A hCG-secreting testicular seminoma revealed by male infertility: mechanism of hCG-evoked endocrine disturbances

Unusual imaging findings associated with abdominal pediatric germ cell tumors

Germ cell tumors of childhood are tumors arising from germline cells in gonadal or extragonadal locations. Extragonadal germ cell tumors are characteristically located in the midline, arising intracranially or in the mediastinum, retroperitoneum, or pelvis. These tumors are generally easily diagnosed due to typical sites of origin, characteristic imaging findings, and laboratory markers. However, germ cell tumors can be associated with unusual clinical syndromes or imaging features that can perplex the radiologist. This review will illustrate atypical imaging/clinical manifestations and complications of abdominal germ cell tumors in childhood. These features include unusual primary tumors such as multifocal primaries; local complications such as ovarian torsion or ruptured dermoid; atypical presentations of metastatic disease associated with burned-out primary tumor, growing teratoma syndrome, and gliomatosis peritonei; endocrine manifestations such as precocious puberty and hyperthyroidism; and antibody mediated paraneoplastic syndrome such as anti-N-methyl-D-aspartate-receptor antibody-mediated encephalitis. This review aims to illustrate unusual imaging features associated with the primary tumor, metastatic disease, or distant complications of abdominal germ cell tumors of childhood.

Hyperandrogenism and Hyperestrogenism Secondary to Mixed Germ-Cell Testicular Tumor

Testicular cancer with androgen and estrogen secretion is classically associated with Leydig cell tumors. Rare case reports have described this finding in germ-cell tumors along with signs of androgen and estrogen excess including gynecomastia and infertility. We report the case of a 19-year-old male with a non-seminomatous testicular germ-cell tumor found to have hyperandrogenism, hyperestrogenism, and suppression of central sex hormones. Similar findings may be underreported in the literature, and males with suspected testicular malignancy should be appropriately screened for signs of androgen and/or estrogen excess so they can be offered appropriate monitoring and counseling.

β-human chorionic gonadotropin-secreting intracranial germ-cell tumor associated with high testosterone in an adult man: A case report

A 38-year-old male patient presented with general weakness, polydipsia and a body weight loss of 10 kg in two years. Hypopituitarism with central hypothyroidism and central adrenal insufficiency were noted at Taipei City Hospital (Taipei, Taiwan). However, hypogonadotropic hypergonadism was also observed. The patient was diagnosed with an intracranial β-human chorionic gonadotropin (β-hCG) secreting germ-cell tumor, and brain magnetic resonance imaging revealed that the tumor involved the pineal gland, stalk, posterior pituitary gland, right basal ganglion, hypothalamus, corpus callosum and posterior hippocampus. The cerebrospinal fluid (CSF) β-hCG level was 1936 IU/l, while the α-fetoprotein (AFP) level was <0.24 ng/ml. The serum AFP level of the patient was 3.28 ng/ml, and the β-hCG level was 178 IU/l with a CSF:serum β-hCG ratio >2:1. The patient was successfully treated with chemotherapy and radiotherapy, as demonstrated by a marked decrease in size of the tumor and in the serum β-hCG levels. Intracranial β-hCG secreting germ-cell tumors are rare in adults and manifest differently compared with patients of early pubertal age. In contrast with the precocious puberty frequently observed in young patients, the diagnosis of adult patients is often delayed and the symptoms are associated with tumor size and location. The present case report described an adult male with an intracranial β-hCG secreting GCT, demonstrating hypopituitarism and asymptomatic hyperandrogenemia, and reviews and discusses the literature relevant to the case.

Testicular cancer and male infertility

PURPOSE OF REVIEW

Testicular cancer and infertility affect a similar age group of patients and have common biologic, epidemiologic, and environmental backgrounds. In this review, we provide current literature on links between infertility and testicular cancer, and new developments in the management of testicular cancer aimed at improving quality of life in men with testicular cancer.

RECENT FINDINGS

In-utero environmental exposure to endocrine disruptors modulates the genetically determined fate of primitive gonad and results in testicular dysgenesis syndrome, which may result in infertility and testicular cancer. Excellent response of testicular cancer to radiation and chemotherapy results in over 90% of survival and quality of life--fertility and sexual function--is of significant concern to patients and clinicians. The testicular-sparing management of testicular masses emerges as a sound alternative to radical orchiectomy and allows for preservation of spermatogenesis and hormonal function, and at the same time achieving similar survival rates. Secondary malignancies, pulmonary, and cardiovascular complications are recognized as late complications of treatment for testicular cancer.

SUMMARY

Better understanding of common mechanisms involved in infertility and testicular cancer, and scientifically driven evidence-based treatment options should improve quality of life in young men faced with this potentially life-threatening disease.

Hypogonadotropism with elevated serum testosterone: reversible causes of secondary infertility

BACKGROUND

A 33-year-old man presented with secondary infertility, increased libido, and extreme oligospermia. Testicular volumes were reduced, but no gynecomastia was apparent and androgen abuse was denied.

INVESTIGATIONS

Physical examination, semen-volume and sperm-density assessment, laboratory tests for serum levels of luteinizing hormone, follicle-stimulating hormone, testosterone, and dehydroepiandrosterone sulfate, karyotyping, testicular ultrasound, pelvic and abdominal CT, assessment for serum testicular tumor markers (alpha-fetoprotein and human chorionic gonadotropin), and histologic examination of testicular tissue.

DIAGNOSIS

Benign Leydig-cell adenoma.

MANAGEMENT

Left orchidectomy.

Cystic transformation of the rete testis

In a review of the testicular and epididymal specimens obtained from autopsies (1,798 men) or surgery (518 men), cystic transformation of the rete testis (CTRT) was found in 20 autopsies and 18 surgical specimens. When both testes were studied (autopsies), the lesion was bilateral. Ultrasonography revealed a widened mediastinum testis showing small hypoechoic areas. Arteriography showed thin or irregularly outlined testicular arteries, and the epididymal artery was lacking or appeared stenosed. Simple CTRT (without epithelial alteration) was found in both testes of 17 autopsied patients (all were elderly men) and in eight surgically removed testes from patients with sarcoma, tuberculous orchidoepididymitis, or hematocele. The most frequent epididymal lesion was bilateral efferent duct atrophy. In three patients, the rete testis presented nodular proliferation of calcifying connective tissue. CTRT with columnar transformation of the rete testis epithelium was observed in both testes from three patients with alcoholic cirrhosis, and in 10 surgically removed testes from patients with testicular tumor, cryptorchidism, or nonspecific orchitis. In cirrhotic patients, the efferent ducts appeared atrophied. In patients with testicular tumors, the efferent ducts were infiltrated by carcinoma in situ cells (CISs) and often contained granular material, cell debris, or hyaline globules. In both kinds of CTRT (without or with epithelial metaplasia), the most frequent seminiferous tubule lesions were tubular ectasia, hypospermatogenesis, tubular sclerosis, spermatogonium arrest, and sloughing of immature germ cells (spermatids and spermatocytes). The mechanism leading to CTRT might be mechanic (compression of the epididymis by an epididymal tumor or a spermatic cord tumor, or the result of a long-standing epididymitis or traumatic hemocele); ischemic (autopsied elderly men); hormonal (cirrhotic patients); malformative (cryptorchidism); or unknown (the remaining cases).