Contemporary Updates on Sex Cord-stromal Tumors of the Testis

Testicular sex cord-stromal tumors (TSCSTs) are relatively rare, representing ~5% of testicular neoplasms overall. Historically, TSCSTs have been classified into 3 major entities: Leydig cell tumor, Sertoli cell tumor, and granulosa cell tumor. In recent years, immunophenotypic and molecular analyses have led to a more detailed understanding of the biological and genomic features of these neoplasms, resulting in the description of new entities, some of which have been included in the latest WHO classification. This review summarizes novel histopathologic, clinical, and molecular findings that may lead to a reappraisal of established concepts and help improve the diagnosis and clinical management of TSCSTs in the coming years.

Molecular characterization of large cell calcifying sertoli cell tumors: A multi-institutional study of 6 benign and 2 malignant tumors

Large cell calcifying Sertoli cell tumors (LCCSCTs) are rare testicular tumors, representing <1 % of all testicular neoplasms. Almost 40 % of patients with LCCSCTs will present in the context of the inherited tumor predisposition syndrome, the Carney complex. While most LCCSCTs are benign, 10-20 % have malignant behavior. The aim of our study was to analyze LCCSCTs for novel molecular alterations in addition to PRKAR1A mutations and to identify potential drivers for malignant progression. Eight LCCSCTs diagnosed at two institutions were included. Two patients had the Carney complex confirmed on subsequent genetic testing, and two tumors had several adverse pathological findings. One patient presented with metastatic disease at the time of initial diagnosis. Targeted next-generation sequencing detected PRKAR1A alterations in all cases, with heterozygous PRKAR1A mutations in 5 tumors, germline Carney-complex-associated PRKAR1A mutation in 2 patients, and PRKAR1A fusion in 1 tumor. Additionally, sequencing the metastatic case identified CDKN1B and TERT promoter gene mutations. All tumors showed a low tumoral mutational burden and unremarkable copy number alterations except for frequent LOH of 17q24 encompassing the PRKAR1A locus. RNA expression analysis showed increased expression of several markers including novel PRUNE2, and usual markers like inhibin and calretinin. Our study showed that while LCCSCTs have been reported in the setting of cancer predisposition syndromes, the majority of these tumors occur sporadically. PRKAR1A alterations were present in all cases and appear to be the major driver in LCCSCTs. It remains to be determined whether malignant progression may be caused by additional driver mutations.

[Testicular Malignant Sertoli Cell Tumor with Long-Term Survival After Pulmonary Metastasectomy: A Case Report]

A 45-year-old man was referred to our hospital with a complaint of right scrotal discomfort. With a diagnosis of testicular tumor, right orchiectomy was performed. The tumor was histologically diagnosed as malignant Sertoli cell tumor pT1N0M0. A pulmonary nodule appeared, 53 months after the operation, and increased in size there after. Thoracoscopic left upper lobectomy was performed 64 months after the operation, and the pathological diagnosis was metastasis of malignant Sertoli cell tumor. No recurrence has been observed for 94 months after the resection of the metastatic lesion.

Sclerosis in Sex Cord-Stromal Tumors Other Than the Sclerosing Stromal Tumor: A Report of 70 Cases

Sclerosis is well-known in sclerosing stromal tumors (SSTs), as its name indicates, but has not been evaluated in other ovarian sex cord-stromal tumors (SCSTs). Its presence in other SCSTs has sporadically caused diagnostic problems in cases we have seen, and this prompted us to review SCSTs with appreciable sclerosis; tumors containing at least 20% sclerosis were included. Seventy cases were identified: 20 thecomas, 20 juvenile granulosa cell tumors (JGCTs), 8 adult granulosa cell tumors (AGCTs), 5 sex cord tumors with annular tubules, 6 retiform Sertoli-Leydig cell tumors (SLCTs; all of the intermediate differentiation), 4 nonretiform SLCTs (3 well-differentiated, 1 of intermediate differentiation with heterologous elements), 4 Sertoli cell tumors, and 3 microcystic stromal tumors (MSTs). Paucicellular sclerotic zones comprised 20% to 95% of the tumors and when conspicuous often obscured diagnostic features. Thirty-one tumors (10 thecomas, 19 JGCTs, 1 AGCT, and 1 MST) showed sclerotic zones focally enveloping nodules of tumor cells, imparting a pseudolobular appearance, and sclerosis often occurred within lobules as well. Ten of these (5 thecomas and 5 JGCTs) also had prominent staghorn blood vessels, generating a low-power appearance focally similar to SST. In 17 tumors, the sclerosis resulted in "compression" of the tumor cells into cords and/or solid tubules. Correct diagnosis in these cases is dependent on careful examination of the cellular zones of the neoplasms, but awareness of the extent of sclerosis that may be seen in diverse SCSTs may be crucial in suggesting the correct diagnosis particularly when the material is limited as in the intraoperative setting. Our findings highlight for the first time the occurrence and character of sclerosis in sex cord tumors other than SSTs and fibromas. Sclerosis is seen in descending proportion of the tumor types as follows: retiform SLCTs, thecomas, MSTs, JGCTs, sex cord tumors with annular tubules, Sertoli cell tumors, AGCTs, and nonretiform SLCTs. Its character can vary somewhat, having particular features in the sex cord tumor with annular tubules (hyaline material within tubules often coalescing and extending beyond the nests to form confluent aggregates) and retiform SLCTs (common in papillary cores).

