Malignant Sertoli cell tumor of the testis

Therapeutic strategies for uncommon testis cancer histologies: teratoma with malignant transformation and malignant testicular sex cord stromal tumors

Testicular cancer is the most common solid malignancy in male adolescents and young adults, with germ cell derived seminomas and non-seminomas being by far the most common histologies. Teratoma with somatic-type malignancy is a rare chemo-resistant phenotype of testis cancer associated with poor prognosis in patients with advanced stage disease. Malignant gonadal-stromal tumors comprise 5% of testicular neoplasms and approximately 10% are malignant and considered chemo-radiation resistant. Prognostic factors and treatment strategies for these uncommon histologies are lacking.

Overview of pediatric testicular tumors in Korea

Prepubertal testicular tumors are rare compared with postpubertal testicular tumors. The incidence of prepubertal testicular tumors peaks at 2 years of age, tapers off after 4 years of age, and then begins to rise again at puberty. Prepubertal and postpubertal testicular tumors show many differences, including the typical tumor histology, molecular biological differences, and the malignant potential of tumors at different ages. Pediatric testicular tumors are classified as benign or malignant on the basis of their clinical behavior and histologically are divided into germ cell and gonadal stromal (nongerm cell) tumors. Many histological and biological studies have further confirmed the distinct nature of prepubertal and postpubertal testicular tumors. These differences have led to various management strategies for prepubertal and postpubertal tumors. Because overall about 75% of prepubertal testicular tumors are benign, a testis-sparing approach is becoming more common in children. Orchiectomy and observation with very selective use of chemotherapy has become the standard approach when a malignant tumor is identified. Retroperitoneal lymph node dissection and radiation therapy play very limited roles.

Sex cord-stromal tumors of the testis in children. A clinicopathologic report from the Italian TREP project

PURPOSE

Testicular sex cord-stromal tumors (SCSTs) are very rare in children and include a variety of neoplasms with different clinical features and biologic behavior. Aim of the study was to report the clinical findings and results observed in a series of patients with testicular SCST, registered in a multi-institutional Italian network on rare tumors in children and adolescents.

MATERIALS AND METHODS

The records of 11 patients, enrolled in 6 Italian centers from January 2000 to December 2008, were reviewed. The Children's Oncology Group (COG) staging system was adopted. Chemotherapy was recommended in patients with incomplete surgery or metastatic disease.

RESULTS

A testicular mass was the most common symptom. All patients underwent primary removal of the tumor; orchiectomy with high ligation of spermatic cord was performed in 7 and tumor enucleation in 4. At histology, 4 patients had Leydig cell tumors, 4 juvenile granulosa cell tumors, 1 Sertoli cell tumor, 1 incompletely differentiated SCST, and 1 SCST with an intermediate pattern Sertoli cell tumor/mixed form. The histology of 8 of 11 cases was reviewed and investigated through immunohistochemical stains. Ten children were in stage I; 1 patient, who did not undergo hemiscrotectomy after enucleation through a transscrotal access, was considered stage II. All the patients are in first complete remission (mean follow-up, 59 months; range, 8-94).

CONCLUSIONS

Our experience confirmed the rarity of testicular SCST. They have to be considered in the differential diagnosis of testicular solid masses, taking into account that hormonal signs are present in a minority of cases. All patients were cured with surgery alone. The sparing surgery represented a choice in selected cases.

Pediatric urologic oncology: organ-sparing surgery in kidney and testis

Technological advances in imaging as well as increased knowledge of tumor-specific biology have promoted the role of organ-sparing approaches to pediatric renal and testicular tumors. Application of these techniques continues to evolve as data on long-term follow-up become available and as protocol-guided investigation provides answers to therapeutic outcomes of these approaches. Optimally, organ-sparing surgery will continue to provide increased potential for preservation of both renal function and fertility.

Benign and Malignant Neoplasms of the Testis and Paratesticular Tissue

Benign and malignant tumors of the testes and paratesticular tissues present an interesting spectrum of diagnostic entities often encountered in routine surgical pathology practice. Germ cell tumors are the most common tumors of the testes and, despite a rising incidence, have excellent prognosis because of their radiosensitivity and/or effective chemotherapeutic agents. The proper classification of these tumors aids in the choice of appropriate treatment options. This article reviews benign and malignant neoplastic entities of the testes and paratesticular tissues and illustrates the classic pathologic characteristics. The differential diagnosis, along with ancillary studies, clinical significance, and presentation are discussed also.

