Leydig cell tumors of the testis: a case report

Leydig Cell Testicular Tumor Presenting as Bilateral Breast Masses: A Case Report

Leydig cell tumors are rare but are the most common nongerm cell gonadal tumors. They are mostly benign but malignant variants have been reported. Leydig cells constitute the main androgen-synthesizing compartment in adult males but are also capable of estrogen production. This can manifest with clinical features of excessive hormone elaboration. We report a case of a 39-year-old man with abnormal bilateral breast development, reduced libido, and weak erection of 3 years' duration. He never noticed any testicular swelling before presentation. Examination revealed well-developed breasts bilaterally and a mass in the lower pole of the left testis. Scrotal ultrasound confirmed a hypoechoic tumor measuring 2 × 3 cm in the lower pole of the left testis and hormonal evaluation revealed a markedly elevated estradiol level. A diagnosis of estrogen-secreting testicular tumor was made. He had a testis-sparing excision of the scrotal lesion as well as liposuction and excision of glandular tissues of the breasts. He had an uneventful postoperative recovery and was discharged a day after surgery. Histology of excised testicular lesion revealed a benign Leydig cell tumor. Four months following surgery, there was an improvement in libido, erection, and sperm concentration of the patient. The patient was also very satisfied with the cosmetic outcome of the excision of the bilateral gynecomastia. We recommend self-examination of testicles as an important step for early diagnosis of testicular tumors.

Leydig cell tumor of the testis with characteristic contrast patterns of tumor and non-tumorous testicular parenchyma on MRI: a case report

PURPOSE

Testicular Leydig cell tumor (LCT) is a rare subtype of testicular neoplasms that occurs in the interstitial tissue of testes, accounting for 1-3% of total testicular masses removed annually. We report a case of 70-year-old man diagnosed as testicular LCT. This report demonstrates a testicular LCT with intratumoral and non-tumorous testicular parenchymal enhancement in the affected testis, which should be considered characteristic findings of LCT.

METHODS

Ultrasonography showed a hypoechoic mass. On magnetic resonance imaging, the tumor showed low signal intensity comparable to the surrounding testicular tissue on T1-weighted images (T1WI) and low signal intensity on T2-weighted images (T2WI). On gadolinium contrast-enhanced T1WI (CE-T1WI), the tumor showed a rapid and marked wash-in and subsequent prolonged washout. The spared, non-tumorous testicular parenchyma showed slow and progressive enhancement in the early phase, which was as strong as or stronger than that of the mass in the delayed phase. The patient underwent right orchiectomy.

RESULTS

Pathologically, the tumor was diagnosed as a testicular Leydig cell tumor (LCT). Leydig cell proliferation was observed with well-developed microvessels, atrophy of the seminiferous tubules, and stromal edema in the non-tumorous testicular parenchyma. Leydig cells in the non-tumorous parenchyma were positive for estrogen receptors.

CONCLUSION

Since the contrast findings in the non-tumorous testicular parenchymal region on CE-T1WI likely match the histopathological features of LCT, our case suggests that the presence of non-tumorous testicular parenchymal enhancement on imaging might indicate a diagnosis of LCT.

Simultaneous Sertoli Cell-Only Syndrome and Leydig Cell Tumor in a Patient with Azoospermia: A Rare Case Report

Testicular cancers comprise 1-1.5% of entire cancers in men, and sex cord-stromal tumors include 5% of testicular cancers. This study aims to report a simultaneous Sertoli cell-only syndrome and Leydig cell tumor in the same patient. A 32-year-old man presented with a history of primary infertility for 3 years. Physical examination revealed normal secondary sexual characteristics. Two successive seminal fluid analyses revealed azoospermia. A scrotal ultrasound scan showed a 28 × 27 mm hypoechoic and hypervascular right testicular mass. Right radical orchiectomy and simultaneous left testicular biopsy were conducted. The histopathological examination revealed Sertoli cell-only syndrome and Leydig cell tumor with focal Leydig cell hyperplasia. Reversing fertility following the management of Leydig cell tumor is rarely mentioned in the literature. A study revealed that fertility recovered following 4 months of management in a primary infertile male. However, infertile men with nonobstructive azoospermia due to SCOS can only have a child by testicular sperm extraction technique. Despite the rare occurrence of Leydig cell tumor, it could be seen in association with Sertoli cell-only syndrome in infertile men with azoospermia. Clinical examination and imaging studies are important in these patients as the possibility of having a testicular mass is high among them.

