Luteoma da gravidez: um pseudotumor ovariano / Luteoma of pregnancy: an ovarian pseudotumor

Contexto: Luteoma é neoplasia rara e benigna do ovário, específica da gravidez. Considera-se que seja causada por efeitos hormonais, principalmente da gonadotrofina coriônica. Objetivo: Analisar artigos selecionados sobre luteoma da gravidez e realizar revisão bibliográfica a partir dessas publicações. Desenho: A busca dos artigos foi realizada por meio da plataforma PubMed. Procedeu-se uma busca aos descritores da doença e seu correspondente em inglês (luteoma) no portal da BVSalud. Métodos: Consistiu em revisão bibliográfica, onde foram utilizados artigos publicados de 1972 até 2022. Resultados: A origem celular dos luteomas ainda é desconhecida, mas considera-se que tal processo ocorra devido a uma reação hiperplásica à gravidez, visto que o efeito de virilização regride após o parto. Discussão: Sendo pouco diagnosticado, tendo menos de 200 casos reportados, são geralmente achados durante parto cesáreo ou durante ligadura tubária no pós-parto. Seu aparecimento está relacionado a fatores hormonais da gravidez e hiperplasia ocasionada pela luteinização das células estromais. Os efeitos do luteoma gravídico no organismo estão relacionados, além da virilização da paciente e do feto, com o surgimento da síndrome do ovário policístico e diabetes. Conclusões: Tendo baixa incidência, o luteoma gravídico pode se apresentar como desafio para seu diagnóstico adequado. O diagnóstico precoce permitirá o tratamento adequado, evitando-se efeitos indesejáveis, virilizantes, para a gestante e para o nascituro. É fundamental o preparo dos profissionais de saúde para o diagnóstico e tratamento do luteoma gravídico.

Luteoma del embarazo. Reporte de caso / Luteoma of pregnancy. A case report

Luteoma of pregnancy is an infrequent non-neoplastic pathology of the ovary. It is usually an incidental finding during the evaluation of a pregnant patient in the third trimester or during a cesarean section. Occasionally, it may raise suspicion of cancer, resulting in unnecessary surgical resection of the ovary. We present the case of a 34-year-old woman who was in her third pregnancy and during the cesarean section, a 9 cm tumor of the right ovary was incidentally found and resected. The histological study was compatible with luteoma of pregnancy.

El luteoma del embarazo es una patología no neoplásica del ovario, de incidencia poco frecuente. Suele presentarse como hallazgo incidental durante la evaluación de una paciente embarazada en el tercer trimestre o en el momento del acto quirúrgico de una cesárea. En ocasiones, puede llevar a sospechar una neoplasia maligna, derivando así en una resección quirúrgica innecesaria del ovario. Presentamos el caso de una mujer de 34 años que cursaba su tercera gestación y a quien, durante la cesárea, se le halló una tumoración ovárica derecha de 9 cm de diámetro que fue resecada. El estudio histológico fue compatible con luteoma del embarazo.

Ovarian intratumoral 21-hydroxylase deficiency in a postmenopausal hirsute woman / Deficiência de 21-hidroxilase ovariana intratumoral na virilização da mulher pós-menopausa

Virilising ovarian tumours are a rare cause of hyperandrogenism in women, accounting for less than 5% of all ovarian neoplasms. It occurs most often in - and postmenopausal women. We report a case of a 64 year-old woman with signs of virilisation that had started 3 years before. Blood hormone analysis revealed increased levels of testosterone, and 17-hydroxyprogesterone. The tetracosactin test revealed 21-hydroxylase deficiency. Radiological imaging demonstrated a nodule in her left ovary. The patient was submitted to bilateral laparoscopic oophorectomy, and histopathological examination revealed a luteoma of the left ovary. Postoperative serum testosterone level and 17-hydroxyprogesterone returned to normal levels in one month. Virilism regressed within six months. Our patient also showed an elevation in 17-OHP serum levels. Normalization of 17-OHP after oophorectomy suggests a case of intratumoral 21-hydroxylase deficiency. To our knowledge, this is the first description of ovarian intratumoral 21-hydroxylase deficiency in a postmenopausal woman. Arq Bras Endocrinol Metab. 2012;56(9):672-6.

