Imaging in gynecological disease (27): clinical and ultrasound characteristics of recurrent ovarian stromal cell tumors

OBJECTIVE

To describe the clinical and ultrasound characteristics of recurrent granulosa cell and Sertoli-Leydig cell tumors.

METHODS

This was a retrospective observational study performed at Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico, IRCCS, Rome (Gemelli center), Italy. Patients with a histological diagnosis of recurrent granulosa cell tumor or Sertoli-Leydig cell tumor were identified from the database of the Department of Gynecological Oncology. Those who had undergone a preoperative ultrasound examination at the Gemelli center between 2012 and 2020 were included, and the data retrieved from the original ultrasound reports. In all of these reports, the recurrent tumors were described using International Ovarian Tumor Analysis (IOTA) terminology. If a patient had more than one episode of relapse, information from all episodes was collected. If there was more than one recurrent tumor at the same ultrasound examination, all tumors were included. One expert sonographer also reviewed all available ultrasound images to identify typical ultrasound patterns using pattern recognition.

RESULTS

We identified 30 patients with a histological diagnosis of recurrent granulosa cell tumor (25 patients, 55 tumors) or Sertoli-Leydig cell tumor (five patients, seven tumors). All 30 had undergone at least one preoperative ultrasound examination at the Gemelli center and were included. These women had a total of 66 episodes of relapse, of which a preoperative ultrasound examination had been performed at the Gemelli center in 34, revealing 62 recurrent lesions: one in 22/34 (64.7%) episodes of relapse, two in 4/34 (11.8%) episodes and three or more in 8/34 (23.5%) episodes. Most recurrent granulosa cell tumors (38/55, 69.1%) and recurrent Sertoli-Leydig tumors (6/7, 85.7%) were classified as solid or multilocular-solid tumors, while 8/55 (14.5%) recurrent granulosa cell tumors and 1/7 (14.3%) recurrent Sertoli-Leydig cell tumors were unilocular cysts and 9/55 (16.4%) recurrent granulosa cell tumors were multilocular cysts. The nine unilocular cysts had contents that were anechoic (n = 2) or had low-level echogenicity (n = 7), had either smooth (n = 4) or irregular (n = 5) internal cyst walls, and ranged in largest diameter from 8 to 38 mm, with three being < 20 mm and five being 20-30 mm. On retrospective review of the images, two typical ultrasound patterns were described: small solid tumor measuring < 2 cm (15/62, 24.2%) and tumor with vascularized echogenic ground-glass-like content (12/62, 19.4%).

CONCLUSIONS

Some granulosa cell and Sertoli-Leydig cell recurrences manifest one of two typical ultrasound patterns, while some appear as unilocular cysts. These are usually classified as benign, but in patients being followed up for a granulosa cell tumor or Sertoli-Leydig cell tumor, a unilocular cyst should be considered suspicious of recurrence. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Imaging, clinical, and pathologic findings of Sertoli-leydig cell tumors

To explore the clinical features, imaging findings, and pathological manifestations of ovarian Sertoli-Leydig cell tumors (SLCTs). The clinical and pathological manifestations, tumor location, size, morphology, vascularity, computed tomography (CT) density, magnetic resonance imaging (MRI) signal intensity, and contrast enhancement patterns in five cases with SLCTs were retrospectively reviewed. SLCTs most commonly occurred in young women. Virilization was observed in three cases (60%). All five tumors were unilateral and oval or round, with a clear boundary. The solid part of the tumor was isoattenuated on the conventional CT scan, and showed isoattenuation or slight hypoattenuation relative to adjacent myometrium on T1 weighted imaging (T1WI) and T2 weighted imaging (T2WI). On contrast-enhanced images, three tumors showed marked enhancement. DICER1 hotspot mutations were commonly seen in SLCTs. A highly vascularized mass with low signal intensity (SI) of the solid part on T2WI and androgen overproduction symptoms may suggest an SLCT.

