess is a state of relative or absolute androgen excess originating from the adrenal gland and/or ovaries. In either case, doctors need to assess such patients and exclude relatively rare potential causes of tumors. Any woman who has hirsutism or frank evidence of markedly increased testosterone should exclude this kind of possibility of androgen producing tumors. It is possible to determine the origin of androgen hypersecretion with the severity of symptoms, the extent of androgen excess, and the relevant imaging studies. Since LCT are rare ovarian sex-cord stromal tumors, it can be beneficial for diagnosis with careful research of patient history of the defeminization followed by virilization, and a CT and MRI image.

Hormone producing gynecological tumors: pathologic entities and clinical significance

INTRODUCTION

Due to their derivation from the cell types involved in gynecologic hormonal networks, many gynecologic tumors may produce hormones. In a normal physiological setting, these hormones are essential for regulating the biology and function of gynecological organs, the ovary and uterus in particular. Overproduction of hormones by the tumor may lead to abnormal clinical manifestations of the patients and spillage of excess hormonal products into the blood. Abnormal elevation of serum hormones may be considered as biomarkers that are important to pathologists and clinicians in making precise tumor diagnoses and likely useful in monitoring the tumor burden/recurrence to guide patient treatment options. This review will discuss gynecologic neoplasms that produce hormonal biomarkers and assess their relevance to pathological diagnosis, evaluation for therapeutic response and monitoring disease progression.

AREAS COVERED

Studies involving hormonal production by a gynecologic tumor were candidates for inclusion in this review.

EXPERT COMMENTARY

Serum hormonal biomarkers have clinical utility both in the diagnosis of gynecologic neoplasms and clinical monitoring of treatment efficacy and recurrence.

Recurrent endometrial hyperplasia as a presentation of estrogen-secreting thecoma - case report and minireview of the literature

Thecoma is a rare ovarian tumor, presenting usually in postmenopausal women as unilateral, benign, solid lesion. About 15% of affected patients develop endometrial hyperplasia (EH) and 20% are diagnosed with endometrial cancer. In this case report, we present 60-year-old women admitted because of recurrent spotting of 5 years duration, which started 1 year after menopause. In history, the patient underwent three times curettage procedures and once (1 year before admission) had estradiol levels typical for reproductive-age women. At admission, we found elevated serum levels of estradiol (222.5 pg/ml) and a small mass in the right ovary. The markers of germ cell tumors were negative. After the initial diagnosis, the patient was qualified for total abdominal hysterectomy with bilateral salpingo-oophorectomy. The histopathological examination and immunohistochemical staining confirmed the thecoma diagnosis. In follow-up examination after 8 weeks, we found decreased serum estradiol levels and relief of the symptoms. In conclusion, we want to underline that in cases of EH, especially in patients with a history of recurrences, the special attention should be paid for differential diagnosis. In such cases, the estrogen-secreting tumors should be excluded.

Ovarian granulosa cell tumor: An uncommon presentation with primary amenorrhea and virilization in a pubertal girl

A 16-year-old girl presented with primary amenorrhea and excess hair growth on her body and face for the last three years, along with pain and a mass in her lower abdomen for last one year. Examination revealed hirsutism and other virilizing features, with an irregular mass in the lower abdomen corresponding to 16 weeks'gestation. Serum testosterone was 320 ng / dl and ultrasonogram of the pelvis revealed a solid mass of 5 × 4 cm in the left adnexa. Suspecting it to be a virilizing tumor of the left ovary, the patient was subjected to staging laparotomy, which revealed stage 1a ovarian involvement amenable to surgical resection alone. Histopathological examination confirmed the diagnosis of granulosa cell tumor of the ovary. Postoperatively the serum testosterone returned to 40 ng / dl and her menstrual cycle started after two months of surgery.

Gonadotropin-releasing hormone agonist treatment in postmenopausal women with hyperandrogenism of ovarian origin

CONTEXT

The most frequent cause of virilization in postmenopausal women is excessive androgen production of ovarian origin. Bilateral oophorectomy is usually performed, even in cases of benign tumors or hyperthecosis. This is the first report of a case series of long-term GnRH-agonist treatment of hyperandrogenism in postmenopausal women.

OBJECTIVE

We present three women with postmenopausal hyperandrogenism of ovarian origin who were treated with GnRH agonists.

