Conservative Surgical Therapy for Leydig Cell Tumor

Ultrasound contrast-enhanced diagnosis of testicular Leydig cell tumor: A case report and literature review

Leydig cell tumor (LCT) is a rare testicular tumor. We report a case of an elderly male patient who discovered a left testicular mass during a regular health examination four years ago. The patient did not experience any significant discomfort and opted for regular follow-up visits. During the most recent visit, we performed routine ultrasound and contrast-enhanced ultrasound (CEUS) examinations. By observing the lesion's location, echogenicity, margins, vascular distribution, as well as the rapid enhancement and slow washout characteristics on contrast-enhanced ultrasound, we arrived at a diagnosis of LCT. Subsequently, the patient underwent left inguinal orchiectomy. Postoperative pathology and immunohistochemistry confirmed the diagnosis of LCT. Additionally, we conducted a comprehensive review of LCT-related literature from PubMed and SCOPUS, summarizing the clinical features, follow-up duration, prognosis, and ultrasound characteristics associated with LCT.

Pediatric, adolescent, and young adult breast and reproductive tumors

Tumors of the breast and reproductive organs that occur in children, adolescents, and young adults (AYA) have different biological features and can present special challenges. Although prognosis for these tumors is generally favorable, the long-term effects of treatment can be debilitating. Treatments are often multimodal and may include surgery as well as chemotherapy and/or radiation, which can cause considerable distress and anxiety related to loss of femininity or masculinity, concern over future fertility, or sexual dysfunction. Thus, tumors of the reproductive organs in pediatric/AYA patients require special consideration of the treatment effects beyond the intended oncologic outcome. Multidisciplinary teams should be involved in their care and address issues of fertility, sexual dysfunction, and psychosexual concerns before treatment begins. This review addresses histology, risk factors, prognosis, staging and treatment of gynecologic, breast and testicular cancers in pediatric and AYA patients.

Outcomes of organ-sparing surgery for adult testicular tumors: A systematic review of the literature

Objective

To perform a systematic review on the effects of testicular sparing surgery (TSS) on the oncological, functional, and hormonal outcomes of adults with testicular tumors.

Methods

A literature search was performed after PROSPERO registration (CRD42020200842) and reported in compliance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methods. We conducted a systematic search of Medline (Ovid), Embase, Cochrane CENTRAL, CINAHL, Scopus, Web of Science, ClinicalTrials.gov, and the WHO/ICTRP from inception to November 20, 2020. Manuscripts and published abstracts were included if they involved testis-sparing surgery (TSS) and contained data on any outcomes related to fertility, hormonal parameters, or oncological control, or if they evaluated surgical technique.

Results

Our initial search yielded 3,370 manuscripts, with 269 of these screened for full-text eligibility. After our exclusion criteria were applied, 32 studies were included in the final analysis. Oncological outcomes were obtained from 12 studies (average follow-up 57.8 months), functional data from 26 studies (average follow-up 49.6 months), fertility information from 10 studies (average follow-up 55.8 months), and data on nonpalpable tumors from 11 studies (average follow-up 32.1 months). Oncological control appears to be excellent in studies that reported these outcomes. Presence of germ cell neoplasia in situ was controlled with adjuvant radiation in nearly all cases. Functional outcomes are also promising, as development of primary and compensated hypogonadism was rare. Semen parameters are poor preoperatively among men with benign and malignant testis tumors, with occasional decline after TSS. Frozen section analysis at the time of surgery appears to be very reliable, and the majority of nonpalpable tumors appear to be benign.

Conclusions

TSS is a safe and efficacious technique with regards to oncological control and postoperative hormonal function based on retrospective, noncontrolled studies. TSS avoids unnecessary removal of benign testicular tissue, and should be given serious consideration in cases of nonpalpable, small tumors under 2 cm. In cases of malignancy, TSS can safely avoid anorchia in men with bilateral tumors and in men with solitary testicles. The use of the operating microscope, while theoretically promising, does not necessarily lead to better outcomes, however data are limited.

Oncological and functional outcomes of testis sparing surgery in small testicular mass: a systematic review

INTRODUCTION

The prevalence of testicular tumor is constantly increasing, with an estimated incidence rate of about 3-10 new cases per 100,000 males/per year. Radical orchiectomy or testis sparing surgery (TSS) are recognized therapeutic approaches in these cases. However, the risk for hypogonadism and infertility is higher with the former compared with the latter. The aim of this systematic review is to evaluate the oncological outcome and testicular function (endocrine and reproductive aspects) in patients who had undergone TSS for small testicular lesions.