Sertoli-Leydig cell tumors of ovary: A case series

INTRODUCTION

The purpose of this study was to report the clinical features, computed tomography (CT) and magnetic resonance imaging (MRI) findings, clinical management, and prognoses of 7 patients with Sertoli-Leydig cell tumors (SLCT) of ovary, and to review the literature of this rare condition.

METHODS

Seven patients with pathologically confirmed ovarian SLCT were included. Their clinical, CT and MRI characteristics (CT images obtained from 6 patients and MR images from 4 patients), clinical management, and prognoses of 7 patients were retrospectively analyzed.

RESULTS

Patients symptoms included irregular menstruation (n = 3), infertile (n = 1), vaginal bleeding after 7 years of menopause (n = 1), a palpable abdominal mass (n = 1), and abdominal pain (n = 1). Three patients had elevated alpha-fetoprotein (AFP), 1 had elevated cancer antigen 125 (CA125), and 2 had elevated Testosterone (T). The 7 tumors of 7 patients were solid or mixed solid-cystic mass with clear boundaries. The solid components of the tumors showed iso-dense on CT. On MRI, the solid components showed iso- or slightly low signal intensity (SI) on T1-weighted imaging (T1WI), high or slightly high SI on T2WI, and high on diffusion-weighted imaging (DWI) with low apparent diffusion coefficient (ADC) value. On contrast-enhanced CT and MRI, 1 tumor exhibited heterogeneous enhancement consisting of multiple nodules with relatively marked homogeneous enhancement, and other 6 tumors showed moderate or marked and constantly heterogeneous enhancements. All patients were treated with surgical excision. Only 3 had received postoperative chemotherapy. With the exception of 1 patient lost to follow-up, the other 6 patients exhibited tumor-free survival with a median follow-up time of 13.5 months, the longest follow-up time being 24 months.

CONCLUSION

The patients of SLCT can present with hormonal magnification and manifest high AFP, CA125, and T levels. SLCT is characterized by a solid or mixed solid-cystic mass on CT/MR scans, and shows marked or moderated heterogeneous and constantly enhancement upon postcontrast study. The clinical characteristics and imaging findings are features and appropriated imaging should be performed whenever an SLCT is suspected.

Sertoli-Leydig cell tumors: current status of surgical management: literature review and proposal of treatment

To identify the appropriate management we review the current literature on the diagnostic and different surgical procedures to which the patients affected by Sertoli-Leyding cell tumors (SLCTs) were submitted. Through the description of a case report we also propose an interdisciplinary diagnostic approach and a laparoscopic surgical staging, with a long-term follow-up. The analysis shows that pelvic ultrasound is primary diagnostic procedure, and only 36% of publications clearly describe to have performed more specific investigation. The hormone assessment is performed in the presence of specific endocrine symptoms. Laparoscopic approach is chosen by a few surgeon. Laparotomic surgery is preferred based in not recent recommendations for ovarian cancer treatment, although it is demonstrated the efficacy and safety of laparoscopy in the treatment of ovarian epithelial tumors. Different steps that are usually used for oncological ovarian cancer staging are not always performed. Conservative and fertility sparing surgery is commonly accepted, and even preferred due to the young age of patients. In the surgical treatment of SLCTs is necessary to adopt common guidelines, and evenly define the steps that the patient should be submitted. If are observed epithelial cancer oncological principles, laparoscopic surgery should be the approach of choice for these patients.

Imaging of gynecological disease (2): clinical and ultrasound characteristics of Sertoli cell tumors, Sertoli-Leydig cell tumors and Leydig cell tumors

OBJECTIVE

To describe the clinical history and ultrasound findings in women with ovarian Sertoli cell, Sertoli-Leydig cell and Leydig cell tumors.

METHODS

Women with a histological diagnosis of Sertoli cell tumor, Sertoli-Leydig cell tumor or Leydig cell tumor who had undergone preoperative ultrasound examination were identified from the databases of each of three participating ultrasound centers. The tumors were characterized on the basis of ultrasound images, ultrasound reports and research protocols (when applicable) using the terms and definitions published by the International Ovarian Tumor Analysis (IOTA) group. In addition, all images were reviewed and described using pattern recognition.