Tumores ovarianos virilizantes são uma causa rara de hiperandrogenismo em mulheres, contabilizando menos de 5% de todos as neoplasias ovarianas. Esses tumores ocorrem mais comumente em mulheres em peri ou pós-menopausa. Relatamos aqui o caso de uma mulher de 64 anos de idade com sintomas de virilização que começaram 3 anos antes. O perfil hormonal revelou níveis aumentados de testosterona e de 17-hidroxiprogesterona (17-OHP). O teste de tetracosactin demonstrou deficiência de 21-hidroxilase. Exames radiológicos mostraram um nódulo no ovário esquerdo. A paciente foi submetida à ooforectomia laparoscópica bilateral e o exame histopatológico revelou um luteoma no ovário esquerdo. A concentração sérica de testosterona e de 17-hidroxiprogesterona após a cirurgia retornou aos níveis normais em um mês. A virilização regrediu em 6 meses. Nossa paciente também revelou uma elevação dos níveis séricos de 17-OHP. A normalização da 17-OHP após a ooforectomia sugere um caso de deficiência de 21-hidroxilase intratumoral. Esta é a primeira descrição de deficiência de 21-hidroxilase intratumoral em uma mulher na pós-menopausa. Arq Bras Endocrinol Metab. 2012;56(9):672-6.

Ovarian intratumoral 21-hydroxylase deficiency in a postmenopausal hirsute woman.

Virilising ovarian tumours are a rare cause of hyperandrogenism in women, accounting for less than 5% of all ovarian neoplasms. It occurs most often in - and postmenopausal women. We report a case of a 64 year-old woman with signs of virilisation that had started 3 years before. Blood hormone analysis revealed increased levels of testosterone, and 17-hydroxyprogesterone. The tetracosactin test revealed 21-hydroxylase deficiency. Radiological imaging demonstrated a nodule in her left ovary. The patient was submitted to bilateral laparoscopic oophorectomy, and histopathological examination revealed a luteoma of the left ovary. Postoperative serum testosterone level and 17-hydroxyprogesterone returned to normal levels in one month. Virilism regressed within six months. Our patient also showed an elevation in 17-OHP serum levels. Normalization of 17-OHP after oophorectomy suggests a case of intratumoral 21-hydroxylase deficiency. To our knowledge, this is the first description of ovarian intratumoral 21-hydroxylase deficiency in a postmenopausal woman.

Luteoma gestacional não virilizante simulando neoplasia ovariana / Pregnancy luteoma without virilization mistaken by an ovarian tumor

Objetivo: descrever um caso de ooforectomia em paciente com luteoma gestacional, um pseudotumor ovariano relacionado a uma resposta exagerada do estroma ovariano aos hormônios da gravidez que regride após o parto. Relato do caso: mulher de 42 anos, em sua terceira gestação, evoluiu sem intercorrências. Durante a realização de cesariana, observou-se a existência de tumoração ovariana bilateral, sendo realizada ooforectomia. A análise histopatológica demonstrou-se tratar-se de um luteoma gestacional. Considerações finais: por não constituir um tumor verdadeiro e pela tendência à regressão no pós-parto, readquirindo as dimensões normais, deve-se avaliar com cautela a realização de ooforectomias em pacientes gestantes que apresentem aumento das dimensões ovarianas.