EVIDENCE ACQUISITION

To accomplish this, 684 articles were retrieved and screened; 24 retrospective and two prospective studies were selected and finally included in this systematic review.

EVIDENCE SYNTHESIS

Overall the TSS attempts were 1096 but TSS was definitively performed in 603 cases (55%). Frozen section examination was performed in 996 TSS attempts (22 out of the 26 studies selected) and showed a benign histology in 37-100% of cases, a malignant histology in 0-63%, and an inconclusive result in 0-16%, respectively. Five studies reported that a total of 22 patients were able to father after conservative surgery. None of these studies reported cases of hypotestosteronemia after surgery and a low prevalence (1.66%) of complications was associated with this type of surgery.

CONCLUSIONS

In conclusion, TSS showed to be safe and practicable if used according to the specific guidelines. It can be safely performed to treat recurrence eventually associated to local adjuvant radiotherapy when an intra-tubular neoplasia is present. Urologists can therefore consider TSS as an important means against testicular tumor in selected and well-informed patients.

Testis-preserving strategies in testicular germ cell tumors and germ cell neoplasia in situ

Testicular germ cell tumors (TGCT) are rare malignancies which affect young adults and adolescents between the ages of 15 and 40 years. In suspected malignant TGCT, the treatment of choice is radical orchiectomy. However, in specific cases this routine surgical approach has been challenged in favor of an organ-preserving approach with comparable oncological outcome. Thus, testis-preserving strategies should be considered in unilateral or bilateral synchronous or metachronous TGCT as well as incidentally found small testicular masses, which are mostly benign lesions including Sertoli cell tumors, Leydig cell tumors, adenomatoid tumors or epidermoid cysts. In case of a testis-preserving surgery, adjuvant postoperative radiation therapy (20 Gy) is recommended. The rational for this approach is that the remaining parenchyma harbors germ cell neoplasia in situ (GCNIS), which might lead to locally recurrent TGCT in 50% in the next following 5 years. However, testicular radiotherapy might result in infertility and 'Sertoli-cell only' syndrome because of radiation-induced destruction of germ cells as well as Leydig cell insufficiency in 20% of all patients leading to life-long androgen substitution. Therefore, radiation therapy should be delay or sperm banking be should performed in fertile patients wish to have children. This review provides an overview on literature regarding testis-preserving strategies in TGCT as well as GCNIS.

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.

Testis-sparing surgery: Experience in 13 patients with oncological and functional outcomes

INTRODUCTION

We present oncological and functional outcomes of patients who underwent testis-sparing surgery (TSS).

METHODS

Overall, 13 patients were included. Mean patient age was 29.9±12.5 years. In five patients, TSS was performed for sequential bilateral testicular tumours. One patient underwent concurrent left radical orchiectomy and right TSS. In eight patients with normal contralateral testis, seven underwent left and one underwent right TSS.

RESULTS

Mean pathological tumour size was 14.6±12.5 mm. Intraoperative frozen section evaluation of the mass was performed in eight patients that revealed benign lesions. No intraoperative tumour bed biopsies were taken in this patient group. Regarding the remaining five patients, intraoperative tumour bed biopsies were taken and testicular intraepithelial neoplasia (TIN) was reported in two (40%) patients; no local testicular radiotherapy was given postoperatively. Tumour pathology was malignant in all but one lesion, including Leydig cell tumour (n=1), seminoma(n=2), embryonal carcinoma (n=1), and adenomatoid tumour (n=1). During 47.2±22.5 months of followup, local recurrence was detected in one patient who underwent radical orchiectomy. No additional local recurrence or systemic metastasis was identified in other patients with malignant lesions. For patients with malignant tumours, of the three patients with a normal preoperative testosterone levels, testosterone level was normal in one patient (with no erectile dysfunction [ED]) and was decreased in two patients (with ED) following TSS. No ED was reported in the nine patients with benign lesions.

CONCLUSIONS

In carefully selected cases, TSS appears to be a safe, feasible procedure with adequate cancer control that could preserve sexual function.

