Malignant Leydig cell tumour of the testis: a case report and review of the literature

Malignant testicular unclassified sex cord stromal tumor: a case report

Background

Most testicular tumors are germ cell tumors; sex cord stromal tumors are infrequent, accounting for only 3–5% of testicular tumors. Unclassified sex cord stromal tumors are extremely rare. Generally, 10% of sex cord stromal tumors are malignant. We report a case of malignant unclassified sex cord stromal tumor with retroperitoneal lymph node metastasis at first visit and a corresponding literature review.

Case presentation

A 72-year-old Japanese man visited our department primarily for indolent right scrotum enlargement in September 2020. Blood biochemistry examination, urinalysis, and tumor markers (alpha-fetoprotein, human chorionic gonadotropin, and lactate dehydrogenase) showed no abnormal findings. Contrast-enhanced computed tomography showed enlarged para-aortic lymph node (18 × 16 and 10 × 10² mm); a 50 × 45² mm mass with uneven contents was found in the right testicle. The patient underwent inguinal orchiectomy in September 2020. As per immunohistochemistry, the tumor cells were diffusely positive for SF-1 and Ki-67, partially positive for inhibin, and negative for CAM5.2, CK7, CK20, C-KIT, CD30, LCA, GATA-3, TTF-1, and PAX8. Calretinin was expressed in approximately 5% of tumor cells; thus, sex cord/gonadal stroma components were considered to be involved. The final pathological diagnosis was unclassified malignant sex cord stromal tumor. The patient was diagnosed with pT1, N1, M0, S0, and tumor–node–metastasis stage IIA disease. The patient received postoperative chemotherapy with four courses of etoposide and cisplatin therapy from November 2020. Post-chemotherapeutic computed tomography showed new metastatic lesions including lung, liver, pancreas, and para-aortic lymphadenopathy, which increased in size. Disease progression was observed. Cancer genome research was performed using the OncoGuide National Cancer Center oncopanel system; however, no gene mutation for which the drug could be expected to be effective was found. The patient opted for best supportive care at a nearby hospital and died from cancer progression in January 2022.

Conclusion

We encountered a case of malignant testicular unclassified sex cord stromal tumor pathologically diagnosed as testicular tumor with retroperitoneal lymph node metastasis in a patient who underwent inguinal orchiectomy. Future data collection is necessary to establish multimodality therapy for malignant testicular unclassified sex cord stromal tumor.

Promising Immunotherapy in Metastatic Testicular Sex Cord Stromal Tumours After First-Line Chemotherapy

Background

Testicular sex cord stromal tumours (TSCSTs) are rare, with few studies focusing on the metastatic TSCST prognosis. The value of treatments, including radical orchiectomy (RO) and retroperitoneal lymph node dissection (RPLND), in preventing metastasis is controversial. Additionally, metastatic TSCSTs are resistant to chemotherapy. We aimed to assess the effectiveness and safety of immunotherapy in metastatic TSCSTs after first-line chemotherapy.

Methods

We retrospectively screened patients with testicular tumours undergoing testis surgery between January 2005 and January 2019. Patients with TSCSTs who had undergone testis-sparing surgery (TSS) or RO were identified. The malignant type was defined as metastasis confirmed by pathology. Treatment responses, progression-free survival (PFS), overall survival (OS) and safety were analysed.

Results

Among the 494 testicular tumour patients who received TSS or RO, 11 (2.2%) patients with histologically proven TSCSTs were identified. At the last follow-up, 7 patients survived without tumours, and 4 patients developed metastasis and received first-line cisplatin-based chemotherapy, with 1 of them achieving an objective response. Their PFS times were 1.5, 2.2, 9.0, and 17.0 months, respectively. Two patients received immune checkpoint inhibitors (ICIs) after developing chemotherapy resistance and achieved a partial response up to the last follow-up; one of them experienced Grade 1 adverse events, and the other experienced Grade 2 adverse events during immunotherapy. The median OS time of the 4 patients with metastatic TSCSTs was 32 months.

Conclusions

TSCSTs are rare, and most are benign with a good prognosis. ICIs represent a promising option for improving clinical outcomes in metastatic TSCSTs.

Malignant leydig cell tumor in a 91-year-old man: Case report

Testicle tumors are a rare entity among men population, accounting for only 1-1.5% of all cancers among men. The stromal tumors of the sexual cord correspond just 4% of all testicular cancers. Only 10% of them are malignant. The major representative of the sex cord-stromal tumors is the Leydig cell tumor, corresponding to 75 to 80% of the total. It has bimodal age incidence, involving children and adults between 30 and 60 years. We report the caso of a 91-year-old man with malignant Leydig cell tumor, presenting increase of the volume of scrotum, local pain and hyperemia. The are few cases in the literature, only 1 with pacient above 85 years old.