Purpose:to report a case of pregnancy luteoma, an ovarian pseudotumors usually diagnosed during cesarian section or at postdelivery tubal ligation. After delivery the ovary size returns to normal in a few weeks. Case Report: A 46 year old female,(G 3, P 2) without complains. During cesarian section It was noticed an increase of the ovarian size, the approch was bilateral ooforectomy.The histhopathological diagnostic was pregnancy luteoma .Final Considerations: being just a pseudotumor that decrease after delivery the surgeon must remember this nosological entity, that is easily mistaken by true ovarian tumors, and try to avoid an ooforectomy.

Differential gonadotropin releasing hormone (GnRH) expression, autoregulation and effects in two models of rat luteinized ovarian cells.

GnRH has been suggested to participate in corpus luteum function. Here we studied the expression of GnRH mRNA and peptide in two models of rat luteinized tissues: ovarian cells from PMSG-hCG treated prepubertal rats (SPO) and from intrasplenic ovarian tumors (Luteoma). A GnRH autoregulatory effect was evaluated as well as its action on cell proliferation and apoptosis. GnRH mRNA was present in SPO, isolated corpora lutea from SPO and Luteoma from 1 week to 7 months of development. In vitro cultures of Luteoma cells expressed 2-fold higher GnRH mRNA and 10-fold higher GnRH peptide than SPO cells. Buserelin (GnRH analog) increased GnRH mRNA and peptide expression in SPO but not in Luteoma cells. While basal proliferation was very low in Luteoma cells, SPO cells showed a significant increase in cell number by both the thymidine and the MTS methods after 72 h in culture. Buserelin induced a decrease in cell number in both cell types to a similar degree. Although basal apoptosis levels were higher in SPO than in Luteoma cells, Buserelin-induced apoptosis was only detected in Luteoma cells after 48 h treatment. These results show that the two types of rat, luteinized tissues, Luteoma and SPO, markedly differed in some intrinsic properties and in their local GnRH systems. Luteoma cells proliferate very weakly, express and secrete high amounts of GnRH, do not show an autoregulatory effect and respond to the decapeptide with apoptosis stimulation. In contrast SPO cells proliferate significantly, secrete low levels of GnRH but possess a positive, autoregulatory mechanism and respond to GnRH stimulation with impairment of proliferation.

Gonadotropin-releasing hormone signaling pathways in an experimental ovarian tumor.

Previous results showed that GnRH signaling is altered in cells from rat luteinized ovarian tumors (tumor group) because it did not activate the phospholipase C pathway, in contrast to control ovarian cells from superovulated prepubertal rats (SPO). In the present work, alternate GnRH-induced second messengers such as phospholipase A(2) and phospholipase D activation, cAMP production, ERK1/2 phosphorylation, and the presence of G proteins were evaluated to determine GnRH mechanism of action in tumor cells. G proteins examined were present in both cell types. Buserelin, a GnRH agonist, (1, 10, and 100 ng/ml) increased phosphatidylethanol in SPO, indicating phospholipase D activation. Only 100 ng/ml buserelin induced a significant response in the tumor group. Buserelin (100 ng/ml) increased (3)H-arachidonic acid in culture media in SPO, indicating phospholipase A(2) activation; no effect was observed in the tumor group. Buserelin (100 and 1000 ng/ml) induced pertussis toxin-insensitive cAMP increases in both cell types, with similar potencies. In the tumor group, buserelin (100 ng/ml) inhibited human chorionic gonadotropin-induced cAMP and progesterone; this effect was protein kinase C (PKC) dependent (inhibited by GF109203X, a PKC inhibitor). Buserelin (100 and 1000 ng/ml) induced ERK1/2 phosphorylation in both cell kinds. Buserelin-induced ERK1/2 activation was G(i/0) independent and PKC dependent. Only in the tumor group, buserelin-induced ERK1/2 activation was cAMP dependent (abolished by SQ 22536, the adenylyl cyclase inhibitor). Furthermore, dibutyryl cAMP-induced ERK1/2 activation in the tumor group was PKC dependent (inhibited by GF109203X). In conclusion, activation of phospholipases in tumor cells does not seem to mediate GnRH effects. GnRH signaling seems to involve adenylyl cyclase activation, PKC stimulation, and ERK1/2 phosphorylation.

