Molecular-cytogenetic characterisation of sex cord-stromal tumours: CGH analysis in sertoli cell tumours of the testis

Sertoli cell tumours (SCT) are rare and poorly explored neoplasias, and the genetic features of these uncommon tumours are largely unknown. Data about chromosomal aberrations in human SCT of the testis are very rare. We present in this paper the first molecular-cytogenetic study of SCT of the testis. DNA was isolated from paraffin-embedded tumour material from 11 patients with unilateral SCT. We used comparative genomic hybridisation to investigate changes in DNA copy number. The detected DNA imbalances showed variation from case to case, indicating a high genetic heterogeneity. Chromosomal aberrations were detected in 9 of the 11 tumours evaluated, with 13 losses versus 14 gains. The most frequent aberrations detected were gain of chromosome X (5 of 11 cases) followed by losses of entire or part of chromosomes 2 and 19 in three cases. This study suggests a high variability in histomorphological and genetic patterns. Only gain of the entire chromosome X seems to be a frequent aberration in these tumours. Further studies of these tumour types are necessary to clarify the significance of chromosomal alterations in carcinogenesis of SCT.

[Clinicopathological study of primary carcinoid tumor of the testis]

OBJECTIVE

To study the clinicopathological characteristics, immunohistochemical features and histogenesis of primary testicular carcinoid tumor and its differential diagnosis.

METHODS

Light microscopy and immunohistochemical stains were performed in 4 cases of primary testicular carcinoid tumor.

RESULTS

The patients sought care for scrotum mass presented from 2 to 36 years, 2 cases accompanied with tender swelling of the testis. The tumors were described as nodular, yellowish-gray in color, 3.0-4.0 cm in the greatest dimensions, and well circumscribed, focal necrosis seen in 1 case. Histologically, they showed insular and trabecular patterns separated by fine fibrous bands. The tumor cells were round or polygonal with regular monomorphic nuclei, stippling chromatin and eosinophilic granular cytoplasm. There were rosette-like and tubuloglandular patterns with eosinophilic secretion in the cavity. Immunohistochemical staining for synaptophysin, chromogranin A, NSE and cytokeratin showed diffusely positive expression in the tumor cells.

CONCLUSION

Primary testicular carcinoid tumor is extremely rare with good prognosis and its histogenesis remains controversial. Diagnostically it has to be differentiated from seminoma, metastatic carcinoid tumor, Sertoli cell tumor and granulosa cell tumor.

Giant Sertoli cell nodule of the testis: distinction from other Sertoli cell lesions

The case of a 33-year-old man with a clinically suspected testicular neoplasm is reported here. The radical orchidectomy specimen showed a sharply demarcated, firm, yellow-white 1-cm nodule beneath the tunica albuginea at the upper pole. Microscopical examination showed the encapsulated nodule to be composed of tubules lined by immature Sertoli cells with interspersed spermatogonia and an interwoven network of hyalinised basement membrane having foci of calcification. Immunohistochemical studies verified the fetal phenotype of the Sertoli cells and the non-neoplastic nature of the germ cell component. Except for the large size, the findings were identical to those of a Sertoli cell nodule-a typically microscopic, unencapsulated lesion commonly detected in cryptorchid testes. The term "giant Sertoli cell nodule" is used for this unique, hitherto undescribed lesion and its distinction from other Sertoli cell lesions of the testis is considered here.

Sertoli-stromal cell tumor of the right ovary: radiological-pathological correlation

A case of Sertoli-stromal cell tumor of the right ovary is reported. The patient was a 50-year-old perimenopausal woman with abdominal distention due to a large pelvic tumor. She had no signs of androgen excess. A large solid sponge-like tumor with multicystic areas throughout, in which there were some small hemorrhagic spots, was shown on magnetic resonance (MR) imaging. No endometrial thickening of the uterus was seen. Pathology examination revealed a Sertoli-stromal cell tumor with intermediate-to-poor differentiation. The edematous, watery, sponge-like appearance on the MR images correlated with the pathological findings.

Extratesticular interstitial and Sertoli cell tumors in previously neutered dogs and cats: a report of 17 cases

Primary neoplasms derived from testicular tissue and in an extratesticular location are extremely rare. Clinical and surgical information was collected and verified from 15 different submitting practices for 12 dogs and 5 cats that spontaneously developed neoplasms of testicular origin after castration. Eleven dogs had Sertoli cell tumors in an extratesticular location. One dog and all 5 cats had an extratesticular interstitial cell tumor. Six animals (1 dog, 5 cats) had developed secondary sexual characteristics that reversed after removal of the tumor. All had a palpable mass in the scrotum or at the site of the original prescrotal incision. No animals died of neoplasia-related disease and no metastases were identified. Several possibilities, including the presence of embryological ectopic tissue or the presence of testicular tissue transplanted during castration, are considered as causal.

[Ovarian oxyphilic Sertoli cell tumor: case report and review of the literature]

Ovarian oxyphilic Sertoli cell tumor is a rare neoplasm (only three cases were reported in literature). Sometimes the rarity itself of a lesion raises some problem in the diagnostics, especially if the case is send to several consultants. An unusual case of ovarian neoplasm came to our attention, and we sent some slides of the case to two well known referees of different Departments of Pathology. Pathologist 1 made a diagnosis of endometrioid adenocarcinoma, while Pathologist 2 made the diagnosis of oxyphilic Sertoli cell tumor. He sends the same slides to Pathologist 1, who confirmed his diagnosis. The two different diagnosis set different managements of the lesion for the clinician, but overall they set the pathologist who requested the consultation in a difficult position. In fact, when a pathologist sends to two experienced consultants a case, he really thinks to solve definitely the case itself. Unfortunately, sometimes it does not happen.