Stromal testis tumors in children: a report from the prepubertal testis tumor registry

PURPOSE

Stromal testis tumors are rare and generally exhibit a benign behavior in prepubertal patients. We reviewed the Prepubertal Testis Tumor Registry to elucidate further the behavior of these tumors.

MATERIALS AND METHODS

Epidemiological and clinical information on stromal testis tumors was compiled and reviewed from the Prepubertal Testis Tumor Registry. In addition, original pathology reports were requested for all patients registered as having undifferentiated stromal tumors.

RESULTS

There were 43 patients registered with stromal tumors. Of the 21 patients with unspecified stromal tumors pathology reports were obtained on 11. Eight patients had truly mixed or undifferentiated stromal tumors. Mean patient age at presentation was 38 months (Leydig cell 70, Sertoli cell 52.5, juvenile granulosa cell 1.5 and mixed/undifferentiated 41.2). No patient with a Leydig cell, Sertoli cell or juvenile granulosa cell tumor had metastases at presentation or metastatic disease during an average 24.6 months of followup. One undifferentiated tumor demonstrated malignant behavior by presenting with metastatic disease. Pathological examination revealed a poorly differentiated tumor with extension into the adjacent tunica and frequent mitotic figures. While other stromal tumors displayed mitotic figures, none showed local invasion.

CONCLUSIONS

Stromal testis tumors are rare. Data from the Prepubertal Testis Tumor Registry confirms the benign behavior of most of these tumors. However, undifferentiated stromal tumors may exhibit metastatic behavior. A high index of suspicion is appropriate when there are a large number of mitotic figures, the tumor is poorly differentiated or when local invasion is present in the primary tumor. Metastatic evaluation and close followup are warranted for this select group of patients.

The spectrum of Sertoli cell tumors in children

The spectrum of Sertoli cell tumors in children covers a wide range of testis and ovarian tumors classified as sex cord-stromal tumors. Sertoli cell tumor of the testis is extremely rare in the pediatric population. The American Academy of Pediatrics Section on Urology Prepubertal Testicular Tumor Registry has reported a total of six cases of Sertoli cell tumor of the testis, accounting for 1.3% of the 430 cases reported to the registry as of October 1996. Despite their rarity, Sertoli cell variants of sex cord-stromal tumors have generated keen interest because of their variable histologic appearance and biologic behavior, including endocrine activity. Because sex cord-stromal tumors occur in the ovary and testis, a primitive cellular origin to these tumors is likely in males and females.

Sertoli cell tumors of the testis, not otherwise specified: a clinicopathologic analysis of 60 cases

Sixty Sertoli cell tumors of the testis, excluding large cell calcifying and sclerosing subtypes, are described. Patient age ranged from 15 to 80 years (mean, 45 years). The initial manifestation was usually a testicular mass; in 14 cases it had been enlarging slowly for a period of up to 14 years (mean 3.7 years). Only five patients had testicular pain. Four patients had metastatic disease at the time of presentation. All the tumors were unilateral and ranged from 0.3 cm to 15 cm (mean 3.6 cm). They were typically well circumscribed. Sectioning usually disclosed firm, tan-gray, white, or yellow tissue with areas of hemorrhage and a minor cystic component in approximately one third. Microscopic evaluation usually revealed diffuse sheets or large, nodular aggregates of tumor cells, within which solid or hollow, sometimes dilated, tubules and, less often, cords were usually at least focally identifiable. A relatively acellular, often vascular, fibrous to hyalinized stroma was frequently conspicuous. The tumor cells typically had moderate amounts of pale to lightly eosinophilic cytoplasm, but 10 tumors had cells with abundant eosinophilic cytoplasm. Large cytoplasmic vacuoles were prominent in 26 tumors. Nuclear atypicality was absent or mild in 54 cases, moderate in 4 cases, and marked in 2 cases. Mitotic rate ranged from less than 1 to 21 per 10 high power fields, with 50 tumors having no or only rare mitoses. Vascular space invasion was present in 11 cases and was prominent in 8. Follow-up of more than five years (average 8.4 years), or until evidence of metastasis was seen, was available for 16 patients. Nine were alive and well with no evidence of disease. Four were alive with disease and three died of disease. The pathologic features that best correlated with a clinically malignant course were as follows: a tumor diameter of 5.0 cm or greater, necrosis, moderate to severe nuclear atypia, vascular invasion and a mitotic rate of more than 5 mitoses per 10 high power fields. Only one of nine benign tumors for which follow-up data of 5 years or more were available had more than one of these features, whereas five of seven malignant tumors had at least three.