Large Cell Calcifying Sertoli Cell Tumor: A Clinicopathologic Study of 18 Cases With Comprehensive Review of the Literature and Reappraisal of Prognostic Features

We present a series of 18 (8 clinically benign, 8 clinically ambiguous [ie, lacking sufficient follow-up to determine behavior], and 2 clinically malignant) large cell calcifying Sertoli cell tumors (LCCSCT) of the testis. The median patient age and size were 15.5 years and 1.9 cm for the benign tumors; 19 years and 1.6 cm for the ambiguous tumors; and 28.5 years and 2.3 cm for the malignant tumors. The most common presentation was a mass (n=12/18, 67%). Two patients (11%) had the Carney complex, and 2 had neurofibromatosis type 1. All tumors showed nodular growth with frequent lymphoid aggregates at the periphery. Within the nodules, there were nests and trabeculae of pale to eosinophilic epithelioid tumor cells with frequent cytoplasmic vacuolization interspersed with hypocellular, often myxoid stroma with conspicuous neutrophils. Spindled tumor cells were a minor component (<5%) in the clinically benign, ambiguous, and malignant tumors, except in 1 malignant tumor where they comprised 50% to 60% of the cellularity. Calcifications were noted in all but 2 benign tumors that were otherwise of typical appearance. Six tumors (3 in the clinically benign, 1 in the clinically ambiguous, and 2 in the malignant groups) were considered potentially malignant based on the presence of ≥1 adverse pathologic features previously recognized (see reference 1)-that is, size>4 cm, extratesticular growth, necrosis, significant atypia, vascular invasion, and >3 mitotic figures/10 HPFs. Of these, 3 tumors had ≥2 adverse features. One in a 7-year-old was clinically benign despite 5 "malignant" features; the remaining 2 in 27- and 30-year-olds, were clinically malignant, with both fulfilling previously suggested criteria for pathologically malignant tumors (age above 25 y and ≥2 adverse pathologic features). No clinically benign or ambiguous tumor met those same criteria. Of the adverse features, each of the 2 clinically malignant tumors showed tumor necrosis and lymphovascular invasion. All patients, except 1 with a clinically malignant tumor, were alive at a median follow-up of 33 months. In addition, in our literature review of 97 additional LCCSCTs, we identified 2 clinically malignant tumors in 42- and 45-year-old men that lacked any documented adverse pathologic criterion and 2 clinically malignant cases in patients with either the Carney complex or Peutz-Jeghers syndrome. In summary, our study and literature review support that all LCCSCTs in patients above 25 years old should be considered potentially malignant, and those in this age group with ≥2 adverse pathologic features warrant aggressive clinical management; furthermore, syndrome-associated cases are not uniformly benign. Tumor necrosis and lymphovascular invasion likely should receive greater adverse prognostic weight. LCCSCTs in young children may show benign outcomes despite several adverse pathologic features.

Case Report of Misleading Features of a Rare Sertoli Cell Testicular Tumor

Testicular Sertoli cell tumors are extremely rare. Generally, they are benign neoplasms, which belong to a group called sex cord–stromal tumors. In this article, we present a case report of a Sertoli cell tumor, which was accidentally discovered during a urological consultation of a 42-year-old male. An ultrasound showed a 2.1 × 2.2 cm hypoechogenic, hypervascular tumor in the middle third of the left testicle. Serum tumor markers (α-fetoprotein, alkaline phosphatase, β-human chorionic gonadotropin, and lactic dehydrogenase) were all within the normal range. Rapid microscopic evaluation of fresh frozen sections during the operation was inconclusive, which led to a decision not to perform a radical orchiectomy immediately. On formalin-fixed paraffin-embedded (FFPE) sections, the tumor histology showed atypical patterns, and immunohistochemical analysis was performed in order to determine the type of neoplasm and differentiate it from other types of testicular tumors, so as to assign the further course of treatment. Radical inguinal orchiectomy was performed. The final pathology report showed a tumor with no predictive signs of aggressive behavior, which most closely resembled a Sertoli cell tumor.

Large-cell calcifying Sertoli cell tumour with macrocalcification in partially resected testis of young adult patient

INTRODUCTION

There are less than 100 cases of Large-cell calcifying Sertoli cell tumour (LCCSCT) reported in English literature. Most of them are benign, bilateral and affect paediatric population. Malignant cases occur in older patients. LCCSCT is often associated with Carney complex or Peutz-Jaghers syndrome. We present the clinicopathological features of a young adult, with unilateral "stone-like" LCCSCT, without changes in hormonal status and no clinical characteristics of noted genetic disorders.

CASE REPORT

A 24-year-old male presented with painless hardening of the right testis. There was no gynaecomastia, and serum levels of human chorionic gonadotropin and α-fetoprotein were normal. Ultrasound depicted hyperechogenic, clearly demarcated intratesticular lesion. Partial orchiectomy was performed. Macroscopically, tumour appeared as almost entirely calcified round mass, measuring 10 mm. Histopathological evaluation showed well-circumscribed, unencapsulated tumour composed of massive calcified geographic formations, surrounded with tumour cells. Neoplastic cells were large, polygonal, with abundant eosinophilic cytoplasm, and formed irregular cords, pseudo tubular structures, and nests in a fibrous and myxoid stroma, surrounded with lymphocytes. Other forms of calcification were also present: Needle-like deposits and lamellar, mulberry-like structures. There was no necrosis, mitotic activity and nuclear pleomorphism. Immunohistochemical study was positive for inhibin α and negative for Melan A, EMA, synaptophysin, chromogranin and AFP.

DISCUSSION

LCCSCT needs to be differentiated from other, more frequent, sex cord stromal tumours. Clinical and genetical evaluation of these patients had to be performed, due to connection of LCCSCT with genetic abnormalities. In evidently benign cases, organ-sparing surgery should be considered for younger patients, followed by long term follow-up.

A Contemporary Review of Common Adult Non-germ Cell Tumors of the Testis and Paratestis

This article provides a comprehensive review of non-germ cell tumors of the testis and paratestis in adults, incorporating the latest 2016 World Health Organization updates. Clinical features, gross pathologic findings, key morphologic details, immunohistochemical profiles, and differential diagnoses are covered, with an emphasis on how to resolve commonly encountered, and sometimes difficult, differential diagnoses.