High TGFbeta1, estrogen receptor, and aromatase gene expression in a large cell calcifying sertoli cell tumor (LCCSCT): implications for the mechanism of oncogenesis

Large cell calcifying Sertoli cell tumors (LCCSCT) are associated with Carney complex and Peutz-Jeghers syndrome. The mechanisms linking these 2 genetic defects to the genesis of this tumor are obscure. Studies of CYP19 (aromatase) and transforming growth factor (TGF)-beta1 messenger RNA (mRNA) abundance, estrogen receptor (ER), TGFbeta1, and TGFbeta type II receptor (R) immunochemistry were carried out in the testis of a patient with this tumor to gain information on possible mechanisms of cell tumor development. Testicular tissue of a prepubertal patient, collected at gonadectomy, was separated into 2 macroscopically distinct fractions: tumoral nodules (Tu) and extratumoral, normal-looking testicular tissue (ExTu). The patient was a 9.5-year-old boy with a 5-year history of bilateral gynecomastia (Tanner stage 4), no pubic hair, incipient genital development, and bilateral testicular nodules. Multiple pigmented lesions of the skin were present. Bilateral mammectomy and gonadectomy was performed. RNA was extracted from Tu and ExTu for semiquantitative reverse transcriptase-polymerase chain reaction of CYP19 and TGFbeta1. Protein expression of ER, TGFbeta1, and TGFbeta type II R in Tu and ExTu was detected by immunohistochemistry. Cell proliferation was estimated by Ki-67 antigen immunochemistry and apoptosis using a modified TUNEL assay. Mean expression of aromatase and TGFbeta1 mRNAs in Tu was 6- and 2.3-fold higher than in ExTu, respectively (P<0.05). Tumoral cells exhibited ER staining with a predominant extranuclear localization. Positive staining of Sertoli cells in Tu was higher than in ExTu. TGFbeta1 immunostaining of the interstitial cells in Tu was higher than in ExTu. TGFbeta type II R immunostaining was detected in most Sertoli and interstitial cells, but intensity in ExTu was lower than in Tu. No significant difference was detected in the proliferation index, but in Tu, the percentage of Sertoli cells in apoptosis (1.4%) was significantly lower (P<0.01) than in ExTu (14.0%). The following hypothesis is proposed. The congenital gene defects of Carney complex or of Peutz-Jeghers syndrome might trigger a cascade of intracellular events that leads to overexpression of aromatase in Sertoli cells, favoring the development of a LCCSCT. At some point in the evolution of the disease, a mutational event might induce a higher expression of the ER. Also, TGFbeta1 protein expression is increased in neighboring cells. In this environment, TGFbeta1 might switch from tumor suppressor to oncogenic factor and, along with estrogen-ER complexes, might favor tumor progression by inhibiting apoptosis.

Prepubertal gynecomastia in Peutz-Jeghers syndrome: incomplete penetrance in a familial case and management with an aromatase inhibitor

BACKGROUND

Peutz-Jeghers syndrome (PJS) is a rare autosomal-dominant disorder characterized by multiple gastrointestinal hamartomatous polyps, mucocutaneous pigmentation and increased predisposition to various neoplasms. Endocrine manifestations in PJS include gynecomastia due to calcified Sertoli cell testicular tumors usually referred to as large-cell calcifying Sertoli cell tumors (LSCT).

OBJECTIVE

To evaluate the value of endocrine markers and aromatase inhibitor treatment in children with PJS and LSCT.

DESIGN AND SETTING

Familial cases, followed in a tertiary care center.

PATIENTS

Two male siblings aged 7 and 9 years with PJS and LSCT.

INTERVENTION

Third generation aromatase inhibitor (anastrozole) in one of the patients.

MAIN OUTCOME MEASURES

Longitudinal measurements of sex-steroids, gonadotropins, Sertoli cell markers and auxological evaluation.

RESULTS

The two male siblings with PJS had similar bilateral multifocal testicular calcifications and biochemical evidence of Sertoli cell dysfunction manifested by elevated plasma inhibin-alpha levels. Only one sibling had gynecomastia. Estradiol levels were normal in both. During treatment with anastrozole, estradiol levels, growth and skeletal maturation, as well as Sertoli cell markers (inhibin B, inhibin-alpha and anti-Mullerian hormone) decreased.

CONCLUSIONS

Inhibin-alpha may be considered as a marker for LSCT in children with PJS, pointing to a specific defect in inhibin regulation in this condition. Moreover, the decrease in Sertoli cell markers during aromatase inhibitor treatment suggests that increased estrogen production is a primary event regulating downstream production of Sertoli cell peptides. Anastrozole is efficient in controlling the clinical features of the disease and should be proposed as an alternative to bilateral orchidectomy, which is often performed in this condition.

Mitotic activity of Sertoli cells in adult human testis: an immunohistochemical study to characterize Sertoli cells in testicular cords from patients showing testicular dysgenesis syndrome

