A case report of metastatic ovarian cancer presenting as acute abdomen with obstructed umbilical hernia

Sertoli-Leydig cell tumours (SLCTs) are rare ovarian sex cord-stromal neoplasms, accounting for less than 0.5% of ovarian tumours. They predominantly occur in young women and are frequently associated with androgenic manifestations. Advanced-stage disease in elderly postmenopausal women is exceptionally uncommon. Here , we present a 76-year-old postmenopausal woman with acute abdominal pain and vomiting due to an obstructed, irreducible umbilical hernia. Emergency laparotomy revealed a friable omental mass within the hernial sac, approximately 2 L of ascites and a large 15×15 cm left ovarian mass densely adherent to the rectosigmoid, bladder, uterus, pelvic sidewall and abdominal wall, with multiple peritoneal tumour deposits. Frozen section showed a poorly differentiated malignant neoplasm, with carcinosarcoma considered. Comprehensive cytoreductive surgery including total abdominal hysterectomy, bilateral salpingo-oophorectomy, peritonectomy, omentectomy, rectosigmoid resection and lymph-node assessment was performed. Definitive histopathology demonstrated a poorly differentiated (Grade 3) Sertoli-Leydig cell tumour with heterologous mucinous and cartilaginous differentiation. The tumour showed surface involvement and rupture, parametrial involvement and extrapelvic peritoneal deposits, with negative regional lymph nodes. No virilising features were documented. This case highlights an exceptionally rare presentation of advanced poorly differentiated SLCT in a postmenopausal woman, masquerading as an acute surgical abdomen due to an obstructed umbilical hernia. SLCT should be considered in the differential diagnosis of ovarian malignancy even in elderly women without androgenic manifestations. Heterologous differentiation may mimic epithelial ovarian carcinoma or carcinosarcoma on frozen section, underscoring the importance of definitive histopathological and immunohistochemical evaluation.