Feminizing Sertoli Cell Tumor Associated with Peutz-Jeghers Syndrome (Histologic and ultrastructural study)

A case of Peutz-Jeghers syndrome associated with Sertoli cell tumor of the testis and bilateral gynecomasty in an 8-year-old boy is described. The authors emphasize the unusual histologic and ultrastructural features of the tumor and discuss the physiopathologic aspects of the present case.

Light Microscopic, Immunocytochemical and Ultrastructural Study of a Case of Sertoli Cell Tumor of the Testis

A case of testicular specialized gonadal stroma tumor was evaluated by histologic, ultrastructural and immunohistochemical techniques in a young adult male patient. The neoplastic cells were organized in cords or tubular structures delimited by a basement membrane. The ultrastructural findings suggested a diagnosis of a partially differentiated Sertoli cell tumor. This was also supported by the presence of a vimentin rich cytoskeleton, which is normally present in Sertoli and Leydig cells. The tumor cells did not secrete steroid hormones, as suggested by clinical findings, as well as by hormonal, immunohistochemical, and ultrastructural observations.

Malignant Seminoma with Metastasis, Sertoli Cell Tumor, and Pheochromocytoma in a Spotted Dolphin (Stenella frontalis) and Malignant Seminoma with Metastasis in a Bottlenose Dolphin (Tursiops truncatus)

Seminoma with metastasis was diagnosed in a spotted dolphin ( Stenella frontalis) and an Atlantic bottlenose dolphin ( Tursiops truncatus). Sertoli cell tumor and pheochromocytoma were also diagnosed in the spotted dolphin. The spotted and bottlenose dolphins were adult males that stranded and died on the coasts of northwest Florida and southeast North carolina, respectively. Neoplasia is infrequently reported in cetaceans. This is the first report of seminoma, Sertoli cell tumor, and pheochromocytoma in a dolphin, the first report of three distinct neoplasms in a dolphin, and one of the few reports of malignant neoplasia in dolphins.

Use of aromatase inhibitors in large cell calcifying sertoli cell tumors: effects on gynecomastia, growth velocity, and bone age

CONTEXT

Large cell calcifying Sertoli cell tumors (LCCSCT) present in isolation or, especially in children, in association with Carney Complex (CNC) or Peutz-Jeghers Syndrome (PJS). These tumors overexpress aromatase (CYP19A1), which leads to increased conversion of delta-4-androstenedione to estrone and testosterone to estradiol. Prepubertal boys may present with growth acceleration, advanced bone age, and gynecomastia.

OBJECTIVE

To investigate the outcomes of aromatase inhibitor therapy (AIT) in prepubertal boys with LCCSCTs.

DESIGN

Case series of a very rare tumor and chart review of cases treated at other institutions.

SETTING

Tertiary care and referral center.

PATIENTS

Six boys, five with PJS and one with CNC, were referred to the National Institutes of Health for treatment of LCCSCT. All patients had gynecomastia, testicular enlargement, and advanced bone ages, and were being treated by their referring physicians with AIT.

INTERVENTIONS

Patients were treated for a total of 6-60 months on AIT.

MAIN OUTCOME MEASURES

Height, breast tissue mass, and testicular size were all followed; physical examination, scrotal ultrasounds, and bone ages were obtained, and hormonal concentrations and tumor markers were measured.

RESULTS

Tumor markers were negative. All patients had decreases in breast tissue while on therapy. Height percentiles declined, and predicted adult height moved closer to midparental height as bone age advancement slowed. Testicular enlargement stabilized until entry into central puberty. Only one patient required unilateral orchiectomy.

CONCLUSIONS

Patients with LCCSCT benefit from AIT with reduction and/or elimination of gynecomastia and slowing of linear growth and bone age advancement. Further study of long-term outcomes and safety monitoring are needed but these preliminary data suggest that mammoplasty and/or orchiectomy may be foregone in light of the availability of medical therapy.

[Testis-sparing surgery for benign testicular tumor]

OBJECTIVE

To investigate the safety and feasibility of testis-sparing surgery (TSS) in the treatment of testicular tumor.

METHODS

We retrospectively analyzed the clinical data of 8 cases of benign testicular tumor treated by TSS in our hospital from October 2005 to March 2012.

RESULTS

The 8 patients, aged 18-67 (mean 45) years, were preoperatively diagnosed with benign testicular tumor and all underwent partial testis resection. Rapid intraoperative pathology showed the incisal margins to be negative. Postoperative pathological examination confirmed Sertoli cell tumor in 3 cases, adenomatoid tumor in another 3, and mature teratoma in the other 2. The patients were followed up for 6 months to 7 years (mean 4 years), which revealed no relapse and metastasis, nor significant differences from the baseline in the testosterone level, IIEF score, and routine semen parameters.

CONCLUSION

Testis-sparing surgery is one of the effective options for the management of benign testicular tumor, which can maximally preserve the testis tissue and protect the patient's sexual function.

Role of frozen section examination in the management of testicular nodules: a useful procedure to identify benign lesions

PURPOSE

To assess the validity of frozen section examination (FSE) on testis nodules.

MATERIALS AND METHODS

A series of 86 preselected patients with testicular nodules were recruited in this study. Nodules smaller than 2 cm had been surgically removed and biopsies of the margins performed. Larger nodules were just biopsied. Orchiectomy was the treatment of choice for malignant lesions and stromal tumors. Conservative surgery was performed on 2 previously monorchid patients with Leydig cell tumor because of the presence of just one testis. Conservative surgery was the treatment of choice for benign lesions in 32 cases.

