Response of metastasized sex cord gonadal stromal tumor of the testis to cisplatin-based chemotherapy

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.

[Diagnosis and treatment of rare testicular tumors using the example of malignant mesothelioma of the tunica vaginalis testis and Sertoli cell tumors]

BACKGROUND

Rare tumors of the testis not originating from germinal epithelium are a diagnostic and therapeutic challenge.

OBJECTIVES

To present current approaches in rare tumors of the testis using the examples of Sertoli cell tumor (SCT) and malignant mesothelioma of the tunica vaginal testis (MMTVT).

METHODS

A literature search in PubMed and the abstract databases of ASCO and ESMO was performed. Articles and book chapters were selected based on relevance to everyday treatment.

RESULTS

The low incidence of testicular tumors not originating from the germinal epithelium makes a standardized approach difficult. Diagnosis and treatment depend on the underlying diagnosis. While most SCT are benign, malignant subtypes require extensive resection including metastatic surgery if complete resection is possible. In MMTVT, multimodality treatment concepts are followed, according to the malignant mesotheliomas of the pleura.

CONCLUSION

Systematic registration of rare testicular tumors and comprehensive molecular pathological analysis are urgently needed to improve the understanding of tumor biology and to develop new therapeutic strategies.

Sex cord stromal testicular tumors: a clinical series--uniformly stage I disease

PURPOSE

Sex cord stromal testicular tumors are rare. Historically 10% of lesions are said to be malignant but to our knowledge there are no clinical or histological features that can accurately predict potential malignant behavior. Because of this, groups at some centers have advocated prophylactic retroperitoneal lymph node dissection in patients with clinical stage I disease. We reviewed our experience with these tumors to determine whether this policy is justified.

MATERIALS AND METHODS

We retrospectively reviewed the records of all 38 men older than 18 years with sex cord stromal testicular tumors who were referred to the Wessex regional cancer center for treatment or pathological review during the 25-year period of 1982 to 2006. We then compared our series with a malignant sex cord stromal testicular tumor database generated from the world literature.

RESULTS

All Wessex patients were treated with excision of the primary tumor alone and metastatic disease developed in none. All remained disease-free with an overall median survival of 6.8 years (range 1.4 to 25). Features in the literature favoring malignant behavior, ie metastatic disease, included larger tumors (mean 6.43 vs 1.71 cm), a high mitotic rate, tumor necrosis, angiolymphatic invasion, infiltrative margins and extratesticular extension (each p <0.0001). The malignant group had an overall median survival of 2.3 years (range 0.02 to 17.3).

CONCLUSIONS

No patient had disease progression in our study, which is to our knowledge the largest reported United Kingdom series of sex cord stromal testicular tumors. Our data suggest that malignancy is uncommon and prophylactic retroperitoneal lymph node dissection is unjustified for clinical stage I disease.

Malignant undifferentiated sex cord-stromal testis tumor with brain metastasis: case report

Metastatic undifferentiated sex cord-stromal testis tumors are uncommon. We would like to present a rare case of undifferentiated sex cord-stromal testis tumor with brain metastasis. After presenting with a painless right testicular mass, the patient underwent right radical orchiectomy and retroperitoneal lymph node dissection. One month later, the patient had no visible evidence of tumor recurrence on the follow-up computed tomography of the chest, abdomen, and pelvis. Three months after the first follow-up, the patient was readmitted for new onset of shortness of breath, and 7th and 12th cranial nerve palsy. Computed tomography of the chest and magnetic resonance imaging of the brain showed evidence of distant metastasis. To our knowledge, undifferentiated sex cord-stromal tumor with brain metastasis has not been reported. As with any new onset neurologic deficits in patients with solid tumors, the presence of brain metastases should be considered.