Development of an experimental ovarian tumor: immunocytochemical analysis.

OBJECTIVE: The aim of the present work was to study whether immunocytochemical parameters present in the normal ovary were altered after tumor development under high gonadotropin levels. METHODS: Ovarian tumors (luteoma): castrated female rats had an ovary grafted into the spleen; tumors were left to develop for 1, 2, 3 or 7 months. The presence of apoptotic cells (TUNEL method) and the expression of proliferating cell nuclear antigen (PCNA), gap junction protein (Cx43), steroidogenic acute regulatory protein (StAR), aromatase and synaptosome-associated protein of 25 kDa (SNAP-25) were determined by immunocytochemistry. Some of these findings were confirmed by RT-PCR (Cx43, StAR, SNAP-25). Inhibin subunit mRNAs were investigated by Northern blot. RESULTS: PCNA staining of tumors was mainly found in granulosa cells of transforming follicles and was absent from luteinized follicles. A nearly complete absence of apoptosis was observed. Cx43 was mainly found in follicles, while it was very weakly expressed or absent in luteinized follicles. StAR protein expression, indicating active steroidogenesis, was demonstrated only in luteinized follicles and in thecal cells, but was absent from granulosa cells. Aromatase immunoreactivity was very intense in granulosa and also present in luteal cells. Membrane-associated and cytoplasmic SNAP-25 immunostaining was determined in patches of endocrine cells in the follicles, as well as in the luteinized follicles. The expression of mRNAs for Cx43, StAR and SNAP-25 (RT-PCR) and inhibin subunits (Northern blots) were confirmed in 1-, 3- and 7-month-old tumors. CONCLUSIONS: These results indicated that luteoma most likely develop from unruptured follicles by hypertrophy and proliferation of follicular cells. Circulating gonadotropins seem to play a fundamental role in maintaining the expression of proteins typically expressed in normal ovary, while avoiding apoptosis in this tissue.

Actions of immunosuppressor drugs on the development of an experimental ovarian tumor.

Immunosuppression has been related to the incidence of tumor apparition, including endocrine tumors. The intrasplenic ovarian tumor (luteoma) is a typical benign endocrine tumor that develops under high gonadotropin stimulation and, from the immunological perspective, is located in a critical organ involved in immune response. To establish if immunosuppression could alter the development of this experimental tumor, the effects of cyclosporin A (CsA) and dexamethasone (Dex) were evaluated. After surgery, tumor-bearing and sham animals were kept without treatment for 4 weeks; thereafter, they were distributed into CsA (25 mg/kg), Dex (0.1 mg/kg), or vehicle (75:25 castor oil:ethanol) groups and were injected on alternate days for 50 days. Body weight was evaluated weekly. Animals were sacrificed after a jugular vein blood sample was obtained. Thymi were weighed. Tumors were measured and placed in formaline for histological studies. Serum luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin (PRL), and estradiol were measured by radioimmunoassay. Hematological parameters were determined. CsA induced a significant decrease in survival rates both in tumor-bearing and sham animals (P < 0.01). Dex significantly impaired weight increase in both groups of animals. CsA induced a significant weight loss in sham animals, not observed in tumor-bearing animals. Dex induced thymus weight loss in both groups, whereas CsA induced thymus weight loss only in sham animals. Only Dex induced a decrease in lymphocyte number in both groups. CsA induced an increase in monocyte number only in sham animals. Treatments did not alter LH, FSH, or estradiol, whereas PRL was increased by CsA only in sham rats. Neither Dex nor CsA induced any significant variations in tumor volume, nor did they alter tumor histology. In addition, no visible metastases or alterations in other organs were observed. We conclude that, though immunological parameters were altered by the treatments, immunosuppressor drugs did not condition tumor development. In addition, tumors secrete one or more factor/s that counteract CsA effect.