Testicle-sparing surgery versus radical orchiectomy in the management of Leydig cell tumors: results from a multicenter study

OBJECTIVE

To compare the oncological outcomes of testicle-sparing surgery (TSS) and radical orchiectomy (RO) in patients with Leydig cell tumor (LCT) of the testis.

PATIENTS AND METHODS

A multicenter retrospective clinical study was conducted in 12 centers in France. All the patients with histologically proven LCT were included and analyzed according to treatment (organ-sparing surgery or radical orchiectomy). Patients underwent preoperative clinical, biological and imaging assessment. Demographic, clinical, and pathological variables were collected at baseline and compared between groups according to surgical treatment. Follow-up was calculated using the reverse Kaplan-Meier estimation and was updated at the end of 2015.

RESULTS

Between 1986 and 2014, 56 patients presented with LCT were identified and included in the study. Twenty-one patients (37.5%) underwent TSS and 35 (62.5%) RO. Demographics and tumor characteristics were not significantly different between the groups. Median follow-up was 62 months after TSS, but only 35 months after RO. Two patients (9.5%) developed local recurrence 15 and 34 months after TSS and underwent secondary RO. No local recurrence or metastasis was observed after complementary treatment. No recurrence was observed after RO. Disease-free survival did not differ between the groups (95.2% in TSS versus 77.1% in the RO group, p = 0.23). No patient died in the TSS group, but three patients (8.6%) in the RO group died from other diseases without evidence of relapse. One patient (4.8%) in the TSS group versus five (14.3%) in the RO group were lost to follow-up.

CONCLUSION

Long-term follow-up suggests that testicle-sparing surgery does not compromise relapse-free survival in the treatment of Leydig cell tumor of the testis.

The natural history of Leydig cell testicular tumours: an analysis of the National Cancer Registry

BACKGROUND

Leydig cell tumour (LCT) of the testis is a rare histological subtype of stromal tumours, accounting for 1 to 3% of testicular neoplasms. The natural history of LCT is poorly understood.

AIMS

The aim of this study was to assess the incidence and natural history of Leydig cell tumours (LCT) of the testes.

METHODS

A search of the National Cancer Registry of Ireland database was performed regarding Leydig cell testicular tumours. Recurrence free survival (RFS) and disease-specific survival (DSS) were analysed.

RESULTS

Between 1994 and 2013, 2755 new cases of testicular cancer were diagnosed in Ireland. Of these, 22 (0.79%) were Leydig cell tumours. Nineteen were invasive (stage T1) and three were in situ (stage Tis). One patient developed a local recurrence following an organ preserving procedure and underwent a completion orchidectomy 107 days after initial diagnosis. No further treatment was required. There have been no disease-specific deaths. The 1-, 3- and 5-year overall survival (OS) rates were 95.5, 88.2 and 73.3%, respectively. The 5-year disease-specific survival (DSS) was 100% and the 5-year recurrence free survival (RFS) was 93.3%.

CONCLUSION

From the National Cancer Registry, LCT has been shown to be a rare subtype of testicular tumour. Due to the relatively favourable natural history, it may be possible to tailor less aggressive surveillance regimens in these patients.

Treatment of leydig cell tumours of the testis: Can testis-sparing surgery replace radical orchidectomy? Results of a systematic review

INTRODUCTION

The gold standard for Leydig cell tumours (LCTs) is still considered radical orchidectomy, but testis sparing surgery (TSS) in conjunction with intraoperative frozen section (FSE) has been recently attempted with promising results.

ACQUISITION OF EVIDENCE

Studies were identified by searching electronic databases. A bibliographic search covering the period from January 1980 to December 2012 was conducted using PubMed/MEDLINE and EMBASE database. Studies were excluded if they were single case reports, meeting abstracts and conference proceedings.

SYNTHESIS OF EVIDENCE

The present analysis is based on a total of 13 studies that fulfilled the predefined inclusion criteria. A total of 247 participants were included in the 13 studies examined in this systematic review. 145 were treated with radical orchiectomy and 102 with TSS. In the radical surgery group, the follow-up varied from 6 to 249 months). In the TSS group, the follow-up varied from 6 to 192 months. Frozen section was performed in a total of 96 patients. Sensitivity was 87.5%. None of the patients treated with TSS presented a metastatic recurrence, while in patients treated with radical orchiectomy three patients presented with metastatic recurrence In selected cases radical surgery appears excessive and the potential for a shift to TSS as the standard management is gathering momentum.