A Serial Analysis of Gene Expression (SAGE) database analysis of chemosensitivity: comparing solid tumors with cell lines and comparing solid tumors from different tissue origins

Drug sensitivity and resistance has been most extensively studied in cell lines carried in tissue culture. Furthermore, cell lines have been widely used in testing new anticancer agents, despite the widely recognized observation that cell lines are more sensitive to cytotoxic drugs than are their corresponding solid tumors. We used the Serial Analysis of Gene Expression (SAGE) database to identify differences between solid tumors and cell lines, hoping to detect genes that could potentially explain differences in drug sensitivity. SAGE libraries were available for both solid tumors and cell lines from breast, colon, ovarian, pancreatic, and prostate carcinomas and from gliomas and medulloblastomas. Sixty-two genes were identified as overexpressed in tumors. The immune response and complement pathways were the significant common themes, with extracellular matrix (ECM) proteins third. For the 61 genes overexpressed in cell lines, protein synthesis was the dominant theme. We next used the SAGE database to identify genetic differences between tumor types that convey a broad range of survival to the patients that bear them as distant metastases. SAGE gene expression data were correlated with 5-year survivals documented in the SEER (Surveillance, Epidemiology and End-Results) database for patients diagnosed with "distant" or metastatic cancers. These are unlikely to be amenable to surgical resection; therefore, survival here reflects, to some extent, sensitivity to systemic therapy, i.e., chemotherapy. Using survival data as a surrogate of chemotherapy sensitivity, a spectrum can be generated, with testicular cancer at one end and pancreatic cancer at the other. Favorable 5-year survival, despite a distant presentation, correlates with expression of protein synthesis genes. Poor 5-year survival correlates with expression of cell adhesion, cytoskeletal, and ECM genes, a pattern similar to that found to distinguish solid tumors from the more cytotoxin-sensitive cancer cell lines. One interpretation is that resistance to chemotherapy may arise, in part, from the adherent, relatively inert condition (i.e., low in protein synthesis potential) of refractory cancers. Thus, attachment or ECM genes could be targets for anticancer therapy.

Does retroperitoneal lymph node dissection have a curative role for patients with sex cord-stromal testicular tumors?

BACKGROUND

Sex cord-stromal tumors account for < 5% of all adult testicular tumors, and 10% are malignant. Due to the limited reported experience, there is no agreement on the best management, especially in patients who have tumors with malignant pathologic features or who present with metastatic disease. The authors attempt to evaluate the role of retroperitoneal lymph node dissection (RPLND) in the management of patients with these malignant sex cord-stromal tumors.

METHODS

Reviewing the Indiana University testis cancer registry revealed 17 patients who underwent RPLND for sex cord-stromal tumors. Pathology was reviewed for features suggestive of malignancy. The data examined included clinical and pathologic stage, surgical procedure, additional therapy received, and outcome.

RESULTS

Pathology included Leydig tumors in six patients, Sertoli tumors in four patients, sex cord-stromal tumors in five patients, a granulosa cell tumor in one patient, and a poorly differentiated non-germ cell tumor in one patient. Nine patients had histologic features suggestive of malignancy. Clinical stage at surgery was Stage I in nine patients and Stage IIA-IIIA in eight patients. Patients underwent modified or bilateral RPLND. Nine patients had pathologic Stage I tumors, and the remaining eight patients and had pathologic Stage IIB-IIIA tumors. Follow-up ranged from 8 months to 11 years. Of the eight patients with Stage II-III disease, six patients eventually died of metastatic disease despite additional radiotherapy and/or chemotherapy.

CONCLUSIONS

Sex cord-stromal tumors have a potentially aggressive malignant behavior that is difficult to predict based on clinical and pathologic features. Although the therapeutic role of RPLND in patients with small-volume metastatic retroperitoneal tumors is unclear, RPLND remains an option to be performed immediately after orchiectomy, especially in patients who have tumors with malignant features and/or small-volume metastatic disease.

An enormous testicular sex cord/gonadal stromal tumor

Testicular sex cord/gonadal stromal tumors are relatively rare non-germ cell neoplasms. The authors describe an unusual case of an enormous unclassified sex cord/gonadal stromal tumor, which histologically appeared benign. The implications of the pathological findings and the surgical management are discussed.

Leydig cell tumour in a man with human immunodeficiency virus

We report a case of Leydig-cell testicular tumour in a 32-year-old intravenous drug abuser bearing HIV-infection and pulmonary tuberculosis. The testicular mass was initially interpreted as genital tuberculosis and the diagnosis was made by aspiration cytology. Radical orchiectomy was performed and pathology revealed a Leydig-cell tumour. Gynecomastia was found as a possible sign of endocrine activity. Although testicular malignancies in men with human immunodeficiency virus are increasingly reported, this is the first case of Leydig-cell neoplasia associated to HIV-infection.