During puberty, normal somatic Sertoli cells undergo dramatic morphological changes due to the differentiation of immature pre-Sertoli cells in functionally active adult Sertoli cells. Sertoli cell maturation is accompanied with loss of their mitotic activity before onset of spermatogenesis and loss of pre-pubertal and occurrence of adult immunohistochemical Sertoli cell differentiation markers. Testes of infertile adult patients often exhibit numerous histological signs of testicular dysgenesis syndrome (TDS) such as microliths, Sertoli cell only (SCO) tubules, tubules containing carcinoma in situ and immature seminiferous tubules (Sertoli cell nodules). Sertoli cell tumours, however, are very rare neoplasms possibly due to the fact that the mechanism and temporal origin of neoplastic Sertoli cells underlying Sertoli cell tumourigenesis still remain unknown. To clarify the state of Sertoli cell differentiation in both immature seminiferous tubules of adult patients with TDS and Sertoli cell tumour, we compared the expression of the Sertoli cell differentiation markers vimentin, inhibin-alpha, anti-Muellerian-hormone, cytokeratin 18, M2A-antigen, androgen receptor and connexin43 with that of SCO tubules with hyperplasia. In addition, we demonstrated for the first time the existence of proliferating Sertoli cells by Ki67- and PCNA-immunostaining in Sertoli cell nodules of the adult human testis. Our data indicate that mitotically active Sertoli cells in Sertoli cell nodules will be arrested prior to puberty and, contrary to dogma, do not represent foetal or neonatal cells. Since all markers in Sertoli cell nodules revealed a staining pattern identical to that in neoplastic Sertoli cells, but different to that in Sertoli cells of SCO tubules with hyperplasia, it may be speculated that Sertoli cell tumours in adult men may originate from Sertoli cell nodules.

Sertoli cell tumor: a rare case in an elderly patient

Sertoli-Leydig cell tumors constitute < 1% of ovarian tumors, mostly in young women with virilization; however, not all present endocrine manifestations. A 72-year-old female presented with an abdominal mass and no signs of virilization. Total abdominal hysterectomy with bilateral salpingo-oophorectomy, omentectomy and selective pelvic lymphadenectomy was performed. The pathologic diagnosis was poorly-differentiated sex cord-stromal tumor with Sertoli cells. No adjuvant chemotherapy or radiation was administered. At 12-month follow-up the patient showed no evidence of disease.

Large-Cell Calcifying Sertoli Cell Tumour of the Testis Detected at Screening of a Family with Carney Syndrome

We report the detection of a large-cell calcifying Sertoli cell tumour (LCCSCT) in a 34-year-old male during screening of a family with Carney syndrome. The patient had ignored the testicular swelling for 7 years. He also had a cardiac myxoma. The LCCSCT in this patient had prognostically unfavourable features such as large size (>6 cm) and a high mitotic rate. There is only one previous report of a malignant LCCSCT in a patient with Carney syndrome.

[A case of Sertoli cell tumor]

We report a case of Sertoli cell tumor. A 33-year-old man visited our clinic with a complaint of painless left scrotal swelling on September 29th, 2003. An elastic firm induration larger than a hen's egg in size was palpable on the surface of the left testis. Tumor markers for testicular tumor such as human chorionic gonadotropin-beta, alpha fetoprotein, and lactate dehydrogenase were not elevated. However, ultrasound showed a low echoic mass in the left testis. Therefore, we performed left high orchiectomy under the diagnosis of left testicular tumor. Its histology showed Sertoli cell tumor. Neither recurrence nor metastasis has been detected for about 8 months after the operation.

Very high alpha-fetoprotein in a young man due to concomitant presentation of hepatocellular carcinoma and Sertoli cell testis tumor

Studies reported that there is a close relationship between hepatocellular carcinoma (HCC) and testis carcinoma. Both tumors can be presented as synchronal tumors, or as testicular metastases of HCC or as hepatic metastases of testicular tumor( [7] ). HCC is one of the most common malignancies worldwide and the incidence of HCC increases with age( [8] ). The relationship between hepatitis B incidence and HCC rates is also well recognized. Alpha fetoprotein (AFP) is produced by 70% of HCC. Though a level of AFP >400 ng/mL is diagnostic for HCC, in the presence of active hepatitis B infection, the cut-off level should be considered to be at least 1 000-4 000 ng/mL. Like HCC, germ cell tumors of the testis also release AFP; but it is shown that some of Sertoli cell tumors of testis can also release AFP( [10] ). Herein we have reported about the first case of HCC in the literature which is presented concomitantly with Sertoli-Leydig tumor of testis, leading to extremely high level of AFP in a 21-year-old man.

Sclerosing Sertoli cell tumor of the testis

Sclerosing Sertoli-cell tumor is a rare, sex-cord-stromal tumor of the testis with distinct clinical and pathological features with only 14 such cases reported in contemporary literature. We report such a tumor in a young diabetic and hypertensive male. Serum beta-HCG, alpha-protein and LDH levels were normal. Pathological examination of right radical orchidectomy specimen was consistent with sclerosing sub-type of Sertoli-cell testicular tumor with no invasion. He remains free of disease recurrence at 6 years following surgery.

Cytologic Features of Testicular Tumours in Dog

In this paper, we report on our experience of cytology of fine needle biopsies performed on 92 dogs with testicular tumours during the period from 1998 to 2002. Cytological diagnosis was consistent with seminoma in 20 cases, sertolioma in 16 cases, Leydig cell tumours in 50 cases and mastocytoma in one case. Five cases could not be diagnosed by cytology. Cytological observations were confirmed after surgery by histopathological examination in 87 cases. Cytology provided a sensitivity of 95% for seminoma, 88% for sertolioma and 96% for Leydig cell tumours. The specificity was 100% for all three tumour types. In our experience cytology of fine needle aspirations of testicular tumours is a very reliable technique.

Sertoli cell tumor of the testis in children: reevaluation of a rarely encountered tumor

Testis tumors are uncommon in childhood, and they differ from adult tumors in terms of histology and frequency. Sertoli cell tumors appear in children before 1 year of age. They are more frequently benign, but because of the absence of specific signs of malignancy, treatment consists of radical orchiectomy, sometimes followed by radiotherapy or chemotherapy based on histologic analysis. Malignancy is confirmed by the presence of metastasis or many mitosis and anaplastic cells. Children must be followed for several years to be sure of the absence of relapse or progression. In the authors' hospital, of 13 testis tumors diagnosed since 1996, only 2 were Sertoli cell tumors. It would be helpful to have an algorithm for the management of testis tumors, outlining how to make the diagnosis of malignancy and which treatment and follow-up to pursue.