A Matter of Time: Delayed Presentation and Rapid Progression from Gonadotropin-Independent to Gonadotropin-Dependent Precocious Puberty following Successful Treatment for a Leydig Cell Tumor

Leydig cell tumors, most often benign, are a rare cause of isosexual gonadotropin-independent precocious puberty in boys due to secretion of testosterone. Very rarely do these tumors produce estrogen, causing gynecomastia. Testicular sparing surgery is the mainstay of treatment currently although radical orchidectomy was the choice in the past. Following surgery, clinical signs improve along with a revision of biochemical changes. Occasionally, it has been reported few children are progressed to gonadotropin-dependent precocious puberty (GDPP) after initial clinical and biochemical recovery. Gonadotropin receptor analogs have been successful on them to halt the progression of puberty, and growth hormone administration has been used to optimize the adult height. Here, we report a case of a 10-year-old boy who presented very late due to failure in recognition of features of puberty due to a Leydig cell tumor. Even though he underwent successful radical orchidectomy, just within 1 month following surgery, he entered GDPP in contrast to the published cases where it was earliest detected at 3 months.

Leydig cell tumor of the testis: an incidental finding at 18F-FDG PET/CT imaging

Background

Leydig cell tumors (LCTs) represent the most common form of stromal tumors. We reported the 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) findings of a patient with testicular LCT.

Case presentation

A 50-year-old man with a history of end-stage renal disease and renal transplantation 19 years ago. One year earlier, he started to have a chronic rejection. During the investigation to determine the cause of chronic rejection, a suspicious lesion in the graft with a collection around it was seen on ultrasound (US) images, raising the possibility of post-transplant lymphoproliferative disorder (PTLD). The patient was referred for further evaluation by whole body 18F-FDG PET/CT imaging. The image finding revealed an incidental hypermetabolic focal lesion in the right testicle—no other specific findings in the remaining parts of the body nor definitive FDG avid lymphadenopathy to suggest PTLD. Testicular US was requested and showed a well-defined right-sided heterogeneous hypoechoic intratesticular focal mass at the upper pole of the right testis with significant internal vascularity on the color Doppler imaging. The patient underwent a right radical orchidectomy, and the tumor was pathologically confirmed as an LCT.

Conclusion

In our case, 18F-FDG-PET/CT has been helpful in incidentally detecting this rare testicular tumor in a patient with suspected PTLD.

Transcriptome analysis of human Leydig cell tumours reveals potential mechanisms underlying its development

Leydig cell tumours are the most common sex cord-stromal tumours. In the last years, apparent increased incidence is noted while aetiology of the tumour is still unknown. Therefore, here, we focused on the genetics of Leydig cell tumours using the next-generation sequencing. Leydig cell micronodules were revealed in patients with azoospermia who were qualified for testicular biopsy. Complete gene set of Leydig cell tumours was compared with transcriptome of healthy Leydig cells obtained from donors. Bioinformatic analysis of the obtained sequencing data revealed alterations in expression of 219 transcripts. We showed, for the first time, that a significant proportion of differentially expressed genes is directly involved in regulation of apoptotic process, which downregulation might be important to Leydig cell tumour development. Additionally, we found a significant upregulation of heat shock protein genes that might be a unique feature of Leydig cell tumours when compared to other tumour types. Our study offers fundamental transcriptomic data for future studies on human Leydig cell tumour that are crucial to determine its causes. Moreover, presented here the in-depth analysis and discussion of alterations observed in tumour transcriptome may be important for the diagnosis and therapy of this pathology.