CONCLUSIONS

The results confirm the favourable course of LCT treated with TSS. The results obtained are encouraging and the concept is attractive to become the standard therapy in all patients and not only in people affected by (sub)fertility or with solitary testis.

Leydig cell tumor of the testis with azoospermia and elevated delta4 androstenedione: case report

Background

Secreting interstitial cell (Leydig cell) tumors are rare. In adults, the clinical picture and steroid levels are variable.

Case presentation

This paper presents a case of left testicular tumor, showing azoospermia with normal serum level of total testosterone, collapsed FSH and LH, and high delta4 androstenedione. Histopathological investigation revealed a Leydig cell tumor. TESE allowed spermatozoa extraction and freezing. Testicular histology found hypospermatogenesis and germ-cell aplasia with interstitial fibrosis. Surgical resection of the tumor resulted in normalization of gonadotropins and fall in serum delta4 androstenedione to subnormal levels in the postoperative period confirming that the tumor was secreting delta4 androstenedione. It was hypothesized that high delta4 androstenedione resulted in intra tumoral 17 β-HSD overtaken by delta4 androstenedione or that 17 β-HSD activity in the tumor was different from that of normal Leydig cells. Three months after surgery sperm analysis found a complete recovery of spermatogenesis. A spontaneous pregnancy occurred 3 months after surgery and a girl was born.

Conclusions

In this case, the diagnosis of testicular Leydig cell tumor secreting delta4 androstenedione was made in a context of azoospermia.

Value of dynamic, contrast-enhanced MRI & intraoperative ultrasound for management of a nonpalpable, incidental, testicular Leydig-cell tumor

We report a case of a small, intratesticular, incidentally identified, nonpalpable Leydig-cell tumor in which preoperative, dynamic, contrast-enhanced MRI was essential in characterizing the lesion as a neoplasm. Sonographic evaluation failed to demonstrate internal color Doppler flow, resulting in a differential diagnosis that included debris-filled cyst. At surgical resection, intraoperative ultrasound was essential to locate the mass and confirm complete removal. This case highlights the value of dynamic, contrast-enhanced MRI and intraoperative ultrasound for the management of incidental intratesticular lesions with indeterminate sonographic and Doppler characterization. Radiologists and urologists should be familiar with this approach to the incidental, sonographically indeterminate, nonpalpable intratesticular lesion identified on scrotal ultrasound.

Organ-sparing surgery for testicular tumours

PURPOSE OF REVIEW

Testicular cancer represents the majority of testicular masses, and radical orchiectomy is still considered the standard-of-care. Testis-sparing surgery (TSS) can be an alternative to radical surgery in patients with small testicular tumours, bilateral or solitary testis masses. The aim of this manuscript is to review the current indications, oncological and functional outcomes of TSS.

RECENT FINDINGS

Our review confirmed that literature lacks studies with a high level of evidence on comparing TSS with radical surgery. Indications for TSS are controversial, specifically for patients with normal contralateral testis. For nonpalpable testicular masses less than 2 cm, bilateral tumours and solitary testis mass, TSS seems to be a viable treatment option. Frozen-section examination is a critical tool for assessment at the time of TSS that allows for diagnosis of benign from malignant tumours and evaluation of margin. TSS has been shown to be associated with less fertility alterations, hormonal deficit and potential lower impact on sexual and psychosocial aspects. Intermediate to long-term follow-up results have not revealed any significant risk of local and/or distant recurrences after TSS.

SUMMARY

TSS is well tolerated and feasible for selected patients with testicular mass without compromising oncological and functional outcomes. Further studies with a higher level of evidence are needed to confirm these findings.

