INDING THE NEEDLE IN A HAYSTACK

Abstract

INTRODUCTION
Leydig cell tumours (LCT) of the ovary are rare ovarian tumours that usually present with hyperandrogenism. Radiological imaging is helpful in localizing these tumours. However, some tumours may be too small to localize before surgical exploration. When imaging is unrevealing, selective ovarian and adrenal venous sampling (SOAVS) is the next option. We report a case of LCT that was localized by SOAVS.

CASE
A 43-year-old nulliparous Chinese woman presented with a 6-month history of increased growth of terminal hair in the face, chest, abdomen and thighs, associated with deepening of voice, secondary amenorrhea and clitoromegaly. Laboratory investigations showed markedly elevated serum total testosterone of 32.11 nmol/L. Dehydroepiandrosterone sulfate was normal at 4.97 umol/L. ACTH stimulation test for 17-OH progesterone was normal (0 minutes: 4.2 nmol/L; 60 minutes: 7.9 nmol/L). Pelvic ultrasound revealed a small right ovarian cyst measuring 2.1x1.6 cm. CT abdomen and pelvis was normal. FDG-PET showed mild right adnexal FDG hypermetabolism which is within physiological limit. SOAVS was performed to localize the tumour. The total testosterone level in the right ovarian vein was reported to be 1027 nmol/L, while in the left ovary was 26.06 nmol/L. Laparoscopic right salpingo-oophorectomy was done and histopathology confirmed LCT. Post-surgery, her symptoms resolved and testosterone normalized.

CONCLUSION
SOAVS is a useful diagnostic modality that can help localize small ovarian tumours that are otherwise elusive to other imaging techniques.