PATIENTS

We describe three cases of postmenopausal women with virilization and hyperandrogenism of presumed ovarian origin, all with slight enlargement of the ovaries but without visualization of a tumor, who had long-term treatment with GnRH agonists. No histological diagnosis was available, and therefore all patients received careful follow-up, including periodic testing of androgen levels and ovarian imaging by computed tomography scans. The three patients responded in different ways to treatment with GnRH agonists.

CONCLUSIONS

Long-term GnRH agonist treatment is an acceptable choice for treatment of postmenopausal hyperandrogenism in patients where ovarian origin of androgen excess is ascertained, and especially in those patients who have an increased risk for surgery due to comorbidities or who are unwilling to undergo bilateral oophorectomy.

Pure leydig cell tumour of the ovary in a post-menopausal patient with severe hyperandrogenism and erythrocytosis

A 60-year-old woman, presented with hirsutism, male pattern baldness, deepening voice and plethora over the past 5 years. Hormonal evaluation showed markedly elevated serum testosterone level (> 1600 ng/dl) and oestradiol level (220 pg/ml) normal DHEA-SO4 level with suppressed LH and FSH levels. She had markedly erythrocytosis with normal hematological indices. The diagnosis of probable secondary erythrocytosis was made. Trans abdominal ultrasound and CT scan revealed a 14 cm × 11 cm × 9 cm solid pelvic mass. An ovarian androgen secreting tumour was suspected and surgery was performed. Histological examination showed a leydig cell tumour. After the operation testosterone and haematocrit levels returned to normal with regression of clinical symptoms. This is the first case of a leydig cell tumour with an erythropoietic effect of excess testosterone.

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.

Luteinized ovarian thecoma in a postmenopausal women presenting with virilization

We report a case of luteinizing thecoma in a 58-year-old postmenopausal woman who presented with progressive androgenic features and hypertension of one year duration. She did not notice a significant change in her body weight or appetite. Her total serum testosterone level was 4.5 ng/mL. Ultrasound scan revealed a normal-sized uterus and a right-sided solid ovarian mass of 5 cm × 5 cm. Left ovary was normal. She had a total abdominal hysterectomy, bilateral salpingo-oophorectomy, and an omentectomy performed. Histological examination confirmed the diagnosis of luteinized thecoma. This case illustrates the necessity to consider the rare possibility of luteinized ovarian thecoma as a cause for virilization in a menopausal woman.

Ovarian thecoma with virilizing manifestations

A 29-year-old woman presented with secondary amenorrhea, primary infertility, and virilization, which had developed over the past 2 years was suspected to have a virilizing tumor at her left ovary. Her serum testosterone level was markedly elevated (380 ng/dL). Left salpingoophorectomy was performed, and histopathological examination revealed a thecoma of the left ovary. The postoperative serum testosterone level returned to 65 ng/dL. The patient did not have regression of virilism soon. However, the patient had a normal menstruation 29 days after surgery and gave birth to a baby 13 months after surgery.

Incidence, clinical analysis, and management of ovarian fibromas and fibrothecomas

OBJECTIVE

The objective of the study was to identify the incidence, diagnosis, and therapeutic and histological particularities of ovarian fibromas and fibrothecomas.

STUDY DESIGN

This was a retrospective study of 24 patients who underwent surgical treatment for ovarian fibromas and fibrothecomas between January 1994 and December 2006. Clinical, ultrasonographic, tumor marker, therapeutic, and histologic data were analyzed.

RESULTS

The mean age of patients was 49 years. Thirteen patients were menopausal. Ultrasonographic findings were ovarian echogenic tumor in 6 cases, hypoechogenic tumor in 12 cases, mixed tumor in 6 cases, and anechogenic tumor in 1 case. Cancer antigen-125 level measured in 21 cases was abnormal in 3 cases. Twenty-one patients underwent laparotomy. Three patients underwent laparoscopy; however, 1 was converted to laparotomy because of a suspected tumor. Histological findings were 16 fibromas and 9 fibrothecomas.

CONCLUSION

Ovarian fibromas and fibrothecomas are uncommon, accounting for 3.3% of ovarian tumors. These lesions often occur in perimenopausal and menopausal patients. Clinical, ultrasonographic, and tumor marker data remain the best preoperative approach currently available for ovarian tumors. However, the diagnosis remains histological.