Leydig cell tumor in a patient with 49,XXXXY karyotype: a review of literature

49,XXXXY pentasomy or Fraccaro's syndrome is the most severe variant of Klinefelter's syndrome (KS) affecting about 1/85000 male births. The classical presentation is the triad: mental retardation, hypergonadotropic hypogonadism and radio ulnar synostosis. Indeed, the reproductive function of Fraccaro's syndrome is distinguished from KS. Besides, Leydig cell tumors are described in cases of KS, but never documented in the Klinefelter variants.We describe a young adult of 22 years old who presented with hyper gonadotropic hypogonadism, delayed puberty and bilateral micro-cryptorchidism. Chromosomal pentasomy was confirmed since infancy. Bilateral orchidectomy revealed a unilateral well-circumscribed Leydig cell tumor associated with bilateral Leydig cell hyperplasia.Inspired from reporting the first case of Leydig cell tumor in a 49,XXXXY patient, we summarize the particularities of testicular function in 49,XXXXY from one side, and the risk and mechanisms of Leydig cell tumorigenesis in Klinefelter variants on the other side. The histological destructions in 49,XXXXY testes and hypogonadism are more profound than in Klinefelter patients, with early Sertoli, Leydig and germ cell destruction. Furthermore, the risk of Leydigioma development in KS and its variants remains a dilemma. We believe that the risk of Leydigioma is much higher in KS than the general population. By contrast, the risk could be lower in the Klinefelter variants with more than 3 supplementary X chromosomes, owing to an earlier and more profound destruction of Leydig cells rendering them irresponsive to chronic Luteinizing hormone (LH) stimulation.

Efficacy of ultrasound-guided testicle-sparing surgery for small testicular masses

PURPOSE

The aim of the present study was to evaluate evolution of conservative echo-guided surgery for testicular tumours ≤1.5 cm and to assess the safety of this surgical procedure.

METHODS

49 consecutive patients diagnosed with ultrasonography testicular lesions (mono or bilateral) ≤1.5 cm and treated with conservative echo-guided testicular surgery were examined. The parameters considered in this retrospective analysis included case history, physical examination, scrotal and abdominal ultrasonography, computed tomography scan, size of the nodule (maximum diameter), tumour markers, chest radiography, frozen section examination, histologic size of the tumour, overall survival (OS) and findings on follow-up.

RESULTS

Mean age of patients was 33 years (range 18-62). Patients who presented with a palpable testicular nodule were 32.7 %, gynecomastia 10.2 %, precocious pseudopuberty 4 %, and scrotal pain 12.2 %. Permanent section examination confirmed the FSE data in all cases of certainty malignant lesion and definitive histological types were: 22 seminoma, 13 non-seminomatous or mixed germ cell tumours, 4 Leydig tumours, 2 hamartoma, 1 epidermoid cyst, 2 sertoli cell tumours, and 5 fibrous pseudotumour. No complications intra- and postoperative were observed. Overall survival was 100 % and scrotal US showed evidence of local tumour recurrence in 6 patients (12.2 %) after a mean follow-up of 34.7 months.

CONCLUSION

The OS, the low rate of local recurrence, and absence of complications, tend to demonstrate the safety of the procedure. The benefits to testicular-sparing surgery include improving the patient's overall quality of life, fertility, endocrine function and negative cosmetic effects of radical orchiectomy.

Role of testis sparing surgery in the conservative management of small testicular masses: oncological and functional perspectives

INTRODUCTION

Radical orchiectomy (RO) is still considered the standard of care for malignant germ cell tumours, which represent the vast majority of the palpable testicular masses. In those patients diagnosed with small testicular masses (STMs), testis-sparing surgery (TSS) could be an alternative treatment to RO. The aim of this updated review is to evaluate the current indications for TSS, and discuss the oncological and functional results of patients who had undergone organ-sparing surgery for STMs.

EVIDENCE ACQUISITION

A non-systematic review of the Literature using the Medline database has been performed, including a free-text protocol using the terms "testis-sparing surgery", "testicular sparing surgery", "partial orchiectomy", "testis tumour", "sex cord tumour", and "testis function". Other significant studies cited in the reference lists of the selected papers were also evaluated.

EVIDENCE SYNTHESIS

No randomized controlled trials comparing TSS with radical orchiectomy have been reported yet. In those patients with normal contra-lateral testis, the use of TSS is still controversial. In selected cases of gonadal masses < 2 cm, TSS seems to be a safe and feasible treatment option. Frozen section examination allows us to discriminate between benign and malignant neoplasms during TSS. Intermediate and long-term follow-up results showed no significant risk of local and distant recurrences in the main series reported in the literature.

CONCLUSIONS

TSS is an effective treatment for STMs in selected patients, limiting the unnecessary surgical over-treatments, without compromising the oncological and functional outcomes. Further studies are needed in order to confirm the oncological safety.