Testicular Sex Cord–Stromal Tumours: The Edinburgh Experience 1988–2002, and a Review of the Literature

AIMS

Sex cord-stromal tumours of the testis are uncommon tumours, accounting for around 5% of testicular neoplasms. Treatment is primarily surgical, with no adjuvant therapy of proven benefit. We present a single-centre experience over a period of 15 years.

MATERIALS AND METHODS

From 1988 to 2002, 18 patients with a diagnosis of sex cord-stromal tumour were referred to our centre. A retrospective analysis of their case notes was made and a pathological review undertaken.

RESULTS

Sixteen were Leydig-cell tumours and two were Sertoli cell. For the Leydig-cell tumours, the median age at presentation was 42 years, 50% presented with a testicular mass and 31% with gynaecomastia. Two patients followed a malignant course: one revealing disease dissemination at initial staging, and a second 12 months after potentially curative orchidectomy. Salvage retroperitoneal lymphadenectomy in the latter patient proved unsuccessful. Clinical outcome correlated strongly with the presence of adverse pathological features described previously in the literature. After a median follow-up of 46 months, two patients have developed progressive disease, and two patients have died, one of metastatic Leydig-cell tumour. No patient defined as being of low malignant potential on pathological examination has relapsed outside our review period of 2 years.

CONCLUSION

We confirm the overall excellent prognosis for most of the patients with sex cord-stromal tumours of the testis. Compared with most previous reports, pathological features seem to predict with reasonable accuracy the risk of malignant behaviour, and can adequately inform the subsequent review policy.

Large cell calcifying Sertoli cell tumor of the testis: Comparative immunohistochemical study with Leydig cell tumor

Large cell calcifying Sertoli cell tumor is a rare type of testicular tumor. Reported herein is a Japanese patient with this tumor not associated with Carney's complex. An 11-year-old boy was admitted to hospital because of left testicular enlargement, and radical orchiectomy was performed. Macroscopically, the tumor was well circumscribed and had a maximum diameter of approximately 2 cm. The cut surface showed a yellow-white solid mass. Histologically, the tumor was composed of large neoplastic cells with abundant eosinophilic cytoplasm with a tubular, trabecular, and solid arrangement and loose myxoid stroma with irregularly shaped calcification. Immunohistochemically, the tumor cells were positive for vimentin, S-100 protein, calretinin, inhibin-alpha, melan-A, and CD10, and type IV collagen and laminin were observed in the extracellular matrix around the tumor cells. The distributions of melan-A, CD10, and mitochondria were characteristically patchy; in contrast, they were diffusely distributed in the cytoplasm in a control case of Leydig cell tumor. The differences in immunostaining patterns for melan-A, CD10, and mitochondria as well as positivity for S-100 protein-beta might be useful diagnostic hallmarks of large cell calcifying Sertoli cell tumor for discrimination from Leydig cell tumor.

Sex cord-stromal tumors of the ovary and testis: their similarities and differences with consideration of selected problems

Gonadal sex cord-stromal tumors contain some of the most morphologically interesting neoplasms of the gonads and these lead to many important issues in differential diagnosis. The pathology of these tumors is reviewed with emphasis on new information, similarities and differences in the two gonads, and diagnostic problems. Sertoli cell tumors occur in both gonads being more common in the testis where they usually exhibit a lobular pattern of hollow or solid tubules. In the ovary, tubular differentiation is usually the predominant feature but the lobulation typically seen in the testis is generally not as striking. One variant of Sertoli cell tumor, the large cell calcifying form, appears to be restricted to the male gonad and in contrast to other sex cord tumors is much more frequently bilateral and is associated in many cases with unusual clinical manifestations. In both sexes, patients with Peutz-Jeghers syndrome often have distinctive gonadal pathology. In females, it is in the form of the sex cord with annular tubules whereas in males, the lesion has features that are often intermediate between those of a sex cord tumor with annular tubules and a large cell calcifying Sertoli cell tumor. Sertoli-Leydig cell tumors are more morphologically diverse than pure Sertoli cell tumors and for practical purposes are an issue only in ovarian pathology being exceptionally rare in the testis. The classification proposed by Meyer into well, intermediate, and poor differentiation, remains important prognostically. More recently, heterologous and retiform differentiation has been described. Heterologous tumors most often contain mucinous epithelium, sometimes with small foci of carcinoid or less commonly, and generally in poorly differentiated neoplasms, rhabdomyosarcoma or fetal-type cartilage. Such tumors should be distinguished from pure sarcomas and teratomas. The retiform neoplasms, which tend to occur in young females, may mimic serous borderline tumors or even serous carcinomas. Granulosa cell tumors are much more common in females and in both gonads are divided into adult and juvenile forms. In females, granulosa cell tumors and other sex cord tumors may have markedly bizarre nuclei potentially leading to overdiagnosis as more malignant neoplasms. The juvenile granulosa cell tumor of the testis tends to occur in the first 6 months of life and should be carefully distinguished from the yolk sac tumor of the testis, which usually occurs in a slightly older age group. Occasional sex cord-stromal tumors cannot be readily categorized into the Sertoli or granulosa families and are diagnosed as sex cord-stromal tumors unclassified. In females, this is a relatively common placement for a neoplasm in a pregnant patient. Unclassified tumors are overall more common in males and may entrap residual normal germ cells potentially leading to the erroneous placement of the tumor in the category of a mixed germ cell sex cord-stromal tumor. From the practical viewpoint, the most helpful immunohistochemical findings are the negative staining of sex cord tumors for epithelial membrane antigen, and positive staining for inhibin and calretinin, findings that are converse to those seen in endometrioid carcinomas of the ovary, which commonly have formations that simulate sex cord tumors.