Testicular leydig cell tumor revealed by hydrocele

Leydig cell tumor (LCT) is a rare testicular tumor with a low incidence accounting 3% of all testicule neoplasms. Due to its rarity, the natural history of LCT is poorly understood. Patients can present with atypical symptoms and endocrine disorders. The diagnosis of LCT is based on histological and immunohistochemical examination. We report a new case of leydig cell tumor in a 61-year-old man presenting with a left testis hydrocele. The patient underwent a left orchidectomy and the diagnosis of LCT was established. Even in front of a benign pathology such as hydrocele, exploration is necessary to detect any testicle tumor.

SRY-Positive 46, XX Testicular Disorder of Sexual Development With Leydig Cell Tumor

The risk of a gonadal tumor is high in testicular disorder of sexual development (DSD) with the Y chromosome, but cases of DSD without the Y chromosome are extremely rare. We reported a gonadal tumor in a phenotypically male individual with 46, XX testicular DSD. A testicular tumor was incidentally found in a 32-year-old phenotypic male who was presented to the hospital with male infertility. A diagnosis of 46, XX testicular DSD was made by the presentation of karyotype analysis of 46, XX with the sex-determining region of the Y chromosome (SRY) positive and gonadal tissue without female gonads. Surgery was performed due to a gradually growing tumor. The partial orchidectomy was performed with the diagnosis of a benign Leydig cell tumor in frozen biopsy.

Towards understanding leydigioma: do G protein-coupled estrogen receptor and peroxisome proliferator-activated receptor regulate lipid metabolism and steroidogenesis in Leydig cell tumors?

Leydig cell tumors (LCT) are the most common type of testicular stromal tumor. Herein, we investigate the G protein-coupled estrogen receptor (GPER) and peroxisome proliferator-activated receptor (PPAR) implication in regulation of lipid homeostasis including the expression of steroidogenesis-controlling molecules in clinical specimens of LCTs and tumor Leydig cells (MA-10). We showed the general structure and morphology of LCTs by scanning electron and light microscopy. In LCTs, mRNA and protein analyses revealed increased expression of GPER and decreased expression of PPARα, β, and γ. Concomitantly, changes in expression pattern of the lutropin receptor (LHR), protein kinase A (PKA), perilipin (PLIN), hormone sensitive lipase (HSL), steroidogenic acute regulatory protein (StAR), translocator protein (TSPO), HMG-CoA synthase, and reductase (HMGCS, HMGCR) were observed. Using MA-10 cells treated with GPER and PPAR antagonists (alone and in combination), we demonstrated GPER-PPAR-mediated control of estradiol secretion via GPER-PPARα and cyclic guanosine monophosphate (cGMP) concentration via GPER-PPARγ. It is assumed that GPER and PPAR can crosstalk, and this can be altered in LCT, resulting in a perturbed lipid balance and steroidogenesis. In LCTs, the phosphatidylinositol-3-kinase (PI3K)-Akt-mTOR pathway was disturbed. Thus, PI3K-Akt-mTOR with cGMP can play a role in LCT outcome and biology including lipid metabolism.

Interstitial Leydig Cell Tumorigenesis-Leptin and Adiponectin Signaling in Relation to Aromatase Expression in the Human Testis