RESULTS

At FSE we observed that nodules were malignant germinal tumors in 47% of the cases, stromal tumors in 7% of the cases, benign lesions in 45% of the cases and doubtful for lymphoproliferative lesion in 1 case. The diagnosis made by FSE were confirmed in the definitive ones in all of them, we reported just 2 cases of Leydig cell tumor and benign fibrosis lesion. In these 2 cases, definitive histology of the collected specimens revealed areas of Leydig cell hyperplasia and seminomatous foci, respectively.

CONCLUSION

Our data suggest that FSE is a valid tool to discriminate between benign and malignant neoplastic lesions, particularly when an adequate sample is available.

[Sertoli cell tumor of the testis : a case report and questionnaire survey on the reported cases in Japan]

We report a case of Sertoli cell tumor of the testis. A 33-year-old man visited our hospital with the complaints of macroscopic hematuria and fever. The left testis was swollen on palpation. Serum levels of human chorionic gonadotropin-β and lactate dehydrogenase were not elevated, while α fetoprotein was slightly over the normal range. Ultrasonography showed a hypoechoic lesion in the left testis. There was no evidence of retroperitoneal lymph node enlargement or distant metastasis on computed tomography. A left orchietectomy was performed under the diagnosis of left testicular tumor. The tumor, measuring 20 mm in size was histologically diagnosed as benign Sertoli cell tumor. No adjuvant therapy was performed. Neither recurrence nor evidence of metastasis has been detected for 6 months postoperatively.

Mixed testicular neoplasia in a short beaked common dolphin Delphinus delphis

A diagnosis of mixed testicular neoplasia in a short beaked common dolphin Delphinus delphis involving a Sertoli cell tumor, an interstitial (Leydig) cell tumor and a seminoma is presented. Lymphatic spread of the Sertoli cell tumor to an adjacent retroperitoneal lymph node was observed. Testicular neoplasms have been infrequently reported in marine mammals. Demonstration of clinical signs and further health implications is extremely challenging when dealing with non accessible wildlife species, such as dolphins. However, metastatic potential for these neoplastic conditions should be considered.

Testicular sclerosing Sertoli cell tumor: an additional case and review of the literature

Sertoli cell tumours are very rare testicular tumours accounting for 0.4-1.5% of all testicular neoplasms. In the current report, we present a case of sclerosing Sertoli cell tumour. The histology and clinical features were compared to those of other Sertoli cell tumour subtypes in order to assess if the different subtypes really represent distinct clinical and prognostic entities. The current literature was also reviewed. Only 20 cases of sclerosing Sertoli cell tumours have been encountered. Our case, a 38-year-old man represents the 21st case. Distinction among Sertoli cell tumours is important not only histologically; sclerosing Sertoli cell tumours have a distinct clinical behaviour and prognosis, different from those of classic and large-cell calcifying Sertoli cell tumours. Pathologists and urologists should know and understand all the types of Sertoli cell tumours in order to be able to choose the correct therapeutical approach when they encounter these tumours.

Sertoli cell tumor and gonadoblastoma in an untreated 29-year-old 46,XY phenotypic male with Frasier syndrome carrying a WT1 IVS9+4C>T mutation

OBJECTIVE

Frasier syndrome (FS) phenotype in 46,XY patients usually consists of female external genitalia, gonadal dysgenesis, high risk of gonadoblastoma and the development of end stage renal failure usually in the second decade of life. FS is caused by heterozygous de novo intronic splice site mutations of the Wilms' tumor suppressor gene 1 (WT1), although a few cases with typical exonic WT1 Denys-Drash mutations that resemble an FS phenotype have been described. The aim of this study was to present further data on the spectrum of FS phenotypes through the evaluation of a 29-year-old patient with a predominantly male phenotype and coexistence of Sertoli cell tumor and gonadoblastoma.

RESULTS

Genetic analysis using standard methods for DNA sequencing confirmed FS due to a WT1 gene mutation, IVS9+4C>T.

CONCLUSIONS

This very rare case illustrates the natural course of FS over many years due to the neglect by the patient to address his need for follow-up, while adding further data on the spectrum of FS phenotypes associated with IVS9+4 C>T mutations. The coexistence of the rare Sertoli cell tumor and gonadoblastoma emphasizes that early clinical recognition and molecular identification facilitates appropriate patient management, especially with respect to the high risk of gonadal malignancy.

Organ-sparing surgery of the bilateral testicular large cell calcifying sertoli cell tumor in patient with atypical Peutz-Jeghers syndrome

Large cell calcifying sertoli cell tumor (LCCSCT) is an exceptionally rare neoplasm originating from sperm cord cells. The tumors have relatively low malignant potential and unlikely proceed to metastasis formation. The lesions may occur in an isolated form or in ca. 40% of cases may be associated with genetic abnormalities, by and large Peutz–Jeghers syndrome and Carney complex. At presentation, 20% of LCCSCT cases are bilateral and/or multifocal. Owning to characteristic skin lesions and particular hyperechoic ultrasound image of the tumor, preliminary diagnosis of the syndromic LCCSCT is possible in the preoperative period. Consequently, testicle organ–sparing procedure can be attempted, which is especially justified in bilateral lesions. Here, we report a case of a bilateral LCCSCT in a 20-year-old man with atypical Peutz–Jeghers syndrome due to amplification of the exon 1 of STK11 gene who was successfully treated with bilateral testicle-sparing tumorectomies.

Identification of the estrogen receptor GPER in neoplastic and non-neoplastic human testes

BACKGROUND

Estrogen signaling is mediated by estrogen receptor beta isoforms in normal and neoplastic human testes. Recently, a G-protein-coupled-receptor (GPER) has been suggested as being involved in rapid responses to estrogens in different normal and tumor cells.

METHODS

This study investigated the GPER expression in paraffin-embedded samples from non neoplastic and neoplastic human testes (sex-cord stromal and germ cell tumors) by immunohistochemical and Western Blot analyses.

