Combined Ovarian and Adrenal Venous Sampling for Diagnosis of an Androgen Producing Ovarian Tumor in a Patient with an Adrenal Adenoma

Program: Abstracts - Orals, Featured Poster Presentations, and Posters
Session: SUN 498-523-Female Reproductive Endocrinology & Case Reports
Sunday, June 16, 2013: 1:45 PM-3:45 PM
Expo Halls ABC (Moscone Center)

Poster Board SUN-522
Ekta Kapoor*, James C Andrews and William F Young Jr.
Mayo Clinic, Rochester, MN
Background: Androgen-producing ovarian tumors tend to be small and may not be detectable on conventional imaging.  Identifying the source of tumorous androgen hypersecretion can be problematic in those patients with positive adrenal and negative ovarian imaging.

Clinical case: A 67-year-old postmenopausal woman presented with gradually progressive deepening of voice, moderate clitoral enlargement, and marked facial hirsutism over 7 months.  She denied scalp hair loss or increase in muscle mass.  Her past medical history was essentially unremarkable and her menstrual cycles had been regular before menopause at age 52.

Laboratory studies included: serum total testosterone = 260 ng/dL (N, 8-60 ng/dL); LH = 22.3 IU/L (N, 10-60 IU/L for postmenopausal female); FSH = 65.3 IU/L (N, 16.7-113.6 IU/L for postmenopausal female); androstenedione = 79 ng/dL (N, 30-200 ng/dL); and, DHEA-S = <15 mcg/dL (<15–157 mcg/dL). CT scan of the abdomen and pelvis revealed a hypodense 1.4 cm right adrenal nodule.  The ovaries appeared normal on the CT. Pelvic ultrasound revealed a normal appearing left ovary, but the right ovary looked slightly more prominent, measuring 1.2 cm x 1.6 cm x 2.5 cm with slightly increased vascularity and a solid component that was atypical for a post-menopausal gonad. However, a definite ovarian mass was not identified.

In the absence of definitive evidence implicating the ovary as source of the excess androgen and the finding of an adrenal nodule, we decided to proceed with combined ovarian and adrenal venous sampling for testosterone.  Adrenal vein cortisol values confirmed valid sampling. Testosterone levels were 109 ng/dL, 159 ng/dL , 210 ng/dL , 13,100 ng/dL, and 210 ng/dL (N, 8-60 ng/dL) respectively from right adrenal vein, left adrenal vein, inferior vena cava, right ovarian vein, and left ovarian vein.  These data unequivocally localized the source of testosterone hypersecretion to the right ovary.

The patient underwent bilateral oophorectomy, was found to have a 1.2 cm right ovarian Leydig cell tumor. She had near-complete resolution of virilization in a few weeks post-operatively.

Conclusion: Combined adrenal and ovarian venous sampling for testosterone localized the source of excess androgen to the ovary, and avoided an unnecessary adrenalectomy in a patient with an adrenal nodule and equivocal ovarian imaging.

Nothing to Disclose: EK, JCA, WFY Jr.

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