Although epidemiological studies from the last years report an increase in the incidences of Leydig cell tumors (previously thought to be a rare disease), the biochemical characteristics of that tumor important for understanding its etiology, diagnosis, and therapy still remains not completely characterized. Our prior studies reported G-protein coupled estrogen receptor signaling and estrogen level disturbances in Leydig cell tumors. In addition, we found that expressions of multi-level-acting lipid balance- and steroidogenesis–controlling proteins including peroxisome proliferator-activated receptor are altered in this tumor. In order to get deeper into the other molecular mechanisms that regulate lipid homeostasis in the Leydig cell tumor, here we investigate the presence and expression of newly-described hormones responsible for lipid homeostasis balancing (leptin and adiponectin), together with expression of estrogen synthase (aromatase). Samples of Leydig cell tumors (n = 20) were obtained from patients (31–45 years old) and used for light and transmission electron microscopic, western blotting, and immunohistochemical analyses. In addition, body mass index (BMI) was calculated. In tumor mass, abundant lipid accumulation in Leydig cells and various alterations of Leydig cell shape, as well as the presence of adipocyte-like cells, were observed. Marked lipid content and various lipid droplet size, especially in obese patients, may indicate alterations in lipid homeostasis, lipid processing, and steroidogenic organelle function in response to interstitial tissue pathological changes. We revealed significantly increased expression of leptin, adiponectin and their receptors, as well as aromatase in Leydig cell tumors in comparison to control. The majority of patients (n = 13) were overweight as indicated by their BMI. Moreover, a significant increase in expression of phospholipase C (PLC), and kinases Raf, ERK which are part of adipokine transductional pathways, was demonstrated. These data expand our previous findings suggesting that in human Leydig cell tumors, estrogen level and signaling, together with lipid status, are related to each other. Increased BMI may contribute to certain biochemical characteristics and function of the Leydig cell in infertile patients with a tumor. In addition, altered adipokine-estrogen microenvironment can have an effect on proliferation, growth, and metastasis of tumor cells. We report here various targets (receptors, enzymes, hormones) controlling lipid balance and estrogen action in Leydig cell tumors indicating their possible usefulness for diagnostics and therapy.

Management of Leydig cell tumors of the testis-a case report

We report 1 case of Benign Leydig cell tumor. A 45-year-old male was admitted to the Urology department with a large painless mass in the right testis of 1 year duration. The patient underwent radical high right orchiectomy, with a preliminary diagnosis of right testicular tumor. On the basis of the pathologic and immunohistochemical findings, the testicular mass was diagnosed as a benign Leydig cell tumor. Long-term follow-up is necessary to exclude recurrence or metastasis and also the endocrine profile and imaging investigations need to be repeated periodically.

Effect of estrogen-related receptor silencing on miRNA protein machinery expression, global methylation, and deacetylation in bank vole (Myodes glareolus) and mouse tumor Leydig cells

The function of estrogen-related receptor (ERR) in testicular cells is at the beginning of exploration. Our previous findings showed that expression pattern of estrogen-related receptor (ERR) in mouse Leydig cell depends on physiological status of the cell. Exogenous hormones/hormonally active chemicals affect ERR expression. In Leydig cells in vitro, ERRα and ERRγ show opposing regulatory properties. The aim of this study was to examine the role of ERR in epigenetic processes in cells with altered level of secreted estrogens; mouse tumor Leydig cells and bank vole Leydig cells, respectively. In Leydig cells, ERRα and ERRγ were silenced via siRNA. mRNA and protein expression and protein localization of molecules required for miRNA biogenesis and function (Exportin 5, Dicer, Drosha and Argonaute 2; Ago2) were studied with the use of qRT-PCR, Western blotting, and immunohistochemistry. Global DNA methylation and histone deacetylation status together with estradiol secretion were determined with fluorometric, and immunoenzymatic assays. Regardless of ERR type knockdown in tumor Leydig cells, downregulation (P < 0.05; P < 0.01; P < 0.001) of Exportin5, Dicer, Drosha but not Ago2 was revealed while at protein level only Drosha was downregulated (P < 0.01) by both ERRα and ERRγ. Oppositely, Exportin5, Dicer and Ago2 showed ERR type-dependent regulation (downregulation; P < 0.01 by ERRα and upregulation; P < 0.01; P < 0.001 by ERRγ). In ERR-silenced vole Leydig cells, expression of Exportin5, endonucleases and Ago2 was not changed. Immunolocalization of Dicer and Ago2 was independent of the cell origin in contrast to localization of Exportin5 and Drosha which was dependent on the cell origin and ERR type knockdown. Absence of ERR effected on cell methylation status (ERRα increased it; P < 0.01 while ERRγ decreased it; P < 0.01, P < 0.001) but it not changed histone deacetylates activity. ERRα and ERRγ silencing decreased (P < 0.01, P < 0.001) estradiol secretion in both tumor and vole Leydig cells. In mouse and bank vole Leydig cell, Exportin5, Dicer, Drosha and Ago2 expression as well as methylation status are regulated by ERR in a manner related to receptor type, molecule type, cell origin and level of secreted estrogen.