Luteoma recorrente da gravidez com virilizaçäo materna e fetal / Recurrent luteoma of pregnancy with maternal and fetal virilization

Os luteomas da gravidez säo pseudotumores ovarianos diagnosticados pelo exame ultra-sonográfico ou durante realizaçäo de cesariana e laqueadura pós-parto. Determinam, na segunda metade da prenhez, sinais de virilizaçäo materna em um quarto dos casos, o mesmo ocorrendo com a metade dos fetos femininos destas gestantes virilizadas nos quais se observa hipertrofia clitoridiana ou fusäo labial. As dosagens séricas maternas dos hormônios androgênicos durante a prenhez e do sangue umbilical por ocasiäo do parto revelam taxas significativamente aumentadas. No exame ultra-sonográfico apresentam-se como estruturas sólidas ou cístico-sólidas, que após o parto tendem a regredir com o ovário readquirindo as dimensöes normais em poucas semanas. Os autores apresentam uma paciente que em duas gestaçöes sucessivas apresentou virilizaçäo materna e fetal. Ao exame ultra-sonográfico foram evidenciadas imagem ovariana nodular e dosagens elevadas dos androgênios plasmáticos.

Quiste folicular gigante luteinizado del embarazo y el puerperio. Presentación de un caso y revisión de la literatura / Large luteinized follicle cyst of pregnancy and puerperium. A case report and review of the literature

Mujer de 23 años con embarazo de 37 semanas de EG y diagnóstico ecográfico de masa quística anexial derecha clínicamente benigna, quien fue llevada a cesárea para atención del parto y resección de la masa. El estudio anatomopatológico del tumor mostró un quiste folicular gigante solitario luteinizado (QFGSL) del embarazo. El manejo quirúrgico de la paciente fue conservador, con una evolución adecuada y óptimo pronósico. Se discuten los aspectos referentes a la historia natural de la enfermedad, las características anatomatológicas y la posible patogenia

Alterations in intracellular messengers mobilized by gonadotropin-releasing hormone in an experimental ovarian tumor.

Cells derived from an experimental luteinized ovarian tumor are more sensitive to GnRH endocrine action than control luteal cells. In an attempt to understand the possible causes of the differential sensibility to GnRH action, we examined the number and affinity of GnRH receptors and the second messenger response to GnRH stimulation in both tissues. For GnRH receptor studies membranes were obtained from 4- to 6-week-old ovarian tumors (luteoma) and ovaries from prepubertal rats treated with 25 IU PMSG and 25 IU hCG (SPO) and were incubated with [125I]Buserelin. The number of GnRH receptors were increased in luteoma compared with that in SPO ovaries; dissociation constants were similar in both tissues. GnRH stimulation of second messenger release was assessed in cells obtained from luteoma and SPO ovaries by collagenase treatment. Buserelin (100 ng/ml) induced a significant 35% calcium increase in SPO cells, as determined by the fura-2 method; in luteoma cells no response was observed after buserelin stimulation, although a calcium transient was induced by thapsigargin (0.5 microM), an inhibitor of Ca2+-adenosine triphosphatase associated with the endoplasmic reticulum. The effect of buserelin on inositol phosphates was evaluated after incubation of luteoma and SPO cells with [3H]myoinositol for 48 h. Buserelin induced a 400% increase in inositol trisphosphate in SPO cells. Again, luteoma cells did not respond to buserelin stimulation, although NaF (10 mM), an activator of G proteins coupled to phospholipase C, induced an 800% increase in inositol trisphosphate. Although the number of GnRH receptors is augmented in luteoma cells, justifying an increased endocrine response, neither inositol phosphates nor intracellular calcium were released by a GnRH analog, indicating the uncoupling of GnRH receptors from phospholipase C. These data provide evidence that the transformation of the ovary into a luteoma implies the acquisition of novel characteristics in the GnRH receptor second messenger-generating system.