Switch of cadherin expression as a diagnostic tool for Leydig cell tumours

Leydig cell tumours comprise about 3% of all testicular tumours. The pathogenesis of Leydig cell tumours is still poorly understood. We investigated testis with Leydig cell hyperplasia and Leydig cell tumours for their expression pattern of P- and N-cadherin. We could show a switch of expression of P- and N-cadherin in Leydig cell hyperplasia and Leydig cell tumours in comparison with normal Leydig cells. Cadherins could be established as a new immunohistochemical marker for this testicular tumour entity; their possible role in tumour genesis will be discussed.

Testicular tumors in patients with exstrophy-epispadias complex

PURPOSE

Due to separated pubic bone and patent processus vaginalis, males with exstrophy-epispadias complex often present with inguinal hernia during infancy. Since most of these testicles are operatively repositioned, testicular development is assumed to be normal. However, there is a paucity of knowledge about long-term testicular development in males with exstrophy-epispadias complex. We identified males with sonographic intratesticular abnormalities or testicular tumor in exstrophy-epispadias complex.

MATERIALS AND METHODS

Since 2003, a Germany wide cross-sectional followup study has been permanently offered to men with exstrophy-epispadias complex, focusing on andrological issues. A total of 22 men with exstrophy-epispadias complex presented to our clinical service for andrological evaluation, including testicular ultrasound.

RESULTS

Sonography showed testicular and epididymal pathology in more than 50% of patients, with intratesticular abnormality in 23%, most commonly testicular microlithiasis (9%). Three patients underwent testicular biopsy. Histopathological evaluation revealed 1 case of testicular intraepithelial neoplasia and 2 benign testicular stromal tumors (1 Sertoli cell tumor and 1 Leydig cell tumor). Followup visits at 10, 28 and 68 months were uneventful.

CONCLUSIONS

The observation of comorbid testicular tumor in males with exstrophy-epispadias complex should prompt a preventive health examination after puberty, which gives these patients the opportunity for further appropriate diagnostics and treatment if necessary. Biopsy is recommended for sonographically detected intratesticular lesions. Organ sparing procedures are worth considering, especially when stromal tumors with favorable outcome are discovered. However, current oncologic principles must be strictly followed. Although the etiology and true incidence of testicular tumors in exstrophy-epispadias complex are still unclear, our findings highlight the importance of long-term followup in patients with exstrophy-epispadias complex.

Leydig Cell Tumor Associated with Testicular Adrenal Rest Tumors in a Patient with Congenital Adrenal Hyperplasia due to 11β-Hydroxylase Deficiency

Congenital adrenal hyperplasia (CAH) describes a group of inherited autosomal recessive disorders characterized by enzyme defects in the steroidogenic pathways that lead to the biosynthesis of cortisol, aldosterone, and androgens. Chronic excessive adrenocorticotropic hormone (ACTH) stimulation may result in hyperplasia of ACTH-sensitive tissues in adrenal glands and other sites such as the testes, causing testicular masses known as testicular adrenal rest tumors (TARTs). Leydig cell tumors (LCTs) are make up a very small number of all testicular tumors and can be difficult to distinguish from TARTs. This distinction is interesting because LCTs and TARTs require different therapeutic approaches. Hereby, we present an unusual case of a 19-year-old patient with CAH due to 11β-hydroxylase deficiency, who presented with TARTs and an epididymal Leydig cell tumor.

Testis-sparing surgery for benign and malignant tumors: A critical analysis of the literature

In order to explore the latest advances in organ-sparing treatment of testicular tumors, a literature search of the Medline/PubMed database was carried out for published data in the English language up to 2007.

In the recent past the management of testicular tumors has evolved in favor of a testis-sparing approach in selected cases, both in the adult and pediatric population. The widespread use of high-frequency testicular ultrasound has led to detecting an increasing number of asymptomatic, non-palpable, small-volume masses. A higher proportion of testicular lesions of benign nature than previously reported has now been documented. The high accuracy of frozen section examination and the increasing interest in the potential functional, psychological and cosmetic advantages related to preserved testicular parenchyma are other arguments currently favoring the adoption of an organ-sparing policy for most testicular masses. Greater experience has been gained in also managing conservatively malignant tumors. Patients with germ-cell cancer in solitary testis or bilateral tumors can be submitted to testis-sparing surgery, provided that the maximum size of the lesion is <2 cm, preoperative testosterone is normal and adjuvant radiotherapy of the residual parenchyma is delivered. Cancer-specific survival is excellent, local recurrence rate very low and androgen supplementation unlikely.