Management of testicular Leydig cell tumor: A case report

RATIONALE

Testicular Leydig cell tumor (LCT) is a rare neoplasm. It commonly presents as a painless testicular mass with or without endocrine changes. Histological and immunohistochemical examination play important roles in differentiating LCT from testicular germ cell tumors.

PATIENT CONCERNS

We highlight the imaging phenotype, as well as the pathological findings of a case of LCT in a 62-year-old male.

DIAGNOSES

Preoperative noncontrast CT scan of the abdomen revealed a 7.0 × 6.4 × 5.3 cm oval mass with heterogeneous density, located in the right testis. Pelvic noncontrast MRI showed a heterogeneous mass on T1-weighted and T2-weighted images. The solid part of the tumor exhibited high signal on the diffusion-weighted imaging, and an obvious enhancement on the contrast-enhanced MR imaging. Ultrasonography examination demonstrated a large mixed echogenic space occupying lesion involving the whole right testis with multiple cystic areas and increased vascularity. This patient underwent radical orchiectomy. The pathologic diagnosis was LCT.

INTERVENTIONS

This patient underwent operative resection of the tumor. Due to the negative resection margins and absence of distant metastases, the patient did not receive additional radiotherapy or chemotherapy.

OUTCOMES

Four months after the surgery, the follow-up CT-scan did not reveal any local recurrence and distant metastases.

LESSONS

This case improves our ability to detect and diagnose LCT by summarizing its imaging characteristics as well as reviewing the literature. Additionally, we described the state-of-the-art management of the management of this rare tumor.

Leydig cell tumor of the testis, presenting with azoospermia

Case

A case of Leydig cell tumor, associated with azoospermia, is presented.

Outcome

The levels of sex hormones obviously were decreased, including luteinizing hormone (LH) and follicle‐stimulating hormone (FSH), with elevated testosterone. Computed tomography revealed no adrenal gland tumor, but a significant calcification in the right scrotal content was observed. He received a right radical orchiectomy and then he was unable to ejaculate. An endocrine panel revealed significantly decreased levels of testosterone and the low LH level had remained. Hormone replacement therapy with combined LH and FSH successfully recovered and preserved spermatogenesis.

Conclusions

Although the patient’s sexual function deteriorated after surgery, hormone replacement therapy was successful in establishing spermatogenesis.

An inguinal hernia with cryptorchidism with a Leydig cell tumor in an elderly man: A case report

INTRODUCTION

Cryptorchidism is common in children but is rare in the elderly. It often presents with a constellation of signs and symptoms similar to routine inguinal hernias. We present the case of an elderly man with cryptorchidism containing a Leydig cell tumor and provide clinical insights.

PRESENTATION OF CASE

An-84-year old man was admitted with an incarcerated right lower quadrant hernia. Both testes were absent on palpation of the scrotum. After reduction of the hernia, computed tomography scan revealed a round lesion in the hernia sac, which was suspected to be the ectopic testis. Laparoscopic exploration was performed in combination with an open anterior approach. The hernia orifice was the right internal inguinal ring, and the inguinal canal was obliterated by adhesions because the spermatic cord did not pass through it. The ectopic testis was resected with the hernia sac, and the hernia repaired with a KUGEL™ patch (Bard, USA).

DISCUSSION

Laparoscopic exploration was useful to delineate the anatomy of this unusual inguinal hernia. The open anterior approach was necessary to dissect the ectopic testis and the hernia sac. Pathological findings revealed tumor cells with clear cytoplasm in the resected testis, diagnosed as a Leydig cell tumor.

CONCLUSION

The combination of laparoscopic and anterior approaches facilitated the surgical treatment of an unusual inguinal hernia with cryptorchidism. The resected ectopic testis should undergo thorough histopathologic examination.