RESULTS

In control testes, a positive GPER immunoreactivity was detected in Leydig and in Sertoli cells while all germ cells were immunonegative. Furthermore, neoplastic cells of the Sertoli cell tumor, Leydig cell tumor, seminoma and embryonal carcinoma samples were all immunopositive. The immunoblots of testis extracts confirmed the results.

CONCLUSIONS

These findings suggest that GPER could mediate estrogen signaling in both normal and transformed somatic cells of human testis, but they reveal a differential expression of the novel estrogen receptor in non neoplastic and neoplastic germ cells.

[Large cell calcifying Sertoli cell tumor: report of one case]

Sertoli cell tumors are less than 1% of all testicular tumors. We report a 14-year-old male presenting with a left testicular mass. Orchiectomy was carried out and the pathological study informed a large cell calcifying Sertoli cell tumor (LCCSCT). Its association with the Carney complex and Peutz-Jeghers syndrome was subsequently discarded. Surgical excision was completed with a radical orchiectomy. After eight months of follow up, there is no evidence of tumor relapse.

[Large cell calcifying Sertoli cell tumor of the testis: a clinicopathological observation]

OBJECTIVE

To investigate the clinicopathological characteristics of large cell calcifying Sertoli cell tumor (LCCSCT) of the testis.

METHODS

We studied a case of LCCSCT by light microscopy, Western blotting and immunohistochemistry, reviewed relevant literature, and analyzed the clinical, morphological and immunohistochemical features, treatment and prognosis of the tumor.

RESULTS

The patient was a 25 years old man. Pathohistologically, the tumor was characterized by a mass of polygonal tumor cells in a tubular and trabecular growth pattern, with abundant acidophilic cytoplasm, enlarged vesicular nuclei, and extensive calcified debris in stroma. The tumor cells were positive for inhibin, S-100, vimentin and alcian blue, but negative for PLAP, SMA, CK, AFP and periodic acid-Schiff (PAS) reaction.

CONCLUSION

LCCSCT is a rare testicular sex cord stromal tumor. Its diagnosis is based on immunohistochemical staining, and it is to be differentiated from other lesions of the testis, including seminoma, Leydig cell tumor, Sertoli cell node, and androgen insensitivity syndrome. For the treatment of LCCSCT, surgical resection often has a good prognosis.

Spermatocytic seminoma with neuroectodermal differentiation and sertoli cell tumor in a dog

Two distinct nodules developed in a cryptorchid testis of an 8-year-old male West Highland White Terrier. One nodule was a Sertoli cell tumor. The other was a spermatocytic seminoma with focal primitive neuroectodermal differentiation: formation of Homer-Wright rosettes and perivascular pseudorosettes, with immunoreactivity for S-100 protein, neuron-specific enolase, synaptophysin, neurofilament-68 kDa, microtubule-associated protein 2, and vimentin. The dog was alive and healthy 2 years after castration.

Pure Sertoli cell tumor. a case report and review of the literature

Pure Sertoli cell tumor (SCT) is a rare sex cord tumor and a subtype of Sertoli-Leydig cell tumors according to the WHO Classification. They lack a Leydig cell component and do not contain the immature neoplastic stroma found in the neoplasms of the Sertoli-Leydig cell category. The age of the patients ranges between two and 79 years. Sertoli cell tumors occur in women of reproductive age but a few can also occur in children. The most common clinical presentation when occurring in children is isosexual pseudoprecocity. Women of reproductive age and postmenopausal women frequently present with abdominal pain, swelling and menstrual abnormalities. Occasionally SCTs occur in patients who have Peutz-Jeghers syndrome. The tumors are hormone functional in 40-60% of cases. They are often estrogenic, occasionally also androgenic or rarely both. Grossly they are usually yellow to brownish, solid or with several cystic areas. Microscopically they show always almost a tubular growth pattern, but they may also have other growth patterns which can be extensive, making the correct diagnosis difficult. These histologic patterns may result in SCTs mimicking other ovarian tumors. The immunohistochemical panel which usually includes EMA, inhibin, chromogranine, CD99 and calretinin is often helpful in establishing the diagnosis. Most SCTs are Stage I, unilateral, cytologically bland, and clinically benign, but occasional examples are high stage. About 11% of Stage I tumors have worrisome histologic features that may portend an adverse outcome.

Sertoli cell tumor of the testis: a case with late metastasis

We report on a 20-year-old male who underwent a radical orchidectomy when he was 12 years old which revealed a Sertoli cell tumor in his right testis, and who presented with a 5 x 3 cm retroperitoneal metastatic mass 8 years after orchidectomy. Current experience on Sertoli cell tumor of the testis (SCTT) is insufficient to prognosticate the clinical behavior of the primary tumor on the long term. Case reports in the literature on patients with late metastases suggest a very long followup after orchidectomy may be required.

Conditional deletion of Smad1 and Smad5 in somatic cells of male and female gonads leads to metastatic tumor development in mice

The transforming growth factor beta (TGFbeta) family has critical roles in the regulation of fertility. In addition, the pathogenesis of some human cancers is attributed to misregulation of TGFbeta function and SMAD2 or SMAD4 mutations. There are limited mouse models for the BMP signaling SMADs (BR-SMADs) 1, 5, and 8 because of embryonic lethality and suspected genetic redundancy. Using tissue-specific ablation in mice, we deleted the BR-SMADs from somatic cells of ovaries and testes. Single conditional knockouts for Smad1 or Smad5 or mice homozygous null for Smad8 are viable and fertile. Female double Smad1 Smad5 and triple Smad1 Smad5 Smad8 conditional knockout mice become infertile and develop metastatic granulosa cell tumors. Male double Smad1 Smad5 conditional knockout mice are fertile but demonstrate metastatic testicular tumor development. Microarray analysis indicated significant alterations in expression of genes related to the TGFbeta pathway, as well as genes involved in infertility and extracellular matrix production. These data strongly implicate the BR-SMADs as part of a critical developmental pathway in ovaries and testis that, when disrupted, leads to malignant transformation.