Sertoli cell tumor of the testis (not otherwise specified) with the expression of neuroendocrine markers and without the expression of inhibin-alpha

Sertoli cell tumor of the testis (not otherwise specified) in a 43-year-old man is reported. Macroscopically, the testicular mass measured 3.0 x 2.3 x 1.5 cm and was well circumscribed. The cut surface was white to tan-gray in color. Neoplastic cells with eosinophilic cytoplasm proliferated with solid and tubular structures. Neoplastic cells focally contained vacuoles of various sizes in the cytoplasm. Cystic formation and cord formation in the hyalinized stroma was also observed. Immunohistochemically, neoplastic cells were positive for cytokeratin 8, chromogranin A and synaptophysin, but neoplastic cells were negative for placental alkaline phosphatase, inhibin-alpha and pancytokeratin. The stroma in the tumor center and capsule contained a significant number of myofibroblasts that were positive for alpha-smooth muscle actin and negative for h-caldesmon, but no CD34-positive stromal cells were detected in the stroma of the tumor center. Ultrastructurally, neoplastic cells had cytoplasmic processes and abundant rough endoplasmic reticulum and lipid droplets in the cytoplasm. However, dense core granules were absent. It is important to differentiate between Sertoli cell tumor and carcinoid tumor because of the positive reaction for neuroendocrine markers in both tumors. Myofibroblasts are a major stromal component of Sertoli cell tumor of the testis.

Sertoli Cell Tumors of the Ovary

Ovarian Sertoli cell tumors are rare, and their morphologic spectrum, behavior, and factors influencing the latter are not clearly established. They may be mimicked by many different tumors, some of them more frequent than Sertoli cell tumors; immunohistochemistry may aid in this differential, but its role has not been analyzed in a large series. We studied the clinicopathologic features of 54 Sertoli cell tumors, including the immunohistochemical profile of 23 of them. The patients, 6 of whom had Peutz-Jeghers syndrome, ranged from 2 to 76 years of age (mean, 30 years). Eleven patients had estrogenic and 4 had androgenic manifestations. The tumors ranged from 0.8 to 30 cm, with the majority being in the range of 4 to 12 cm. They were all unilateral, usually solid, and often yellow. The predominant microscopic pattern was tubular, seen, albeit often only focally, in all tumors; other patterns were cords or trabeculae (28), diffuse (21), pseudopapillary (4), retiform (3), islands or alveolar arrangements (3), and spindled (3). The tubules were solid or hollow with the former being somewhat more common. Delicate septa were occasionally seen and were conspicuous in areas of one tumor. The stroma was abundant in 15 tumors with marked sclerosis in 4. The cells usually had pale to occasionally densely eosinophilic cytoplasm, but 6 tumors were composed of cells with prominent foamy cytoplasm, falling in the category of "lipid-rich" Sertoli cell tumor, and one had cells with clear non-foamy cytoplasm. Forty-four tumors were stage I (42 of them were stage Ia and 2 were stage Ic), 1 was stage II, 3 were stage III, and 6 were not adequately staged. Follow-up was available for 27 patients with stage I tumors, and all were alive and well at last follow-up except for 2 patients with stage Ia and 1 with stage Ic disease. Those 3 patients had pelvic-abdominal recurrences 18, 36, and 9 months, respectively, after the initial diagnosis. Two of the three clinically malignant stage I tumors had moderate to severe cytologic atypia and brisk mitotic activity (>5 or more mitoses/10 high power fields [HPFs]), and one of these had tumor cell necrosis. Among the 10 clinically benign stage I tumors with more than 5 years of follow-up, only 3 had >5 mitoses/10 HPFs, but none had more than mild cytologic atypia and none had tumor cell necrosis. Two of the three patients with stage III disease had follow-up information and one was alive at 16 months and the second developed splenic metastases 2 years after the initial diagnosis. Two of the three stage III tumors had at least moderate cytologic atypia and brisk mitotic activity. Immunohistochemical stains showed positivity for AE1/3-Cam5.2 in 15 of 23 tumors; Epithelial membrane antigen (EMA) was negative in all the tumors. Inhibin was positive in 18 of 22 tumors, calretinin in 10 of 20, CD99 in 19 of 22, vimentin in 17 of 18, smooth muscle actin in 4 of 18, neuron specific enolase in 8 of 16, S-100 in 2 of 20, and chromogranin was negative in all 21 cases studied. Although Sertoli cell tumors usually have a distinctive tubular pattern that facilitates the diagnosis, other patterns may occasionally predominate, causing confusion with various other primary and metastatic ovarian tumors. EMA, inhibin, and chromogranin represent the most helpful triad of immunomarkers serving to exclude two common mimics of Sertoli cell tumors (endometrioid carcinoma [inhibin-; EMA+; chromogranin-] and carcinoid tumor [inhibin-; EMA+; chromogranin+]). Although CD99 and calretinin are often expressed in these tumors, they are much less specific and not as helpful in the differential diagnosis. Most Sertoli cell tumors are stage I, unilateral, cytologically bland, and clinically benign, but occasional examples are high stage, and about 11% of stage I tumors have worrisome histologic features that may portend an adverse outcome. The tumors typically occur in young females, sometimes children who typically present with sexual precocity, and occasional patients have Peutz-Jeghers syndrome.