RESULTS

Of 22 patients identified, 15 had Sertoli-Leydig cell tumors, two had Sertoli cell tumors and five had Leydig cell tumors. Four patients were postmenopausal, one 48-year-old woman had undergone hysterectomy, 16 were of fertile age and one was a 4-year-old girl. Most patients (82%, 18/22) had endocrine symptoms, the most common being bleeding disturbance (64%, 14/22) and hirsutism (32%, 7/22). Twenty-two (96%) of 23 tumors (one woman had bilateral tumors) contained a solid component; 16 (70%) were purely solid. Pattern recognition showed that the Leydig cell tumors were small solid tumors (four of five had a largest diameter of 1-3 cm) and the two Sertoli cell tumors were somewhat larger solid tumors (4 cm and 7 cm); the Sertoli-Leydig cell tumors were either small (3-4 cm) or medium-sized (6-7 cm) solid tumors, or multilocular solid tumors of any size (3-18 cm) with purely solid areas mixed with areas of innumerable closely packed small cyst locules.

CONCLUSIONS

On the basis of endocrine symptoms, the woman's age and ultrasound findings, it should be possible to suggest a correct preoperative diagnosis of Sertoli cell, Sertoli-Leydig cell or Leydig cell tumors in many cases.

[Ultrasound of the scrotum]

Ultrasound is an excellent tool for the diagnosis of benign or malignant intra- and extratesticular lesions depending on their structure and location in the scrotum. Besides the sonographic appearance, the clinical history and the location of a scrotal mass is crucial for the differential diagnosis between benign and malignant masses. In cases of acute scrotum or of vascular and inflammatory lesions, Doppler ultrasound is mandatory. This article gives a systematical survey of the most frequent scrotal lesions and their appearance in ultrasound.

[Androblastoma in a female patient with the signs of virility: a clinical-morphological and genetic study]

We report a case of 24 year old patient with secondary amenorrhea, virilization and elevated serum testosterone concentration, in which cystic-solid tumor in right ovary was found. Surgical treatment was applied--adnexectomy. Histopathologic examination supported suspicion of androblastoma. After treatment regulation of menses and serum testosterone level was obtained.

Late presentation of an alpha-fetoprotein secreting isolated large upper abdominal retroperitoneal Sertoli-Leydig cell tumor recurrence

The following case reports the surgical and adjuvant treatment of a solitary upper abdominal retroperitoneal recurrence of a poorly differentiated Sertoli-Leydig cell tumor (SLCT) which presented 4 years after the original diagnosis. The patient was treated with en bloc resection of the mass, which included her left kidney, adrenal gland, and distal pancreas. She received four courses of adjuvant chemotherapy and remains without evidence of malignancy. Both the primary and recurrent tumor secreted alpha-fetoprotein allowing serologic follow-up. The utility of serum alpha-fetoprotein in disease response to treatment and for surveillance of recurrence is also shown.

Localization of small ovarian Sertoli-Leydig cell tumors by transvaginal sonography with color Doppler

Color Doppler ultrasound is a non-invasive diagnostic modality that has been gaining popularity in the evaluation of gynecological tumors. It demonstrates blood flow in a visually familiar way, and facilitates detection of neovascularity in pelvic tumors. In this article we describe, for the first time, a case in which a small androgen-producing ovarian tumor was localized by color Doppler ultrasound after other non-invasive imaging techniques failed.

Steroid secretion by a lipoid cell tumor causing virilization and its diagnosis with computerized tomography

Presented is the case of a virilized woman with a lipoid cell tumor of the ovary localized by computerized tomography. The major secretory products of the tumor were testosterone and estradiol; the production of androgens was responsible for the clinical features and hindered the effects of estrogens. Elevated levels of estradiol indicated important ovarian aromatase activity as reflected by large ovarian-peripheral venous gradients.