Sklerosierender Sertoli-Zell-Tumor des Hodens – ein seltener Tumor

Sertoli cell tumors of the testis are extremely rare (0.4-1.5% of all testicular neoplasms) and have a heterogeneous pathology. Histopathologically classic, large cell calcifying and sclerosing subtypes are differentiated.Up to now, 14 cases of sclerosing Sertoli cell tumor are known. This article presents a new case and compares the three subtypes. The subtypes differ in particular in age of onset, malignant potential, prognosis, and therapy. While no cases of sclerosing Sertoli cell tumor with a malignant course have been reported, both other subtypes have been found to be potentially malignant. In the case of malignancy the prognosis is very poor, and it is difficult to select the best treatment because there is so little experience with this type of tumor. Once the diagnosis of a Sertoli cell tumor has been confirmed, exact determination of the histological subtype is essential to allow appropriate risk-adapted therapy. The various histological subtypes are presented with the clinical features, prognosis and treatment of each.

Surgery in infants and children with testicular and paratesticular tumours: a single centre experience over a 25-year-period

Testicular and even more paratesticular tumours in children are rare. The aim of the study is to characterise the spectrum of these lesions with focus on the feasibility and effectiveness of testis sparing surgery. Twenty-four boys treated between 1980 and 2004 at the University Leipzig Medical Centre were evaluated. At presentation patients were between 5 months and 18 years old (median 23 months). Generally a high rate of malignant or potentially malignant tumours was observed. The majority of these tumours occurred in the first three years of age. The spectrum of testicular tumours comprised 13 germ cell tumours (6 yolk sac tumours, 6 teratomas, 1 embryonal carcinoma) and 4 sex cord stromal tumours (2 Leydig's cell, Sertoli's cell, granulosa cell). Both Leydig's cell tumours were endocrine active. Further on, we observed 3 boys with paratesticular rhabdomyosarcoma (RMS), and three with testicular and paratesticular metastases (Wilms' tumour, neuroblastoma, leukaemia). Serum alpha1-fetoprotein (AFP) was clearly elevated in 5 of 6 yolk sac tumours but remained within normal limits concerning the other entities. Human chorionic gonadotrophin was normal in all cases tested. During the observation period high inguinal orchidectomy was the surgical standard method. Dependent on tumour histology, stage and the recommended treatment schedule postoperative chemotherapy was added. Testis sparing surgery was performed in 3 boys with primary testicular tumours (2 Leydig's cell, mature cystic teratoma). Local relapses were not observed. Systemic relapses occurred in 3 cases (2 RMS, leukaemia). During a median follow up of 5 years all patients with primary testicular tumours survived event free. Meta-analysis of the recent literature revealed that testis sparing surgery is feasible and save in prepubertal boys after exclusion of a malignant tumour. If a testis sparing approach is planned, the following criteria are essential: 1. The presence of a well defined circumscribed nodule confirmed by imaging. 2. Normal levels of serum AFP and hCG. 3. The presence of sufficient healthy testicular parenchyma. However, the high rate of malignant or potentially malignant tumours suggests that high inguinal orchidectomy should remain the surgical standard of therapy.

Novel germ cell markers characterize testicular seminoma and fetal testis

Seminomas are characterized by expression of several stem cell markers, supporting their origin from germ cells. The current study focuses on novel germ cell markers in normal testes compared to those in fetal testes and different progression stages of seminomas. Microarray data were followed by RT-PCRs and immunohistochemistry on pure seminomas (pT1 to pT3) compared to adult and fetal testis. An upregulation of known germ cell markers, KIT, OCT4 and NANOG, was confirmed in seminoma specimens. We also identified novel germ cell markers such as BOB1 (POU2AF1, OBF1) and prominin 1 (PROM1, CD133), which were significantly upregulated in seminoma specimens, compared to normal testes. Furthermore, two Sertoli cell markers, SCGF (SCF) and the newly identified neuronal stem cell factor, MCFD2 (SDNSF), were expressed in seminoma cells. While BOB1 was expressed in fetal testis of second and third trimester of gestation, MCFD2 and PROM1 were only present in gonocytes up to the second trimester. All marker genes investigated were not further regulated in progressing tumour stages between pT1 and pT3. In conclusion, the germ cell markers described here provide evidence for the origin of seminoma cells, which could be from the developmental stage of early gonocytes or from spermatogonia re-expressing markers of the developing germ cells.

Conservative management of bilateral Sertoli cell tumors of the testicle in association with the Carney complex: a case report

Large cell calcifying Sertoli cell tumor of the testicle is a rare, hormonally active sex cord-stromal tumor seen in patients with Carney complex. When such tumors occur bilaterally, treatment options for preserving fertility and addressing the secondary effects of excess hormone production must be considered. The availability of specific antiestrogen drugs means that bilateral orchiectomy for this benign tumor may no longer be warranted. Testicular-sparing surgery and advances in reproductive technology may also improve the overall prognosis for fertility. Gynecomastia in prepubescent boys can be emotionally very distressing. Approximately two thirds of teenaged boys will develop some degree of breast enlargement that spontaneously regresses as testosterone levels rise (Ill Med J 1938;73:113). In all cases, a thorough history and physical examination are required to exclude nonphysiologic causes such as drugs, pulmonary disease, chronic liver disease, exogenous estrogens, and estrogen-producing tumors (Seashore J. Disorders of the breast. In: Rowe MI, O'Neill JA, Grosfeld JL et al, editors. Pediatric surgery, 5th ed. St Louis (MO): Mosby Year Book, 1998). We report on a child who presented with a 2-year history of gynecomastia with associated bilateral testicular swellings and discuss a novel treatment strategy for managing bilateral testicular tumors in the context of the Carney complex.