Testicular juvenile granulosa cell and Sertoli cell tumours: a clinicopathological study of 29 cases from the Kiel Paediatric Tumour Registry

Testicular Sertoli cell tumours (SCT) and juvenile granulosa cell tumours (JGCT) are rare in childhood. This study was designed to investigate the clinical picture, morphology and disease course in a comparatively large series of cases (total number = 29). Of 198 cases of childhood testicular tumour documented in the Kiel Paediatric Tumour Registry 18 were cases of infantile SCT (9.1%) and 11 of JGCT (5.6%). The average age at the time of diagnosis was 4.2 months for infantile SCT and 0.4 months for IGCT. SCT and JGCT often showed infiltrative growth into adjacent testicular tissue, dense cellularity and considerable proliferation activity. Immunohistochemically all cases expressed vimentin intermediate filaments in both tumour types. Next in frequency of expression were cytokeratins (SCT: 7/16; JGCT: 7/10) and smooth-muscle actin (SCT: 9/15; JGCT: 4/10). Follow-up studies (24/29) showed that in cases of tumour manifestation in infancy and after complete tumour removal (usually orchiectomy) no local recurrences and no metastases occurred. The most important conclusion for diagnosis and therapy is that despite infiltrative growth, incomplete differentiation, dense cellularity and considerable proliferation activity, after surgical excision infantile SCT and JGCT have a good prognosis. Adjuvant chemotherapy or more extensive operations with lymphadenectomy are thus not indicated.

Testicular sex cord-stromal tumors in children: clinicopathologic study of sixteen children with review of the literature

Sex cord-stromal tumors of the pediatric testis present diagnostic and therapeutic challenges. This study examines the clinicopathologic features of 16 testicular sex cord-stromal tumors from children less than 18 years of age. Four juvenile granulosa cell tumors and five tumors of Sertoli or incomplete differentiation in this study had high mitotic rates and/or sarcomatoid areas that suggested malignancy, but none of these children developed recurrence or metastases. Some of these tumors had been initially misdiagnosed as yolk sac tumors or rhabdomyosarcomas because of the presence of areas superficially resembling these neoplasms. These morphologic pitfalls have received little attention in the literature. Even incompletely differentiated sex cord-stromal tumors have at least focal areas characteristic of juvenile granulosa or Sertoli cell differentiation. In addition, immunohistochemical negativity for alpha-fetoprotein, muscle specific actin, and desmin are useful for ruling out yolk sac tumor and rhabdomyosarcoma. Four patients had Leydig cell tumors and three had large cell calcifying Sertoli cell tumors. Children with Leydig cell tumors are not at risk for metastasis, but children with large cell calcifying Sertoli cell tumors are at risk for endocrine syndromes as illustrated by one of our cases. The differential diagnosis of these tumors is also discussed.

Hetero- and isosexual pseudoprecocity associated with testicular sex-cord tumors in an 8 year-old male

Enlargement of the right breast, axillary hair, and acceleration of linear growth rate were first noted at 8 years of age in an otherwise healthy male with no known exposure to exogenous hormones. At 9.5 years of age the right subareolar mass was excised; histologic examination revealed fibrous breast tissue. Subsequently pubic hair appeared. At 10.7 years of age, the patient complained of right inguinal pain after a minor injury. Examination revealed a tall (height age 12.7 years), mature, muscular boy with enlarged (R: 5 x 3 x 2 cm; L: 3 x 2 x 3 cm) firm, irregular testes, Tanner stage II pubic hair, and modest axillary hair. No perioral pigmentation was present. Testicular ultrasonography revealed multilobular echogenic foci with calcifications. Bone age was 13 years, the LH and FSH secretory responses to GnRH were minimal (LH: < 0.038-->0.28 mIU/ml; FSH: < 0.063-->0.11 mIU/ml), and basal serum testosterone (< 10 ng/dl) and estradiol (< 10 pg/ml) values were undetectable. Following administration of human chorionic gonadotropin (hCG), the serum testosterone concentration increased to 275 ng/dl, while estradiol remained unmeasurable. Spermatic vein concentrations of testosterone were undetectable in the basal state and increased after hCG administration. After bilateral orchiectomy, pathologic examination revealed multifocal tumors composed of brightly eosinophilic, large polygonal cells arranged in nests, cords, and clusters within dense connective tissue or mucinous stroma with lamellar calcifications of varying sizes. These pathologic findings were compatible with a large cell calcifying Sertoli cell (sex-cord)tumor of the testes. Testosterone, estradiol, immunoreactive and bioactive aromatase activity were not detectable in the tumor. Thus, both heterosexual (gynecomastia) and isosexual (increased musculature, pubic and axillary hair) precocious puberty may occur in boys with testicular sex-cord tumors.