GnRH receptors and GnRH endocrine effects on luteoma cells.

An ovary implanted into the spleen of an ovariectomized rat develops into a luteinized tumor, growing in response to gonadotrophins. Previously, it was shown that in vivo Buserelin, a gonadotrophin-releasing hormone (GnRH) analog, inhibited tumor growth. To determine if GnRH had a direct effect on tumor cells, the presence of GnRH receptors as well as the endocrine effects of buserelin were studied on tumoral tissue. GnRH receptors were present in luteoma in similar concentrations and dissociation constant (Kd) to control estrous ovaries. In vivo treatment with buserelin did not modify luteoma GnRH receptors. In organ incubations, luteoma secreted significantly higher estradiol and lower progesterone than estrous ovaries; addition of buserelin did not modify steroid secretion. The same difference in basal steroid secretion between luteoma cells and luteal cells superovulated prepubertal ovaries was observed in cell cultures. Although luteinizing-hormone (LH)-stimulated progesterone in both kinds of cells, buserelin significantly inhibited LH-stimulated progesterone only in luteoma cells. These results describe clear differences in basal steroid secretion between tumoral and normal tissue. Furthermore, they show that luteoma possess GnRH receptors similar to those in normal ovarian tissue, and that GnRH analogs have endocrine effects on these cells. Therefore, a direct effect of buserelin on luteoma cells can be postulated.

Luteoma estromal como causa de hirsutismo pós-menopausa / Estromal luteoma due post menopausal hirsutism

O objetivo deste trabalho é apresentar um caso de hirsutismo após a menopausa, provocado por um tumor de células esteróides (luteoma estromal) do ovário, atendido no Centro de Atendimento Integral à Saúde da Mulher (CAISM) da UNICAMP. Trata-se, geralmente, de um tumor benigno, pequeno e que ocorre com maior freqüência em mulheres idosas. Os autores chamam a atençao para a suposiçao diagnóstica de tumor ovariano em uma mulher após a menopausa com níveis elevados de testosterona, na qual afastou-se a possibilidade de tumor adrenal, mesmo sem haver um diagnóstico imagenológico prévio.

Effect of a gonadotropin releasing hormone analog on an experimental ovarian tumor: direct and indirect actions.

An ovary autotransplanted into the spleen of a bilaterally ovariectomized rat develops into a luteoma, which grows under constant gonadotropin hyperstimulation. The effect of a long-acting GnRH agonist (GnRH-a), on tumor growth and hormone secretion was investigated. Two experimental models were used: Model 1: GnRH-a (0.33 mg/rat sc) or estradiol valerianate (50 micrograms/rat sc injected once a week for four weeks) was administered simultaneously with ovary implantation; Model 2: the drugs were administered after 1 month of tumor development. The treatment with estradiol was used as a control of tumor regression. Saline injected ovarian grafted rats and Sham operated animals were used as controls. In Model 1: The GnRH-a significantly inhibited tumor development (Positive tumors: Saline: 100% vs GnRH-a: 43%, p < 0.01). In Model 2: the GnRH-a and estradiol significantly reduced the volume of one month old tumors (52% and 39% of initial volumes respectively, p < 0.01). Gonadotropin secretion was significantly inhibited or its increase blunted by the GnRH-a and by estradiol treatments in both models. Estradiol and progesterone in portal blood, which collects the steroids secreted by the luteoma, were significantly reduced by GnRH-a treatment in both models. On the other hand, in tumor cells cultured "in vitro", the GnRH-a was able to inhibit the LH induced progesterone secretion in a concentration dependent way. These results clearly show that the GnRH-a is effective in inhibiting tumor growth or reducing its volume, when already developed; furthermore, it suppresses tumor steroid hormone production. These actions were exerted at both the hypophyseal and tumor levels.