Diagnostic Utility of WT1 Immunostaining in Ovarian Sertoli Cell Tumor

WT1, the Wilms tumor gene product, can be expressed in various tumors from different anatomic sites, including some types of ovarian tumors. Regarding the latter, most studies have focused on surface epithelial-stromal tumors in which serous carcinomas are usually positive and endometrioid carcinomas are negative. Very few studies have specifically investigated this marker in ovarian sex cord-stromal tumors; however, limited data in the literature suggest that WT1 may be frequently expressed in sex cord-stromal tumors. As pure Sertoli cell tumor can be in the histologic differential diagnosis of endometrioid tumors (particularly borderline tumor and carcinoma) and carcinoid, immunostaining for WT1 might be of diagnostic value. Immunohistochemical staining for WT1 was performed in 108 ovarian tumors: pure Sertoli cell tumor (n=26), endometrioid borderline tumor (n=25), classic well-differentiated endometrioid carcinoma (n=23), sertoliform endometrioid carcinoma (n=12), and carcinoid (n=22). Additionally, inhibin and calretinin immunostaining were performed in all cases of Sertoli cell tumor for purposes of comparing expression with WT1. Extent of immunostaining was scored on a 0 to 4+ semiquantitative scale, and immunohistochemical composite scores based on a combination of extent and intensity of immunostaining were calculated in positive cases (possible range, 1 to 12). Nuclear expression of WT1 was present in 96% of Sertoli cell tumors, 16% of endometrioid borderline tumors, 13% of classic well-differentiated endometrioid carcinomas, 25% of sertoliform endometrioid carcinomas, and 0% of carcinoids. In Sertoli cell tumors, expression was diffuse (>50% of positive cells) in all positive cases. When positive in the non-Sertoli cell tumors, the extent of expression tended to be focal to patchy (50% or less positive cells). In Sertoli cell tumors, inhibin and calretinin were expressed in 96% and 54% of cases, respectively. The extent of expression of inhibin tended to be diffuse, similar to WT1; however, the extent of immunostaining for calretinin tended to be focal to patchy. The immunohistochemical composite scores for WT1, inhibin, and calretinin were 11.2, 7.6, and 4.8, respectively. Coordinate patterns for the extent of expression of WT1, inhibin, and calretinin in pure Sertoli cell tumor showed that all 3 markers were positive in 54% of cases; however, 42% were positive for WT1 and inhibin but negative for calretinin. In cases positive for both WT1 and inhibin, expression of both markers was diffuse in 84% of cases, but WT1 was diffuse while inhibin was focal to patchy in 16% of cases. We conclude that ovarian Sertoli cell tumor should be added to the growing list of WT1-positive tumors. This marker is useful for the distinction of Sertoli cell tumor from endometrioid tumors and carcinoid. The diagnostic utility of WT1 in Sertoli cell tumor is similar to inhibin but better than that of calretinin.

A pure Sertoli cell tumor of the ovary in a 10-year-old female

STUDY OBJECTIVE

To document an unusual presentation of a pure Sertoli Cell tumor.

DESIGN

Case report.

RESULTS

We present a 10-year-old female who presented with abdominal pain and diarrhea with no symptoms of puberty. Surgical exploration revealed a metastatic pure Sertoli Cell tumor, which was treated with resection and chemotherapy.

CONCLUSION

Sertoli cell tumors are rare occurrences and should be considered in the differential diagnosis for a prepubescent girl with an abdominal mass.

[Ovarian steroid cell tumor, not otherwise specified: a clinicopathologic study]

OBJECTIVE

To study the clinicopathologic features, diagnostic criteria, differential diagnosis and treatment options of ovarian steroid cell tumor, not otherwise specified (NOS).

METHODS

Light microscopy and immunohistochemical study was carried out in 8 cases of ovarian steroid cell tumor, NOS. The literature was reviewed.

RESULTS

The 7 cases of benign ovarian steroid cell tumor, NOS were composed mainly of polygonal cells with granular eosinophilic cytoplasm and larger cells with vacuolated cytoplasm. They resembled the architecture of normal adrenal gland, with formation of cell nests and trabeculae. The single case of malignant ovarian steroid cell tumor had evidence of significant cellular pleomorphism, haemorrhage and coagulative tumor necrosis. The mitotic count measured about 7 per 10 high-power fields. Immunohistochemical study showed that the tumor cells expressed calretinin and alpha-inhibin. Differential diagnosis included oxyphilic granulosa cell tumor, thecoma, Sertoli cell tumor and clear cell carcinoma. The treatment options of benign ovarian steroid cell tumor, NOS was local excision or ipsilateral salpingo-oophorectomy, while the malignant counterpart should be treated with a combination of surgery and chemotherapy, including administration of GnRH agonist.

CONCLUSIONS

Ovarian steroid cell tumor, NOS, is the most common type of ovarian steroid cell tumors. Most of which are associated with a benign clinical outcome. Immunohistochemistry is an important adjunct for diagnosis. The treatment options of ovarian steroid cell tumor, NOS depend on its malignant potential.

Synchronous sertoli cell and serous cystadenoma tumors of the ovaries with mixed epithelial and stromal tumor of the kidney: a case report

We present a rare case of a 68-year-old postmenopausal woman with a mobile, hard, and painless pelvic abdominal mass that was palpated to the umbilical scar. Ultrasonography demonstrated a solid mass in the upper pole of the right kidney and a predominantly solid pelvic abdominal mass. Serum testosterone was 413 ng/dL. The patient underwent laparotomy on the renal tumor, which was thought to have a probable ovarian metastasis. Bilateral ovariectomy and right nephrectomy were performed. Immunohistochemical and histopathologic assessment identified a right ovarian Sertoli cell tumor, a left ovarian serous cystadenoma, and a mixed epithelial-stromal tumor in the kidney with positive hormonal receptor. Because our patient had an ovarian neoplasm producing steroids and a kidney tumor expressing hormonal receptors, the hypothesis of possible endocrine dependence in the pathogenesis of mixed epithelial stromal tumor is reinforced.