Secondary IgA nephropathy presenting as nephrotic syndrome with glomerular crescentic changes and acute renal failure in a patient with autoimmune hepatitis

Patients with end-stage liver disease are prone to hemodynamic and immunologic renal injury, the latter at times manifesting as glomerulonephritis. Elevated serum immunoglobulin A (IgA) levels and mesangial IgG-IgA deposits are common in these patients, but are often clinically silent. We report a patient with autoimmune hepatitis and secondary IgA nephropathy (IgAN) who presented with nephrotic syndrome, acute renal failure (ARF), with 30% of the renal glomeruli having undergone crescentic change, and with IgA2 deposits in the glomerular mesangium. This article discusses secondary IgAN pathogenesis and its therapeutic management.

Expression of a Transcription Factor, SOX9, in Sertoli-Stromal Cell Tumors of the Ovary

Two cases of ovarian Sertoli-stromal cell tumor were examined for expression of a transcription factor, SOX9, which plays an essential role in Sertoli cell differentiation, downstream of Sry, as in the testis. By reverse transcriptase polymerase chain reaction, SOX9 mRNA was expressed in both tumors, despite the absence of Sry. These findings suggest that SOX9 expression probably plays some role in Sry-independent testicular differentiation in ovarian Sertoli-stromal cell tumors.

Comparative Immunohistochemical Analysis of Granulosa and Sertoli Components in Ovarian Sex Cord-Stromal Tumors with Mixed Differentiation: Potential Implications for Derivation of Sertoli Differentiation in Ovarian Tumors

Granulosa cell tumors of the ovary occasionally show admixed Sertoli components, just as tumors that are predominantly Sertoli or Sertoli-Leydig cell tumors can contain minor granulosa elements. Although the immunoprofiles of pure granulosa cell tumors and pure Sertoli cell tumors have been characterized, little is known regarding what immunophenotypic relationships exist between the granulosa and Sertoli components in ovarian sex cord-stromal tumors that contain both elements. Furthermore, it is not completely understood why sex cord-stromal tumors of the ovary with female-type (granulosa) differentiation can produce male-type (Sertoli) differentiation. To better understand why simultaneous differentiation into female-type and male-type components occurs, eight tumors with mixed differentiation were stained with a panel of antibodies to androgen receptor (AR), calretinin, CD10, CD99, estrogen receptor, inhibin, Ki-67, low molecular weight cytokeratin, pancytokeratin, progesterone receptor, p53, and vimentin. Immunohistochemical composite scores were determined separately for the matched pairs of granulosa and Sertoli components in each case. Differences between both components were statistically analyzed using the Wilcoxon signed rank test. AR and vimentin expression showed a difference at the 10% statistical significance level (p < 0.1), demonstrating higher levels of expression in the granulosa components. The differences between the granulosa and Sertoli components in expression of CD99, inhibin, or pancytokeratin were not statistically significant (p > 0.1, each). Statistical calculations could not be made for calretinin, CD10, estrogen receptor, Ki-67, low molecular weight cytokeratin, progesterone receptor, or p53, although the overall mean levels of expression of CD10 and low molecular weight cytokeratin were substantially higher in the Sertoli components. Not surprisingly, the granulosa and Sertoli components of ovarian sex cord-stromal tumors with mixed differentiation show overlapping immunophenotypic profiles consistent with derivation from a common lineage rather than reflecting a composite tumor. However, because components of a sex cord-stromal tumor simultaneously differentiate along granulosa or Sertoli lines, they seem to show preferential expression of certain antigens. CD10 and low molecular weight cytokeratin are more often associated with Sertoli cell differentiation, whereas AR and vimentin expression seem to reflect granulosa differentiation.

[Unilateral Sertoli-cell androblastoma in the ovary of a young woman]

The authors present a case of a Sertoli-cell type androblastoma of the ovary. The tumor is mainly seen in young women and is mostly discovered through hormonal dysfunctions linked to it. Histopathological evaluation is indispensable for an exact diagnosis. Because of its rarity, there is little experience with the tumor and the histological identification is also sometimes very challenging. The tumor is occasionally associated with Peutz-Jeghers syndrome, tumor of the thyroid, or goiter. Biologically it follows a low-malignant course with a fair prognosis, long-term complex patient follow up is necessary after unilateral oophorectomy of the diseased organ.

Malignant large cell calcifying Sertoli cell tumor of the testis

A 45-year old man presented with a slow-growing, unilateral beige testicular mass, with a diameter of 4 cm. The testosterone, FSH, LH, estradiol and betahCG serum levels were within normal limits, and there were no associated hormonal syndromes. The patient was treated with inguinal orchidectomy. Microscopically, the tumor was composed of nests of cells with large eosinophilic, slightly granular cytoplasm. There was only a mild degree of atypia and no mitotic activity. The tumor extended into the rete testis. There were intratumoral calcifications, and in the vicinity of the tumor, there was intratubular growth. Although this case is histologically similar to the three previously reported cases of clinically benign large cell calcifying Sertoli cell tumor of the testis with rete testis involvement, the current patient developed right sided para-aortic lymph node metastases 18 months after the initial diagnosis.

Metastatic ovarian Sertoli-cell tumor: FNA findings with immunohistochemistry

A malignant Sertoli cell tumor of the ovary is a rare sex-cord stromal derived neoplasm. Sertoli cell tumors account for approximately 4% of Sertoli-stromal cell tumors (Hsu et al., J Histochem Cytochem 1981;29:577-580). The diagnosis of this entity by fine-needle aspiration and needle core biopsy can be difficult when the differential also includes a metastatic renal cell carcinoma, due to the overlap of both cytological and histological features. Here, we show that immunohistochemical staining on cytological material including alpha-inhibin can be used to differentiate between these two malignant tumors.