Les tumeurs testiculaires à cellules de Leydig: à propos de quatre cas et revue de la littérature

Introduction

Les tumeurs testiculaires à cellules de Leydig (TTCL) sont rares, elles représentent entre 1 et 3 % de l’ensemble des tumeurs testiculaires, ce sont les plus fréquentes des tumeurs des cordons sexuels et du stroma. Ces tumeurs se développent le plus fréquemment (55 %) chez les sujets jeunes de 15 à 35 ans, mais elles peuvent se voir aussi chez les enfants lors de la première décennie (20 %) et chez les hommes après 50 ans (25 %). Le mode de révélation le plus fréquent chez l’adulte est la gynécomastie, par contre chez l’enfant, c’est la pseudopuberté précoce isosexuelle. Elles posent le problème de leur diagnostic biologique devant des formes non palpables et du choix de leur traitement chirurgical en raison de la difficulté diagnostique entre les formes bénignes et malignes.

Matériel et méthodes

Nous rapportons quatre présentations différentes de cette pathologie dont les paramètres étudiés seront l’âge, le mode de révélation, le profil hormonal, le type de traitement et le mode évolutif.

Résultats

L’âge moyen de nos patients était de 37 ans et demi. Le mode de révélation était deux fois sur quatre en rapport avec une grosse bourse unilatérale, une fois pour grosse bourse bilatérale, une fois en rapport avec une gynécomastie. Dans tous les cas, la testostérone était normale ou basse et l’estradiol normal ou élevé. Les quatre patients ont subi une orchidectomie associée à une énucléation controlatérale chez un seul des patients. L’évolution était favorable pour tous nos patients, avec un recul moyen de 15 mois.

Conclusion

Le but de cette revue est de présenter, sur la base de quatre observations cliniques différentes et de l’analyse de la littérature, les différents aspects cliniques, biologiques, radiologiques pathologiques et thérapeutiques des TTCL.

Surgical enucleation of testicular leydigioma in a young child: case report and literature review

BACKGROUND

The leydigioma is the most frequent interstitial neoplasm of the testis. Clinical symptoms of all leydigioma usually are isosexual precocious pseudo-puberty due to autonomous testosterone overproduction, suppressed gonadotropin levels and a testis mass. Nowadays its therapy is debated.

DESIGN AND METHODS

We report a case of a young child treated in 2008 for a leydigioma of the testis with atypical clinical behavior. Testicular oncologic markers and hormonal profile were assessed.

RESULTS

The patient was treated successfully with organ-confined surgery.

CONCLUSION

We want to confirm the safety of conservative surgery against radical orchiectomy and review the literature of the last decade on this debated matter.

Leydig cell tumour revealed by bilateral gynecomastia in a 15-year-old adolescent: a patient report

Pubertal gynecomastia is common, and may affect up to 70% adolescents boys. Its course is spontaneously benign with resolution occurring by age 18 years. Although the exact physio-pathological mechanism remains unknown, it is thought to result from hormonal imbalance between estrogens and testosterone at puberty. Association with Leydig cell tumour is more common in adults, so that scrotal ultrasound is part of routine work up. A 15-years-old boy with Leydig cell tumour revealed by bilateral gynecomastia is reported. Diagnosing this condition requires high level of suspicion, we suggest that clinicians always do a testicular examination on adolescents especially if they have gynecomastia, scrotal ultrasound may be performed in boys aged > or =14 years with gynecomastia that measures > or =4 cm, should there be any doubt.

Targeted testicular excision biopsy: when and how should we try to avoid radical orchidectomy?

Small, incidental testicular lesions are often benign, but in the past have usually been treated by orchidectomy. An alternative is an operative excision biopsy, with localization by ultrasound if necessary, and characterization of the lesion by frozen section analysis. The present review summarizes the indications for the procedure, lists the likely diagnoses, and describes the technique. Frozen section is accurate for distinguishing benign from malignant lesions, testicular function is usually preserved, and there is no evidence that oncological safety is impaired. Such testis-preserving surgery is a rewarding ground for collaboration between urologists, radiologists, and pathologists.