Intratubular large cell hyalinizing sertoli cell neoplasia of the testis: a report of 8 cases of a distinctive lesion of the Peutz-Jeghers syndrome

We report the clinical and pathologic features of 8 boys with Peutz-Jeghers syndrome who had distinctive testicular lesions. The patients were 4 to 13 years of age (mean, 6.5 y), and all had gynecomastia, which was the presenting feature in 7. Physical examination demonstrated bilateral testicular enlargement in the absence of a discrete mass. Advanced bone age and elevated serum estradiol were demonstrated in 3 and 4 cases, respectively. Testicular biopsy, performed in all cases, usually showed no gross abnormality, but on microscopic examination there were patchily distributed clusters of expanded seminiferous tubules that contained large Sertoli cells with vacuolated to eosinophilic cytoplasm admixed with globular deposits of basement membrane that extended from a thickened peritubular basement membrane. Small, focal calcifications occurred in 3 cases; no invasive tumor was present in any of the cases. Follow-up was available in 5 patients after biopsy, and none showed evidence of progression at 10 months to 5 years (median, 4 y). Review of the previously reported cases of testicular lesions in Peutz-Jeghers patients verified a low frequency of invasive tumors (27%) and no known case with metastasis. The testicular lesions seen in patients with Peutz-Jeghers syndrome mostly represent multifocal intratubular neoplasia of large Sertoli cells with unique morphology distinct from other lesions such as the large cell calcifying Sertoli cell tumor and sex cord tumor with annular tubules. The process usually remains confined to the tubules for prolonged intervals (years), but it may occasionally progress to invasive large cell Sertoli cell tumors with or without associated calcification. This indolent course justifies management by careful follow-up, including ultrasound examination, rather than orchiectomy in the majority of cases. Orchiectomy is indicated when there is evidence of an invasive tumor and may be necessary to control hormonal manifestations.

Sertoliform Endometrioid Carcinoma of the Endometrium With Dual Immunophenotypes for Epithelial Membrane Antigen and Inhibin ??

We report a rare case of sertoliform endometrioid carcinoma of the endometrium in a 71-year-old African American woman who presented with postmenopausal bleeding. Her medical condition was remarkable for hypertension, diabetes, and obesity. She underwent total hysterectomy, right salpingo-oophorectomy and lymph node sampling. The endometrium was occupied by a 4.5-cm solid polypoid tumor, which grossly invaded into the myometrium. Microscopically, the tumor consisted of small hollow tubules, anastomosing cords and trabeculae, and tightly packed nests. Microglandular areas mimicking adult granulosa cell tumors were also present. But true Call-Exner bodies were absent. Component of typical endometrioid carcinoma was noted only focally. The uninvolved endometrium demonstrated atypical complex hyperplasia. The tumor cells were diffusely immunoreactive for epithelial membrane antigen, estrogen receptor, and progesterone receptor (PR), and focally for vimentin. The tumor cells were also diffusely positive for inhibin alpha and CD99. Immunostains for other sex cord markers (calretinin, WT-1, and Melan-A) were also positive in approximately 30% to 40% of the tumor cells. Immunostains for CD10, smooth muscle actin, desmin, or HHF35 were negative. Two ovarian sertoliform endometrioid carcinomas from our archived tissue were, however, immunoreactive for epithelial membrane antigen but negative for inhibin alpha. Despite the prominent sertoliform features, both histologically and immunohistochemically, the tumor was of a high-grade endometrial carcinoma and will likely behave as such. As of today, dual differentiation of epithelium and sex cord by immunohistochemical staining has not been demonstrated in sertoliform endometrioid carcinomas of either endometrial or ovarian origin. Our case is the first documentation of such example and suggests that endometrial carcinoma can undergo true sex cord differentiation.

Interstitial cell tumor and Sertoli cell tumor in the testis of a cat

Testicular tumors are rarely reported in cats. We describe a case of interstitial cell tumor and Sertoli cell tumor in a cat that developed aggressive behavior and inappropriate urination 7 years after it was obtained from a shelter as an allegedly castrated 2 year old. At physical examination, the urine odor and the presence of penile papillae implied testosterone production. Testes were not palpable, but the left testis was found in the scrotum by surgical exploration and was mostly replaced by the 2 tumors. The interstitial cell tumor, but not the Sertoli cell tumor, was immunohistochemically positive for Melan-A, consistent with steroid production. Behavior improved after excision of the testis and penile papillae began to regress, but the cat was euthanatized 3 1/2 months after castration at the owner's request. Neither tumor had metastasized. The right testis was never found and was presumed to have been removed during the reported castration procedure.

Sertoliform endometrioid carcinoma of the ovary: a potential diagnostic pitfall

Sertoliform endometrioid carcinoma of the ovary (SEC) is an uncommon variant that bears histologic similarity to Sertoli and Sertoli-Leydig cell tumors (SLTs). Clinically, SEC affects an older population (60-70 years), while patients with SLT have an average age of 25 years and may exhibit endocrine manifestations. A number of histologic features can be used to distinguish the 2 entities, the most important ones being (1) the presence of areas with the usual pattern of endometrioid carcinoma, and (2) the presence of mucin at the apical borders of the tumor cells. Cytokeratin stains positively, while inhibin and calretinin stain negatively in SEC; the converse is true for SLTs. Based on the clinicopathologic behavior of this entity, SEC should be considered a well-differentiated carcinoma with relatively good prognosis if limited to the ovary.