Cyclin D2 and p27 are tissue-specific regulators of tumorigenesis in inhibin alpha knockout mice

Inhibins are heterodimeric (alpha:betaA and alpha:betaB) endocrine, paracrine, and autocrine factors of the TGFbeta superfamily that are produced predominantly by ovarian granulosa cells in females and testicular Sertoli cells in males. Control of granulosa and Sertoli cell proliferation is lost in the inhibin alpha (Inhalpha) knockout mouse model, leading to gonadotropin-dependent gonadal tumors of the granulosa/Sertoli cell lineage in both females and males. Castrate Inhalpha knockout mice develop sex steroidogenic tumors of the adrenal cortex. Physiological control of granulosa/Sertoli cell cycle progression depends on p27Kip1 and cyclin D2, which function in the G1-->S phase transition. To study the cell cycle-regulatory factors involved in ovarian, testicular, and adrenal tumor development in vivo, we have bred Inhalpha mutant mice to mice with targeted disruptions of the p27 and cyclin D2 genes. Our previous studies demonstrated that inhibins act cooperatively with p27 to negatively regulate granulosa cell proliferation, as double mutant mice lacking inhibins and p27 develop and succumb to ovarian tumors more rapidly than Inhalpha knockout mice. Here, we report that cyclin D2 antagonizes this inhibition and is key in promoting gonadal growth and tumor development, and tumor development is markedly suppressed in double-mutant mice. We found that double-knockout females lacking cyclin D2 and Inhalpha lived longer than mice lacking inhibins alone; the majority of these double-knockout mice lived longer than 17 wk, as opposed to inhibin alpha single-knockout females with 50% survival at between 12 and 13 wk of age. Moreover, 95% of inhibin alpha knockout males succumb to testicular tumor development by 12 wk of age, whereas double knockouts were protected from early signs of tumor development and had a 50% survival of 40 wk. Interestingly, the results of these studies reflect tissue-specific consequences of loss of these cell cycle regulators. In castrate mice, loss of p27 has little effect on adrenal cortical tumor progression in the absence of inhibins, whereas loss of cyclin D2 prolongs the lifespan of cyclin D2, Inhalpha double knockouts. After gonadectomy, 50% of cyclin D2, Inhalpha double-knockout males live to more than 46 wk of age, 10 wk longer than 50% of littermates lacking only inhibins. Similarly, 50% of female cyclin D2, inhibin alpha double knockouts live to 47 wk of age before succumbing to adrenal tumor development, in contrast to the 50% survival of Inhalpha single-knockout females at between 27 and 28 wk. Thus, identification of genetic modifiers of the Inhalpha knockout tumor phenotype has led us to a better appreciation of how specific components of the cell cycle machinery contribute to tumorigenesis in the ovary, testis, and adrenal gland.

Sexually dimorphic roles of steroid hormone receptor signaling in gonadal tumorigenesis

Sex steroids control cellular phenotypes by binding to receptor proteins that in turn regulate downstream gene expression. They are important tropic factors in hormonally responsive tissues and have been implicated in the pathogenesis of both benign proliferations and malignancies at some of these sites. Knockout mice lacking inhibins, alpha:beta heterodimeric peptide hormones of the TGFbeta superfamily, develop gonadal tumors that produce sex steroids and depend on pituitary gonadotropin hormones. To better appreciate how sex steroid receptor signaling pathways contribute to the loss of granulosa/Sertoli cell proliferation in the ovary and testis of inhibin alpha (Inhalpha) knockout mice, we are using both pharmacologic and genetic approaches. Roles of androgens in testicular tumor development have been investigated in our previous studies using double-mutant mice lacking inhibins and carrying the null testicular feminization (tfm) mutation of the androgen receptor. Herein, we report that androgens also participate in the development of ovarian tumors, as tumor development is forestalled in mice treated with flutamide, a nonsteroidal inhibitor of androgen actions. Additionally, we generated double-mutant mice lacking estrogen receptor alpha (ERalpha) and Inhalpha or ERbeta and Inhalpha, as well as triple-mutant mice lacking ERalpha, ERbeta, and Inhalpha to determine the effects of individual and combined ER signaling pathways on tumor development. Although estrogens may have proliferative effects during follicle development and are important in specifying the granulosa cell phenotype, ERalpha and ERbeta signaling are not essential for timely granulosa cell tumor development or granulosa cell-like morphological features in ovarian tumors. However, redundant ER signaling through ERalpha and ERbeta in males is critical for testicular tumor formation, as triple-knockout, but not double-knockout, males are protected from early Sertoli cell tumorigenesis and death. Together, these studies indicate important and sexually dimorphic functions of estrogens and androgens in tumor development in this mouse model and indicate, for the first time, overlapping functions of ERalpha and ERbeta in Sertoli cell pathophysiology.

[Endocrine tumors of the testis]

The most characteristic endocrine tumours of the testis are germ cell tumours and sex cord/gonadal stromal tumours. They include the primary carcinoid, the relation of which to teratomas is still unclear. In general, gonadal stromal tumours are rare, however, endocrine activity occurs in at least 10%-20%. Among gonadal stromal tumours, only Leydig cell tumours and Sertoli cell tumours are of practical importance. Endocrine disorders are mostly related to Leydig cell tumours (gynaecomastia, pubertas praecox). Although less frequent than the other gonadal stromal tumours, they can, in principle, occur. The large cell calcifying Sertoli cell tumour occurs in association with other complex disorders (i.e. Peutz-Jeghers syndrome). Valuable markers are: inhibin, calretinin, cytokeratin, melan-A, CD-99, Ki-67, androgen receptor and p53. As the conventional morphology and immunohistological markers frequently overlap, unclear cases should be referred to specialised centres.