Malignant gonadal stromal tumor

A case of malignant gonadal stromal tumor is reported, and the 24 cases reported in the English and Japanese literature are reviewed. A thirty-four-year-old male visited our hospital with a painless tumor in the left scrotum. Left high orchiectomy was performed under a diagnosis of testicular tumor, and histologic examination of the resected specimen demonstrated that it was a malignant gonadal stromal tumor. There has been no evidence of disease for forty-one months following surgery. Of the 15 cases reported in the English literature, retroperitoneal lymph node dissection was performed in 3 cases, and metastasis was present in the resected lymph nodes in 2 of the cases. These 3 patients survived with no evidence of disease for follow-up periods ranging between six months and five years. However, lymph node metastasis was observed in 5 of 6 patients who underwent orchiectomy alone or in combination with radiation to the retroperitoneal lymph nodes. The 3 patients described in the Japanese literature who had received high orchiectomy and retroperitoneal lymph node dissection survived with no evidence of disease for follow-up periods ranging from eighteen months to forty-one months following surgery. These findings indicate that retroperitoneal lymph node dissection is useful as a treatment for malignant gonadal stromal tumor. However, the prognosis for patients with advanced disease is very poor, because neither chemotherapy nor radiotherapy is effective. Corroborative study of many patients is necessary to understand the pathophysiology of malignant gonadal stromal tumor and to develop useful treatments.

Primary testicular and paratesticular tumors of childhood

Testicular and paratesticular neoplasms are uncommon tumors of childhood. Consequently, the experience gained with regard to their optimal management is limited in any given children's cancer centre. Here we review the classification, diagnosis, and staging of testicular and paratesticular neoplasms and subsequently discuss the more frequently occurring ones: germ cell tumors, gonadal stromal tumors, gonadoblastoma, tumors of the supporting tissue, lymphomas and leukemias, tumor-like lesions, secondary tumors, and tumors of the adnexa.

Prepubertal Testicular Tumor Registry

The Prepubertal Testicular Tumor Registry has been in existence for 12 years. Information on 327 patients was collected and registered in the database. Demographic data have been analyzed, leading to a better understanding of these rare tumors. Information regarding the natural history and behavior of the tumors has also evolved from a retrospective review of the tumors. The registry will continue in an effort to collect centrally information on these unusual tumors and to attempt to aid in developing a better understanding of the natural history and behavior of the tumors to provide early detection, consistent treatment and improved survival.

Non-germ cell tumors of testis

Testicular tumors of non-germ cell origin represent from 5 percent to 10 percent of all testicular neoplasms. Included in this group are sex cord/gonadal stromal tumors, most originating from Leydig or Sertoli cells, mixed tumors, and tumors of mesenchymal or hematopoietic origin. In addition, various miscellaneous lesions, tumor-like conditions, and secondary testicular tumors may be classified as non-germ cell tumors. This review covers the presentation, diagnosis, and treatment of these rare lesions.

Malignant sertoli cell tumour of the testis in a child

Very few cases of malignant Sertoli cell tumour of the testis are reported in the literature. The average age at discovery of this tumour is 39 years. Malignant Sertoli cell tumour of the testis in a child is presented, the fourth case reported in the literature. We present our case to increase awareness of this tumour in this age group, to point out the capability of Sertoli cell tumours to metastasize, and to document the remarkable initial response to combination chemotherapy, a hitherto unreported feature.

Malignant Sertoli cell tumour of the testis. An immunohistochemical study and a review of the literature

The fifteenth case of malignant Sertoli cell tumour is reported and the literature is reviewed. The reported case was unilateral with lung metastases. Immunohistochemical examination showed positive staining reaction within the tumour cells for vimentin and cytokeratin, while AFP, HCG, PLAP, EMA and CEA were not found, which is in accordance with the staining pattern found in normal Sertoli cells.

Gonadal stromal tumors: a report of the Prepubertal Testicular Tumor Registry

A total of 15 gonadal stromal tumors in prepubertal boys has been reported to the Prepubertal Testicular Tumor Registry of the Section on Urology of the American Academy of Pediatrics. Leydig cell tumors invariably are benign and patients usually present with precocious puberty when they are 5 to 9 years old. Other gonadal stromal tumors either present in infancy as a scrotal mass and exhibit a benign behavior or occur later in childhood and may be malignant.