The legacy of the F344 rat as a cancer bioassay model (a retrospective summary of three common F344 rat neoplasms)

The Fischer 344 (F344) rat was used by the National Toxicology Program (NTP) for over 5 decades for toxicity and carcinogenicity studies. However, in 2006, the NTP decided to switch to a different rat stock due largely to high background control incidences of Leydig cell tumors (LCTs) and mononuclear cell leukemia (MNCL), also known as large granular lymphocytic (LGL) leukemia. In the current review, we aim (1) to provide a summary of NTP bioassays with treatment-associated effects involving MNCL and LCTs in addition to male F344-specific tunica vaginalis mesothelioma (TVM); (2) to describe important pathobiological differences between these F344 rat tumor responses and similar target tissue-tumor response in humans; and (3) to present the NTP reasons for switching away from the F344 rat. We show that due to the highly variable background incidence of F344 MNCL, more reliance on historical control data than is usual for most tumor responses is warranted to evaluate potential effect of any chemical treatment in this rat strain. The high spontaneous incidence of LCTs in the testes of male F344 rats has made this tumor endpoint of little practical use in identifying potential testicular carcinogenic responses. TVM responses in F344 rats have a biological plausible relationship to LCTs unlike TVM in humans. Given their high spontaneous background incidence and species-specific biology, we contend that MNCL and LCT, along with TVM responses, in F344 rat carcinogenicity studies are inappropriate tumor types for human health risk assessment and lack relevance in predicting human carcinogenicity.

Eleven patients with testicular leydig cell tumors: clinical, imaging, and pathologic correlation

We present the sonographic and magnetic resonance imaging findings of Leydig cell tumors in a series of patients, along with a brief review of the literature. We evaluated the sonographic features of 11 cases of Leydig cell tumors, including echogenicity, size, margins, and patterns of vascularity. The magnetic resonance imaging characteristics of 9 patients were also assessed, with special attention to the appearance of the tumors on T2-weighted imaging and postcontrast T1-weighted imaging. Seven tumors were hypoechoic, and 4 were almost isoechoic. Ten patients showed various patterns of hypervascularity in the tumors, combined in some cases with feeding vessels. One case presented with a single feeding vessel. The tumors showed homogeneous or heterogeneous low signal intensity on T2-weighted imaging and marked enhancement on postcontrast T1-weighted imaging. The small size of these tumors, the various patterns of vascularity on color and power Doppler sonography, and the marked enhancement on postcontrast T1-weighted imaging are considered valuable but generally nonspecific for identification of these tumors.

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.

Management of Adult Leydig-Cell Testicular Tumors: Assessing the Role of Laparoscopic Retroperitoneal Lymph Node Dissection

BACKGROUND AND PURPOSE

Leydig-cell tumors represent <5% of malignant testicular tumors in adults. Orchiectomy is curative in approximately 90% of cases; however, the remaining men can develop metastases refractory to chemotherapy and radiation. We evaluated the role of laparoscopic retroperitoneal lymph node dissection (RPLND) in adult Leydig-cell tumors.

PATIENTS AND METHODS

Between 1999 and 2001, laparoscopic RPLND was performed with four transperitoneal ports within a unilateral template for six patients with pure Leydig-cell tumors. Presenting signs and symptoms, operative time, blood loss, intraoperative complications, postoperative complications, length of hospitalization, pathology reports, ejaculatory function, and survival were reviewed retrospectively.

RESULTS

Laparoscopic RPLND was successful, without open conversions or reinterventions. Two vascular injuries occurred during dissection; additional intraoperative complications were not observed. Postoperatively, one patient developed erysipelas, but no other postoperative complications were recorded. The mean operative time was 190 minutes, and the mean length of hospitalization was 4.3 days. Pathologic analysis of lymph nodes revealed no evidence of metastatic Leydig-cell tumor. At 12 months' mean follow-up (range 3-29 months), no recurrences have been identified.

CONCLUSIONS

Laparoscopic RPLND is a safe, minimally invasive procedure for Leydig-cell tumors. Additional clinical experience is required to evaluate its effectiveness for pathologic stage II tumors and to determine if a therapeutic advantage can be realized with a protocol employing laparoscopic RPLND for adult Leydig-cell tumors.

Spinal cord compression from metastatic Leydig's cell tumor of the testis: case report

A case of spinal cord compression from metastatic Leydig's cell tumor of the testis is presented. This 67-year-old man exhibited paraparesis and neurogenic bladder dysfunction secondary to a spinal epidural mass at the T5 level as the initial manifestation of his cancer. Surgical resection was undertaken for tissue diagnosis and spinal cord decompression. The histopathological features of the epidural mass and the excised left testicle were identical, indicative of Leydig's cell carcinoma. The literature is reviewed for previous experience with this exceedingly rare tumor. Unlike most metastatic spinal malignancies, radiation therapy is an ineffectual treatment modality for this tumor. Surgical resection is the only therapeutic option available for amelioration of spinal cord compression.

Therapy of gonadal stromal cell testicular tumours

At our regional centre, 504 patients with testicular tumour were treated from 1 January 1980 to 31 December 1993. In the course of the treatment, 10 patients (2%) with gonadal stromal cell testicular tumours were found. Histopathological examination identified Sertoli cells in 3 cases, granulosa cells in 1 case, and Leydig cell primary tumours in 6 cases. Leydig cell testicular tumours, the most significant clinically, should not be regarded as benign. In 3 of 6 cases metastatic processes developed. Three patients died in spite of the surgical and chemotherapeutic interventions. Analysis of these cases suggests that, following the semicastration of Leydig cell testicular tumours, a primary retroperitoneal lymph node dissection should be performed, and an exact identification of the pathological stage should be carried out.