Endokrin aktive Tumoren des Ovars

Most hormonally active ovarian tumors belong to the category of tumors of the gonadal stroma. These account for less than 5% of all ovarian tumors. About two-thirds of tumors of the gonadal stroma produce steroid hormones. The pathologic secretion of estrogenic or androgenic hormones leads to specific effects on the hormone-sensitive target organs. The clinical manifestations depend on both the amount of hormones secreted and the age of the patient. Tumors of the gonadal stroma are potentially malignant, ranging between noninvasive (borderline) tumors and invasive epithelial tumors of the ovary. Besides the specifically steroid hormone-producing tumors, a wide variety of ovarian tumors other than those in the stroma of the ovary and steroid cell tumors may be hormonally active as the result of an increase in and/or stimulation of nonneoplastic ovarian stromal cells within or adjacent to the tumor.

Malignant Sertoli cell tumor in the retained abdominal testis of a unilaterally cryptorchid horse

A 13-year-old Morgan gelding was evaluated because of a mass in the caudal region of the abdomen. The horse had been presumed to be a gelding, but necropsy findings revealed a retained testis in the right retroperitoneal space. Histologically, the retained testis contained neoplastic cells; metastases were identified in the liver, spleen, lungs, and sublumbar lymph nodes. Immunohistochemical examination of the testis and metastatic tissues confirmed the diagnosis of malignant Sertoli cell tumor. Testicular neoplasms are infrequently reported in stallions. Seminomas are most commonly reported, whereas Sertoli cell tumors are considered to be rare. Typical biological behavior of Sertoli cell tumors in horses is unknown. To the authors' knowledge, there have been 2 reports of Sertoli cell tumors in horses; the tumors developed in descended testes, and 1 tumor was malignant.

"Onco-tese": testicular sperm extraction in azoospermic cancer patients before chemotherapy-new guidelines?

OBJECTIVES

To examine the usefulness of pretreatment testicular sperm extraction because some patients have tumor-induced azoospermia. In view of the high cure rates for testicular germ cell tumors and malignant lymphomas, increasing clinical importance is attached to protecting fertility. High-dose cytostatic therapy may be expected to cause long-term infertility. Thus, the standard procedure for fertility protection is cryopreservation of ejaculated spermatozoa before therapy.

METHODS

Contralateral testicular biopsies were taken from 14 azoospermic patients with malignant testicular germ cell tumors. In addition, 17 patients with malignant lymphomas underwent unilateral (n = 6) or bilateral (n = 11) testicular biopsy. The tissue specimens were cryopreserved, and the histologic workup was performed at the same time.

RESULTS

Of the 14 patients with malignant testicular germ cell tumors, 6 had spermatozoa in their testicular biopsies. Sertoli cell-only syndrome was found in 5 patients, and 3 had maturation arrest without detection of spermatozoa. Successful sperm recovery was possible in 8 of the 17 patients with malignant lymphoma, 4 had Sertoli cell-only syndrome, and 5 had maturation arrest. None of the patients had evidence of secondary wound healing or treatment delay because of the testicular biopsy.

CONCLUSIONS

Our results show that testicular sperm extraction is a useful technique for obtaining spermatozoa before cytotoxic therapy in azoospermic cancer patients. This procedure should be considered as an option for fertility preservation in azoospermic cancer patients, because high cumulative cytostatic doses can cause irreversible fertility alterations.

Sertoli cell tumor associated with polyomavirus infection in a Gouldian finch (Erythrura gouldiae)

A 3-yr-old male Gouldian finch (Erythrura gouldiae) died after 2 wk of lethargy, emaciation, feather loss, and abdominal distension. The bird was housed in an aviary for breeding, but it had shown loss of fertility in the previous breeding season. Necropsy revealed a gross, firm, and yellow mass involving the left testis. Histologically, the mass was a mixed form, intratubular and diffuse, Sertoli cell tumor. Some neoplastic cells had intranuclear inclusion bodies that immunoelectron microscopy proved to be polyomavirus particle aggregates. There were no viral inclusions in other tissues. The possible role of infection in the pathogenesis of the tumor is discussed.

Blood plasma concentrations of oestradiol-17beta, testosterone and testosterone/oestradiol ratio in dogs with neoplastic and degenerative testicular diseases

Oestradiol-17beta and testosterone blood plasma concentrations were measured in dogs with Leydig-cell tumours (n=20), Sertoli-cell tumours (n=6), seminomas (n=9), unilateral inguinal cryptorchidism (n=7), abdominal cryptorchidism (n=9, one bilateral), degenerate scrotal testicles (n=6, two bilateral), and animals with normal scrotal testicles (n=20). The testosterone/oestradiol ratio (testosterone concentration [ng/mL]x100/oestradiol concentration [pg/mL]) was calculated.A considerably higher oestradiol concentration was found in dogs with Sertoli-cell tumours (29.0, 14.4-48.3 pg/mL; median, minimum-maximum; P=0.0256, Mann-Whitney test) and lower oestradiol levels were found in animals with seminomas (12.0, 3.4-17.6 pg/mL; P=0.0025) compared to the healthy control group (18.0, 8.6-31.5 pg/mL). Testosterone concentration was decreased in dogs with Sertoli-cell tumours (0.08, 0.03-0.77 ng/mL) when compared to the control group (1.95, 0.05-3.70 ng/mL; P=0.0012). Testosterone/oestradiol ratios differed from the control (9.6, 0.58-35.8) only in dogs with Sertoli-cell tumours (0.32, 0.06-2.80; P=0.0005). Clinical signs of feminization were observed in five dogs with Sertoli-cell tumour and one dog with a Leydig-cell tumour, and were more often associated with decreased testosterone/oestradiol ratios than with an increased oestradiol-17beta concentration.

Sertoli cell tumour with Call-Exner-like bodies in a dog

An histological diagnosis of Sertoli cell tumour and concurrent seminoma was formulated after complete resection of the right testicle in a 8-year-old Doberman. The unusual histological feature of abundant eosinophilic material with a extracellular location forming the Call-Exner-like bodies is reported.