Testicular tumors in infants and children

Primary malignant tumors of the testis are uncommon in infants and children. Tumors of germ cell origin are identified most frequently. The clinical presentation is usually due to the presence of an enlarging scrotal mass. Determinations of the serum alpha fetoprotein (AFP) and beta subunit of human chorionic gonadotropin (beta-hCG) levels are helpful for diagnosis and management. All suspected testicular tumors should be surgically evaluated through a high inguinal incision. Postoperative chemotherapy is recommended for some patients with yolk sac tumor and all patients with embryonal rhabdomyosarcoma. Prolonged relapse-free survival is possible for most infants and children with malignant testicular tumors.

Neonatal gonadal stromal tumor of the testis: limitations of tumor markers

We report case 10 of a gonadal stromal tumor of the testis in a neonate. This tumor may occur in the testis or ovary, and is defined as a tumor of any of the specialized supporting structures of the male or female gonad. All neonatal tumors reported to date have been benign. The serum alpha-fetoprotein level, although elevated for adults, was within the normal range for an infant.

Malignant Sertoli cell tumor of testicle

The eleventh case of malignant Sertoli cell tumor of the testicle is described. The tumor displayed malignant character with local invasion into the epididymis. Retroperitoneal lymph node dissection revealed a malignant deposit around the left renal artery.

Malignant sex cord-stromal tumor of testis

We report a case of sex cord-stromal tumor in the testis, which metastasized to the retroperitoneal space, resulting in death 13 months after orchiectomy. The primary lesion consisted of granulosa cells, theca cells, Sertoli cells and undifferentiated gonadal stroma. Biopsy of the retroperitoneal metastasis showed predominance of the Sertoli cell component.

Sertoli cell testicular tumors

The testicular Sertoli cell tumor is generally considered a benign tumor that can be treated by orchiectomy and close follow-up. It accounts for less than 1.5 per cent of testis tumors and may be malignant in 10 per cent of cases. Approximately 30 per cent have endocrine activity. We present 5 additional cases to the 75 previously reported in the world literature.

Sertoli tumors of the ovary. A clinicopathologic study of 28 cases with ultrastructural observations

The clinical and pathologic features of 28 Sertoli tumors of the ovary are presented. Seventeen of the 18 neoplasms had a functional effect. The effects were hyperestrinism (eight women), isosexual precocious puberty (three girls), virilization (four women), a progestational decidual reaction on the peritoneum (one woman), and a combination of virilizing and estrinizing signs (one woman). There were three histologic patterns: simple tubular, complex tubular, and folliculome lipidique. Two neoplasms recurred, both of which had the distinctive feature of invasion of the supporting stroma by individual and columns of tumor cells in the original tumors. Electron microscopic evaluation of three neoplasms disclosed. Charcot-Böttcher filaments unequivocally identifying the Sertoli differentiation of the predominant cells in the neoplasm. The identification by electron microscopy of a smaller population of cells within the three tumors similar to typical ovarian stromal cells suggests that Sertoli tumors arise from ovarian stromal cells.

Sertoli cell tumor (gonadal stromal tumor) in an infant

An 8-mo-old boy had an orchiectomy for a Sertoli cell tumor. Malignancy was suspected histologically. He underwent a retroperitoneal lymphadenectomy and no nodes contained metastases. The histologic criteria for malignancy in Sertoli cell tumors are controversial. Individual case reports of patients with these tumors are encouraged to help establish their natural history and optimum management.

Sertoli cell tumor of testis

A case is reported of a patient with Sertoli cell tumor of the testis, the second known to have had a lymphangiogram and the third with histopathologic examination of retroperitoneal lymph nodes. Lymphangiography was performed because of extension of the tumor through the tunica albuginea into the adjacent adherent scrotum at the site of previous testicular biopsy. The lymphangiogram proved to be falsely positive following retroperitoneal lymph node dissection. The patient has remained clinically free of tumor for eight years.

Bilateral Sertoli cell tumor of testes with feminizing and masculinizing activity occurring in a child

A case of an unusual, histologically atypical, bilateral Sertoli cell tumor of testis, in association with masculinization and feminization effects, that occurring in a 5-year-old boy, is presented. Although Sertoli cell tumors are not infrequent, this case is morphologically and endocrinologically unique.